Conquering the chaos when
disaster strikes
Recovery, rebuilding
efforts test supply chain resolve and resilience
by Rick Dana Barlow
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Photo courtesy Mercy’s St. John’s Regional Medical
Center |
Disasters
can draw out the best and worst of people, as well as an organization’s
operational effectiveness and efficiency.
Some healthcare product manufacturers and
group purchasing organizations may equip and man high-tech, globe-spanning
situation rooms deep within their campus bowels that would give British
superspy James Bond and the multi-ethnic Mission: Impossible team members
pause. (Editor’s Note: See
January 2009 Healthcare Purchasing News cover story for an
example.)
Hospitals, on the other hand, may usurp and
retrofit a conference room with white boards and a cache of colored markers,
using satellite and smart phones to fortify and link a virtual crisis
management team to support front-line clinicians and behind-the-scenes
administrators, including supply chain professionals.
Regardless of pedigree or position,
clinicians and non-clinicians typically unite around a common cause when
disaster strikes: Both groups become caregivers who fly in the face of
danger.
Whether blizzards, severe thunderstorms,
flooding, hurricanes, mudslides, tornados or a host of other weather-related
or man-made calamities choke patient care delivery and supply chain
operations, hospitals must be ready to react with the right people,
strategies, tactics and technology to minimize disruption.
Some might lament that it’s easier said
than done, particularly without painstakingly detailed planning.
But in the spring of 2011, two
organizations 1,005 miles apart saw their disaster preparations tested to
the max. Yet amid the harrowing destruction and devastation emerged hope,
resilience and resolve – three key elements needed for recovery and
rebuilding.
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Mercy’s St. John’s Regional Medical Center before the
tornado |
Nearly nine months have passed since two
crises nearly devastated two communities. In one, a thunderstorm originating
in Canada caused the headwaters of the Souris River to swell and overflow
its banks, swamping Minot, ND, with flood levels reaching 12 feet deep in
spots. Farther south, a violent multi-vortex EF5 tornado swept through
Joplin, MO, with 200 mile-per-hour winds. Both weather-related disasters
wreaked havoc on those communities by either submerging houses, business
buildings and healthcare facilities to their rooftops or by laying waste to
them and leveling a landscape littered with debris.
Healthcare Purchasing News revisited
with key supply chain executives at St. Alexius Medical Center and Mercy’s
St. John’s Regional Medical Center, both of which felt weather’s fury back
in last spring.
Flooding
frustrations
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Frank Kilzer |
In Bismarck, ND, St. Alexius had to juggle
the implementation speed of its disaster plans with proximity issues. Frank
Kilzer, St. Alexius’ vice president of material and facility resources, his
team and colleagues, faced the specter of flooding on several campuses
within a short time frame that also were 110 miles apart.
The spring thaw first tested St. Alexius’
disaster planning mettle as Minot officials advised residents and businesses
in the lower elevations along the Souris River to vacate to avoid projected
flooding. St. Alexius’ Minot Clinic facilities were in the flood zone.
"Because of this pending threat we vacated
our clinics and moved equipment and supplies into storage for several days
until the flood threat subsided," Kilzer recalled.
Cooling temperatures, however, averted the
alarm and within a week, the clinics once again were open and operational.
Roughly two weeks later, however, a
Canadian rainstorm quickly overwhelmed the Souris River, which flows south
from Saskatchewan into North Dakota, loops through Minot, and back north
into Manitoba.
"We had less than 12 hours to remove as
much as we possibly could before the water started rising," Kilzer said. "As
the warning sirens were blowing our staff had to stop, and only a few items
were left in the building." One of the casualties was an X-ray machine, too
large to be moved in so short a time.
"Because this was a flood situation our
immediate efforts were focused on salvaging equipment and supplies," he
said. "To accomplish this we knew it would take more than our clinic staff,
however most contract services were already at capacity dealing with the
first flood that was projected. We called moving contractors and were able
to get a commitment for two individuals and a truck. With these people,
staff from our Minot clinic and staff sent from St. Alexius in Bismarck with
a van and trailer were able to move almost everything in the two clinics."
Supply loss was minimal, Kilzer reported,
save for those items mounted to walls, such as soap and towel dispensers.
Similarly, equipment loss was limited to wall-mounted work stations, desks
and "a few office chairs that didn’t get loaded before the sirens started
blowing," as well as the X-ray machine. Total loss for the buildings,
equipment, furniture and the rest amounted to approximately $1 million, he
added.
Not only did St. Alexius have to deal with
the flooding in Minot but also flooding in the Missouri River that affected
its main campus in Bismarck and the Red River flooding that impacted
facilities in Fargo. Because the flooding in Bismarck was projected to
disable the local water treatment plant and sanitary sewer and storm sewer
systems, St. Alexius had to establish strategies for water and sewer
concerns beyond supply chain, according to Kilzer. Over in Fargo, St.
Alexius had to work with suppliers to set up alternate delivery routes to
avoid main roadways underwater.
Aside from supply chain and utilities, St.
Alexius also had to manage patient care within the flooded areas, evacuating
and relocating them, as well as those patients in the home care program
receiving nursing care and home oxygen therapy.
Careful
coordination
Kilzer credited his supply chain staff,
facilities staff, administration, clinic leadership, clinic staff and
physicians during the entire event as they vacated the buildings as the
flood approached, then worked to re-establish a temporary clinic and develop
long-term strategies to replace the facilities that were lost so that St.
Alexius and Minot Clinic could continue serving Minot and the surrounding
region.
For example, Derek Hanson, director of
safety, security and emergency management, coordinated the facility’s
response by implementing formal disaster plans honed through periodic drills
involving city, county and state agencies, as well as other healthcare
facilities where patients were to be transferred to receive appropriate
levels of care.
"Patient care was the highest priority,"
Kilzer emphasized.
"It was important for us to re-establish
clinic services because one of the clinics lost in the flood was used by
independent specialty physicians [in our network] who were seeing patients
referred to them by our primary care physicians," he said. "Until clinic
space could be re-established with X-ray and lab capabilities they wouldn’t
be able to see patients."
Kilzer recognized "our clinic staff in
Minot who were directly involved in tearing apart everything in one location
and getting things relocated in the temporary location we are using today in
the limited time they had, and be able to re-establish services in such a
short time." The staff in Bismarck was instrumental in supporting their
needs, he added, including Kurt Waldbillig, vice president of physician
services, who aided physicians working in the temporary clinic.
"Although our supply chain staff was not
directly involved in actually moving things from the clinics, they worked
with our Minot Clinic staff to identify supplies and equipment that would be
needed to provide care in whatever make-shift clinic arrangements could be
re-established as quickly as possible and they continue to communicate with
the Minot Clinic staff to assure whatever supplies needed are shipped from
our central distribution center in Bismarck using local courier services or
delivered by staff who travel to Minot each week," he said, crediting John
Schreier, director of purchasing, for coordinating those efforts with staff
and suppliers.
An unrelated but nonetheless fortuitous
real estate transaction a few weeks before the flooding actually helped
speed the process. St. Alexius had purchased a 42,000-square-foot building
on 20 acres of land for a call-center operation. "Because the building had
an ‘open beam’ type construction we planned to remodel it into space that
would accommodate both our clinics," he said.
A local contractor worked with St. Alexius
to reconstruct a temporary clinic in that building. "We developed an
immediate plan for minor modification that would be needed, including such
things as installing hand sanitizers, adding walls and doors where needed to
maximize the space, creating an interim reception and waiting area, all
within a few days of being vacated from flooded area," Kilzer said. "As the
number of clinic visits has returned to original numbers this contractor has
continued to work with us creating additional exam rooms, replacing the
mammography room we lost and also replacing the X-ray room."
Another supplier assisted in equipping the
temporary mammography and fully lead-lined X-ray room for Minot clinicians
to communicate with Bismarck radiologists, he added.
Kilzer currently is working with a team to
design a new clinic and potentially break ground for construction sometime
later this year.
Facing the
funnel cloud
Originally, meteorologists had forecast
tornado activity hitting Joplin north of Mercy’s St. John’s Regional Medical
Center on that late Sunday afternoon May 22. That meant any funnel clouds
likely would touch down in the neighborhood where Marilyn Endicott, St.
John’s Regional’s administrative director of materials management, lived.
They miscalculated. Instead, the funnel
cloud clocking in three-digit wind velocity hit the ground and tore through
the hospital.
Because the storm hit when it did St.
John’s Regional contained "essentially only acute services and corresponding
patients and staff," according to Greg Meier, C.P.A.,
executive director, finance, St. Louis-based
Resource Optimization & Innovation (ROi),
the supply chain division for the hospital’s parent company Mercy. Fewer
people on site meant fewer people directly were exposed to the flying debris
whipped up by the storm’s wrath. But it also challenged the hospital to
mobilize the off-duty, off-site staff members coming to grips with the
destruction of their own homes and vehicles.
Within 45 seconds the tornado had snaked
through town, reducing the hospital structure to a darkened husk of broken
glass and twisted metal, a spectacle normally seen in war-torn combat zones.
The wanton destruction extended into the surrounding neighborhood with
collapsed houses and overturned cars littering landscaped yards and clogging
streets. The storm also knocked out power in much of Joplin, as well as
landline phones. Even cellular phone coverage was unreliable.
No matter.
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Marilyn Endicott |
On-site clinicians and administrators at
St. John’s Regional, including a portion of Endicott’s team, activated their
disaster preparedness process, launching what would be a dramatic 90-minute
evacuation of 183 patients from the heavily damaged building and relocating
them to pre-designated triage locations, including Memorial Hall three miles
away and other hospitals across state lines. Mercy established a command
center in Joplin’s Holiday Inn Convention Center to serve as a
"rally/check-in point to account for co-workers and provide them with
personal supplies they might need, such as food, water and clothing,
according to Meier
.
Meanwhile,
off-site clinicians and administrators, including Endicott, checked on their
families and homes before migrating to the facility. Many had to walk two to
three miles after parking their cars because roadways were so cluttered with
debris.
As the storm swelled over Joplin, roughly
an hour before the tornado hit, Endicott already had contacted her staff
from home to make sure they knew what to do should a "Condition Gray" occur.
That included making sure flashlights were available in the event of a power
outage and that an emergency cart [of supplies] were transported to the ER
once called, she noted.
Right after the tornado passed through the
hospital, Endicott received a cell phone call in her darkened basement from
one of her co-workers that the hospital had been hit. Not realizing the
extent of the damage to the hospital, Endicott relied on her nursing skills
and disaster planning regimen. "I started thinking about what was needed to
care for trauma patients," she recalled.
With working phones at either ear, Endicott
contacted a colleague at another Mercy hospital across the border in Kansas
[Mercy Hospital, Fort Scott] to send whatever clinical packs she could
spare, as well as called ROi’s emergency number. Monitoring media reports
roughly 275 miles away, the team at ROi returned her call promptly, asking
what they needed to deliver as Mercy mobilized system-wide.
"Greg Goddard, ROi’s director of operations
at the time, and I decided that they should replicate the last order they
had on record," Endicott said. Mercy operates an integrated supply chain for
its member facilities so ROi co-workers at the Springfield, MO, consolidated
service center roughly 75 miles away, identified necessary supplies and
loaded the first wave of trucks to be dispatched that first night, according
to Meier.
In fact, Mercy and ROi would provide trucks
several times a day for the next few days to shuttle supplies around as
needed, he added. Mercy Hospital in Springfield became a command center for
managing off-site instrument sterilization and preparing hot meals for
clinicians and workers.
Because of the damage and destruction in
Joplin, however, the typical one-hour commute between Springfield and Joplin
more than tripled in duration.
Picking up
the pieces
After recruiting as many of her off-site
co-workers who volunteered to come in, Endicott and her husband then made
their way to the hospital, the last mile-and-a-half on foot. "For several
miles all around the hospital you could see everything, particularly the
hospital," she said. "Before the storm you could only see a part of the
hospital due to trees and houses and other buildings."
When Endicott arrived at St. John’s
Regional she found co-workers from her department and others "pulling what
supplies and equipment they could from the department that were still safe
and useable," she said. "It was organized chaos. People were helping
wherever they could." She learned her colleagues had been evacuating
patients before they moved to salvageable equipment and supplies and joined
them.
"We would put as much as we could on
rolling carts," Endicott told HPN. "We had to navigate through the halls and
outside as best we could because there was debris and water everywhere and
[power] lines were down. We took all the supplies – including gurneys we
rescued – across the street to a tent area set up by the fire department
where the ER had set up for triage.
"We were working as fast as we could
because we didn’t know if the [hospital] structure was safe," she added. "We
heard and saw falling glass everywhere."
By about 10:30 p.m. that night they had
stripped the hospital of everything they could, just as the first truck full
of supplies from ROi arrived at the hospital site and then went to Memorial
Hall as the pre-designated triage facility serving as the central temporary
replacement care center, along with another truck a few hours later.
With the arrival of supplies from ROi and
other Mercy facilities, Endicott and her team faced another hurdle – where
to put everything.
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Scott Nelson |
"Once trucks showed up at Memorial Hall
with supplies we had to do something with them," noted Scott Nelson, ROi’s
vice president, unified supply chain. "We had no automated system for
managing the supplies, so folks had to be creative."
Memorial Hall houses a large basketball
court so Endicott and her team tried to recreate a makeshift storeroom on
tables and carts around the patient care areas and on the stage.
"Trucks would come in and people would
bring the supplies to the staging area," Endicott said. "SPD co-workers
would categorize supplies by product type, and make the rounds. We didn’t
know what we had or what we would need but we did the best we could with
what was available to us.
"With our electronic systems down we
resorted to manual inventory tracking, pen-and-paper record-keeping," she
continued. "Even doing it manually I cannot think of one time where we
needed something and it wasn’t there. Transportation was key. Box trucks and
vans from ROi just started appearing. We didn’t know what we needed early on
but suddenly they were there. The team at ROi anticipated our needs based on
the clinical specialties we offered."
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Greg Meier |
What seemed like magic on one end required
considerable orchestration at the ROi command center. With cell phones and
satellite phones and "a lot of text messaging," JoAnne Levy, ROi’s vice
president, integrated sourcing solutions, and Meier, demonstrated their organization’s clinical
integration with the supply chain, despite signal interruptions and
intermittent coverage.
"We either had to clean, sterilize and
repair products or we had to source from our existing vendors," Levy
indicated. "In some instances we had to source products that weren’t
normally part of our portfolio. For example, we sourced electronic road
signs to help Mercy communicate with Joplin co-workers.
"We were able to turn to R.N.s and
pharmacists on the ROi supply chain team as well as clinicians and experts
within Mercy for their evaluations," Levy noted. "This was a team effort
that incorporated a tremendous amount of expertise and collaboration."
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JoAnne Levy |
Levy and Meier also mobilized supply chain
managers at other Mercy member facilities to develop recovery and rebuilding
plans for that first week following the tornado and beyond, according to
Meier. "Getting information passed out to everyone was a key issue to make
all of this work. The logistics didn’t just involve products but
information, too. We had plans ready on Monday afternoon in time for a
full-blown call on Tuesday for moving forward," he added.
"During that whole first week after the
tornado hit we had to move trucks back and forth between the hospital site,
Memorial Hall and the Holiday Inn Convention Center where Mercy had set up
its command center," Nelson noted. "Our clinicians and co-workers also had
to work within curfews established by local authorities for the city."
Missouri’s Disaster Medical Action Team (DMAT),
which provided extra clinicians to help, led twice daily scheduled briefings
from Mercy’s command center, outlining very regimented priorities, according
to Nelson. "The first meeting would go over the priorities; the second call
would look back at what we accomplished," he said.
The priorities were simple enough,
according to Endicott. "We focused on caring for the patients and clinicians
first and then set up mobile supply carts and storage areas for clinicians
to provide care," she added.
Earned stripes
from disaster recovery efforts
Climate-related disasters can leave a
healthcare facility reeling, particularly because it may have to recover and
rebuild without interrupting the patient-care services it provides.
For two organizations
weathering violent storms last year, the complexities of reacting to a
disaster were broad and deep.
"Any disaster requires a team
effort," said Frank Kilzer, vice president of material and facility
resources, St. Alexius Medical Center, Bismarck, ND. "Formal coordination
and communication among all is essential and this must include the providers
who are at the front line caring for people who need healthcare services
during the disaster. It is also important to give consideration not only to
those who come to the clinic but also patients in their homes who receive
home healthcare services, making sure they have medical supplies, back-up
oxygen and oxygen support systems in the event of power failure or for
extended times while services are being re-established."
Greg Meier,
C.P.A.,
executive
director, finance, Resource Optimization and Innovation (ROi),
the supply chain division of St. Louis-based Mercy, echoed Kilzer’s comments
on the immensity of a disaster response must surpass the immensity of the
disaster itself. Tornado-stricken St. John’s Regional Medical Center,
Joplin, MO, is a member of Mercy.
"The resources needed to
accomplish this are incredible," Meier said. "We are blessed within
Mercy and ROi to have an integrated supply chain which allowed us to
immediately marshal and dedicate the resources needed to make this happen.
"We learned it takes everyone
working together in a collaborative manner and that it truly takes a team of
leaders that trust each other to make decisions to pull it off," Meier
continued. "Our local supply chain leader in Joplin, Marilyn Endicott, and
her team did an unbelievable job focusing on the minute-to-minute. We were
able to supplement her with materials management from other communities to
give her a break. We then had a team of three executives that co-led the
Mercy/ROi supply chain response with an army of folks behind them."
But it’s not enough to
recognize the complexity.
"Ultimately we learned we had
to eliminate the complexity of our processes in order to be creative,
efficient and figure out just how to get it done so that the physicians,
clinicians and staff could deliver the compassionate care our patients
deserved," he added.
Once the tornado’s immediate
aftershocks ebbed, Mercy, ROi and St. John’s reflected on the lessons they
learned.
"We learned a tremendous
amount about disaster planning through this process," Meier
acknowledged. "First, you need to turn the disaster planning process on its
head. We typically make all sorts of assumptions when developing the plans.
We found that a proper disaster plan should make no assumptions.
"For instance, you need to
plan as if:
1. "You have no facility – as
we learned, this can happen.
2. "You have no staff – what
if they can’t get there and/or the existing staff is incapacitated?
3. "You have no communications
methods other than word of mouth – this essentially was where we were at
immediately after the storm.
4. "You have no supplies –
they are destroyed or damaged.
5. "You have no community
support – it is destroyed but thankfully the Joplin community responded."
Meier quoted a colleague’s
sage-like belief that it isn’t over even if it seems to be over.
"If your disaster plans are
developed and you think you will succeed, you may not have thought the plan
through far enough," he added. "Dottie Bringle, COO/CNO at St. John’s
Joplin says, ‘Keep planning for disasters until you see you fail. Then your
plan may actually be close.’" |
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Tech on
target
Despite the lack of power in Joplin, Nelson
emphasized the importance and benefits of technology. "Mercy utilizes a
system-wide electronic health record, effectively linking all our hospitals,
physician offices and clinics together with a single record for each
patient," he said. "[Mercy St. John’s] Joplin had just gone live with the
system a couple of weeks earlier. With the EHR we had a virtual record to
utilize; we were able to pull records and get patients on the proper regimen
to continue their care. Paper records had been strewn all over, some as far
as 100 miles away.
"Through our automated supply chain system,
we were able to rebuild inventory and track patient supply needs by pulling
the most recent electronic requisitions," he continued. "This just
illustrates the value of technology in quickly restoring operations as
absolutely critical."
Levy pointed out that the hospital wasn’t
the only building destroyed by the tornado. Clinics and physician offices
were damaged or destroyed, too, she added, and ROi supported them as they
resumed operations.
That included Endicott’s team, too. "As we
got Memorial Hall up and running as a care center, as well as tents on-site
serving as temporary care facilities we also worked with clinics around town
to get them operational," she said. "One advantage for us is that we’re on a
perpetual inventory system in the OR, cath lab, GI lab, etc. How would we
have identified what we would have lost if we didn’t have that?"
Meier reported that Mercy recorded a
$16.1 million impairment loss for buildings and equipment and another $6
million impairment loss for inventory.
Mercy and ROi also secured off-site
warehouse space needed to house supplies and clinical engineering staff to
evaluate and certify equipment, according to Nelson, as well as additional
truck trailers for distribution and delivery.
Donations continue to arrive from
suppliers, potential suppliers and other organizations within and outside of
Mercy, according to Levy. As a result, they developed a process to manage
the donations and track everything in a database, Meier noted, assuring that
all of it will be used in the community as Mercy rebuilds in Joplin.
Further, Meier and Endicott lauded the
residents of Joplin who rallied around the hospital and helped evacuate
patients with the flatbeds of pick-up trucks serving as makeshift
ambulances. "The people of Joplin were an inspiration to us in the way they
helped out," Meier said. "They didn’t act as victims but as people who were
blessed despite what happened around them."
In the aftermath of the storm, Mercy
replaced the mobile medical tent hospital and physician clinics with modular
units, meaning ROi assisted Endicott’s team in maintaining the supply chain
for the tents while also planning for the modular units, transferring
equipment and supplies and decommissioning unneeded items, Meier noted.
Currently, Mercy is constructing a new
29,000-square-foot pre-cast concrete building to replace the mobile medical
unit scheduled to open in the spring that will remain in operation until
2014 when the new hospital in Joplin should be completed.
Until then, they’re moving forward. "We’ve
learned to adapt to a smaller on-site inventory and maintain a separate
warehouse nearby that is used to supplement the on-site storage," he added.
"Thanks to the combination of team creativity, technology and tenacity, we
are running pretty well right now." 
