Second of three parts
The Old Testament book of Exodus describes what happened when the Egyptian Pharaoh challenged the might of the God of the Hebrews. In Exodus 5:2, Pharaoh asks the seemingly rhetorical question: “Who [is] the LORD that I should obey his voice to let Israel go?” Shortly afterwards, Pharaoh learned what happens when you challenge Yahweh, as 10 plagues descended on the land:
- The water of the Nile was turned to blood
- An infestation of frogs
- Dust was turned into lice
- “arob”—a swarm of wild animals harmed and killed people and livestock
- Livestock became diseased and died
- Men, women and children broke out in boils
- Thunderstorms rained hail and fire
- Locusts swarmed across the land
- Darkness descended on the land for three days
- First-born sons were killed (except for those whose doors were marked by the blood of a sacrificed lamb)
After all these things, Pharaoh sent the Israelites out of Egypt.
In some ways, the time period starting in August 2017 resembled some of those awful times in ancient Egypt:
- August 17-September 2: Hurricane Harvey punishes several islands in the Caribbean, Texas and Louisiana, killing 117 and causing $125 billion in damage
- August 30-September 13: Hurricane Irma devastates the Caribbean, including Puerto Rico, and rumbles ashore in Florida, causing 134 fatalities and $64.76 billion in damage
- September 16-October 2: Hurricane Maria devastates Puerto Rico and Hispaniola, killing between 112 and more than 1,000 and wreaking more than $91.5 billion dollars in damage.
- October-December: Wildfires in California kill 43, cause thousands to be evacuated from their homes and result in $13 billion in damage.
- January 2018: Mudslides resulting from heavy rain onto land denuded by the wildfires kill 21 and cause damage yet to be calculated and assigned a monetary value.
- Winter 2017-2018: The most virulent flu season since 2015 hits. Final numbers are not yet in, but the season is expected to surpass 2014-2015 when 710,000 were affected and 56,000 died.
Now do the math: More than 56,000 dead, more than 710,000 affected, and more than an estimated $294 billion in damages (in fact, let’s round up and call it approximately $300 billion in damages) since last August. Few healthcare organizations — provider and supplier — even see any of these numbers on their financial reports.
Amid this seemingly endless parade of calamity, healthcare supply chain leaders struggled to keep business functioning as close to normal as possible. The impact of the calamities on the healthcare supply chain was an equal opportunity annoyer, affecting individual community hospitals, small and large IDNs, distributors and manufacturers with the same impersonal impunity.
A familiar and similar pattern continued to arise:
- Stockouts or backorders from primary suppliers
- Ditto for secondary suppliers
- Lack of components for manufacturers to produce new products
- A need to address how certain disease states were treated
- A need for tight and continuous communication among key stakeholders
- A need to adapt on the fly
- An understanding that planning for disruption needed to be part of future activity.
I contacted a diverse group of Healthcare leaders involved with the Supply Chains, including people from:
- Cottage Health, Santa Barbara, CA
- ProHealth Care, Waukesha, WI
- Concordance, Tiffin, OH
- Community Hospital, McCook, NE
- University of Vermont Health, Burlington, VT
- Resilinc, San Francisco, CA
- W. P. Carey School of Business, Arizona State University, Tempe, AZ
- Sedlak Management Consultants, Cleveland, OH
Here are the questions I asked, followed by some of their responses: Was your organization affected by any of the natural disasters of the last twelve months, including the extended and large flu outbreak? If so, was the impact primary (meaning, your organization was actually physically impacted) or secondary (meaning the impact on other areas affected your operations)?
Not surprisingly, everyone answered in the affirmative, but only Cottage Health felt primary impact from the wildfires and subsequent mudslides that affected California.
Organization response
Each organization’s story followed a similar path.
- Immediate clamoring to find key supplies, especially IVs and key medications.
The University of Vermont Medical Center took an organized approach. Nicholas Johnson: “As information became available about the number of medical suppliers that were impacted by Maria,” said Nicholas Johnson, Materials Manager, University of Vermont Medical Center, “the first thing our team did was to understand what SKUs were impacted and at risk. This information was gathered through various channels; formal vendor PR communications, sales representatives, backordered details through our purchasing activities as well as data provided by Vizient, who aggregated SKU-level details for most of the vendors who manufactured in Puerto Rico.
“Being a six-hospital network, it was important to then analyze which of our hospitals used what so that we could, 1. Forecast where we would see the risk, but, 2. To also know which hospitals used what so that we could quickly know where else to look for inventory in the event of shortages or constraints,” Johnson continued.
At the University of Vermont Medical Center, analytics were heavily leveraged to facilitate the daily review of our inventory health specific to IV Solutions. Much of the inventory data was represented as “Days of Supply” to assist with the prioritization of work and/or focus, according to Johnson. To facilitate communication and learnings, a weekly call was set up with the network teams to share how each of the facilities were managing through the shortages, learn any tactics to use products more efficiently, and to also allow each facility to share, at the SKU level, their immediate needs. This allowed for the movement of inventory from one facility to another to ensure continuity of services when possible. Through this work, the services we provide to our patients were never at risk of being suspended, he added.
“Due to the longer than normal and extreme flu season, the one vendor from whom we sourced our flu testing kits was not able to keep up with the demand,” Johnson indicated. “Because of this, inventories throughout our network were impacted to the degree of needing to monitor our inventories daily and send product from one hospital to another to meet the testing needs. In addition, our labs were forced to use substitutes until that inventory ran out. Analytics were once again used to forecast where inventory was needed based on assumed consumption rates. Every morning, each hospital shared how much inventory was on hand, what was on order and how many tests they performed the prior day. This information was aggregated to represent the inventory health both at each hospital and at the network level. The data helped communicate where the risk was and provided a tool for leadership to gauge the statuses on a daily basis.”
- Search for acceptable substitutes.
Tom Lindl, Director of Purchasing, ProHealth Care, said, “Everybody is impacted. The problem is exacerbated because many components of products are only produced in one factory, which means all manufacturers are affected by the event.” Then there was always the concern that products from unknown suppliers may not pass the scrutiny of a rigorous Value Analysis review, he added.
- Activation of a focused communications plan with physicians and other key clinical stakeholders and an ongoing review of care delivery options.
The shortage of mini-bags forced many organizations to revert to doing IV pushes, which meant an increased burden on staffing since the drugs had to be administered by nurses.
Lindl recounted the difficulties involved when product shortages required them to look at alternative delivery methodologies, e.g. IV delivery not available, switch to oral delivery or IV pushes. Certain implants not available, switch to implants from another supplier. Every change in care delivery required an extensive and ongoing conversation with key stakeholder to ensure both buy-in and acceptance. Risks and challenges had to be mitigated, and once mitigated, often changed again immediately — the common theme being that outages of one product led to outages with the substitute products as well. As Lindl put it, “One shortage often led to another.”
Jon Reiners, Director of Materials Management, Community Hospital in McCook, NE, pointed out that finding a substitute is not so simple when you factor in the Value Analysis, product acceptability challenges. “Not only to you have to find something quickly”, he said, “it has to pass the rigor of the Value Analysis process as well.”
Cottage Health in Santa Barbara was affected in an entirely different manner. The IDN is located right in the bullseye of both the wildfires and the subsequent mudslides. Afshin Fatholahi, Vice President of Support Services, and his staff were not only forced to try to obtain items such as personal protective masks and other similar items for their patients, but also had to fight off the members of the community who were trying to gain access to those items for themselves.
“At one point, we were afraid we were going to have to close the hospital,” he said. “The fires were that close.” Then, when the post-fire mudslides hit, Fatholahi and his staff had to execute emergency agreements with various transportation options just to be able to get people to work. The whole situation was a real-life re-enactment of the movie, “Planes , Trains and Automobiles” and merits recap of its own.
But how did these events change the way healthcare organizations conducted business going forward? You’ll read about that in the third and final installment.
