Supplychaincapacitytorespondtothe COVID-19pandemicinOntario:Challenges facedbyahealthsystemintransition
AnneW.Snowdon,PhD1 andAlexandraWright,MPA1
Abstract
HealthcareManagementForum 2022,Vol.35(2)53–61 ©2022TheCanadianCollegeof HealthLeaders.Allrightsreserved.
Articlereuseguidelines: sagepub.com/journals-permissions DOI:10.1177/08404704211057664 journals.sagepub.com/home/hmf
Thisprovincialcasestudy,oneofsevenconductedasparto fanationalresearchprogramonhealthcaresupplychain managementduringCOVID-19,focusesonOntario.Thecontextofsigni fi cantrestructuringofhea lthorganizationsand regionsinOntariochallengedtheprovince ’ scapacitytorespondtoCOVID-19.Acomplexleadershipstructure,ledby politicalleaders,withlimitedhealthcaresupplychainexpe rtiseatdecision-makingtablesandaprioritizationof “ hospitals first” earlyinthe firstwaveweredescribedaschallengesOntariofacedinmanagingthepandemic.Alackofsupplychaindigital infrastructure andconsequently,lackofavailabledata meantinformeddecision-makingregardingsupplyutilizationanddemand forecastingwasnotpossible.TheOntariocasepresentskeylessonslearnedregardingtheunintendedconsequencesoflackof supplychaincoordinationacrossorganizations,andtheprioritizationofhospitalsandallocationstrategiesonCanada’smost vulnerablepopulationsegments.
Introduction
TheCOVID-19pandemichashighlightedsigni fi cantsupply chainchallengesasprovincialhealthsystemsstruggledto managetheimpactandrapidspreadofthevirus.Inorderfor healthservicesandpublichealthtomeettheunprecedented demandsofthecurrentandfuturepandemics,supplychain andlogisticsinfrastructuremusthavethecapacitytorespond todisruptionstoensurethathealthteams,essentialworkers,and citizenshavetheproductsandequipmentneededtocontain spread,andforhealthservicestoachieveoptimaloutcomesfor thosewhobecomeinfected.Supplychaininhealthsystems sourceanddistributeproductstoensurehealthsystemteams havetimelyaccesstotheessentialproductsandequipment neededforcaredeliveryinatimely,safe,andsecuremanner. Healthservicessupplychainteamssourceanddistribute everythingfrombedstoventilators,Intravenous(IV)pumps andIVtubing,medicationsandvaccines,PersonalProtective Equipment(PPE),andendotrachealtubes.Hospitalsgenerally havewellestablishedsupplychainprocessesandinfrastructure, whereas,communityagencies(e.g.,long-termcare,homecare, andprimarycare)havelittle,ifanysupplychaininfrastructure orexpertise.
Whensupplychainprocessesareinterrupted,therearesevere consequencesthatcanplacepatientsandcliniciansatgreatrisk. A floodin2012atSanofi Pasteur,thesupplierofabladder cancerdrug,ImmuCyst,resultedinsignificantdelaysincancer treatmentsforpatients. 1 Pharmaceuticalmanufacturerswere notabletoincreaseproductiontomeetdemandduetothe timeittakestosourcetheingredientsandmanufacturethis drug.WhenHurricaneMariaknockedouttheelectricalgridin PuertoRicoin2017,Baxter,oneoftheonlymanufacturersof IVbagsintheUnitedStates,experiencedseverestock shortage.2 CanadianandU.S.hospitalswereleftwithoutthe neededsupplyofIVbags,limiti ngtheirabilitytodeliver
intravenousmedicationsforanumberofweeks.Thedemandfor IVbagsgloballyskyrocketed,resultingina600%costincrease forhospitalsthatwereallcompetingforalimitedinternational supply.2
Supplychaininterruptionsduringpublichealthcrisesarealso welldocumented.AkeylessonlearnedfromtheSevereAcute RespiratorySyndrome(SARS)epidemicinOntariowasthe importanceofthesupplyofprotectiveequipmentforhealth workers.Threeofthe44CanadianswhodiedofSARSwere healthcareworkersastransmissionoftheviruswaspoorly understood. 3 Intotal,400personsbecameillwithSARS and25,000peoplewereinquarantine. 4 Althoughpublic healthpracticesandi nfectioncontrolproceduresimproved followingtheSARSepidemic,supplychainpracticesdidnot changeandhealthsupplychainresearchandevidenceremain profoundlyunderdeveloped.Akey findingoftheJusticeCampbell reportforeshadowsthecontextoftheCOVID-19strategyin Ontario:
“
SARStaughtusthatwemustbereadyfortheunseen .,thereis nolongeranyexcuseforgovernmentsandhospitalstobecaughtoff guardandnolongeranyexcuseforhealthworkersnottohave availablethemaximumlevelofprotectionthroughappropriate equipmentandtraining.” – (JusticeArchieCampbell,2006a).
ThecurrentCOVID-19pandemicisofmuchgreaterscale andcomplexitythanSARS,nowshiningabrightlightonthe criticalroleofsupplychainprocessesineffectivelyresponding andmanagingthepandemic.
1UniversityofWindsor,Windsor,Ontario,Canada.
Correspondingauthor: AnneW.Snowdon,UniversityofWindsor,Windsor,Ontario,Canada. E-mail: anne.snowdon@uwindsor.ca
Thereisaremarkabledearthofresearchonhealthsystem supplychaininCanadaandinglobalhealthsystems.Supply chainprocessesinCanadianhealthsystemsarehighlyvariedin structure(e.g.,centralizedinsomeprovincesanddecentralizedin others),withlittlecoordinationacrossjurisdictions,5 andoperate withlittleornotransparency,6 resultinginleadershipdecisions describedbyonephysicianleaderas “flyingblind” while managingtheCOVID-19pandemic.7 Thispandemichaslaid barethecriticalneedforcapacitytoacquireandmoveproducts, equipment,andsuppliestoenablehealthteamstodeliver essentialcareservices.Healthsystemsmuststrengthensupply chainprocesses,informedbyempiricalevidenceofbestpractices andsupplychainresilience.8
Thispaperreportsoncasestudyresearchoftheprovinceof Ontario,revealingempiricalevidenceofsupplychainprocesses andinfrastructurewithinandacrossOntario’sprovincialhealth system,duringthe firsttwowavesoftheCOVID-19pandemic. Thisevidenceisanalyzedrelativetoleadershipstrategiesandpolicy toinformeffective,agile,andresponsivepandemicmanagementfor Canadianhealthsystems.Thiscasestudyisoneofsevenconducted toexaminehealthsupplychaincapacityandinfrastructureacross Canada,the firstnationalstudyofhealthsupplychain,fundedby CIHR(Ref.#VR5172669).
Thecasestudywasdesignedtorespondtothefollowing researchquestions:
· Whatarethesupplychainprocessesandinfrastructure requiredtooptimizeeffectiveandtimelyhealthservices deliveryforthecurrentandfuturephasesoftheCOVID19pandemic?
· Whatprocurementmodels,approaches,andpolicy frameworksoffersecuresourcingofproductstomeetthe surgeindemandforcarebyCOVID-19patients?
· Whatisthedigitalmaturityofsupplychaininfrastructure (andprocesses)inOntario,that,ifstrengthened,could optimizemanagementofCOVID-19?
· Whatarethedatainfrastructureandanalyticsstrategies neededtostrengthentheeffectivenessofhealthsystem supplychainprocessestosupportCOVID-19management?
· Whatistheinfluenceoffederalgovernmentinitiatives, fromtheperspectiveofprovincialstakeholders,on provincialhealthsystemcapacitytomanageCOVID-19?
Methods
Thecasestudyresearchemployedqualitativemethodsgiven therewasnopriorexistingresearchofhealthsupplychainin Canadatodocumenttheessentialfeaturesandbestpracticesof healthcaresupplychain.Theoreticalsamplingidenti fi edkey participantswhorepresentedvariedperspectivesandexpertise includingleadersinsupplychain,procurement,clinicianleaders (e.g.,physicians,nurses,pharmacists,andprimarycare),health executives,government,unionleaders,GroupPurchasing Organizations(GPOs),andSharedServicesOrganizations(SSOs) aswellasindustryleaders.Semi-structuredinterviewsdocumented theexperiences,perspectives,andviewsofhowsupplychain
infrastructureandprocesseswereoperationalized,thestructure, focus,andimpactofleadershipdecisionsonsupplychain management,healthsystemcapacitytorespondtopandemic waves,howsupplychaincapacityinfluencedleadershipdecisions andCOVID-19healthsystemoutcomes;and,howandwhich challenges,solutionsandgapsinsupplychaininfrastructure contributedtoCOVID-19outcomesinOntario.
Interviewswereaudio-recordedusingMicrosoftTeamsand transcribedverbatimbyanindependentcontractedtranscriptionist. Thematicanalysisincludeddetailedandmultiplereviewsof transcriptstodefinethemesacrossinterviewtranscripts.Conceptual categoriesweredefinedandalltranscriptswerecoded,categorizing texttoidentifyperspectivesandpatternsthatweredevelopedinto themes,usingNVivosoftwaretoassistwithorganizationofdata. Thethemesaredescribednextandconnectedwiththeaboveresearch questions.Thefollowingsectionsdescribethethematic findings emergingfromthequalitativeanalysesofthe67interviewtranscripts.
Provincialcontext
OntarioisthesecondlargestprovinceinCanada,withapopulation ofover13.5millionpeople.9 TheprovinceofOntariohasa decentralizedstructurewherebyhealthcareplanning,administration, andimplementationofhealthservicesareledatthelocalor regionallevel,withsomefeaturesofhealthcare,suchasCancer Carebeingcentralizedandmanagedfortheentireprovince.10 Decentralizedhealthsystemshavelimitedoversightofcaredelivery andeachhealthservicesorganizationfunctionsindependentlywith governancestructuresforeachorganizationthatguidethemandate andoperationsofeachorganization.Primarycare,homecare,and long-termcareinOntariofunctionmoreautonomously,withlittle directmanagementbyregionalorprovincialleadersandamixed modelofbothprivatizedserviceorganizations(e.g.,residentialcare, laboratory,andpharmacy)andpubliclyfundedcaredelivery.The publichealthsysteminOntarioisdescribedas “acollaborativeeffort betweenavarietyoforganizations,includingtheMinistryofHealth, PublicHealthOntario(PHO),35localPublicHealthUnits(PHU), andothercollaborativegovernmentpartnerships.”11
HealthcaresupplychaininOntarioissimilarlydecentralized, wherebyhealthcareorganizationsacrossOntariomanagesupply chainprocessesautonomously,decidingonhowbesttomanage suppliesandproductstomeetthesupplyneedsoftheirown organization. 12 ThemajorityofOntariohospitalsparticipatein SSOsaswellasGPOstoachievesavingsthrough “ bulk purchasing” ofproductsandsupplies.TheSSOsandGPOstend toworkindependentlyofeachotherwithlimitedcoordinationacross organizations.Purchasingdecisionsarebasedonthelocalbudgetsof singlehealthcareproviders,focusedprimarilyonachievinglowest cost.Thereislimitedengagementofcliniciansinprocurement processesandthelimitedhumanresourcestoundertakesupply chainmanagementpractices.12
FollowingtheoutbreakofSARSin2003andH1N1in2009, thereweremanyrecommendations13 tostrengthensupplychain capacityinOntario;however,fewoftheserecommendations wereimplemented.WhentheCOVID-19pandemicunfoldedin Ontario,therewasnocentralizedsupplychaininfrastructureand
Figure1. TimelineofkeymilestonesinOntario'sCOVID-19response.
limitedpandemicstockpileresources,whichresultedinorganizations havingtosourcecriticalproducts,incompetitionwitheveryother globaljurisdiction.
ThechallengesofOntario’sdecentralizedhealthsystemwere recentlyhighlightedinareport, AHealthyOntarioBuildinga SustainableHealthcareSystem,14 whichhighlightedthatpatients muchpreferredintegratedcareandwanthealthcareorganizations toworkbettertogether,supportedbyimprovedpartnershipsand datasharing.14 Patientswantedimprovedstreamlinedcare, improvingthetransitioningbetweenservicesandbetterdigital solutionsforconnectionanddigitalcare.14
IntheFallof2019,Ontariowasintheprocessofre-structuring thehealthcaresystem,transitioningfrom14LocalHealthIntegration Networks(LHINs)organizedbygeographicboundaries,to fi veregionsspanningtheprovince. 15 Thetimingofthismajor restructuringeffortwasunderwayastheCOVID-19pandemic beganonJanuary25,2020,whichpresentedsigni fi cant challengesinmobilizingleadershipcapacityacrosstheprovinceto respondtothepandemic.Anewentity,OntarioHealth,wascreated
justweeksbeforethe firstcaseofCOVID-19wasdocumented,which consolidatedsixprovincialagenciesintoonecorporateentity.15 This decentralizedstructureofOntario’shealthsystemwasidentifiedasan importantcontextfromwhichtoexamineOntario ’sresponseand strategytomanagetheCOVID-19pandemic.
COVID-19inOntario
The firstcaseofCOVID-19wasconfirmedinOntarioonJanuary25, 2020,withmuchuncertaintysurroundingthevirus,treatment approaches,andthemodeoftransmission.Mediaimages depictingthedestructiveimpactofthepandemicincountriessuch asItaly,theUnitedStates,andSpainheighteneduncertaintydue tothedevastatingimpactofthevirusonhumanlifeandthe limitedcapacityofhealthsystemstomanagethemassivesurge indemandforcare.Thesequenceofkeyeventsandgovernment initiativestorespondtothepandemicaresummarizedin Figure1
The firstcasewasidentifiedinToronto,andservedas a “timestamp” andturningpointformanyhealthcare organizationsinOntario.Somedescribeditasa “shift,”
“
knowingthatCOVID-19hadnowenteredOntario.Healthleaders describedasenseof “urgency” astheysawarapidsurgeofcases emergeinFebruaryof2020.Theleadershipstrategymobilizedto supportOntario’sresponsetothepandemicisdescribedinthe followingsection.
Leadershipandgovernanceenhancedreporting structure
Threeweeksafterthe firstcasewasconfirmedinOntario,the provincialgovernmentcreatedan “enhancedresponsestructure” tobringtogetheravarietyofstakeholderstoinformOntario’s responsetoCOVID-19.16 Theleadershipstrategywascomprised ofacomplexarrayofcommittees, “tables,” andleadershipgroups, representingvariousjurisdictionsandstakeholdersacrossthe province.OnMarch2,2020,anumberofweeksfollowingthe firstcaseofCOVID-19inOntario,theMinistryofHealth establisheda “HealthCommandTable,” initiallywith21members andthenexpandedtomorethan500participants.17 Decisions wereledprimarilybygovernmentofficialswithdailypress conferencesannouncingpandemicmeasuresbythePremierof Ontario,andonoccasiontheMinisterofHealth.Thesizeand complexityoftheCommandTablewasviewedasslowtoreactto thedynamicchangesinthepandemic ’skeyevents.Despite thesigni fi cantnumberofstakeholdersattheCommandTable, organizationsandstakeholdergroupsacrosstheprovincefunctioned autonomously,whichwasconsis tentwiththedecentralized leadershipstructureacrossthe province,resultinginahighly variedarrayofstrategiesandapproachestomanagingthe pandemic.TheAuditorGeneral ’sReport 17 washighlycritical ofthiscomplexandseemingly “allinclusive” leadershipstructure, describedas “ cumbersome ” and “ slow. ” Akeyinformant describedthevariabilityinl eadershipapproachesacross Ontariostakeholders:
“You’vegotPHO(PublicHealthOntario),you’vegotthevarious publichealthunits,nobodyisagreeingontheapproach,and everybodyissayingI’mgoingtodoitmyway… Andthey’reall different.Likesomecancercentersweremaskingpatients;others weren ’t.Somecancercentersweremaskingallstaff;insomethey weren ’tallowedto,anditwasjust,youknow,itwasabattle.Itwas abattlebyeverybodytotrytodoit.” (HealthSystemLeader)
SupplychainexpertisewasnotpresentattheHealthCommand Table,whichwaswidelyviewedascontributingtoalackof understandingofthenuancesandcomplexityofsupplychain processesinhealthsystems.Asupplychainleaderdescribes:
“Therewasnooneatthetablewhosevoicewasbeingheardwith regardstothesupplychain,andfranklyalsoyouknow,(noone) solicitedorsoughtadviceonwhatwashappeningwiththesupply chain.Itwasanafterthought,it’slikewe’llsetthedirectionand thenthesupplyteamwillhaveto figureitout.” (SupplyChainLeader)
Atthebeginningofthepandemic,theCommandTablewas describedasbeing “hospitalfocused.” Thisprioritizationof hospitalsresultedinlimitedconsiderationforhealthorganizations suchashomecareandlong-termcare,describedinthefollowing:
Thecommandtablefocusedonpublichealthandacutecare,andthe focusonacutecarewasjustabouthowdowefreeupbeds.Andit didn’tmatter,thehomecarecomponentoftheLHINs,tryingtoget peopleoutofhospitalthattheycan’tputinhomecare,andpushing peopleout… ItwasfullcapacityinLTCaswellasretirementhomes. So,youhavemaxedoutcapacityeverywhereelseinthesystem.You havethehospitalsrunningatlike50or60%capacitybecausethey emptiedthemforasurgethat,thankfully,didn’thappen.Butit happenedelsewhere.So,there’sLTCoutthereandittakeslike weeksforgovernmenttoclueinthatthey’vegottogetthe hospitalstohelpLTCturnitaround” (HealthSystemLeader)
Ontario’sleadershipstructurewaswidelyviewedasslowand reactive,prioritizinghospitalsoverothercaredeliveryorganizations, oftenrespondingwithpublichealthmeasuresoncesurgein COVID-19casesoroutbreakswereestablished.Notableinthe leaderperspectiveswastheabsenceofengagementorcollaboration withfederalagenciesinrespondingtothepandemicinOntario.
Limitedsupplychaincapacityorvisibility
AtthetimethepandemicwasdeclaredinCanada,Ontario’s healthsupplychaininfrastructurewaslocalizedtoindividual organizations,resultinginlimitedvisibilityofproductand equipmentinventoriesandlocations(e.g.,PPE)acrossthe province.TheHealthCommand Tablehadnolineofsightto productinventoriesavailableinanyhealthorganizationinthe province,andnoaccesstosupplychaindatatoinformdecisions. Priortothepandemic,organizationssuchashospitalsprioritized lowestcost,resultinginthemajorityofsuppliesbeingsourced fromChina theepicentreofthepandemic.Asquarantine measureswereimplementedacrossChina,manufacturing capacitystopped,demandsforsuppliesrapidlyescalatedacross everyglobaljurisdiction,resultingincriticalshortagesandsupply chainteamscompetingacrosstheglobeformedicalsupplies.The procurementofessentialproductsandsuppliesforOntariowasnot coordinatedwiththeeffortsofsupplychainteamsinhealth organizationssuchashospitals,describedinthefollowing:
“Attimeswewerebumpingintoprovincialbuyswhereit’slike,your orderfor50,000units you ’vebeenbumpedbecausetheprovince isbuying fivemillionunits.Well,we’vejustbeenthroughthis30dayprocessofvettingthesupplierandqualifyingthem,lookingat theproducts,gettingasample,andnowwe’rereadytobuyonlyto findoutthattheprovinceisgoingtobebuying fivemillionunitsand ohbytheway,you’re[only]getting(some)ofthose.” (Regional Leader)
Healthsystemcapacitytomeettheincreaseindemandfor criticalproductsmeantthatsupplychaincoordinationand collaborationacrosstheprovincewascriticallyneeded.Each regionvariedwidelyintheirsupplychaincapacityand strategiesforprocuringproducts,levelofexpertise,and capacitytocoordinatePPEallocationandimplementationof Ministrydirectivesacrosstheirregions.Whilesomeregionshad well-establishedsupplychainexpertiseandcapacity,others startedfromscratchhavingtohiresupplychainleaders, contractwithdistributors,buildingasupplychainstrategy,
describedasa “ piecemeal” approach,havinglittlechoicebut to “ buildthebridgewhiledrivingoverit. ” Aregionalleader describesthechaosofbeingbroughtintoleadthedevelopment ofasupplychainstrategyinaregionwhichhadnosupply chainexpertiseorcapacity:
“Findingtimetoworkwith(supplychainteamsinprivatesector) and(GPOname)andthehealthserviceprovidersinallofthiswas alsobeingdoneatthetimeweweretryingtogetthemcriticalPPE immediatelybecausetheyhadCOVIDravagingthesystem.We wereworking12hoursaday,7daysaweek.TheMinistry EmergencyOperationsCenter(MEOC)hadasupplyof pandemicPPEandtheMinistryhadsentanemailoutandsaid theseareyourregionalleads,emailthem.So,weweregettingallof theseemailsfromhealthserviceproviderswhoneededcritical PPE,itwasaspreadsheetthattheywere fillingin,theywere sendingittous,andquitehonestlyatthebeginning,someofthe requestswerelikecrazyhigh,like20,000gownsandI’dlike10,000 glovesandbythewaythatwilllastmeaweek.” (RegionalLeader)
Thenewlyformedregionswereillequippedtomanagethe significantdemandforcriticalproducts,andregionalteamshadnot beenwellestablishedineachregiongiventhelimitedprogress madetowardsrestructuringthe14LHINsinto fiveregionsatthe timethepandemicunfolded.Regionalleadersmobilizedresources wherevertheycouldastheystrivedtomeetthedemandsofhealth organizationsmanagingthepandemicresponse.
Sourcingandprocurementchallenges. Formanyoftheregions acrosstheprovince,oneofthegreatestchallengeswasensuring allorganizationshadthecriticalproductsneededtoensurethe safetyoftheworkforceandenableclinicianstodelivercareto patients.Largerorganizations,suchashospitals,hadsupplychain teamswhoworkedwithSSOsandGPOstosourceandprocure products.However,GPOsandSSOswereunabletosource productsintherequiredvolumestomeetthesurgeindemand duetotheglobalshortagesofcriticalproducts,whichresultedin GPOsandSSOshavingtoplacetheircustomersonallocationto conserveproductinventories.Allocationmodelslimitedsupply distributiontoprovidingorganizationswithproductvolumes accordingtopre-pandemiccontracts.Thesurgeindemand requiredmuchhigherproductvolumesthantheGPOsand SSOscouldprovidetoalmosteveryhealthorganization.One leaderdescribesthedesperationoftheireffortsto findnewsources ofcriticalproductsinordertomeetsurgeindemand:
“[Wemade]callsthatIcan’ttellyou,callingeverybodyunderthe sunatanytimeofnightandmakingdeals,likeunthinkabledeals toswitchtoreusablegownsandbasicallyyouknow,getvery aggressivetosayyouhavetodothisbecausewe’rerunningoutof ourhistoricallevels.Soitwas,Iwoulddescribeitasatotal[****] show.” (HealthcareLeader)
Smallerorganizationsinparticularwereexceptionallyvulnerable. Smallerbudgets,limitedsupplychainexpertise,andprioritization of “hospitals first” madeitdifficult,ifnotimpossible,tosource andprocuresupplies.Provincialdecisionswerewidelyviewedto befocusedonconservingsupplychaincapacitybyprioritizing
hospitalsandleavingotherhealthorganizationstosource supplies,describedinthefollowing:
“
Itwasastruggle.Therewereacoupletimeswherechemotherapy unitswerethreateningtohavetoshutdownbecausetheyonlyhad threedays’ worthofmasksandstuff.Thefactthatsomeonecan’tget cancertreatmentbecausewecan’t findamaskwasjust,youknow, unbelievable.” (HealthcareLeader)
AllocationframeworktoconservePPEinventoryandmanagecrisisof criticalshortages. TheallocationofPPEwasadefiningfeatureof the firstandsecondwaveofthepandemicandthe “allocation framework” createdbytheprovincewasdesignedtoguide decisionsonallocationofcriticalproducts,describedinthe following:
“Basically,it(theallocationframework)justsaid,thesuppliesgo wherepeopleneeditandwe’lldivideitupandthengoonabasisof analgorithm.Bythattime,wehadalreadybasicallydescribedthe allocation.Butatthatpointpeoplethoughttherewassomesecret frameworkandthenitjustgotembarrassingbecauseiftheyhad sentitout,itwouldbelikethe ‘emperorhasnoclothes’.It’ s basicallyasetofpriorities(thatarefollowed);it(PPE)goesto patients first,healthcareworkersnext,youknow,pharmacy,itwas justatieringof(whogetsPPE first) …” (HealthSystemExpert)
AllocationstrategieswereacommonpracticeusedbyMinistry ofHealthteams,GPOs,SSOs,anddistributorsintheprivatesector. Criticalproductinventoriesweredramaticallyreducedonce regionsinChinawereunderquarantineandmanufacturing capacitycametoahalt.AllocationframeworkswereadecisionmakingtooltoguidedecisionsregardingthedistributionofPPE productsfromprovincialstockpilestothoseorganizationsin greatestneed.Thegoaloftheallocationstrategywastoconserve inventoriesofcriticalproductsuntilsuchtimeasPPEproducts couldbesourcedandprocured,inordertoreducetheriskof runningoutofcriticalproducts.Akeyinformantdescribes:
“Forourcontractdemand,theycontinuedtoprovidesomeproduct withinthecontextofthecontract,butbecauseofthesheer volumesofrequeststhattheyweregetting,everybodywenton allocation.Youonlygotacertainpercentageofwhatyouwere goingtoget,andthepercentagewasnotgoingtokeepupwithour utilization.Ourconsumptionnumberswerewaytoohighforthat.” (SupplyChainLeader)
Communityorganizationsweredeeplyimpactedbycritical shortagesofPPEduetotheirlimitedsupplychainexpertiseand lackofcapacitytoprocurecriticalsupplies.AquotefromOntario’s Long-TermCareCOVID-19Commissiondescribeshowlongtermcarehomeswere “ontheirown”:
“GiventhePPEshortageandtheabsenceofaprovincialstockpile, theprovinceadvisedhealthcareorganizations,includinglong-term carehomes,toimplement “ supplystewardship”— thatis,to “rationyoursupply.” Attheoutset,long-termcarehomeswereon theirown;theyneededtoaccesstheirownsupplychainsandcouldnot dependonaprovincialbackstop.” Ontario’sLong-TermCare COVID-19Commission
Manykeyinformantsdescribedhowtherewasa “hospital first” strategybytheprovincialgovernment,wherehospitals wereprioritizedforcriticalsuppliesandPPE:
“
Itwaswhentherewasverylimitedsupplythey[governmentof Ontario]madeanallocationdecision,towherethatsupplywould havethegreatestimpact.Andmadeadecisionthatthatwouldbein acutecare.Right;wrong;I’mnotsure.” (HealthSystemLeader)
AsofMay26,2020,therewere298outbreaksatlong-term carehomescomparedto84outbreaksathospitals.18 InOntario, infectionanddeathrateswereexceptionallyhigh,with61%ofall deathsinlong-termcare,reaching4,000deathsbyApril2021.19
TheCanadianArmedForceswerecalledintotheworst-hitlongtermcarehomesandfoundextremecrisisinthesesettings.20 Theworkforcefaced “intolerablelevelsofstress,” facedwith fearofexposuretothevirusandspreadingtheinfectiontotheir families.Akeyinformantdescribeshowlong-termcarehomes couldonlyreceivePPEfromtheprovinceonceanoutbreakhad occurred:
“Wehadonlyonce,onetime,didwereceivesupplies.Wepushedthe systemandreceivedsuppliesfromtheMinistryandthatwaswhen wehadaconfirmedoutbreakhere.” (Long-termCareLeader)
Anotherstrategyusedtoconserveproductsupplyduringthe earlywavesofthepandemicwasfocusedonmanaginghospital bedcapacitybycancelling “elective” surgeriestofurtherreduce thedemandsforcriticalproductsneededforpatientcaredelivery. Electiveisconsideredanysurgerythatisplanned,whichis distinctfromemergencysurgeriesthatareunplanned.Aclinician describestheimpactofshuttingdownofnon-essential(e.g., elective)services:
“Themajorityofcancercasesweresuddenlyallbeingturfed.And wedon’tconsideranytumourgrowinginsomeone’sbodyanelective surgery Likethehospitalsbasicallycancelledeverythingwithin days.Thespeedatwhichthesystemshutdownwasjustmind boggling,justhowfastthathappened andeventothisday, there’s10,000[cancer]tumoursouttherewaitingtoberemoved.” (ClinicianLeader)
Theimpactofthereductioninservicesiswidelyviewedasa challengethatwillhavesignificantimpactonthehealthofthe citizensofOntariointhecomingmonthsandyears.Thecritical shortagesofprotectiveproductsinOntarioduetothe “hospitals first” approachcontributedtothedevastatingimpactonthe long-termcaresector,duetothesignificantimpactofsupply shortagesandtheconservationofhospitalcapacity,which resultedintransferstolong-termcare.Theseandmany otherfactorscontributedtodevastatingoutcomesfor Ontarioseniorslivinginlong-termcare,whichresultedin theprovincehavingtorequestsupportfromtheCanadian Militarytogointohomestoprovidecareforseniors. 17 Military supportfromfederalagencieswastheonlysubstantive engagementofFederalagencie sdescribedbyparticipantsin thiscasestudy.
Limitedsupplychaindataandunderdevelopeddigital infrastructure. Therewerefew,ifany,organizationsor governmententitiesinOntariothathaddigitalinfrastructure thatofferedtransparencyofdata,includingpublichealth testingdata,COVID-19casecountsacrosshealth organizations,orhospitalizationrates.Digitalinfrastructure wasadvancedinsomehospitals;however,noneofthe organizationshaddigitalconnectivity,orinteroperability,across organizationsorregions.Leadersanddecision-makerswere left “flyingblind”7 whenmakingsupplychaindecisions,with littledataabletoaccuratelytrackutilizationratesofcritical supplies,ordemandforcriticalproducts.Theimpactofthe lackofdataanddigitalinfrastructureisdescribed:
“It’sbeenveryclearthatoursystemwasnotsetupforCOVIDand wewereprobably,ofallprovinces,theleastwelldesignedto addressapandemiclikethis,andIwouldsaythebiggestfailing wasdataandalackofvisibilityintowhatwehadonhand,howfast weweregoingthroughit,andwhat’scomingin.” (SupplyChain Leader)
Totrackthedemandandutilizationofcriticalproducts, decision-makersreliedonmanualcountsofPPE,collected byfrontlinestaffwhoreporteddailycountsofPPEproduct volumes.Onekeyinformantdescribed: “Dataqualitywas nothingtowritehomeabout,” anddecision-makingwas “at thewhimofdailyreporting.” Themanualcountingrequired valuabletimeforteamsinclinicalsettingstocompleteeveryday andwasconsideredinaccurateandunderreportedduetofears thatcriticalproductswouldbere-directedtootherorganizations ifreportingwasaccurate,describedbyahealthcareleader:
“
Thegovernmentstarteddatacollectionandvalidationtools becausesomepeoplewereexaggeratingtheirneedandtheir demand,everybodywasscaredright,noonewassayingIhave this(productcounts),becausenooneknew.” (HealthcareLeader)
Ontariohadnoprovincial-leveldataordigitalinfrastructureto supportaccuratetrackingofproductutilization,andorganizations experiencingthegreatestneedforproductstorespondtoCOVID19cases.Thelackofdatainfrastructureresultedinlackof transparencyofsupplyinventorydataneededtoinform decisions,describedinthefollowing:
“Itwasabsolutechaos.Itwaschaosonanumberoffrontsbecause wedidn’thave,westillhave,verypoordataaroundwhatinventory wasactuallyinthesystemandwedidn’thaveclearsightlinefor confidenceinordersthatwerecominginfromChina.Alotofthem werereallydisruptedandwehadordersthatdidn’tcomethrough, thatgottakenfromusofftheloadingdock,allkindsofthings.We didn’thavealotofconfidenceinwhatwascomingintothe warehouse,wedidn’tknowreallythatmuchaboutwhatwasin thesector.” (ProcurementLeader)
ThedecentralizedleadershipstructureofOntario’shealth system,coupledwiththelackofdatainfrastructure,contributed toachaoticenvironmentwherebyorganizationswereleftto find alternativesourcesofcriticalproducts.Provincialleadersand
decisionmakerswere “flyingblind”,makingdecisionsto managetheeventsofthepandemicwithoutdatatoinform theirdecisions.ThehardesthitsectorinOntariowaslong-term care,whichwasunabletosafelyprotectseniorcitizenslivingin thesesettingsandnotabletoofferprotectiveequipmenttosupport thesafetyofthehealthworkforceacrosstheprovince.
DevastatingimpactofCOVID-19inlong-termcare
ByApril2020,seniorsinCanadahadthehighestratesofCOVID19with79%ofalldeathsinCanadaconnectedtolong-termcare andsenior ’shomes.21 OntariomirroredthesefactsasofMay26, 2020,therewere298outbreaksatlong-termcarehomescompared to84outbreaksathospitals.18 Manyexpertssuggestedthatlongtermcarehomeswere “completelyneglected” atthebeginningof thepandemicwhilehospitalswere notonlybetterprepared,their staffhadbetteraccesstopersonalprotectiveequipmentand securitywhenitcomestoemployment.18 InMay,theCanadian ArmedForcesweresentintosomeofOntario’sworst-hitlongtermcarehomesandreporteddevastating findings.TheOntario governmentannouncedaformalenquirytoexaminethegapsin long-termcaretoinformdecisionsandinitiativestobetterprotect seniorsasthepandemicunfolded.Long-termcareandtheimpact ofCOVID-19onseniorsacrosstheprovincewereamongthe mostdevastatingoutcomesofthepandemicinthisprovince.
Conclusionsandimplicationsforhealthleaders
Ontariowasseverelychallengedinrespondingtotheglobal pandemicofunprecedentedscopeandscale,caughtinthemidst ofmajorrestructuringofhealthorganizationsandregions acrosstheprovince,havingnocentralizedleadershipstructure orcoordinationofpandemicmanagementeffortsacrossthe province,andlittleornoaccesstodatatoinformdecisions. Theprovince’scapacitytorespondwasfurtherchallengedbya largeandcomplexleadershipstructurethathadnoclearline ofaccountabilitytoorganizationsacrosstheprovince,resulting ininconsistenciesineffortstomanagethepandemicineach geographicregion.Therewasnodigitalinfrastructuretomake visiblethesupplychallenges ,criticalproductinventories,or accuracyinratesofproductdemandutilization,which precludeddata-drivendecisionstooptimizesupplychain capacitytodistributecriticalproductsacrosstheprovince. Limitedrepresentationofkeyareasofexpertise,suchas healthsupplychainandclinicianleadershipatdecisionmakingtables,andlackofdataanddigitalinfrastructureto informdecisionsortoaccuratelyforecastutilization contributedtothemanychallengesevidentintheOntario case.Theintensecompetitionforcriticalproductsglobally, andlackofsupplychainmanagementexpertisefurther contributedtosignificantchallengesforhealthorganizations acrosstheprovince,particularlyorganizationsprovidingcare tovulnerablepopulations,mostnotablyOntarioseniors.
TheOntariocaseprofilesanumberofcriticallessonslearned andimplicationsforhealthleaders,whichalignwiththeLEADS framework,22 describedinthefollowing.
Engageothers wasastrategythattheOntariogovernment attempted;however,thecomplexityandthemassivenumber ofstakeholdersengagedattheHealthCommandTablelacked clearlystatedgoals,withlittleevidenceofcollaborationand coordinationofeffortstocontributetoeffectivemanagementof thepandemic.Responsibilities andaccountabilitiestorespondto demandsforcareremainedwithinindividualorganizationsand sectors(e.g.,hospitals,publichealth,andlong-termcare),with limitedopportunityforengagingleaderstoshareideas,bringkey areasofexpertisetodecision-makingtables,andverylimited evidenceofcooperationorcollaborationacrossorganizationsto achieveresults.Despiteengagingmorethan500membersinthe CommandTable,theabilitytofosterdevelopmentofothers, ensureclarityandconsistencyofcommunication,buildateam abletoworkmeaningfullytogetherwasnotevidentinthisOntario case.TheOntariocasedemonstratesthecriticaldimensions ofleadershipstrategiesthatengageotherstofoster development,establishclearlinesofcommunicationto supportasenseofteamworkandmeaningfulengagementto advancetheobjectivesofprovincialeffortstocoordinate pandemicmanagement.
Achievingresults wasachallengeinOntariowherebythe underlyingdecentralizedleadershipmadeitnearly impossibletosetthedirec tion,strategicallyalign stakeholdervalues,visionandevidence,takeactionto implementdecisions,andevaluateoutcomesandresults. Ontarioleadersweredisadvantagedbythechallengesofthe healthsystemrestructuringprocess,justasthepandemicstarted, leavinghighlevelsofuncertaintyregardingleadership structuresandaccountabilities,whichwerechangingwiththe restructuringprocess.Clarityofthedirectionandstrategyforthe pandemicresponsewasverylimited,andtakingactionatthe provinciallevelwaslimitedtoa “powerandcontrol” strategyto imposepublichealthrestrictions,whichwereimplementedwith ahighdegreeofvariabilityacrosstheprovince.Integrationof organizationalstrategytoadvanceprovincial-levelresponses wasnotpossibleduetothehighlydecentralizedstructureof healthorganizationsacrosstheprovince.Healthleaderswere limitedtomanagingwithintheirpersonalscopeofpracticeand accountability,whichprecludedacoordinatedorcollaborative approachtopandemicresponsiveness.
Developcoalitions. Partnershipsandnetworksofexpertisewere largelyabsentinOntario,whichprecludedleadership collaborationacrosstheprovince.Therewasnoevidenceof developingcoalitionstocoordinateeffortsorbuild collaborationsacrossthemultiple “tables,” committees,and decision-makinggroupsformedattheonsetofthe pandemic.Collaborativeapproachestoleadershipwere furthercompromisedbytheveryslowresponsetoformulating aHealthCommandTable,announcedonMarch2,2021, five weeksafterthe firstCOVID-19casewasdiagnosedinthe province.Coalitionsbetweengovernmentdecision-makers, healthprofessional(workforce)organizations,andsectorleaders (e.g.,long-termcare,homecare,andcommunitycare)werenot
evidentintheOntariocase,whichprecludedacollaborative approachtoleadershipstrategiestoeffectivelymanagethe pandemic.Specifically,coalitionswithfederalagencieswerealso notevidentintheOntariocase,withtheexceptionoftherequest formilitarysupporttomanagethecrisisinlong-termcare, documentedintheAuditorGeneral’sreport.
Systemtransformation. TheprovinceofOntariowasveryearly inasystemtransformationprocess,havingdismantled theleadershipteamsandboardsforeachofthe14localhealth integrationnetworksacrosstheprovince,leavingasignificantgap inleadershipinfrastructureatthetimethepandemicunfolded. Systemsthinking,implementingeffectiveprocessesacross stakeholdergroups,particularlyacrossthemanysupplychain stakeholders,wasnotevidentintheearlyphasesofthepandemic. Theprocessesimplementedwerewidelyviewedasslowto respondwithlengthyimplementation,resultingin “buildingthe bridgewhiledrivingoverit.” Thevirtualsupplychainstrategy reliedonmanualcountsofcriticalproducts,whichwasthen uploadedintoadatabasetoinformdecisions.Distributionof criticalproductsin shortsupplywereallocatedonlyafter outbreakswereestablished,ratherthanbeingproactivein preventingoutbreaksforhigh-riskpopulationssuchasseniors livingincongregatesettings.The crisisthatemergedinlong-term carewasaclearindicationofthelimitedcapacityoftheprovinceof Ontariotoadequatelyrespondtothepandemic,hamperedbyavery decentralizedleadershipmodel,atransitiontowardhealthsystem restructuring,alackofdataanddigitalinfrastructuretoinform decisions,andalackofsupplychaininfrastructureandcapacity tocoordinateeffortstosourceandprocurethecriticalproducts neededtoensuresafeworkenvironmentsforthehealthworkforce, andtopreventtransmissionofCOVID-19inhigh-riskcommunities andworkenvironments.
Anumberofkeylessonslearnedforhealthleadersare illustratedbythisOntariocasestudy:
a.Leadershipstructures,accountabilities,andinfrastructure mustbeclearlyestablished,withagreedupondecisionmakingstructuresandstrategiestoeffectivelyengage stakeholders,ensurethenecessaryexpertiseisinforming decisions,andcoalitionsofstakeholdersaremobilizedto effectivelymanageunexpectedeventssuchaspandemics. Itisnotablethatthemanyrecommendationsandlessons learnedfromSARSweresimplynotimplementedor recognizedintheyearsfollowing2006,despiteevidence andrecommendationsoftheJusticeCampbellinquiry. Thereisnoquestionthatpandemicswillunfoldinfuture, andpreparednessrelativetoleadershipinfrastructureand accountabilitiesiscriticaltosuccessfulmanagementof sucheventsinfuture.
b.Effectiveleadershiprequiresa results-orientedstrategythat meaningfullyengagesothers, clearlyestablishesdirection, valuestheuseofevidence,andissupportedbydata-driven decision-making.Achievingresultsnecessarilyrequires accurateandaccessibledatatoinformdecisions,and evaluateeffectivenessandoutcomesofdecisions,
particularlysupplychaincapacityandoutcomes,during eventssuchaspandemics.Leadersmustaccuratelymeasure theeffectivenessandcapacityofhealthsystemstorespond tosucheventsinamannerthatisequitable,andvalidated bydataandevidence.
c.Systemtransformationiscriticaltoanyprovincialhealth systemresponsetocrisiseventssuchasapandemic. AlthoughOntariowascompromisedinitsresponseto thispandemicduetosystemrestructuring,criticallessons learnedmustbecarefullyconsideredatthesystemlevelto informandencouragesysteminnovationtoprepare Ontarioforsucheventsinfuture.Digitalinfrastructure thatcreatestransparencyofhealthsystemcapacityto respondtosurgeindemandwillbecriticaltoOntario’s futurecapacitytorespondtopandemicevents.Datathatis open,transparent,andaccessibletoallstakeholdersisa strategicasset,particularlysupplychaindata,andenables collaborationandcoordinationacrossorganizationsto supporteffectiveandhig hperformingcoalitionsof stakeholderstomobilizeandadvanceemergency responsestoeventsinfu ture.Digita lly-enabled healthsystemsandsupplychaininfrastructurein particular,willbestrateg icassetsabletosustain healthsystemcapacitytoeffectivelyandproactively managepandemiceventswellintoOntario ’sfuture.
Funding
ThisworkwassupportedbyCanadianInstitutesofHealthResearch, VR5172669.
ORCIDiD
AnneW.Snowdon https://orcid.org/0000-0003-4640-6842
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