Supply chain capacity to respond to COVID-19 in Newfoundland and Labrador: An integrated leadership

SupplychaincapacitytorespondtoCOVID-19 inNewfoundlandandLabrador:Anintegrated leadershipstrategy

AnneW.Snowdon,PhD1 ;andMichaelJ.Saunders,PhD1

Abstract

HealthcareManagementForum 2022,Vol.35(2)71–79 ©2022TheCanadianCollegeof HealthLeaders.Allrightsreserved.

Articlereuseguidelines: sagepub.com/journals-permissions DOI:10.1177/08404704211058414 journals.sagepub.com/home/hmf

Thisprovincialcasestudy,oneofsevenconductedaspartofanationalresearchprogramonhealthcaresupplychainmanagement duringCOVID-19,focusesonNewfoundlandandLabrador(NL).Facedwiththedestabilizationofitstraditionalsupplychain,NL leveragedanexistingcentralizedhealthcaresupplychainstructuretoorganizeitssupplychainresponsetothepandemic.To overcomeproductshortages,healthleaderscollaboratedwiththeirlocalbusinesscommunityandindustriestosourceandprocure personalprotectiveequipmentandcreatedomesticmanufacturingcapacityforcriticalsupplies.Thehealthcaresupplychain responseinNLdemonstratesthevalueofahighlyintegratedandcentralizedhealthcaresupplychainmanagementstrategy.Italso makesclearthevalueofadiversi fiedhealthcaresupplychain,onewhichdrawsonlocalmanufacturingcapacitytocreateadomestic sourceofcriticalsuppliesandovercomeshortagesfromglobalsuppliers.

Introductionandreviewoftheliterature

TheCOVID-19pandemichasshoneabrightlightonthecritical importanceofhealthcaresupplychain.Supplychainandlogistics infrastructureisastrategicassetinhealthsystems,whichensures thathealthcareworkershavetheproductsandequipment necessarytodelivercare.Itcreatessafeworkenvironments forthehealthworkforceandenablesqualitycaredeliveryfor Canadians.Supplychaininhealthsystemsincludesthesourcing anddistributionoftheproductsthatensurehealthcareteamshave accesstotherightproductsattherighttimeinordertodeliversafe andeffectivepatientcare.1 Inhealthsystems,supplychainteams sourceacomplexanddiversearrayofproductsandequipment, fromventilatorsandintravenouspumps,tomedications,vaccines, andPersonalProtectiveEquipment(PPE).Andyet,thestrategic importanceofthehealthcaresupplychainforhealthsystem capacitytodelivercareis,forthemostpart,neitherreflectedin currentresearchliteraturenorinthedevelopmentofhealthsupply chain-specificbestpractices.

Supplychaindisruptionscanoccurduetonaturaldisasters andpublichealthcrises,resultinginsevereconsequencesthat puthealthworkersandpatientsatsignificantrisk.Forexample, duringHurricaneMariain2017,electricalgridswerewipedout inPuertoRico,whichimpactedtheproductionofIVbags manufacturedbyBaxter.2 Theresultingshortageinsupplyof IVbagscausedanincreaseincostby600%.2 Similarly,a flood in2012impactedSanofi Pasteur,thesupplierofthecancerdrug ImmuCyst.Theresultwassignificantdelaysincancertreatment forpatients,asmanufacturerscouldnotincreaseproductionof thedrugrapidlyenoughtomeetthedemand.3 Publichealth crises,suchastheSARSepidemic,alsoputextremepressureon healthsystemsupplychains,duetoanincreaseindemandfor thecriticalproductsrequiredtokeephealthworkersandpatients safe.Notonlydothesecrisesputthephysicalhealthofthese essentialworkersatrisk threeofthe44Canadianswhodied fromSARSwerehealthcareworkers4 emergingevidencealso

identifiessignificantimpactonthementalhealthoftheworkforce. TheinadequatesupplyofPPEandtheuncertaintythesesupply shortagescreatedamongCanada’shealthcareworkforcegreatly impactedtheirmentalhealthduringtheCOVID-19pandemic.5

Healthcaresupplychainsinvolveadiversityofstakeholder groups,includingpatients,clinicians,suppliers,healthcare organizations,grouppurchasingorganizations,distributors,and insurers,whichaddstotheircomplexity.6,7 Comparedtoother sectors,however,researchandevidenceofbestpracticesfor healthcaresupplychainprocessesandmanagementlagsfar behind.8-10 Whileresearchdedicatedtounderstandingsupply chainandlogisticshasbeenwellestablishedintheprivatesector, significantgapsinresearchremaininthehealthcaresector.11-14 Whereresearchdoesexist,itoftenattemptstoapplynonhealthcaresupplychain-specificinsightstohealthcaresupply chainchallenges.However,theattempttotranslateindustrial ornon-healthcaresupplychainprocessestohealthcaresupply chainmanagementriskselidingthespecificityofthehealthcare supplychain,especiallyitsuniqueendpointinthecareforhuman life.Practicesthatarerelevanttoindustrialsupplychain management(suchas,forexample,just-in-timelogistics)may notbereadilyapplicabletohealthcaresupplychainmanagement becauseanydestabilizationofthehealthcaresupplychainmay compromisethequalityofcareandsafetyofbothpatientsandthe workforce.AsAldrighettietal.15 note,thestandardbywhich healthsupplychaincapacityismeasured,ortherequiredservice levelofahealthsupplychain,isdifferentfromthatofindustrial supplychains: “InthecontextofHSCs[healthcaresupply chains],suchdisastrousevents[asdisruptions]canpotentially

1 UniversityofWindsor,Windsor,Ontario,Canada.

Correspondingauthor: AnneW.Snowdon,UniversityofWindsor,Windsor,Ontario,Canada.

E-mail: anne.snowdon@uwindsor.ca

havedevastatingeffectsbecausehumanlivesareonthetable: thesenetworkscannotaffordtoregistermissingdrugsinthe hospital,i.e.itshouldalwaysperformwithservicelevelequalto 100%.”15

Thisneedforthecapacityofahealthsupplychaintomaintaina “servicelevelequalto100%” helpstocontextualizetheurgency ofthedevelopmentofstrategiesforhealthcaresupplychain resilience,anditisakeydifferentiatorofthehealthcaresupply chainfromindustrialsupplychains.Whenthehealthcaresupply chainbreaksdown,theresultisadirectimpactonhumanlife.15-17 TheCOVID-19pandemichashighlightedtheurgentneedfor healthcaresupplychainfocusedresearchinordertofurther understandthenuancesevidentinthissectorandtodevelop healthcaresupplychainspecificstrategiesforsupplychain management.

Thispaperreportsoncasestudyresearchoftheprovince ofNewfoundlandandLabrador(NL),revealingempirical evidenceofsupplychainprocessesandinfrastructurewithin andacrossthisprovincialhealthsystem,duringthe firsttwo wavesoftheCOVID-19pandemic.Thisevidenceisanalyzedto documentleadershipapproachesandstrategies,supplychain capacitytorespond,implicationsforkeylessonsandleadership strategiestoinformeffective,agile,andresponsivepandemic managementforCanadianhealthsystems.Thiscasestudyisone ofsevenprovincialcasestudies(BritishColumbia,Alberta, Manitoba,Ontario,Quebec,NewfoundlandandLabrador,and NovaScotia)conductedtoexaminehealthsupplychaincapacity andinfrastructureacrossCanada,the firstnationalstudyofhealth supplychain,fundedbyCIHR(Ref.#VR5172669).Thecase studywasdesignedtorespondtothefollowingresearchquestions:

1.Whatarethesupplychainprocessesandinfrastructure requiredtooptimizeeffectiveandtimelyhealthservices deliveryforthecurrentandfuturephasesoftheCOVID19pandemic?

2.Whatprocurementmodels,approaches,andpolicy frameworksoffersecuresourcingofproductstomeet thesurgeindemandforcarebyCOVID-19patients?

3.Whatisthedigitalmaturityofsupplychaininfrastructure (andprocesses)inNewfoundlandandLabrador,that,if strengthened,couldoptimizemanagementofCOVID-19?

4.Whatarethedatainfrastructureandanalyticsstrategiesneededtostrengthentheeffectivenessofhealth systemsupplychainprocessestosupportCOVID-19 management?

5.Whatistheinfluenceoffederalgovernmentinitiatives, fromtheperspectiveofprovincialstakeholders,on provincialhealthsystemcapacitytomanageCOVID-19?

Methods

ThiscaseexaminestheprovinceofNewfoundlandand Labrador ’sresponsetoCOVID-19,highlightingitsunique challenges,opportunities,andexperiencesinhealthcaresupply chainmanagementduringthisunprecedentedpandemic.The UniversityofWindsor ’sResearchEthicsBoardprovided

approvalforthisproject.Thiscasewasoneofseven,aspart ofanationalCIHRRapidResearchprogramentitled “DevelopmentofanImplementationFrameworktoAdvance ProvincialandNationalHealthSystemSupplyChain ManagementofCOVID-19 ” Acasestudyapproachwasused tounderstandNewfoundlandandLabrador ’shealthcare supplychainresponseduringtheCOVID-19pandemic. Casestudiesofferawaytoexploreandinvestigatereal-life phenomenonthroughanalyzingthecontextofeventsandthe relationshipsbetweenthem.18 Theprimarygoalofthiscase studyresearchwastounderstandtherelationshipsbetween leadershipstrategies,keysupplychainmanagementstrategies andcapacity,andhealthsystemresponseacrosssevenCanadian provinces.Theprimarydatasourceforthisempiricalstudycame fromsemi-structuredinterviewswithninekeyinformants.This includednineindividualinterviewsandtwogroupinterviews,for atotalofeleveninterviews.Ofthenineindividualinterviews, fourwerefollow-upinterviewswithkeyinformants.Document analysisandpreviousresearchinformedtheconceptual frameworkandinterviewguide.Purposefulsamplingwas usedtoidentifytheparticipantswhorepresentedvaried perspectivesandexpertise,includinghealthcareleaders (n=4),government(n=1),andhealthcaresupplychain experts(n=4).Keyinformantswerecontactedbye-mailand providedwithaparticipationletterpriortotheinterview, identifyinginformationaboutthestudyandtheirroleandrightsas aparticipant.InterviewswereaudiorecordedusingMicrosoftTeams andtranscribedbyaprofessionaltranscriptionist.Keyinformant responsesdescribedexperiences,perceptions,andperspectives onsupplychaincapacity,processes,andhealthsystem responsesandsupplymanagementduringthe firstandsecond waveoftheCOVID-19pandemic.

Anonymitywasensuredthroughde-identificationof participantsanddata(e.g.,removalofanypotentialidentifiers, suchasindividualororganizationnames),suchthatonlythe researchersconductingtheinterviewwereawareofparticipant identities.Codingofinterviewsproceededasdatawerecollected, wherebyresearcherswereabletoidentifyemergingthemesand conceptstoenablereflexivityasinterviewdatawerecollectedand analyzed.Dataanalysissoftware,N-Vivo(version12)wasused toassistwiththeorganizationandanalysisofsemi-structured interviewdata.Thefollowingsectiondescribestheresultsofthe analysisforthiscasestudy.

ProvincialcontextoftheNewfoundlandand Labradorhealthsystem

ThehealthcaresysteminNLisorganizedintofourRegional HealthAuthorities(RHAs):Labrador-GrenfellHealth,Central Health,EasternHealth,andWesternHealth.RHAresponsibilities encompassacutecareinhospitals,long-termcare(oftenthrough facilitiesco-locatedwithhospitals),communitycare,andpublic health.Healthcaresupplychaingovernanceandmanagementin theprovinceiscentralizedtooneoftheRHAs(CentralHealth). Thiscentralizedgovernanceandsupplychainmanagement structure(orprovince-widesharedservicesmodelforsupply

chainmanagement)wasestablishedtwoyearspriortothe COVID-19pandemic,wherebythematerialmanagement departmentsineachofthefourRHAswereconsolidatedinto onedepartmentintheCentralHealthAuthority.19

Thisnewsupplychaingovernancemodelwasprogressing aspartofa fi ve-yearoperatingplanatthetimeoftheonsetof thepandemic.ThehealthcaresupplychainteamatCentral Healthmanagesthesupplychainteamslocatedinallfour RHAsandprovidesleadsupplychainservicesforfourRHAs.

FollowingtheH1N1pandemicin2009,NLimplementeda pandemicpreparednessstrategy, 20 whichincludedthe creationofwarehousingspaceandapandemicstockpile resourcethatwasmanagedbyoneoftheRHAs.However, inSeptember2016,NLdecidedtostoprentingthewarehouse spacethathouseditspandemicsupplystockpileofpersonal protectiveequipment.Afterdecidingthattheproductcould notbeconsumedataregularusagerate,thesupplywasleftto expireandwaslaterdiscard ed.Accordingly,priortothe COVID-19pandemic,andfollowingtheclosureoftheNL pandemicstockpilewarehouse,amuchsmallervolumeof healthcaresuppliesforNL,includingPPE,werestoredin hospitalsettings.

COVID-19inNewfoundlandandLabrador

InJanuaryof2020,NLhadexperiencedanunprecedentedsnow storm,resultingin12to15footsnowdrifts.AStateof Emergencywasineffectforseveraldaysinordertomanage theimpactofthisunprecedentedstormandmuchofNL’shealth systemresponseatthistimewasfocusedonmanagingurgent healthservicesforthepopulation.Theimpactofthemassive snowfallmadetravelnearlyimpossibleandlimitedaccessto essentialservicessuchashealthcareservices.The first documentedcaseofCOVID-19inCanadawasjustfourdays

later,onJanuary26,2020.LeadersinNLhadlittletimeto preparefor,andrespondto,theunfoldingpandemic.Thekey milestonesoftheCOVID-19pandemicinNLduringthe first twowavesofthepandemicaresummarizedbelowandin Figure1 toprovidecontextfortheprovince’scapacityto respond:

1.OnMarch14,2020,the firstcaseofCOVID-19inNL wasannouncedbytheChiefMedicalOfficerofHealth (CMOH).

2.BetweenMarch15andMarch17,therewasanoutbreak ofCOVID-19inNL,linkedtoafuneralhome,which resultedin167casesofCOVID-19.21

3.OnMarch18,2020,aprovincialstateofemergencywas declaredandgatheringsofover50peoplewereprohibited.

4.March30,the firstdeathintheprovincewas announced,22 with148casesintheprovince.

5.OnMay4,2020,atravelbanwasputinplaceinNL,in whichnon-residentswereprohibitedfromenteringthe province.

6.However,onJuly3,thistravelbanwasrelaxedtopermit thefreemovementofresidentsamongtheAtlantic provincesonly(PrinceEdwardIsland,New Brunswick,NovaScotia,andNL),creatingwhatwas calledthe “Atlanticbubble.”

7.OnNovember23,2020,withrisingCOVID-19casesin NewBrunswickandNovaScotia,NL,andPrince EdwardIslandannounceditsintentiontowithdraw fromtheAtlanticbubble.23 Throughoutthe first monthsof2021,variousannouncementsweremade concerningtherestorationoftheAtlanticbubble; however,spikesinCOVID-19casesintheregion preventedthefullrestitutionofthebubble.

Figure1. TimelineofkeyCOVID-19pandemicmilestonesinNL.

8.AsofJuly1,2021,withthesuccessfulrolloutanduptake ofvaccinationprogramsacrossCanada,alltravellersare permittedtoenterNL.24

9.Todate,NLhashadatotalof1,486casesandonlyseven deaths.25

Thefollowingdescribethekey findingsofthehealthcare supplychaincasestudyofthecapacityofNLtorespondtoand managetheCOVID-19pandemic.

Integratedleadershipanddecision-making strategy

ThegovernancestructureforNL’spandemicresponsewas centredontheformationofEmergencyOperationCentres (EOCs)ineachofthefourRHAswithoversightbyaprovincial EOC,whichwasledbytheCMOH.TheprovincialEOCmade allpolicydecisionsundertheleadershipofPublicHealthand theEOCsineachRHAoperationalizedthesedecisionstorespond toandmanagethepandemicacrosstheprovince.Thehealthcare supplychainteamatCentralHealthactivelyengagedwiththe EOCsineachRHA.NLhadalreadyestablisheditssupplychain coordinationandmanagementprocessesacrossthefourRHAs,and supplychainprocesseswerecentrallymanagedforallhealthcare facilitiesandcaresettings,includinghospitals,long-termcare,and communitycare.NLhadonecentralizedhealthcaresupply chainmanagementstructure,withacleardelineationofroles andanintentionalfocusonensuringeveryhealthorganization waswellservedbythecentralizedsupplychainstrategy.Thiswas describedbyahealthcaresupplychainleader:

“Movingfromdecentralized,[from]the4materialsmanagement [departments]toonesupplychain,therewereissues,somepeople alwaysonthefence:willitworkorwillwegetthesameservice.I thinkwedidbuildalotofgoodwillthroughthiswholeprocessthat weconvincedalotofpeoplethatacentralizedsupplychain,forget evenPPE,butacentralizedsupplychaincanworkforthesystem andnothaveabias.Likeweserviceeverybody.Webalancedoutthe needsofeverybodyanditwasn’toneRHAoveranother.” (Supply ChainLeader)

AsthepandemicunfoldedacrossCanada,NLmobilizedits centralizedhealthcaresupplychainstrategytobegintoaddress PPEshortages.Theexistingsharedserviceshealthsupplychain modelprovedtobeadvantageousduringthiscrisis.Inthewords ofanotherhealthcaresupplychainleaderinNL:

“Wewouldhavebeentwomonthsjust figuringthatout[a centralizedsupplychainmanagementstrategy]andgovernment wouldhavehadtostepin,andtheywouldhavehadtobuildthis.” (SupplyChainLeader)

GiventhecrucialityofPPEforthepandemicresponse,NL alsoformedaprovincialPPEtaskforce,whichincluded representativesfromalloftheRHAs,PublicHealth,Infection PreventionandControl(IPAC),andOccupationalHealth& Safety(OH&S).Thistaskforcewasresponsiblefor determiningappropriatePPEutilizationforthevariousclinical

teamsandhealthservicesacrosstheprovince,adetermination whichtheninformedthesourcing,procurement,anddistributionof PPE.InadditiontothisPPEtaskforce,theprovincialgovernment inNLdesignatedadeputyministertoprovideaspecializedfocus onsupplychainandPPEprocurement.Thisdeputyministerboth liaisedwiththeFederalgovernmentandhelpedprovide financial approvalforpandemicpurchasingorders.Insodoing,NLcreateda provincial-levelstrategyfortheprocurementofPPE,whichoffered coordinationbetweentheprovincialgovernmentandhealthcare supplychainteams,tosupportresponsivenessinthesupplychain strategyandpandemicmanagement.

Duringthepandemic,thisprovince-widesupplychain mandateencompassedallhealthcaredeliveryorganizations. Healthcaresupplychainteamswereresponsibleforsupporting allhealthorganizations,includingEmergencyMedicalServices, personalcare,homecare,socialservices,andlong-termcare. MultiplehealthleadersinNLstressedtheintegratednatureof theirhealthsystem,whichencompassesbothacuteandsub-acute care.Inthewordsofahealthcaresupplychainleader:

“Wehaveanintegratedsystem.LTC[long-termcare]isfully integratedwithourRHAs,soishomesupportandcommunity care.So,they’reallourcustomers,they’reallourfamily.” (Supply ChainLeader)

Accordingly,long-termcare(LTC)wasprioritizedequally withthehospitalsystemrelativetosupplychainservices,as describedbyonehealthsystemleader:

“They[LTC]weresuppliedthesameasourhospitalsrightfromthe get-go.” (HealthSystemLeader)

Informedbytheintegratednatureofthehealthsystem,NL healthcareleadershiptooktheviewthatprotectingvulnerable populationswouldhelptoreducethedemandsonthehospital system.Ahealthsystemleaderdescribedthisperspective:

“

Acutecare,wehadtobereadyforsurge,wehadtobereadyfor volumesofpatientsthatmightcomethroughEmergencyRoomas wellasbeadmitted,lookingatareaslikeMedicine,butalso significantimpacttocriticalcare.Andthentheotherpartofthe blockI’llsaywithinservicedeliveryisLTC.Andwesawacrossthe countrywhathappenedinLTC.Sotherehadtobeprotectionofthat vulnerablepopulationbecausethatotherpartofitisiftheyweren’t adequatelyprotected,thatwasgoingtomeanyou’dhavemore peoplelookingtothehospitalforsupportaswell.So,everybodyhad tostayintheirbox,butsupportingeachotheryouknow.” (Health SystemLeader)

“We’reanintegratedhealthsystemhereinNewfoundlandand Labrador,right,soyouknow,oneimpactinoneareaimpactsthe otherareaintermsofpatient flow.Also,ifyoulookatitfroma publichealthresponseandcommunityresponse,iftheyweren’t doingthejobthattheyneededtodothenweweregoingtosee spillageI’llsayintotheothersectorsbecausetheirjobreallywas youknow,protectionandcontrol,right.” (HealthSystemLeader)

Thisintegrationwasdescribedbyhealthleadersasacriticaland successfulcomponentofNL’spandemicresponse.Acentralized,

integratedleadershipstrategythatservedallorganizationsacross theprovinceprovedtobeaconsiderablestrengthforNL’scapacity torespondtothepandemic.AstransmissionofCOVID-19casesin NLwereweekslaterthancasesinOntario(whereCanada’s first casewasconfirmedinJanuary2020),NLleadersalsohadthe benefitoflearningfromotherprovinces.

SupplychaincapacitytorespondtoCOVID-19

TheglobalsurgeindemandforPPE,andtheclosureof manufacturinginChinaduetopandemicquarantine,createda verycompetitiveglobalmarketforPPE.Duringthe firstwaveof thepandemic,PPEutilizationratesincreasedby1,200%inNL. ThesurgeindemandforPPEcreatedasenseofurgencyandahigh degreeofuncertaintyregarding theavailabilityof criticalsupplies.

InlateJanuaryof2020,NLhealthcaresupplychainteams firstattemptedtosourceandprocureadditionalPPEsuppliesin anticipationofthesurgeindemandbyplacingordersforPPE withtheirtraditionalsuppliers.Inordertoinformpandemic sourcingandprocurementstrategies,linkagesbetweentheNL healthcaresupplychainteam,clinicalleaders,IPACandOH&S teamswereestablishedtoinformdecisionsonsourcingPPE products.Criticalproducts PPEessentialforhealthsystem pandemicresponse were firstidentifiedbytheseclinicaland IPACteams.Healthcaresupplychainteamswouldthenreach outtotheircontractedvendorstoassessiftheycouldmeetthe demandfortheseproducts.However,onlysmallquantitiesof PPEwerereceived,andordersweredelayedwellbeyondwhat wasexpected.TraditionalsuppliersplacedNLonallocation, wherebythequantitiesofPPEdeliveredwerelimitedtohistoric, contracted(pre-pandemic)volumes.Insomecases,traditional supplierswereunabletoprovideeventhesehistoricvolumesof product,leavingNLfacingsevereshortagesofPPE.Ahealth systemleaderdescribedthissituation:

“Traditionalsuppliers[ ]wereofsomevalue,butlittle.They couldn’thelp,theyhadnothing,theiranswerwasyou’ reon allocation,that’sit.” (HealthSystemLeader)

Toovercomeproductshortages,NLleadersengagedwith federalagenciestosourceproductsfromthefederalstockpile. However,only5-10%ofNL’ssupplyneedswereabletobemet byFederalallocationfromtheemergencystockpile.Moreover, thesuppliesthatwerereceivedfromthefederalstockpilewere oftennotdeemedofsufficientquality,describedbyahealth systemleaderinNL:

“Evenwhatthefederalgovernmentwassendingupfromthenational stockpile,alotofthestuffthattheyweresendingwaspoorquality, expired,youknow,sowewereconstantlydealingwiththatwhilewe wereinthemiddleofanoutbreak.” (HealthSystemLeader)

OnegovernmentleaderinNLsuggestedthattherewasalsoa misalignmentbetweenFederalprocurementeffortsandprovincial needs:

“Westillrunintochallengesaboutknowingorunderstanding appropriatelabellingofwhat’scomingandwestillhavethe

situationthatthefedsdon’tnecessarilyunderstandwhatitiswe need,andI’lluseonesmallrecentexample.Andit’saroundgloves. Anumberofjurisdictions,usincluded,generallyprocure universallyacceptablegloves,12” nitrothatyoucanusefor chemo,that’sgenerallywhatwewouldprocure.So,thefedshad goneoutwithanRFPnowfor9” nitrogloves butwestill findthat we ’renotallalignedonwhat’sbeingprocuredanddoesitmeetwith astandardfromInfectionControlandOccupationalHealth& Safetystandpointthatprovincialjurisdictionsaregoingto accepttheproduct.” (GovernmentLeader)

Traditionalvendorswereunable tosupplythesecriticalPPE products,andproductsavailablefromthefederalstockpilewere insufficienttoovercomethecriticalchallengesinsupplyshortages. Accordingly,NLhealthcaresupplychainteamspursuedtwo primarystrategiestoaddressthechallengesofhealthcaresupply chaindestabilizationandtheriskofcriticalproductshortages:(i) collaborationwithlocalbusiness leaderstosourcePPEand(ii)the employmentofconservationstrategiesthatreliedonallocation frameworkstodeterminetheusageofandrationPPE.

(1) Collaborationwiththelocalbusinesscommunityto sourceandmanufacturecriticalsupplies:Akey componentoftheNLstrategywasthecollaboration betweenhealthleadersandlocalbusinessleadersto supportboththesourcingofPPEsuppliesthroughtheir uniquesupplychannelsandthecultivationofalocal manufacturingcapacityforPPE.Agroupof75privatesectorandcommunityvolunteers,termed “TaskforceNL,” cametogetherandindependentlywentaboutengaging industrialsupplychainnetworksfromsectorssuchas mining,gasandoil,andretail,tosourceandprocurePPE. Withintwoweeks,TaskforceNLwasabletosourceand donateover1.5millionPPEitemstotheNLhealthcare system.26 AccordingtoahealthsystemleaderinNL, almostallofthelocalindustrialPPEintheprovincewas donatedtothehealthcaresystem:

“

Theygoteverythingfromallindustryhereintheprovince,anything thatwaslocalthatpeoplehadliketheoilrefinery,andalltheminesin Labrador,wegoteverypieceofPPEtheyhad,theygaveittous.And thentheystarted,becausetheyweresupplychainexperts,andPPE crossesallindustries,notjusthealthright,sotheywereusingtheir industrialsuppliersandtheypassedthoseleadsontousandthey helpedussecureatremendousamountofPPE.” (HealthSystem Leader)

TaskforceNLfacilitatedconnectivitybetweenNLhealth supplychainteamsandindustrialsuppliersinthelocal businesscommunity,TaskforceNLalsoestablishedtheirown sourcingandprocurementteam,whichwasfocusedonalternate sourcesofproductsassociatedwithotherbusinesssectors.Once TaskforceNLexhaustedtheirPPEsourcingefforts,theyturned theireffortstowardthecreationofdomesticmanufacturing capacityinNL,whichresultedinthelocalmanufacturingof surgicalmasks,faceshields,andmedicalgowns.Themajorityof thisdomesticmanufacturingcapacityemergedfromtheretoolingorre-purposingofexistingmanufacturingcompanies.

Businessleadersengagedwithunionleadershiptoensurethatthe domestically-producedproductswouldbeacceptableforutilization byfrontlinehealthcareworkers.Theestablishmentofanetworkof localorcommunitypartnershipsandthecreationofadomestic manufacturingcapacitywerebothcrucialcomponentsofNL’s diversifiedsourcingandprocurementstrategy.Thedevelopmentof adomesticmanufacturingcapacityforgownsandfacemasks helpedNLovercomesomeofthesupplyshortagesandstabilizethe supplyofcriticalproducts:

“

OncewespreadouteverythinglocalandthatgotusthroughApril [of2020],werealizedwehitthewallonsourcing.Andso,the taskforcenow,becausetheywereusingvolunteersandworkingall nightlong[and]becauseofthetimedifferenceinothermarkets, [realized]thatwewouldn’thaveenough[supplies].So,whatthey decidetodo[isthink], “well,maybewe’llstartmanufacturingPPE herelocally.” Andso,theygotalltheindustrialsuppliersinthe provinceandstartedmakingfaceshields.AndwegotHealth Canadaapproval,sowe’reusingthosecurrently.Theydecided tomakeLevel3gowns.Agarmentsbagmanufacturerhere,they startedmakingLevel3gownsandgotHealthCanadaapproval. We’reusingthosecurrently.Andtheystartedmakingsurgicalmasks andwe’reusingthosenowforallthepatientsthatareenteringour buildings.Sothatreallyhelped.” (HealthSystemLeader)

(2) PPEconservationstrategies: theNLhealthsystem experiencedsignificantshortagesinN95masks, particularlyintheearlywavesofthepandemic.In ordertosafeguardthelimitedsupplyofPPE,NL implementedaseriesofconservationmeasures, includingtherationing,allocation,andreprocessing ofN95s.EachRHAestablishedasystemfor rationingproducts,creatingguidelinestoindicate situationswhenproductssuchasN95masksshould beusedinpatientcaresettings.Throughthisallocation system,supplychainteamswereabletocloselymonitor andcontrolproductorders.NLsupplychainleadersalso re-distributedproductsfromoneorganizationtoanother basedonprioritizationofneed,aprocessdescribedin thefollowingwordsbyaseniorhealthsupplychain leader:

“

Ifwegotstuckatacertainfacility,weoftentappedintoanother facilitythatprobablyhadasurplusandprobablyweren’tneedingit atthisparticulartime.So,wewererobbingPetertopayPaulin somecasestoo.” (SupplyChainLeader)

Theuseofallocationproceduresgeneratedsignificantconcern amonghealthcareunionsinNL,whoadvocatedfortheabilityof clinicianstomakedecisionsontheuseofPPE,guidedby precautionaryprinciples.Amajorsourceofcontentionbetween theprovincialteamsmanagingtheallocationofPPEandthe healthcareunionswastheallocationofN95masks.Bothunion andhealthleadersdescribedatremendousamountofanxiety amongthehealthcareworkforceregardingtheirpersonalsafety, whichwaslinkedtolimitedaccesstoN95respirators.The implementationoftheseallocationandrationingstrategies resultedinsomeworkrefusals,particularlyinthecommunity

healthsector.Staffprovidingpatientcareincommunitysettings refusedtodoCOVID-19testing(usingnasalswabs)unlessthey hadaccesstoN95respirators.Intheopinionofoneclinician leader,theserefusalsbroughttolightadisparityinthePPE allocationorrationingframework:notably,N95swerereserved foraerosolgeneratingprocedures,whichtakeplaceprimarilyin acutecaresettings.Thisallocationprinciple limitingN95sto aerosolgeneratingprocedures resultedincommunityhealth nurseshavinglittleornoaccesstoN95masks,furtherfuelling fearanduncertaintyregardingtheirpersonalsafetyandthesafety oftheworkplace,describedinthefollowingbyaclinicianleader

“Incommunity[care]theaccesstoN95siftheriskassessmenttold themthattheyneededanN95,theywerenotavailablesoeithertheir managerwouldrefusetoletthemhaveaccesstoitortheyweren’t suppliedbecausetheemployer ’spositionwas,you’renotdoingan aerosolgeneratingprocedureandyourarelydothemincommunity, sowedon’tneedtoevenhavethemavailablethereifyouneeded them.Sothatwasadoublestandard.” (ClinicianLeader)

AseniorhealthsystemleaderinNLlaterreflectedontheuse ofallocationapproachesandthewaysinwhichtheyconstrained theabilityoffrontlinehealthcareworkerstoexercise professionaljudgementinmakingdecisionsonappropriate PPEforcaredeliveryanderodedtrustbetweenhealthcare workersandhealthleadership.Theydescribedthisasa majorlessonlearnedfromthepandemic:

“

IfIwasdoingit[leadingthepandemicresponse]again,Iwould certainlyallowanemployeeself-assessmenttobethetrigger,the riskassessment,whatevertheoutcomeofthatis.” (HealthSystem Leader)

Theyfurthersuggestedthattheerosionoftrustbetweenhealth leadersandfrontlinehealthcareworkerswouldbelong-lasting:

“Ithinkwe’lllivewiththatlongpastthepandemic.Itwilltakea whileforthose,becausethosefeelings[ofalossoftrustinthehealth systemleadership]arethere,especiallyfromnursing,andthat’ s practicalnursingandregisterednursing,thosefeelingsarethere.I dothinkalljurisdictionswilltakeyearstoovercomesomeofthe feelingsfromthis.” (HealthSystemLeader)

Thissameleaderstressed thatthepreservationand incorporationofhealthcareworkerexpertiseintotheirdecisionmakingprocesseswasacriticallessonlearnedfromthepandemic:

“Itwasfoolishness!BecausehowcanyoutellaprofessionalI’ m givingyoutwo[masks]andyou,likeitjustdon’tmakesenseandI thinkofallthings,Imeanwewouldneverdothatnormally ..,ifwe wantedtounderstandsomethingwewouldaskprofessionals becausethat’swhatwe’repayingthemfor.Wewouldn’ttellthem howtodothisorhowtoprotectthemselves.That’salearning.” (HealthSystemLeader)

Aspartofthebroaderconservationstrategy,NLhealth leadersalsoconsideredthesterilizationandreprocessingof N95respirators.However,thisstrategy althoughnever implemented elicitedtremendousconcernfromthehealth workforceandhealthcareunions.Despiteengagementof

cliniciansandIPACexpertiseinthePPEtaskforcetoinform supplyallocationdecisions,thislevelofclinicianengagement wasnotsufficientenoughtomitigatetheprofoundimpactthat allocationandconservationapproacheshadontheanxietyand uncertaintyexperiencedbythehealthworkforce.

DatavisibilityanddigitalInfrastructure

OneoftheearlychallengesfacedbyNLhealthcaresupplychain teamswasalackofdigitalsupplychaininfrastructureand interoperabilityacrosstheinformationtechnologiesineachof thefourRHAs.Theintegratedsupplychainstrategywas centralizedtooneRHA;however,digitalinfrastructurewas notyetintegratedacrossthefourRHAstoofferadigital infrastructureabletotrackPPEutilizationacrosstheprovince. AsthedemandforPPErapidlysurged,healthsystemandsupply chainleadershiphadnoabilitytotrackutilizationrates(or “burn rates”)ofPPE.Toremedythislackofvisibility,healthcaresupply chainleadershipturnedtotheNewfoundlandCentreforHealth Information,anorganizationwiththemandatetosupportthe RHAsinthedeliveryofinformationtechnologyandeHealth servicesfortheNLhealthcaresystem.27

TheCentrecollaboratedwiththeRHAstointegratesupply chaindatafromeachofthefourindependentRHAMeditech systems,andthencreatedprogramstoanalyzesupplyutilization usingdashboardtoolstoenabletrackingofPPEproduct utilizationineachregionoftheprovince.Eachofthefour RHAspossessedaMeditechsystemthatindicatedtheinventory fortheirsuppliesatacentralinventorylevel,butthatdidnot captureproductutilizationatthepoint-of-care.Althoughhealth systemandsupplychainleadersdidhavesomevisibilityto supplyutilizationbasedonchangestosupplyinventorylevels, theyhadlittletonovisibilityintoutilizationatthepoint-of-care onclinicalunitsandlittletonolineofsighttoproductinventory availableinpatientcareareas.ThePPEdashboardprovideda provincialoverview,andprofiledPPEinventoriesforeachofthe RHAs.ThisPPEdashboardprovideddataforcurrentPPE inventorylevelsandutilizationratesforeachRHA,which informeddecisionsonthevolumeofsuppliesneeded,the volumeofproductssourcedandprocured,andthelocation ofPPEinventoriesacrosstheprovince.

AgovernmentleaderinNLdescribedthelimitationsofNL healthinformationsystems:

“

Iwouldsayhereoneofourconstraintsisthesupplychainsystems thatwehaveordonothaveatourdisposal,soeverythingthatwe aremeasuringisfromcentralinventoryratherthandirectlywhat’ s onanyparticular floororwingorunit.Andso,understandingthat flowisachallenge,isamajorchallengeforusandthesystemyou know,we’reusingaMeditechsystemwhichjustisnotas sophisticatedaswe’dalllike.” (GovernmentLeader)

Conclusionsandimplicationsforhealth leaders

FindingsemergingfromthiscasestudyoftheNLhealthsystem demonstratedanumberofstrengthsthatservedasstrategic

assetstoenableeffectiveresponsetotheCOVID-19pandemic inNL.The firstsignificantstrengthwastheintegratedleadership structure,whichwaswellestablishedpriortotheonsetofthe pandemic.TheNLleadershipapproachtomanagingthepandemic washighlyinclusive,wherebyallhealthorganizationswere prioritizedequallyforresourcedistribution.Allhealth organizationswereincludedandsupportedintheprovince’s pandemicresponseandtherewasequityintheirapproach no healthorganizationswereprioritizedoverothersaswasevident inotherprovincessuchasOntario(e.g.,theprioritizationof acutecareoverLTC).

ThesecondstrengththatcontributedtotheNLresponsewasthe highlyintegratedprovinciallevelofcoordinationandcollaboration inpandemicresponseefforts,andmorespecifically,inthe managementofhealthcaresupply.Province-levelcoordination ofsupplychaineffortscoupledwithawell-stablishedsupply chainmanagementstrategywasakeystrengthforNL. Pandemicresponsedecisionswereledprovinciallybythe CMOH,whohadsignificantsupportbyboththeMinisterof HealthandthePremier.AthirdstrengthinNLwasarapidand highlyeffectivecollaborationwiththebusinesscommunity,which wasabletorapidlysourcedonationsofcriticalproductsfrom acrosstheprovinceandquicklyopenednewsourcesofproductvia uniqueindustrysupplychannels.ThebusinesssectorinNL broughtimpressivestrengthtoPPEsourcing,whichmadeit possibleforNLleaderstotakethetimeneededto findnew sourcesofproductgloballyandstabilizeinventoriesforthe provinceaslaterphasesofthepandemicunfolded.NLleader collaborationincludedengagementwithfederalagenciesfor supportinovercomingcriticalsupplychallenges;however, despitealleffortstowardsprocuringproducts,federalagencies wereunabletooffertheneededsupportinovercomingsupply shortages.

Similartootherprovinces,NLexperiencedanumberof challengesmanagingthepandemic.Supplyshortagesofcritical productshadasignificantimpactontheconfidenceofthehealth workforce.Theutilizationofallocationandrationingprocesses hadaprofoundimpactonthehealthcareworkforce,whichis viewedasakeylessonlearnedforthisprovince.Despite engagementofInfectionPreventionandControlexperts, collaborationwithworkforcegroupssuchasunionswas limitedandtherestrictionofcriticalsuppliestolargelysitespecificprocedures(aerosolgeneratingmedicalprocedures) resultedinworkforcechallengessuchasworkrefusals, particularlyforcommunityorganizationsthathadnoaccess toN95s.

Leadershipinsightsandlessonslearned

Thiscasestudyhasrevealedthecrucialityofhealthcaresupply chainfunctioningtosupportandenablecaredeliveryinhealth systems.TheNLexperiencehasmadeclearhowquickly healthcaresupplychaindestabilizationcandisruptcare deliveryinhealthorganizations:lackingapandemicstockpile andrelyingonlengthyhealthcaresupplychainsresultedina profoundshortageofcriticalPPEproductsupplyacrossthe

province.Theimpactoftheallocationofessentialsuppliesby thetraditionalsuppliersreverberatedthroughouttheNLhealth system:healthleadership,fearinganoverwhelmingsurgein COVID-19casesandaconcomitantandsustainedsurgein demandforcriticalproducts,sequesteredandallocatedthe availablesuppliesofPPE.Theuseofanallocationstrategy toconservesuppliesimpactedthewell-beingoffrontline healthcareworkers,whowerenotaffordedtheautonomyto exercisetheirprofessionaljudgementthroughapoint-of-care riskassessment.Thisresultedinbothanxietyandanerosionof frontlinehealthcareworkertrustinhealthleadership.Inshort,a criticalimplicationofthisresearchistheindispensableand strategicroleofhealthsupplychaininfrastructureand managementinsupportingandenablingsafeandeffective caredeliverytopatients.DrawingontheLEADSinaCaring Environmentframework(LEADS)28 theNLcasestudymakes clearthreekeyleadershipstrategies:

Collaborativeleadership. NLleadersengagedforthemostpartina verycollaborativeandhighlyintegratedleadershipapproach,in whichcollaborationwiththelocalbusinesscommunitybecamea criticalcomponentoftheirsupplychainstabilizationeffortsand theintegrationofhealthorganizationsencouragedtheequitable distributionofsupplies.Healthcaresupplychainteamswere integratedintothebroaderprovincialhealthsystempandemic responseandgovernmentleadership(e.g.,theappointeddeputy ministerofPPE)wasdeeplyattentivetosupplychainissues throughouttheearlywavesofthepandemic.However,akey leadershiplessonlearnedwasthatafullyrealizedcollaborative strategymayhaveachievedgreatersuccesshadcollaboration beenextendedto,andengagedwith,thehealthcareworkforceto collaborateonthejointstewardshipofPPEresources.Insucha jointstewardshipmodel,theprofessionalautonomyofhealthcare workerscouldhavebeensupportedbyengagingnurses’ unionsin theco-designofstrategiestoconservePPE,whilehonouringthe abilityoffrontlinehealthcareworkerstoexerciseapoint-of-care riskassessment.Amorehorizontaljointstewardshipmodelfor criticalresourcescouldhaveallowedforhealthleadershipto collaboratewith,andbeinformedby,frontlinestaff.

Developingcoalitions. AcrucialaspectofNL’shealthcare supplychainpandemicmanagementresponsewasitsabilityto engagecoalitionsbeyondtheirtraditionalnetworkofrelationships. Acoalitionbetweenhealthleadersandataskforceofbusiness leadersinNL(TaskforceNL)washighlyeffectiveandableto sourcePPEsuppliesatatimewhentheyweredesperatelyneededto supportthesafetyoffrontlineworkers.Asthecoalitionevolved, domesticmanufacturingofPPEproductswasanadditionalsource ofPPEinventorytosupporttheNLhealthsystem.Thecreationofa domesticmanufacturingcapacityinNLwasanothersuccessful outcomeofthiscoalitionwiththebusinesscommunity,which allowedforthemobilizationofdomesticsupplierstosupplytheNL healthsystemwithsuppliessuchassurgicalmasks,faceshields, andmedicalgowns,whichcontributedtohealthcaresupplychain stabilization.

Systemtransformation. Supplychaininfrastructureisthe bedrockuponwhichhealthcaremanagementtakesplace. Post-pandemicsystemtransformationandrecoverywill requiretherecognitionthatthehealthcaresupplychainisa criticalandstrategicassetforhealthsystems.Byensuringthat qualityproductsareeffectivelydistributedtohealthcare workers,resilienthealthsupplychainprocessesmakeit possibleforhealthsystemstodeliverqualitycarethatis timelyandmeetsthedemandforcareacrossthepopulation.

NL’shealthleadershipresponse, whichstressedcollaboration andtheformationofmulti-sect oralcoalitions,allowedfor innovationandsystemtransf ormation:thecreationofa sustainable,domesticsourceofcriticalsupplies,which workedtostabilizeandshortenthehealthcaresupply chain.Theseeffortswouldhavebeenimpossiblewithout buildingcoalitionssupportedb yacollaborativ eleadership approachthatwaswillingtotransformthehealthcaresupply chainstatusquo.WhereNLhealthleadersdidnotenacta collaborativeleadershipapproach,theyriskedcompromising thetrustbetweenhealthcareworkersandleadership.The consolidationoftheseimplicationsmakesclearthatthe healthcaresupplychain(includinghealthcaresupplychain data,infrastructure,andprocesses)andhealthcaresupply chainmanagementmustbeviewedascriticalassetsfor healthleaders.ThekeyimplicationsoftheNLcasestudyfor healthleadersincludethefollowing:coalitionsandcollaborative leadershipmodelshelptofostersupplychainresilienceand supporthealthsystemtransformation;theclinicalintegration ofthehealthcaresupplychain,includingtheestablishmentof linkagesbetweenhealthcaresupplychainteams,health leaders,andfrontlinehealthcareworkersisessential;thejoint stewardshipofresourcesiscrucial;andtheintegrationof healthcaresupplychainmanagementisanessentialcomponent andenablerofsupplychainresilienceandhighlyeffective healthsystemperformance.

Inconclusion,theNLcasehighlightsthevalueandimpactof thefollowing:

· coordinatedandcentralizedhealthcaresupplyprocesses thatservedallhealthorganizationsequitably;

· theimportanceofdedicatedandspecializedhealthcare supplychainteams,whichwerewellorganizedacrossthe fourRHAs;

· theabilitytobringsupplychainexpertisetoprovincial decision-makingtables;and

· thevalueofdiversifiedsourcing,whichincludeddomestic manufacturingcapacity.

ThesefeaturesoftheNLhealthcaresupplychainresponse canserveaswaymarksontheroadtohealthcaresupplychain resilienceinCanada.

Funding

TheworkwassupportedbyCanadianInstitutesofHealthResearch, grantnumberVR5172669.

ORCIDiD

AnneW.Snowdon  https://orcid.org/0000-0003-4640-6842

References

1.SnowdonA,AlessiC. Visibility:TheNewValuePropositionforHealth Systems.WorldHealthInnovationNetwork;2016.Availableat: https:// scanhealth.ca/explore-projects-resources/view-all-articles/89-visibilitythe-new-value-proposition-for-health-systems-condensed-version.

2.WongJC. HospitalsFaceCriticalShortageofIVBagsDueto PuertoRicoHurricane.TheGuardian;2018. https://www. theguardian.com/usnews/2018/jan/10/hurricane-maria-puertorico-iv-bag-shortage-hospitals

3.MostafidAH,RedortaPJ,SylvesterR,etal.Therapeuticoptionsin high-risknon-muscle-invasivebladdercancerduringthecurrent worldwideshortageofbacilleCalmette-Guerin. EurUrol.2014; 67(3),359-360.doi:10.1016/j.eururo.2014.11.031

4.LowDE.SARS:LessonsfromToronto.2004.In:KnoblerS, MahmoudA,LemonS,MackA,SivitzL,OberholtzerKeds. LearningfromSARS:PreparingfortheNextDiseaseOutbreak: WorkshopSummary.Ottawa,ON:NationalAcademiesPress. 63-83.

5.SmithPM,OudykJ,PotterG,etal.Theassociationbetweenthe perceivedadequacyofworkplaceinfectioncontrolproceduresand personalprotectiveequipmentwithmentalhealthsymptoms:A cross-sectionalsurveyofCanadianhealth-careworkersduringthe COVID-19pandemic. CanJPsychiatry.2021;66(1):17-24.doi: 10.1177/0706743720961729

6.AbdulsalamY,GopalakrishnanM,MaltzA,etal.Healthcare matters:Supplychainsinandofthehealthsector. JBusLogist. 2015;36(4):335–339.doi:10.1111/jbl.12111

7.LandryS,BeaulieuM.Thechallengesofhospitalsupplychain management,fromcentralstorestonursingunits.In:DentonBed. HandbookofHealthcareOperationsManagement.NewYork: Springer;2013:465–482.doi:10.1007/978-1-4614-5885-2_18

8.RicklesH. TheMysteriousCaseofHealthcareLogistics,AHRMM AnnualConference.SanFrancisco:SettingtheStandard;1999.

9.EbelT,GeorgeK,LarsenE,etal. BuildingaNewStrengthinthe HealthcareSupplyChain,McKinsey&Company;2013. https://www. mckinsey.com/~/media/mckinsey/dotcom/client_service/pharma %20and%20medical%20products/pmp%20new/pdfs/mckinsey %20white%20paper%20-%20building%20new%20strenghts% 20in%20healthcare%20supply%20chain%20vf.pdf .Accessed September1,2021.

10.KwonIWG,KimSH,MartinDG.Healthcaresupplychainmanagement;strategicareasforqualityand financialimprovement, TechnologicalForecastingandSocialChange.2016;113(partB): 422-428.

11.DixitA,RoutroyS,DubeySK.Asystematicliteraturereviewof healthcaresupplychainandimplicationsoffutureresearch. IntJ PharmHealthcMark.2019;13(4):405–435.doi:10.1108/IJPHM05-2018-0028

12.GendyAWA,LahmarA.Reviewonhealthcaresupplychain [conferencepaper].2019IEEE/ACS16thInternationalConference onComputerSystemsandApplications(AICCSA);3–7November

2019;AbuDhabi,UnitedArabEmirates.pp.1–10.doi:10.1109/ AICCSA47632.2019.9035234

13.KumarS,BlairJTUS.Healthcare fix:Leveragingthelessonsfrom thefoodsupplychain. TechnolHealthCare.2013;21(2):125–141. doi:10.3233/THC-130715.

14.ArshoffL,HenshallC,JuzwishinD,etal.Procurementchangein Canada:Anopportunityforimprovingsystemperformance. HealthcManageForum.2012;25(2):66-69.doi:10.1016/j.hcmf. 2012.03.002.PMID:22931011.

15.AldrighettiR,ZennaroI,FincoS,etal.Healthcaresupplychain simulationwithdisruptionconsiderations:Acasestudyfrom NorthernItaly. GlobJFlexSystManag.2019;20(1):81–102. doi:10.1007/s40171-019-00223-8

16.MandalSTheinfluenceoforganizationalcultureonhealthcare supplychainresilience:moderatingroleoftechnologyorientation. JBusIndMark.2017;32(8):1021-1037

17.SnowdonAW,SaundersM.COVID-19,workforceautonomyand thehealthsupplychain. HealthcQ.2021;24(2):16-26.

18.Yin,RK. CaseStudyResearch:DesignandMethods.4thed. ThousandOaks,CA:Sage;2009.

19.GovernmentofNewfoundland&Labrador.Newsrelease:Minister Haggieannouncesimplementationofasharedservicesmodelfor SupplyChainManagement.July17,2021. https://www.releases. gov.nl.ca/releases/2017/health/0720n04.aspx

20.CowanPNL ClosedWarehouseswithMillionsofMasksandGowns inYearsbeforePandemic.CBCNews https://www.cbc.ca/news/ canada/newfoundland-labrador/pandemic-warehouse-covid-19-nl1.5554977.UpdatedMay5,2020.AccessedSeptember1,2021.

21.KellandA.Caul’scluster. CBCNews https://newsinteractives.cbc. ca/longform/cauls-cluster.PublishedApril8,2020.Accessed September1,2021.

22.AyearofCOVID-19:Milestonesandmomentsinanunforgettable year. CBCNews https://www.cbc.ca/news/canada/newfoundlandlabrador/milestones-moments-covid19-1.5946036 UpdatedMarch 14,2021.AccessedSeptember1,2021.

23.GrantT.AsCOVID-19casesrise,N.L.andP.E.I.exitAtlanticBubble foratleast2weeks.CBCNews. https://www.cbc.ca/news/canada/ nova-scotia/atlantic-bubble-burst-1.5812454 UpdatedNovember24, 2020.AccessedSeptember1,2021.

24.Travelrestrictions.GovernmentofNewfoundlandandLabrador. https:// www.gov.nl.ca/covid-19/travel/travel-restrictions AccessedSeptember 1,2021.

25.PandemicUpdate – CurrentStatus.Newfoundland&Labrador COVID-19pandemicupdatehub. https://covid-19-newfoundlandand-labrador-gnl.hub.arcgis.com/ AccessedSeptember1,2021.

26.Blitzlaunchedformasks,gloves,gownsandotherPPEitems. CBCNews https://www.cbc.ca/news/canada/newfoundland-labrador/ taskforce-nl-ppe-covid-19-1.5527325 PublishedApril9,2020. AccessedSeptember1,2021.

27.Newfoundland&LabradorCentreforHealthInformation. https:// www.nlchi.nl.ca/

28.DicksonG,ThollB.Bringingleadershiptolifeinhealth:LEADS inacaringenvironment. PuttingLEADStoWork.2nded. Switzerland:Springer;2020.doi:10.1007/978-3-030-38536-1