Supplychainintegrationasastrategyto strengthenpandemicresponsivenessinNova Scotia
andMichaelJ.Saunders,PhD1HealthcareManagementForum 2022,Vol.35(2)62–70 ©2022TheCanadianCollegeof HealthLeaders.Allrightsreserved.
Articlereuseguidelines: sagepub.com/journals-permissions DOI:10.1177/08404704211061223 journals.sagepub.com/home/hmf
Abstract
Thisprovincialcasestudy,oneofsevenconductedaspartofanationalresearchprogramonhealthcaresupplychain managementduringCOVID-19,focusesonNovaScotia.Duringthe firstwaveofthepandemic,NovaScotiafacedthemassive destabilizationofitstraditionalsupplychannelsandhadtograpplewithroleclarityandcommunicationinitsemergency responsestructure.NovaScotiawasabletocentralizeitspandemicsourcing,procurement,andmanagementeffortstoits provincialhealthauthority.Healthcaresupplychainteamswereabletorapidlymodifytheirsourcingandprocurementprocessesin ordertocompensateforthedestabilizationoftheirstandardsupplychannelsandassumeresponsibilityfortheprovince-wide managementanddistributionofpandemicsupplies.TheNovaScotiacase findingsmakeclearboththevalueofacentralizedand dedicatedhealthcaresupplychainresponse thatintegratesallprovincialcaredeliveryorganizations andthediversi ficationofthe healthcaresupplychain.
Introductionandreviewofliterature
Supplychaininhealthsystemsincludesthesourcingand distributionoftheproductsnecessarytoensurethat healthcareteamshaveaccesstotherightproductsattheright timeinordertodeliversafeandeffectivepatientcare.1 Inhealth systems,supplychainteamssourceacomplexanddiversearrayof productsandequipment,fromventilatorsandintravenouspumps, tomedications,vaccines,andPersonalProtectiveEquipment (PPE).Andyet,thestrategicimportanceofthehealthcare supplychainforhealthsystemcapacitytodelivercareis,for themostpart,neitherreflectedincurrentresearchliteraturenor profiledrelativetobestpracticesalignedwiththeuniquemandate ofhealthsystems.Therecentglobalpandemichasclearly demonstratedtheuniqueroleofsupplychaininenablinghealth systemstodelivercareinatimelyandsafemanner.
Thereisalonghistoryofsupplychaindisruptionsthathave occurredduetonaturaldisastersandpublichealthcrises, resultinginsevereconsequencesthathaveputhealthworkers andpatientsatsignificantrisk.OneexamplewasHurricane Mariain2017,whereelectricalgridswerewipedoutinPuerto Rico,whichdisruptedtheproductionofintravenoustherapy products,(e.g.,IVbags)manufacturedbyBaxter.2 Thedemand forIVbagsskyrocketedglobally,causinganincreaseincostby 600%.2 Similarly,a floodin2012impactedSanofi Pasteur,the supplierofthecancerdrugImmuCyst.Theresultwassignificant delaysincancertreatmentforpatientsasmanufacturerscould notincreaseproductionofthedrugrapidlyenoughtomeetthe demand.3 Publichealthcrises,suchastheSARSepidemic,also putextremepressureonhealthsystemsupplychains,duetoan increaseindemandforthecriticalproductsrequiredtokeep healthworkersandpatientssafefromtransmissionofthe SARSvirus.Notonlydothesecrisesputthephysical healthofessentialworkersatrisk threeofthe44 CanadianswhodiedfromSARSwerehealthcareworkers4
emergingevidencealsoidentifiessignificantimpactonthe mentalhealthoftheworkforce.Inthecurrentpandemic,the inadequatesupplyofPPEandtheuncertaintythesesupply shortagescreatedamongCanada ’shealthcareworkforce resultedinhighratesofmentalhealthissues,suchasanxiety anddepression.5
Healthcaresupplychainsinvolveadiversityofstakeholder groups,includingpatients,clinicians,suppliers,healthcare organizations,grouppurchasingorganizations,distributors, andinsurers,whichaddstotheircomplexity.6,7 However, researchandevidenceofbestpracticesforhealthcaresupply chainprocessesandmanagementlagsfarbehindotherbusiness sectors.8-10 Whileresearchdedicatedtounderstandingsupply chainandlogisticshasbeenwellestablishedintheprivate sector,significantgapsinresearchremaininthehealthcare sector.11-14 Currentresearchonsupplychainandlogisticshas focusedprimarilyonotherbusinesssectorsandoftenattemptsto applynon-healthcaresupplychain–specificevidenceand insightstohealthcaresupplychainchallenges.However,the attempttotranslateindustrialornon-healthcaresupplychain processestohealthcaresupplychainmanagementriskseliding thespecificityofthehealthcaresupplychain,especiallyits uniqueendpointinthecarefor,andprotectionof,human life.Practicesthatarerelevanttoindustrialsupplychain management(suchasjust-in-timelogistics)maynotbe readilyapplicabletohealthcaresupplychainmanagement becauseanydestabilizationofthehealthcaresupplychain maycompromisethesafetyofcaredeliveryforbothpatients
1 UniversityofWindsor,Windsor,Ontario,Canada.
Correspondingauthor: AnneW.Snowdon,UniversityofWindsor,Windsor,Ontario,Canada. E-mail: anne.snowdon@uwindsor.ca
andtheworkforce.AsAldrighettietal.note,giventhattheend ofthehealthsupplychainishumanlife,thestandardbywhich healthsupplychaincapacityismeasured,isdifferentfromthat ofindustrialsupplychains:
“InthecontextofHSCs[healthcaresupplychains],suchdisastrous events[asdisruptions]canpotentiallyhavedevastatingeffects becausehumanlivesareonthetable:thesenetworkscannot affordtoregistermissingdrugsinthehospital,i.e.itshould alwaysperformwithservicelevelequalto100%.”15
Thisneedforthecapacityofahealthsupplychaintomaintain a “servicelevelequalto100%” helpstocontextualizetheurgency ofthedevelopmentofstrategiesforhealthcaresupplychain resilience,anditisakeydifferentiatorofthehealthcare supplychainfromindustrialsupplychains.Whenthe healthcaresupplychainbreaksdown,theresultisadirect impactonhumanlife.15-17 TheCOVID-19pandemichasled tounprecedentedchallengesforhealthcaresystemstomeetthe surgeindemandforcareofpeoplesufferingwithCOVID-19 infections.Researchisneededtounderstandtheuniquefeatures andoutcomesofhealthcaresupplychainandtocreateevidenceto informthedevelopmentofbestpractices.
Thispaperreportsoncasestudyresearchoftheprovinceof NovaScotia,revealingempiricalevidenceofsupplychain processesandinfrastructurewithinandacrossthisprovincial healthsystemduringthe firsttwowavesoftheCOVID-19 pandemic.Thisevidenceisanalyzedtodocumentleadership approachesandstrategies,supplychaincapacitytorespondtothe pandemic,andarticulatetheimplicationsandkeylessonslearned forleadershipstrategies.Together thisanalysisisofferedtoinform thedesignofeffective,agile,andresponsivepandemicsupply managementstrategiesforCanadianhealthsystems.Thiscase studyisoneofsevenprovincialcasestudies(BritishColumbia, Alberta,Manitoba,Ontario,Quebec,NewfoundlandandLabrador, andNovaScotia),fundedbyCIHR(Ref.#VR5172669),thatwere conductedtoexaminehealthsupplychaincapacityand infrastructureacrossCanada.Thisresearchconstitutedthe first nationalstudyofhealthsupplychain.Thecasestudywasdesigned torespondtothefollowingresearchquestions:
· Whatarethesupplychainprocessesandinfrastructure requiredtooptimizeeffectiveandtimelyhealthservices deliveryforthecurrentandfuturephasesoftheCOVID19pandemic?
· Whatprocurementmodels,approaches,andpolicy frameworksoffersecuresourcingofproductstomeet thesurgeindemandforcarebyCOVID-19patients?
· Whatisthedigitalmaturityofsupplychaininfrastructure (andprocesses)inNovaScotia,that,ifstrengthened, couldoptimizemanagementofCOVID-19?
· Whatarethedatainfrastructureandanalyticsstrategies neededtostrengthentheeffectivenessofhealthsystem supplychainprocessestosupportCOVID-19management?
· Whatistheinfluenceoffederalgovernmentinitiatives, fromtheperspectiveofprovincialstakeholders,on
provincialhealthsystemcapacitytomanageCOVID-19?
Methodology
ThiscaseexaminestheprovinceofNovaScotia’sresponseto COVID-19,highlightingitsuniquechallenges,opportunities,and experiencesinhealthcaresupplychainmanagementduringthis unprecedentedpandemic.TheUniversityofWindsor’sResearch EthicsBoardprovidedapprovalforthisproject.Thiscasewasone ofseven,aspartofanationalCIHRRapidResearchprogram entitled “DevelopmentofanImplementationFrameworkto AdvanceProvincialandNationalHealthSystemSupplyChain ManagementofCOVID-19. ” Acasestudyapproachwasdesigned tounderstandNovaScotia’shealthcaresupplychainresponse duringtheCOVID-19pandemic.Casestudiesofferawayto exploreandinvestigatereal-lifephenomenonthroughanalyzing thecontextofeventsandtherelationshipsbetweenthem.18 Theprimarygoalofthiscasestudyresearchwastounderstand therelationshipsbetweenleadershipstrategies,keysupply chainmanagementstrategiesandcapacity,andhealth systemresponseacrosssevenCanadianprovinces.The primarydatasourceforthisempiricalstudycamefrom15 semi-structuredinterviewswith11keyinformants.Ofthese15 interviews,fourwerefollow-upinterviewswithkeyinformants. Theoreticalsamplingwasusedtoidentifyparticipantsthat representedvariedperspectivesandexpertise,including informantsfromgovernment,healthcareorganizations, healthcaresupplychainexperts,healthcareunions,and publichealth.Documentanalysisandpreviousresearch informedtheconceptualframeworkandinterviewguide. Purposefulsamplingwasusedtoidentifytheparticipants whorepresentedvariedperspectivesandexpertise,including healthcaresystemleaders(n=9),healthcaresupplychain experts(n=1),andunionleaders(n=1).Keyinformants werecontactedbyemailandprovidedwithaparticipation letterpriortotheinterview,i dentifyinginformationabout thestudyandtheirroleandright sasaparticipant.Interviews wereaudiorecordedusingMicrosoftTeamsandtranscribed byaprofessionaltranscriptionist.Keyinformantresponses describedexperiences,perceptionsandperspectiveson supplychaincapacity,processes,andhealthsystem responsesandsupplymanagementduringthe fi rstand secondwaveoftheCOVID-19pandemic.
Anonymitywasensuredthroughde-identi ficationof participantsanddata(e.g.,removalofanypotential identi fi ers,suchasindividualororganizationnames),such thatonlytheresearchersconductingtheinterviewwereaware ofparticipantidentities.Codingofinterviewsproceededas datawascollected,wherebyresearcherswereabletoidentify emergingthemesandconceptstoenablerefl exivityas interviewdatawerecollectedandanalyzed.Dataanalysis software,N-Vivo(version12)wasusedtoassistwiththe organizationandanalysisofsemi-structuredinterviewdata. Thefollowingsectionsdescribetheresultsoftheanalysisfor thiscasestudyofNovaScotia.
Figure1. TimelineofKeyCOVID-19pandemicmilestonesinNS.
Provincialcontext
InNovaScotia,therearetworegionalhealthauthorities,Nova ScotiaHealth(NSH)andtheIWKHealthCentre(IWK),which areaccountableforthedeliveryofhealthservicesacrossthe province.Theseregionalhealthauthoritiesreporttothe DepartmentofHealthandWellness(DHW).In2015,nine districthealthauthoritieswereconsolidated,creatingasingle healthauthority(theNovaScotiaHealthAuthority,whichwas renamedasNovaScotiaHealth)withfourregionalmanagement zones(Western,Northern,Eastern,andCentral).19 TheIWK HealthCentre(theIWK),awomenandchildren’shospital,was notincludedinthisamalgamationprocessandremainsa separatecorporateentitywithitsownboardofdirectors.19
Anexistingstockpileofpandemicsupplieswasinplaceprior totheCOVID-19pandemic,whichwasmanagedbytheDHW. However,thispandemicstockpilewasnotadequatetomeetthe rapidsurgeindemandduringthe firsttwowavesoftheCOVID19pandemic.Thislackofadequatepandemicstockpile preparednesswasattributedtotwokeyfactors:(1)the stockpilewasprimarilycreatedfortheH1N1pandemicand wasthereforeinsufficientforthescopeandscaleoftheproduct demandcreatedbytheCOVID-19pandemic;and(2)therewas noclearstrategytomanagethestockpileinventory,resultingin expiredandoutdatedproductsinthestockpilethatwere discarded.Accordingly,keyinformantsstressedthatthisprepandemicsupplypreparednessstrategywasnotadequateto meetthedemandsoftheCOVID-19pandemic.
PriortotheCOVID-19pandemic,NSHandtheIWKhad theirowndistinctsupplychainmanagementteams.Ifhealthcare supplychainteamsneededtoprocureaproduct,theywould first engagetheircontractedvendorstosourcetheproduct.Iftheir
existingvendorscouldnotsecuretherequiredproductorfulfilla particularsupplyvolumerequirement,theywouldthenturntoa GroupPurchasingOrganization(GPO),whichleveragedthe aggregatebuyingpowerofmultiplehealthorganizationsto securethelowestpossibleproductcostfromvendors. Establishedvendorcontractswerethecornerstoneoftheir pre-pandemicsourcingofproductstosupportcaredelivery. Grouppurchasingorganizationswereengagedonlywhen supplycouldnotbeprocuredfromexistingvendorcontracts inNovaScotia.OncetheCOVID-19pandemicunfolded,the establishedsystemofcontractedvendorswasdestabilizedand unabletosupplysufficientquantitiesofproductstomeetthe surgeindemandforcare.
COVID-19inNovaScotia
OnMarch15,2020,the firstthreepresumptivecasesofCOVID19wereannouncedinNS.20 OnMarch22,2020,NSdeclared aprovincialstateofemergency,andanyoneenteringthe provincewasrequiredtoself-isolatefor14days.21 Amajor outbreakofCOVID-19intheNorthwoodLongTermCare(LTC) facilityoccurredinAprilof2020andresultedin360people becominginfected(bothresidentsandstaff)andthedeathsof53 residents.ThedeathsintheNorthwoodoutbreakaccountforjust overhalfofthetotaldeathsduetoCOVID-19inNovaScotia. FromMaytoJuneof2020,withadecreaseinnewcases,Nova Scotiabegantorelaxpublichealthrestrictions.InJune,its emergencyresponsestructurewasstooddown.OnJuly3,2020, residentswerefreetotravelwithintheAtlanticprovinces (PrinceEdwardIsland,NewBrunswick,NovaScotia,and NewfoundlandandLabrador),creatingwhatwascalledthe “Atlanticbubble.” However,onNovember23,2020,with
Figure2. NSCOVID-19pandemicresponsegovernancestructure.
risingCOVID-19casesinNewBrunswickandNS, NewfoundlandandLabradorandPrinceEdwardIsland announcedtheirwithdrawalfromtheAtlanticbubble.22 To date,NovaScotiahashad6038casesand94deathsdueto COVID-19.23 ThekeymilestonesforCOVID-19inNovaScotia areillustratedin Figure1
Emergencygovernancestructures, decision-making,androleclarityintheNS pandemicresponse
InJanuaryof2020 beforetheappearanceofthe firstcaseof COVID-19intheprovince anNSHincidentmanagement teambegantomonitorandprepareforpotentialcasesof COVID-19.Torespondtotheearlywavesofthepandemic, NovaScotiaimplementedanEmergencyOperationsCentre structureforboththeprovincialgovernment(Departmentof HealthandWellness)andNSH.TheIWKengageditsIncident ManagementCommittee(IMC)inmid-February(Figure2).
TheprovincialEOCstructurewasledbytheChiefMedical OfficerofNovaScotia.Eachofthehealthauthorityzones (Western,Northern,EasternandCentral)hadtheirown EOCsthatreportedintoNovaScotiaHealthEOC.InmidFebruary,withtherealizationthatthepandemicwouldbeof significantscopeandscale,theIWKmobilizeditsIMCto manageitspandemicresponse,whichwasfullymobilizedby March2020,whenthestateofemergencywasdeclaredinNova Scotia.
TheNSleadershipstructurewasmulti-layeredandwas viewedbysomeinformantstobecomplexandchallengedby communicationandlackofroleclarity,describedinthe following:
“Roleclarity[wasanissuefrom]toptobottom,likebetween individuals,betweendepartments,betweengovernment.Insome areasdepartmentofhealth,what’syourrolehere?Youknow,NSHA, what’syourrolehere?Andwehadenormouschallengeswithrole clarityrightfromthefrontlineallthewaythroughtothetop.” (ClinicianLeader)
Specifically,communicationanddecision-makingbetween publichealthandthehealthauthoritieswasnotwellestablished. PublicHealthdecisionswereperceivedtobeinfluencedbythe perceptionthatPPEwasinshortsupply:
“Insomesituations,IstillthinkPublicHealthdidnotimplement someprotocolsassoonastheycouldbecausetherewasstillthis concernthatifwedidhaveanoutbreak,thatsomeofthosesupplies wouldbeeventuallyneededbythecorehealthsystem.Anditdid takeus,ortherehasbeenalotofconvincing,tosay:we’regood, we ’regood,wecanconsiderallofthat.Wehaveenoughforthe doctorsandthefrontlinestaff pleasegoaheadandgiveoutthese maskstothepublic.” (SupplyChainLeader)
GiventhecrucialityofPPEandthecapacityofhealthsupply chaintosupportresponsivenesstothepandemic,amultiorganizationalPPEtaskforcewascreatedinearlyAprilof 2020,whichincludedmembersfromboththeDHWandNSH EOC.Thistaskforcewasmandatedtomakedecisionsonhow PPEsupplieswouldbeusedinclinicalsettings,assessrequests forPPEfromcaresettings,andapprovepandemicprocurement decisions.Significantly,itwasabletoprovideaprovinciallens onhealthsupplychainandPPEissues.Asub-committeeofthis taskforcewasaPPEassessmentgroup.ThisPPEassessment groupwasresponsibleforassessingtheclaimsforPPErequests fromallsectors;theywerealsoresponsibleforthedevelopment oftheallocationmodelsnecessarytoguidedecisionsonhow
PPEandcriticalproductsweredistributedtothevarious organizationsacrosstheprovince.Thedeputyministerleading thePPEgovernmenttaskforcewasabletosupport,approve,and takeresponsibilityforthepurchasingdecisionsofNSH healthcaresupplychainteamsinordertohastenprocurement ofcriticalsupplies.NSHhealthcaresupplychainteamswere ultimatelyresponsibleforallofthepandemicsourcingand procurementeffortsacrosstheprovince.
Followingthe firstwaveoftheCOVID-19pandemic,a “COVIDnetwork” wasestablishedtoformalizetheNS pandemicmanagementandgovernanceresponse.The COVIDnetworkdesignatedclearrolesandresponsibilities forstaffteamswhowereassigneddedicateddutiesaligned withmanagingCOVID-19,asdescribedbyasupplychain leaderinNS:
“…withtheCOVIDnetworkit’sapersistent,constantlypulsing structurethatisalreadyorganizedandfocusedonthetypesofissues needed So,we’vekindofcreatedamorepersistentfocused networkthroughtheCOVIDnetworkstructure,ifthatmakes sense,withpeoplehavingdesignatedrolesandresponsibilities.” (SupplyChainLeader)
Theleadershipstructureshiftedfromamulti-layeredEOC structuretoanetworkstrategyasthedemandsofthepandemic shiftedandchangedovertime.
Supplychaincentralizationandstrategyto supportpandemicresponse
Duringthe firstwaveofthepandemic,thesourcing, procurement,andmanagementofpandemicsupplychain needswere centralized totheNSHsupplychainteam. However,thiscentralizationwasnotimmediate.TheNSH healthcaresupplychainmandatedidnotinitiallyencompass managingandsupportingLTCfacilities.Instead,LTChadto accessandobtainsuppliesprovisionedby,theprovincial stockpileofpandemicsupplies,describedinthefollowing:
“Ithinkwhenwestarted,inNovaScotia,theDepartmentofHealth, thegovernmentarm stillistheoperatorandthedelivererof homecareandnursinghomeservicespredominantly.Theyhadtheir ownseparatestockpile,theirowndecision-makingprocess,their ownsupplychainlogisticsprocess,separatetoNSH.” (Supply ChainLeader)
AccordingtoaPPEtaskforcemember,therewasagapof threeweeksbetweentheimplementationofthesamepolicies (includingmaskingprotocols)anddistributionofthesame protectivesuppliestoLTCfacilitiesaswereprovidedto acutecarehospitals.
TheinitialapproachoftheNSHEOCwastoprioritizethe distributionofcriticalsuppliestohospitals,astrategythatwas motivated,atleastinpart,bymediareportsfromItalyofhospital systemsbeingoverwhelmedbypatientswithCOVID-19and unabletomobilizeproductstosupportcaredelivery.However, thelargestCOVID-19outbreakinNovaScotiatookplaceinthe NorthwoodLTCfacility.AreviewoftheCOVID-19outbreakat
theNorthwoodLTCfacility ledbygovernmentappointed infectiousdiseaseconsultants suggestedcriticalstaff shortages,dif fi cultyisolatingCOVID-19positivepatients tomitigatetheriskoftransmi ssionofthevirus,andalack ofaccesstoInfectionPrevent ionandControlspecialists, werecontributingfactorstothismajoroutbreak. 24 All pandemicsupplymanagementwaseventuallycentralized totheNSHhealthcaresupplychain,resultinginamore proactiveandequitablesupplymanagementstrategythat workedtosupportall healthcarefaciliti esintheprovince. TheintegrationofLTCintosupplychainmanagementwasa criticallessonlearnedfromexperienceduringthe fi rstwave ofthepandemic:
“Business,industry,healthcare,LTC, everybodygetstheirPPE fromonegroup.Andit’sagroupthatadviseandoverseethisone giantstockpile.So,andwhatthatresultedin,inwave1,isthatthe nursinghomesandLTC,wewerelatedecidingtomaskthem, decidingonpoliciestoprotectthem,thethingsyouputinplacein hospital,wewere3weeksgettingthesamepolicyandprocedures andgearouttothenursinghomesandthatkilledus.Thatwasthe biggestproblem.So,wave2starts,we ’ vegot fi ttestinginnursing homes,onthesamedaywe’ vegot fi ttestinginendoscopyand departmentswe’ reworriedaboutinacutecare.” (Clinician Leader)
Sourcingstrategies. Supplyshortageswereachallengewell beforethe firstcaseofCOVID-19wasconfirmedinNova Scotia.However,asthepandemicunfoldedglobally,supply chainteamssetouttosourceandprocurecriticalsuppliesin ordertobuildcapacitytorespondtoanticipatedcasesof COVID-19.InFebruary,NSHsupplychainleaderssent outwhattheycalled “pulsebuys”—likearadarpulse doublingtheirorderswiththeirtraditionalvendorsto determinewhichproductswouldbethemostdifficultto sourceandprocure.Throughthesepulsebuys,itbecame immediatelyapparenttohealthcaresupplychainleadersthat thecontractedprovidersorvendorswouldnotbeabletomeet thesurgeindemandacrossthehealthsystemforsomecritical products.Alongsidethedestabilizationofthetraditionalhealth supplychain,asourceofuncertaintyforNShealthleadership wastheFederalhealthsupplychain.Aclinicianleader describedhowtwofactorscompromisedthereliabilityof theFederalhealthsupplychainduringthe fi rstwaveofthe pandemic:(1)alackofproduct;and(2)alackofvisibilityto theFederalsupply:
“So[theywere]uselessat firstbecausethey[theFederal government]didn’thavemuchtogive.Reallyhardtonailthem downonwhattheymightbeabletosourceandsupply,sotheywere notonourradaratall,liketheywere,werankourorders,they neverbecamealowriskorder.Theywerealwayslikewedon’tknow, wecan ’tcountonit.” (ClinicianLeader)
“Fromaprocurementandsupply[perspective],wedidnotusethe fedssupplyverymuchatall.Definitelynotatallearlybecausethey didn’t,wehadnovisibilityandnoabilityto figureouthowwemight getit[supplies],whenwemightgetit,etc.” (ClinicianLeader)
Accordingly,NSHhealthsupplychainteamsquickly realizedthatadditionalstrategiestoprocurecriticalsupplies wouldberequiredinordertohavethecapacitytosupplycritical productstohealthcareorganizations.Thelimitedsupply availabletomeetthesurgeindemandforcriticalproducts forcedNSHhealthsupplychainteamstorapidlymodify theirprocurementprocessestobemoreresponsiveandagile insourcingproducts,aprocessdescribedinthefollowing:
“DuringCOVID,weagreedthatduringtheemergencymeasures periodthatwewerein,andtheneedtoreactquicklyandleverage non-traditionalchannels,westillinprinciplefollowed[ourtraditional operationaldesign],so firstwewouldtrytogeteverythingweneed offa[GPO]contract,whichwedidtrytodo,butthen wefound thatmostofthevendorsthatweweredealingwiththroughcontracts werethetraditionalmainlinevendorsandtheydidn’thavealotof extracapacitytoprovidesupply.So,then,ratherthansendingthe requirementtoNovaScotiagovernmentprocurement,we[the healthcaresupplychainteam]executedwhateverdollaramount wasnecessary[topurchaselargevolumesofproducts],becausewe hadthemostintimateunderstandingofwhattherequirementswere andwereabletobeagileandmakethosearrangementsquickly.” (SupplyChainLeader)
Whenseekingoutalternativesourcesofproducts,vendors withaphysicalpresenceinNS,orNS-basedimporterswere prioritizedbyhealthcaresupplychainteamsinordertomore directlyengagewiththenewvendortoensureproductdelivery. Tomitigatetheriskoffurthersupplychaindestabilization, healthsupplychainteamsalsoplacedmultipleordersto multiplevendorsforthesameproduct,andattemptedto identifyproductsourcesinmultiplegeographicregions. Insteadof “puttingalloftheireggsinonebasket,” asa supplychainleaderputit,theyplacedorderswithmultiple vendors,toensurethatmultiplevendorswouldbeworkingon theirbehalftosecureproductsfromsuppliers.Theyalso attemptedtoidentifyproductsourcesinmultiplegeographic regions,undertheassumptionthatthediversificationof geographicsourcesofproductswouldhelptomitigatetherisk offurthersupplychaindestabilization(intheevent,forexample, thataregioncloseditsborders).Inthisdiversifiedprocurement strategy,ifthreeoftheirfamiliarvendors vendorsthattheyhad donebusinesswithbefore couldfulfillanorderforaproduct, thenthefourthvendor “slot” wouldbe filledbyan “unfamiliar” vendor.Theywouldsolicitsamplesfromfouror fiveofthese unfamiliarvendors;the firstvendortoprovideasamplewouldbe awardedthecontract.
ThisrapidlydiversifiedsourcingstrategysuccessfulforNova Scotia.AsupplychainleaderdescribedNovaScotia asa “Goldilocksprovince,” oneideallysuitedforthe cultivationofadomesticmanufacturingcapacity:
“NovaScotiaisaGoldilocksprovincebecausewe’rejustbarelybig enoughtotrytodothingsinanorganizedway,butwe’renottoobig thattryingtodothingsinanorganizedwaycreatesimpossible problemstosolveandtoomanystakeholderstocorral.So,for example,ongowns,wewereabletoconvertafactorythatexisted fort-shirtstomakegowns,andweonlyhadtoconvertonebecause
we ’renottoobig,andthatonefactorywasabletoproduceasmany gownsasweneeded.Wewereabletogetallofthehandsanitizerwe neededfromregionalproductionfromdistilleriesandprivatesector, andwewereabletodothatagainbecausewe’renottoobig.The capacitythatalreadyexistedwaswillingtoshift.” (SupplyChain Leader)
However,inordertoalleviatepressuresonespeciallyscarce criticalproducts,likeN95respirators,NovaScotiaalso implementedallocationandconservationstrategiestoconserve productinventoriesasmuchaspossible.
Supplyconservation. NovaScotiaimplementedallocation frameworkstocontrolaccesstocriticalsuppliesbylimitingthe useofPPEtospecificclinicalsituations.ThePPEsubcommitteeof thePPEgovernmenttaskforcewasresponsibleforthe developmentoftheseallocationmodels.ThescarcityofN95s andalackofup-to-date fit-testingamongthehealthcareworkforce requiredsupplyinventoryofmultipledifferentsizesofN95sto fit testeachstaffmember.Eachemployeeinhealthorganizationswere requiredtobe fittedfortheappropriateN95mask.Onceamask wasusedfor fittesting,ithadtobediscarded.Accordingly,supply chainteamshadtosourceN95sfor fittestingaswellassufficient inventoriestosupportinfectioncontrolprotocols.Thiswas explainedbyasupplychainleader:
“Forthe firstmonthI’dsayandthatwasachallengingdynamic becauseyou’retryingtoacquireN95sandyoualwayshavetofactor inthe fittestingyouknow,timeittakesto fittest,thequantityit wouldtaketo fittest,itdoesn’thelptogetasmallquantityofN95s. Youreallyhavetogetenoughthatyouhaveenoughto fittestand thenconsumeforareasonableperiod.Sothatwasmorethe pressureonN95sattheoutset.” (SupplyChainLeader)
“Thetestingwasn’tuptodateforalotofstaff,staffweren’t fittested acrosstheboardalwaystothekindsofmodelsthatwecould provide,andsoweactuallyusedmoreN95sfor fittestingthanwe didforCOVID-19.” (SupplyChainLeader)
TolimitaccessforN95masks,supplychainteamsremoved themfromclinicalareasthatweredeterminedtonotrequirethe useofthesemasksbasedonthecareproceduresrequiredineach setting.BysequesteringtheN95s(andothercriticalsupplies)to acentralizedwarehouse,NovaScotiasupplychainteamswere thenabletoallocateandmonitorproductusage.The implementationofconservationstrategieshadatremendous impactonthementalwellbeingoffrontlinehealthcareworkers duetoperceivedlackofsafetyintheworkplace,whichwasa sourceofanxietyanduncertaintyforthefrontlineworkforce.A Nurseleaderdescribednurses’ concernsaboutaccesstoPPE:
“
Wehadhundredsandhundredsofcallsfromnurses,mostly concernedaboutPPE.Wehadalotofcallsfromnursesthat maybeareimmunosuppressedortheywerecaringforasenior intheirhomeortheyhadyoungchildrenandsotherewasalossof, agreatdealofanxietyandfearinthe firstI’dsaytwomonths becauseoftheunknown,right.Andtherewassomanychanges,like wedidn’twearmasks,thenwedidwearmasksandyouhadshields, sotherewaschangesalmosteveryotherdayinwhatthePPE
requirementswouldbe.Sothatcreatedalotofangstaswell.” (ClinicianLeader)
NursingunionsadvocatedfornursestohaveaccesstoN95s whencaringforallCOVID-positivepatients.Theyalsoadvised theirnursestorequestN95sifwarranted,followingapoint-of-care riskassessment.PPEusageguidelines,however,restrictedthe usageofN95stoaerosolgeneratingmedicalprocedures,which primarilytakeplaceinacutecaresettings.Allocationmeasures thereforelimitedtheabilityofnursestoexercisetheir clinicaljudgementintheuseofprotectiveproducts.To redressthisdiminishmentofprofessionalautonomy,nurses ’ unionsadvocatedforamemorandumofunderstandingwiththe governmenttoallownursestomakedecisionstodeterminetheuse ofprotectiveproductsinclinicalsettings.However,thisstrategy wasunsuccessful.Accordingtoonesupplychainleader,asupply “conservationmindset” extendedwellintothesecondwaveof thepandemicandcontinuedtoshapethepandemicsupply managementresponse,evenassuppliesstabilized:
“What’sreallyinterestingnowthoughis,wehaveanabundanceof N95snow,butwe’restillholding firmonthosesameprinciplesas wedidbackattheverybeginning,sowe’restillbehavingina conservationmindset.” (SupplyChainLeader)
Despitethesuccessoftheteam’ssourcingstrategies, conservationofPPEsuppliesremainedinplacelongafter supplyinventorieswererestoredandwereabletorespondto thedemandsurgeinsupplyutilization.Aconservationmindset towardssupplydistributioncontinuedthroughouttheearly wavesofthepandemicacrossNovaScotia.
Domesticsourcing. AnothersupplychainstrategythatNS employedtohelptostabilizeitssupplyinventorieswas sourcingfromlocalmanufacturers.Anotableexamplewas theretoolingofalocalgarmentmanufacturingcompany, whichpivotedtomanufacturingmedicalgowns.Local manufacturersquicklyestablishedalocalmanufacturing capacityfocusedonprotectiveproductsorequipmentto supporttheNovaScotiahealthsystem.Thecapacityforlocal manufacturingtosupportthedemandfordomesticsourcesof protectiveproductsisdescribedinthefollowingbyahealthcare supplychainleader:
“
Icouldtellyouforhandsanitizerover90%wasdomestic.For gownsI’dsayabout50%wasdomestic.Forshieldsprobably60% wasdomestic.Forgloveszero.Andforfacemaskszero.Andonthe wholethatprobablymeansabout30-40%wasdomestic.” (Supply ChainLeader)
Localproductionofprotectiveequipmentbecameanimportant sourceofsuppliesofferingabufferagainstthechallengesof sourcing,evaluating,andsecuringgloballymanufacturedproducts.
Datainfrastructureandmodelling
Attheonsetofthepandemic,NovaScotialackedarobustdata infrastructure,whichresultedindecision-makersandsupply
chainteamshavingtoestimatetherateofutilizationof protectiveproductssuchasPPE,thelocations(e.g.,clinical settingsandhealthorganizations)whereproductsweremost needed,andthedegreeofurgencyofproductdemand.To overcomethislackofdatavisibility,themanualcountingof productsineachhealthorganizationwasrequiredtounderstand utilizationrates.Toovercometheinaccuraciesofmanual counting,thesupplychainteamelectedtomonitorandtrack dailyordersforproductsasasurrogateforproductutilization rates.Tableausoftwarewasusedtocreateadashboardofdaily ordersofsupplyvolumesasanestimateofsupplydemandand utilizationratesacrosstheprovince.Thelimitationsofsupply volumeestimatesininventoryandutilizationratesacrossthe provinceremainedachallengethroughoutthepandemic.
Pandemicstockpilestrategy. Adecision approvedbythe government wasmadebyhealthcaresupplychainleaders inNovaScotiatocreatethewarehousingcapacityand pandemicsupplystockpilenecessarytoaddressprovincewidesupplyneeds.Asasupplychainleaderexplained,this pandemicstockpilerequiredthedigitalinfrastructureto incorporatenon-HAcustomers:
“Wegot[the]infrastructureandITtechnologysothatwecouldserve anycustomerregardlessofwhethertheywereprivatesectororpublic sectorthroughacommontechnologyplatform,whichwouldhave beenpreviouslyimpossiblewithournormalERPsystem.So,webuilt alltheunderlyingenablement.” (SupplyChainLeader)
Thecreationofdigitaltoolsenabledamoredata-driven supplychainstrategy,whichincludeddatamodellingto examinevariousscenariosor “whatif” situations.Dataand digitalinfrastructuremadeitpossiblefortheteamtotakeamore proactiveapproachtoplanningforavarietyofpossibleevents, suchassurgeindemandforcriticalproducts.Thiswas describedbythesamesupplychainleader:
“
Whenwemodelourrequirements,wemodelthemunder circumstanceswhereprotocolsthatdon’tevenexistcould possiblyexist.So,wearetryingtoforeseedemandfromplaces thatwe,Iguesslookingatwhatotherjurisdictionshavedone aroundtheworld,weaskourselvesaquestion:whatifwedidthat here,evenifit’snotpotentiallyontheradarhere,justincaseat somepointourleadershipdecidestheywouldliketodothattoo? Andso,wearestillscanningtheenvironment.Wearestillincluding demandinourmodellingwhichthenfeedsourprocurementstrategy forthingsthatarecurrentlynottakingplaceheretotrytoanticipate andbeready.AndforN95sastheexample,wecontinuetoandhave beenprocuringwellabovethequantitythatourcurrentconditions oranyyouknow,reasonablyforeseeablesetofcircumstanceswould predictwe’drequire.So,wearestilltryingtoalwaysnotbe,Iguess, achallengefromanimplementationperspective.” (SupplyChain Leader)
AlthoughdigitalinfrastructureinNovaScotiawasnotwell developedpriortotheonsetofthepandemic,supplychainteams createdthedashboardtoolsanddataanalyticscapacity necessarytomobilizeexistingdata.Thisenabledproactive
modellingtoanticipatedemandsforproductsandensurethat theirhealthcaresupplychaincouldreadilyrespondtoand adequatelysupportpublichealthdirectives.
Conclusionsandimplicationsforhealth leaders
TheCOVID-19pandemichasrevealedthecriticalstrategic importanceofhealthcaresupplychainmanagementand processesforsupportingcaredelivery.Healthcaresupplychain destabilizationcangreatlycompromisetheabilityofhealthcare systemstodelivercare.Atthesametime,measurestoprioritize theallocationofcriticalproductsandconserveproduct inventoriesduringsupplyshortages,canresultinthe inequitabledistributionofsupplies,negativeoutcomesforthe healthworkforce,andputatriskvulnerablepopulations,suchas residentsofLTCfacilities.DrawingontheLEADSinaCaring Environmentframework(LEADS),25 theNovaScotiacase studymakescleartwokeyimplicationsforhealthleaders:
1.Theimportanceofintegratinghealthcaresupplychain expertiseintoleadershipdecision-making
AlthoughhealthcaresupplychainteamsinNovaScotiafelt supportedbyhealthleadership,alackofcommunication betweenseniordecisionmakersandhealthcaresupplychain teamsledtoadelayintheimplementationofcriticalpublic healthpolicies,duetotheperceptionofsupplyshortages.That is,decisionsonpublichealthmeasurestomitigatetheriskof transmissionoftheviruswereviewedasbeingin fl uencedby supplycapacity.Inthiscase,theassumptionmadebyhealth leadersofanabsenceor limitationofsupply attimes in fl uencedleadershipdecision-makingandextendedtheuse ofconservationmeasureslong aftersupplyshortageswere overcomeandinventorieswerereplenished.Theestablishment ofclearlinesofcommunicationbetweenseniorhealthleadership andhealthcaresupplychainteamssupportgreatercollaboration indecision-making,informedbysupplychaindataand capacitytorespondtosupportimplementationofleadership decisions.
2.Systemstransformation:Provincialsupplychainconnectivity forsupplyequity
Ifsupplychainmanagementisacriticalenablerofahealth system’scapacitytodelivercare,thenhealthcaresupplychain processesmustbeequitableandinclusivetoensureallcare deliveryorganizationsaresupportedtodelivercareeffectively andsafely.Alackofdigitallyenabledsupplychain infrastructureinNovaScotialedtoadelayinproviding criticalproductstoLTC.Healthleadershipprioritized hospitals,withonlymanuallycollecteddataonsupply inventorytoinformdecisions.Asufficientlyconnectedand engagedhealthcaresupplychainstrategy,whichisinclusiveof allcaredeliveryorganizations,wouldallowfortheequitable distributionofcriticalproducts.InNovaScotia,afterthisinitial
delay,amorecomprehensiveandinclusivesupplychain strategywasaugmentedbydigitaltools,whichwereableto estimatesupplyutilizationpatternstoinformdecisionson productdistribution.Dataanddigitaltoolstransformed supplychainprocessesandinformedleadershipdecisionsto enableaproactivesupplymanagementapproachforLTCand theintegrationofallcaredeliveryorganizationsintoa centralizedhealthcaresupplychainstrategyacrossthe province.Healthcareleadersareuniquelypositionedto mobilizeresourcestoadvancedigitallyenabledsupplychain processestomanageandensuretheequitabledistributionof criticalproductsnecessarytoprotectCanadiansandthehealth workforce.TheNovaScotiacaseclearlydemonstratesthevalue ofadigitallyenabledsupplychainstrategythatoffershealth systemsthecapacitytorespondproactivelytocriticalshortages andensurethesafeandeffectivecaredeliveryforeverycitizen. Healthleadersshouldconsiderthewaysinwhichcaredelivery dependsuponhealthcaresupplychainresilienceand connectivity uponasupplychainthatcanprovideequitable andcomprehensiveaccesstoessentialsupplies.
TheCOVID-19pandemichasexposedthecrucialityofa connectedanddigitallyenabledhealthcaresupplychainthatis supportedandinformedbydatatoaccuratelytrackutilization andsupplychaincapacitytomeetdemandsforhealthservices. NovaScotiadiversifieditssourcingandprocurementof criticalmedicalproductsbyplacingmultipleorderswith multiplevendors,andbalanceditsprocurementstrategy withadomesticsupplierstrategytooffsetglobalshortages. Atthesametime,theNovaScotiahealthcaresupplychain experienceduringCOVID-19makesclearthenecessityofa supplychainthatencompassesandequitablydistributes productstoallcaredeliveryorganizationswithinaprovince. ThesekeyfeaturesoftheNovaScotiastrategyofferimportant evidencetoinformstrategiestoadvancesupplychainresilience inthepost-pandemicfuture.
Funding
Thisarticleis financiallysupportedbyCanadianInstitutesofHealth Research(VR5172669).
ORCIDiD
AnneW.Snowdon https://orcid.org/0000-0003-4640-6842
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