The COVID-19 pandemic has impacted healthcare organizations globally, particularly from a supply chain perspective. Leaders with successful responses have drawn upon their toolkit to anticipate threats, recognize crises, respond decisively, visibly engage in problem solving and facilitate communication. By harnessing these skills, leaders have tackled COVID-19-related challenges, including panic buying, organizational goal misalignment, staff anxiety and criticism. By applying crisis management theory and presenting learnings from interviews with American and Canadian healthcare leaders, we present solutions and lessons learned, including implementing communication methods, building staff resiliency, reducing staff anxiety and leading virtually.
Crises are unpredictable forces of change, threatening the survival of impacted organizations, particularly those ill-equipped to adapt. Whether human-made or natural, crises share a few underlying themes: creating uncertainty, challenging the status quo and forcing change. Despite the overwhelming nature of crises, there are those who stand against the fierce headwinds: leaders. These are the individuals who create resilient organizations, guide staff through change and motivate others to persevere through the direst of circumstances.
The COVID-19 pandemic is a unique crisis, concurrently impacting all industries globally. The healthcare supply chain was arguably the most impacted among these as personal protective equipment (PPE) production slowed down, but its demand skyrocketed. Healthcare leaders defied the impulse of panic, setting cultures of calm resilience and perseverance.
At the centre of the frenzy was Shared Services West (SSW), a not-for-profit healthcare supply chain organization in Ontario. As a leader in delivering integrated and innovative supply chain services, SSW was in a position to see the impact of the COVID-19 pandemic across the supply chain. To learn from a diverse set of experiences and best practices, we interviewed a variety of healthcare leaders across the US and Canada, including organizations such as the Cleveland Clinic and Toronto's University Health Network (UHN). Their observations and experiences will form the foundation of our recommendations.
Research on Crisis Leadership
Navigating a crisis requires a particular set of skills. Based on the literature and interviews with healthcare leaders, we have categorized our findings into three key themes: crisis preparedness, crisis response and strengthening people.
The crisis mindset represents organizational beliefs about risks (Pearson and Clair 1998). Shaped by leadership, strong crisis anticipation mindsets drive organizations to assess potential threats and engage in crisis preparedness activities (Penrose 2000). As one leader with a strong crisis mindset reflected, "We learned from Hurricane Maria that it's easier to plan for a crisis when you're not in a crisis." While hospitals are no stranger to crisis preparedness activities (e.g., bomb threats and infrastructure failure), many did not consider preparing for a supply chain crisis or a sustained global crisis. As organizations began reacting to the COVID-19 pandemic in December 2019, Mayo Clinic in Rochester, MN, stood out with its crisis preparedness. Having established detailed protocols outlining communication and leadership strategies, as well as stress-testing procedures with mock events, Mayo Clinic had developed a robust crisis response framework, allowing a rapid response to the pandemic.
Decisive responses in the face of uncertainty allowed organizations to move quickly. But this can be challenging when leaders do not even know what the problem is. As Dirani et al. (2020) described, leaders must process information quickly and make decisions swiftly, yet not impulsively, in a way that prioritizes people first. Many healthcare leaders described their response akin to building a plane mid-flight. Leaders also stressed the importance of making decisions with integrity when information was not available. As Tammy Quigley, vice president of Operations at SSW, and one of the authors of this paper, shared:
You make sure you can defend your decisions on the front page of the newspaper.
Clear and open communication is arguably the most important aspect of crisis leadership. Successful leaders keep people informed and are transparent with what is known and what is not to obtain staff buy-in. Structured and informed communications prevent staff from perceiving worst-case scenarios (Wu et al. 2020). Specific communication strategies will be discussed throughout this article.
Recognizing the impact of a crisis is another element of a successful leadership response. Beyond PPE shortages, the pandemic challenged normal processes and impacted each person differently depending on their role. The stressors behind staff anxiety during the pandemic have been distilled into five key themes by Shanafelt et al. (2020): hear me, protect me, prepare me, support me and care for me. Staff look for work environments where their voice is heard, their safety is considered, adequate training is provided and appropriate support is given to assist working under stressful conditions. In times of crisis, when staff are working at the expense of their families and mental health, the expectation is that leadership will rise to create conditions that ease staff burdens. When these conditions are met, staff feel more engaged and have greater faith in their leadership.
Building resiliency is critical for long-duration crises; it helps people maintain a positive outlook when faced with adversity (Wu et al. 2020) and influences work satisfaction and engagement (Cross et al. 2021). While resilience can be built from within oneself, it is also strongly enabled by relationships and networks (Cross et al. 2021). Describing resilience as a "team sport," Cross et al. (2021) shared that it is the daily interactions between people that build resiliency. Examples of such interactions are those that help us laugh, make sense of people and politics and find perspective and purpose. At a broader level, leaders can increase staff resiliency by communicating a defined and clear optimistic vision, a realistic plan, decisive action and frequent honest feedback (Wu et al. 2020). By encouraging interactions that build resiliency, leaders can ensure that staff are equipped to endure the temporary hardships associated with crises.
Key Leadership Challenges during the COVID-19 Pandemic
Throughout the COVID-19 pandemic, healthcare leaders faced a variety of unique challenges. From a supply chain perspective, the landscape had changed. Hospitals began competing with each other for PPE, and there was a misalignment of goals among hospitals, distributors and group-purchasing organizations (GPOs). From a broader perspective, leaders were also faced with staff anxiety and receiving criticism. The healthcare leaders we interviewed shared their strategies on how they applied the elements of crisis leadership to their challenges.
Panic buying: The wild, wild west
As COVID-19 started spreading to the west, suppliers were notifying their hospitals that critical PPE was on a global back order. Hospitals turned to their pandemic stockpiles for reassurance, only to find that most stock had either expired, was grossly understocked or was misaligned with the current need (e.g., stock was not updated to current fit-tested product). Panicked that their need would exceed supply, hospitals and other healthcare organizations began procuring PPE in vast quantities at any price from any vendor. Without a provincial, state or national PPE strategy in the early stages, hospitals entered into competition with each other, driving up the price of critical products and leaving smaller organizations unable to procure the much-needed PPE.
To make matters worse, many individuals saw this lack of coordinated leadership as an opportunity to exploit the healthcare system. Without the luxury of time to properly assess new vendors for reliability and product standards, many organizations purchased counterfeit or subpar PPE at grossly marked-up prices. Accepting this reality, one organization shared, "We purchased level three masks knowing they would likely test at level one."
Foreseeing these issues, many hospitals began increasing their inventory of critical items. To ensure that inventory was sustainable, clinical experts and infection prevention and control professionals were involved to develop PPE conservation strategies and discuss substitutable products. To make data-informed purchasing decisions, hospitals began conducting detailed analyses of PPE usage and inventory trends. Leaders among supply chain organizations and hospitals collaborated to share information and resources, avoiding duplication in vetting new vendors and repurchasing of subpar products. Government agencies at the federal and provincial/state level also stepped in to facilitate coordinated purchasing: Ontario implemented the Supply Chain Management Act (2019), whereby the government used hospital data to prioritize PPE needs and allocate products provincially.
The most significant learning from this is the importance of early leadership collaboration, particularly in a Canadian healthcare context, where there is little competition among hospitals. Leaders should be strengthening their relationships with their counterparts and establishing systems for information exchange during a crisis. Additionally, this highlights the importance of informed decision making. While inventory usage and movement data were hastily compiled during the COVID-19 pandemic, hospitals should explore how it can be incorporated into regular processes and decision making as a shield against panic in future supply chain disruptions.
Organizational goal misalignment within the supply chain: Who is in charge here?
Without a clear, unified approach to supply chain management, misaligned goals within a supply chain can lead to dire consequences during a supply or demand shock such as the COVID-19 pandemic. The key players in most healthcare supply chains include suppliers, distributors, shared service organizations (SSOs) and GPOs and hospitals. Within hospitals, supply chains can get even more complex, incorporating decisions from purchasing departments, physicians, nursing staff and other clinicians. If these entities are not all aligned, the entire supply chain becomes weak and disorganized.
According to McKone-Sweet et al. (2005), the most common goal misalignment within healthcare supply chains has been between ensuring an ample supply of high-quality products and maintaining a low-cost structure. While clinicians are primarily concerned with maximizing the amount and quality of available inventory, hospital purchasing teams, distributors and SSOs/GPOs are often more concerned with reducing the overall cost (particularly for products such as PPE). Because clinicians often lack formal training in supply chain practices, the management of supply chain activities falls to groups focused on providing lower costs (McKone-Sweet et al. 2005). This led to the implementation of stockless inventory systems such as just-in-time and took inventory flow control out of the end-user's hands. As one leader described:
We are victims of our own success in driving cost out of the system. It shouldn't come as a surprise that companies do not keep a year's worth of supply on hand.
While this system of inventory management was effective prior to the COVID-19 pandemic and continued to work effectively for non-critical products during the pandemic, the flow of crucial products such as PPE was severely disrupted by increased hospital demand and reduced product supply caused by the pandemic. Furthermore, the SSOs/GPOs responsible for purchasing the required items for hospitals lacked both authority and discretionary income to make the necessary purchases in a timely manner. In addition, there was little direction provided on how to access federal and provincial/state PPE stockpiles. Smaller hospitals began reaching out to larger organizations that had available funds, such as UHN, which became de facto PPE distributors for a number of healthcare centres around Ontario.
To address this problem, leaders from the Cleveland Clinic in Cleveland, OH, recommended forming a coalition of SSOs/GPOs, hospitals and state/provincial representatives and exploring public–private partnerships with distributors at a state/provincial level. This would have ensured that leaders among all supply chain entities collaborated in decision-making processes and established aligned goals, thereby maximizing inventory and product quality while minimizing product costs.
Staff anxiety: Keep us safe
The COVID-19 pandemic drained healthcare workers physically and mentally. Facing long hours and extreme workloads from the unrelenting flow of COVID-19 cases, staff carried the burden of fear of infecting those at home. Long hours created new concerns for staff, such as access to childcare or even the ability to conduct simple tasks such as grocery shopping. Compounding the external stressors, hospital leadership was constantly changing PPE usage guidelines to conserve stock and align with evolving best practice, but the rapid pace left many staff feeling confused and inadequately supported, resulting in credibility issues among leadership.
Leadership was quick to enact strategies that addressed most of the themes that Shanafelt et al. (2020) outlined. Centred on the theme of "hear me," hospitals engaged clinical and infection prevention and control staff in supply chain discussions. At Cleveland Clinic, leadership created a clinical expert peer group to develop protocol and ensure that it was consistently followed. Rather than emphasizing that there was a PPE shortage, leadership began asking departments why usage was so high. In giving departments an opportunity to be a part of the decision-making process, there was greater buy-in across the organization.
Leaders excelled at "prepare me" and "protect me" by regularly communicating information in a central location and providing PPE coaches throughout the organization to ensure that PPE was being used correctly. Leaders also offered staff COVID-19 testing and infection prevention and control resources to reduce its spread to families. Leaders were exemplary at meeting four of the five criteria to address staff anxiety, and improvement recommendations were focused on the last criterion: care for me. Leaders should be creating a more thorough wellness strategy that provides resources addressing the impact of work-related stress on personal lives. This includes mental health support, supporting tangible needs such as food and child care and paid time off in the event of infection.
Addressing criticism: We are in this together
All leaders face criticism throughout crises. Many individuals were critical of leadership decisions and frequently changing guidelines, some acting in a disrespectful manner, their anger stemming from fear. As Quigley described:
Our challenge now is that everybody is so tired, your resiliency has been beaten down and you're challenged as a leader to keep up your energy, keep your teams motivated and be an authentic leader.
The healthcare leaders we spoke to highlighted the importance and difficulty of developing organizational resiliency. To build resiliency, many leaders implemented a variety of tools to communicate their vision and provide decisive action. Hospitals created virtual interactive town halls and live forums to communicate their vision, understand the concerns of staff and maintain perspective. Much of the criticism stemmed from a belief that leadership was withholding information. To counteract this, leaders shared information they had access to and clearly identified what was known and what was not. Leaders also stressed the importance of being authentic with their communications and empathizing with employees who were struggling throughout the crisis. Once staff knew that they had the same information as leadership and felt acknowledged, criticism was noted to decrease. As leaders continue to strengthen staff resiliency, they should invest in social aspects of resilience building, emphasizing the importance of social interactions and network building.
Applying our three-pronged framework of crisis preparedness, crisis response and strengthening people, we have distilled our findings into five lessons learned:
- Recognize supply chain as a critical component of business operations. Supply chain has been on the back burner of the executive table for years, often taken for granted as a stable component of organizational operations. As Rebecca Repa, executive vice president of Clinical Support and Performance at UHN, shared:
In some ways, we let our guard down. It was not the exciting stuff that brought us down, but the simple things that people thought would be a no-brainer.
A learning for many leaders is that supply chain is not simply a component of business operations but a fundamental enabler of success and quality of care.
- Build and sustain supply chain crisis response plans. Mayo Clinic was able to respond to the pandemic earlier and more decisively by applying lessons learnt from Hurricane Maria's impact on the supply chain. This demonstrates that while documenting lessons learned is important, leaders must go beyond that to ensure that the hard lessons learned from the COVID-19 pandemic are honoured. Lessons should be incorporated into emergency preparedness activities. Regularly updated documents should be created that outline clear accountability during an emergency. Organizations must also undergo drills that encompass multiple departments to simulate a coordinated response under stress. As one leader shared, "You don't become a high-performing sports team with everyone practising on their own."
- Incorporate risk tolerance into decision making. During a crisis, leaders can easily be overwhelmed with information and choices. There are no right or wrong options, but rather options that are better suited to some organizations than others. To ensure quick decisions, leaders must have a strong understanding of their organization's risk tolerance and standards. Leaders must also understand what the key enablers for their organization's success and business continuity are. By understanding risk tolerance, leaders can make quick, thoughtful decisions that are the most appropriate for the organization.
- Share knowledge to enable successful crisis responses. Supply chain is not the core business of hospitals, with many outsourcing their supply chain management or building small in-house expertise. However, many hospitals had neither and were not equipped to navigate the unstable COVID-19 supply chain. Knowledge sharing played a key role in defining the ability of these hospitals to navigate their supply chain needs. Both SSW and UHN shared a wealth of knowledge and resources regarding product quality and vendor reliability, enabling less-resourced hospitals to efficiently procure quality products. Going forward, leaders must be quick to share knowledge and experiences during crises to ensure that quality of care is maintained.
- Strengthen staff by building resiliency. Leaders guide organizations but rely on staff to implement their vision. To assist staff in navigating an unpredictable and heavy workload during a crisis, leaders must meet the needs of staff. Communicating information to staff as soon as it is known by leadership and offering support programs such as paid parking, mental health services and childcare assistance eases the burden of stress among staff. Building staff resiliency must be considered in the development of future crisis response plans to ensure that staff are able to maintain quality of care and act decisively.
Healthcare leaders have overcome the considerable challenges of the COVID-19 pandemic by drawing upon skills in their leadership toolbox. As the crisis becomes more manageable, it is time for leaders to reflect on organizational learning and adapt the organization (Flynn 2002). SSW has completed such a lessons-learned exercise, whereby leaders discussed which approaches worked well and, which did not and what lessons should be incorporated into normal procedures. There are also many key learnings that the healthcare leaders we spoke to reflected upon. Early collaboration between organizations is crucial, both in sharing knowledge and delivering a coordinated response. Data are invaluable, and infrastructure must be in place to collect and analyze data quickly for decision making; when data are not available, decisions should be made based on values and integrity. Our organizations comprise people who are vulnerable to stress, and underlying issues behind anxiety must be part of organizational strategy. Staff depend on leaders to have a vision, communicate frequently and be empathetic and honest in order to build resiliency. Leaders must be adaptable to navigate organizations through sudden changes while maintaining organizational culture. By internalizing these learnings and adapting, leaders can create stronger and more resilient organizations.
About the Author(s)
Roxanne Patel, BHSc, MSc (eHealth), MBA, is a senior business process and data analyst at the University Health Network (UHN) in Toronto, ON. She can be reached by e-mail at firstname.lastname@example.org
Connor Schmidt, BBA, MA (Economic Policy), is a research/analysis officer at Transport Canada in Ottawa, ON. He can be reached by e-mail at email@example.com
Karen Belaire, BA, CPA/CGA, C.Dir, MBA, is the president and chief executive officer of Shared Services West in Burlington, ON. She can be reached by e-mail at firstname.lastname@example.org
Tammy Quigley, BSc, MBA, MCM, CHE, is the vice president of Operations at Shared Services West in Burlington, ON. She can be reached by e-mail at email@example.com
Rebecca Repa, BA, MBA, is the executive vice president of Clinical Support and Performance at UHN in Toronto, ON. She can be reached by e-mail at firstname.lastname@example.org
The authors want to acknowledge the following individuals for discussing their organization's leadership and crisis response strategies: Erich Heneke, director of Business Integrity & Continuity, Supply Chain Management, and Jim Francis, division chair, Supply Chain Management, both at Mayo Clinic; Simrit Sandhu, system executive director, Supply Chain and Support Services at Cleveland Clinic; Anand Joshi, vice president, Procurement & Strategic Sourcing at New York-Presbyterian Hospital; and Mike Hopkins, vice president, Supply Chain Distribution and Logistics from Northwestern Medicine.
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