Strategies for Creating a Resilient Healthcare Supply Chain

Strategies for Creating Architecture a Resilient Healthcare Engineering Supply Chain

Interiors Consulting

One of a series of white papers by Page professionals Written by Monica Perez, Contributers: Hilary Bales, Mary Loftus

With roots extending back to a two-person partnership formed in 1898, Page is one of the most prolific and enduring architecture and engineering design practices. Page architects, engineers, interior designers, planners, strategic analysts and technical specialists provide services throughout the United States and abroad. Our diverse, international portfolio includes projects in the academic, advanced manufacturing, aviation, civic, corporate, government, hospitality, housing, healthcare, mission critical, and science and technology sectors.

The Page portfolio consists largely of complex projects that benefit from our integrated disciplines and that make a significant impact on the communities they serve. We are guided by the three core values of creativity, collaboration, and commitment, and through the force of these ideals, we live up to our promise of design that makes lives better.

Visit our website at pagethink.com

2

Name of Book

INTRODUCTION Healthcare materials and operations managers know that to provide world-class patient care, clinical and support staff must be properly equipped with the right tools and supplies to do their jobs. Supply chain issues have long plagued hospital systems even prior to the Covid-19 pandemic. Inefficient operational workflows, unreliable vendors, product shortages, overabundance of product options, and lack of proper supply tracking are a few of the challenges that hospitals face to keep a fully stocked facility.

In addition to patient overcrowding, the pandemic caused many issues in the daily operations of hospitals. Fear of the unknown and staff/patient safety were exacerbated by large gaps in the supply chain due to reduced manufacturing capacity. This included shortages of personal protective equipment (PPE) for infection control.

Protective clothing, helmets, gloves, face shields, goggles, facemasks, respirators, and other equipment designed to protect the wearer from injury, or the spread of infection or illness, were in high demand and often not available for the hospital staff when they needed it most.

Lack of PPE induced a panic response to scarcity that resulted in the hoarding of materials, as nurses and staff were called to the front lines to address an outbreak and eventually a pandemic.

This led to the purchase of extra materials to ensure future demands could be met, the amount of which the facilities were not equipped to handle or store. Materials were often left unsecured on pallets on loading docks, corridors, supply rooms or wherever additional storage could be found. Labor and supply shortages meant clean rooms were not adequately stocked with PPE and staff were forced to hunt down the necessary supplies to protect themselves as they treated patients.

These compounding issues, listed below and intensified by the pandemic, encouraged many hospitals to re-evaluate their storage, processes and flow within the materials management department.

For the following case studies, Page was engaged to reimagine hospital loading supply management areas and identify opportunities within existing buildings or new proposed designs to improve storage capacities and operational workflow.

UNIVERSAL CHALLENGES

Existing supply chain issues hospital systems have faced, worsened by the pandemic:

Product shortages (high demand, low production)

Lack of supply security (open receiving areas, unlocked storage, no tracking methods)

Labor shortages (illness of self or family members, imposed quarantine, competing demand)

Lack of square footage for proper supply chain receiving, staging, storage, and restocking and over purchasing

Inefficient and increased operational workflows (excessive steps, expanded duties)

Unreliability of supply delivery from vendors (national/international disruptions, transportation issues, driver shortages)

Management of mail deliveries and distribution (ex. Amazon packages, USPS, FedEx)

4

Strategies for Creating a Resilient Healthcare Supply Chain

CASE STUDY – LARGE MID-ATLANTIC HEALTH SYSTEM

The existing loading dock area, approximately 19,000 sq. ft., at a major mid-Atlantic region hospital could not fully manage the daily volume of supplies, linen, and mail while simultaneously processing the volume of outgoing materials, such as soiled linen, trash, and recyclables. To assist in resolving these challenges, Page was hired to streamline the design and develop construction phasing to increase the capacity of an undersized loading dock, receiving staging space, and adjacent materials management / environmental services areas.

As the facility grew over the years, its central stores became more decentralized. With management focused on patient care and revenue generation, logistic integration was not a priority until it impacted care delivery. This led to multiple storage sites around the campus and constant shuffling of supplies to locate supply closer to demand.

The decreased visibility of stock and inventory maintenance became challenging.

An inadequate amount of exterior loading dock bays, coupled with undersized storeroom areas and bulk deliveries during the pandemic led to surplus supplies being stored in corridors. This resulted in a series of issues including the co-mingling of clean and soiled items in the same space, hazardous spaces conditions for staff, and a general lack of organization of stock.

This system has a central service center which feeds multiple sites across the hospital system and allows for measured distribution based on visibility and need. Its primary purpose is to handle vast supply volumes that could then be allocated based on the internal needs of each facility within the system, with deliveries occurring daily. At peak infection rates during the pandemic, multiple daily deliveries were needed from the central service center to meet the clinical need within the units. Materials were often not sorted and distributed to the unit clean supply rooms fast enough and would contribute to the material pile-ups due to lack of holding / staging space.

Page is designing a larger central storage materials management department that allows for greater flexibility while improving inventory controls by locating more supplies in a centralized, monitored location. If additional supplies are required or reserve desired, in case of a patient surge, for example, the space can accommodate higher quantities of those specific supplies and account for their distribution to departments due to improved inventory control and monitoring from a centralized location.

Although space constraints seemed to be the primary concern, there were several indirect project-specific challenges, pandemic included, that contributed to supply chain issues external and internal to the facility. This paper will discuss the additional constraints on supply chains, our approach to the project’s supply chain analysis and design, and provide additional project examples of architectural solutions that could be used for materials management.

Page Southerland Page, Inc.

5

Centralized vs Decentralized Supply Strategies

Assessing centralized versus decentralized supply storage, at campus scale and internal to the facility, is the first step. The approach for new construction will likely be more flexible than reworking an established hospital system with processes already in place.

Campus scale - Site conditions, available square footage, utilities, existing buildings, and transportation access all affect the efficacy of providing a centralized supply warehouse for a medical campus. Pros include the hospital system having a consolidated area for supply management, where there is a high availability of stock and easier capabilities to deliver materials to campus buildings and control distribution logistics. This also frees up space within the medical facilities, allowing their internal materials holding to be right sized to fit their needs.

Parkland Logistics, a project where Page was engaged for design services, not only used an off-site centralized supply strategy but also built underground tunnels connecting the central warehouse to the medical facilities to aid in distribution of materials, reducing the need for vendor transportation.

Another campus strategy, employed by Houston Methodist Willowbrook, was the use of storage pods. This can be an effective and inexpensive way to provide locally centralized materials holding outside of the medical facility.

On-unit scale – Centralized versus decentralized supply storage is also assessed within the departmental design of a facility. The implementation of either strategy requires buy-in from the clinical users and hospital leadership because operational training is needed for all staff to understand new workflows. Strategic medical planning with user input is required for locating medication rooms, clean rooms, and soiled work or holding rooms.

VA Tampa and several Houston Methodist hospitals used other examples of decentralized supply management within a clinical unit such as nurse servers in corridors, in-wall PPE cabinets at patient rooms, and pneumatic tube stations spaced evenly around patient floors. Another example, Parkland Logistics, made use of strategically located pneumatic trash and linen shoots to manage part of its outgoing soiled items operational process.

The system in the mid-Atlantic region hospital project did not require Page to analyze or consider supply distribution beyond the primary Materials Management department and supporting clean supply areas into the clinical units. The on-unit supply storage areas were recognized as steps within the overall workflow processes, but redesign of these areas was not part of the scope of work.

6

Strategies for Creating a Resilient Healthcare Supply Chain

PPE in Short Supply The global pandemic caused PPE shortages worldwide. Masks, gloves, eye protection, and other personal protection equipment were in high demand due to the contagious SARS CoV-2 virus and fear of the unknown. Experts slowly learned more about how to prevent and treat infection. This facility, like others, purchased items whenever available, many times ordering more than typical due to scarcity of stock, effectively stockpiling items whenever possible in central supply centers and within each facility.

Scarcity of supplies coupled with fear can have the detrimental effect of creating hoarding and stockpiling within a facility. Houston Methodist Willowbrook Hospital campus implemented PAR Excellence Bins in their facility, a weight-based inventory Management System.

The bins use precision scales to reorder low-stock items based on real-time data and anomalies in the rate of use flagged immediately to notify managers of changes in staff behavior so that PPE and other items are never in short supply. These storage systems can be designed for various applications, such as operating rooms, nurse stations, clinics, storage rooms, procedure rooms, and emergency departments.

Unreliability of Supply Delivery from Vendors

Typically supply vendors would deliver orders to the central supply center and, at times, direct to individual facilities. Staff would then distribute supplies from the central supply center to each facility once or twice a day, through planned scheduled delivery times. During the pandemic, third party vendors proved unreliable to deliver orders as scheduled due to the increased rate of demand for certain supplies and PPE. Last-minute deliveries increased overall costs for the hospital. Transportation costs and inflated gas prices during this time were also passed on to the hospital.

As a result, the hospital system purchased its own distribution trucks to handle multiple daily deliveries to their portfolio of facilities, improve reliability of on-time arrivals, and keep rising supply chain costs at bay.

This strategy made it easier to balance supply and demand across the system and build reserves for black swan events.

At some facilities, such as Parkland Logistics, third-party vendor contracts must be evaluated and negotiated to ensure logistic strategies are implemented appropriately. For example, it is common for older hospital facilities not to be able to accommodate large semitrucks within their existing loading dock bays. Smaller box truck sizes are needed to work within the restraints of smaller delivery bays and turning radiuses.

Page Southerland Page, Inc.

7

Labor Shortages

Labor shortages became a primary concern for numerous industries during the pandemic. Despite healthcare workers being classified as “essential,” hospital systems were not immune to labor deficiencies, whether due to sick and quarantined staff members, parents caring for children at home while participating in virtual learning, or caregivers needing to provide safe, isolated care to loved ones. The absence of staff contributed to unreliable supply deliveries and led to a lack of supply supervision. Pallets and carts filled with various materials were often left unattended in hallways until moved to proper holding areas for breakdown or redistribution within the hospital units.

One solution Page has implemented to combat staff shortages at other facilities, such as Veteran Affairs (VA) Tampa Health Care and Houston Methodist Willowbrook Hospital, is the use of TUG robots.

A TUG is a mobile robot made specifically for hospitals by Aethon, based in Pittsburgh. The robot uses a built-in map and sensors to navigate hospital corridors and communicates with elevators, fire alarms and automatic doors via Wi-Fi. These robots can transport carts and other supply compartments, along with medication delivery from Pharmacy. They move around the hospital autonomously, providing employees more time to dedicate to helping and interacting with patients. These robots also are a strategy to support infection control policies. With less people in contact with the supplies, there is a decreased risk of spreading germs around the hospital.

Rendering of TUG robot in use.

8

Strategies for Creating a Resilient Healthcare Supply Chain

Unsecure Materials Management Supply

Security is a key factor when to comes to hospital design, specifically for managing patient and staff safety, but also critical when it comes to tracking materials and supplies for invoicing and maintaining proper accounting of hospital costs.

Controlled handling of material goods is critical throughout the supply chain process. Goods originating from the central supply center, are delivered to the facility loading dock, and then unpacked in staging areas prior to being organized within a central storeroom in the facility.

Materials Management and Environmental Services staff, divided into several shifts, will then pack their required daily supplies onto rolling carts to distribute to the different departmental clean supply and linen rooms.

What is often not discussed, although widely known amongst the clinical and nursing staff, is that once on-unit supply rooms are freshly stocked they are often immediately plundered for supplies which are then kept in even more decentralized areas around the unit. For this specific facility, this would then lead to clinical staff leaving their units to search within the materials management storeroom (often unsupervised) and take items off the shelves as needed instead of waiting for the next shift of materials management personnel to restock. Supplies would go missing resulting in increased costs due to the lack of supply tracking.

To help with accountability of used items and tracking costs per department, VA Tampa Health Care purchased vertical carousels and high-density storage for its inventory management. The carousels provide secure access through password protection, access logs and physical protection of stored goods. They can save up to 75% of floor space by using the full ceiling height and can be custom built for any application. Some manufacturer’s storage products can interface with barcoded medical asset tracking systems, which can provide useful data for budgeting and procurement of supplies for restock. Houston Methodist extensively uses PAR Excellence bins to provide secure automatic inventory management.

The pandemic put pressure on an already strained process and the fear caused clinical staff to try to protect themselves and their patients during such uncertain times. This created even more scarcity when supply rooms and storerooms were left unmonitored.

Page Southerland Page, Inc.

9

Inefficient Operational Workflows

All the items discussed previously can contribute to an inefficient workflow processes. Hospital leadership often works with staff to help identify pinch points and obstacles they encounter when carrying out specific tasks in order to reduce friction and improve support processes. In our client’s case, its order of operations was well planned but the lack of space and erratically timed deliveries, mostly caused by outside vendors (laundry return/ regular mail and deliveries), often gummed up the flow of operations.

Regular mail deliveries such as USPS, Amazon, FedEx, and UPS run on their own distribution route schedules. A large quantity of packages arriving while material management staff members are out stocking the units could mean items sit on the loading dock blocking access for other timed deliveries. This facility did not have a dedicated or secure place for these types of deliveries to sit in holding until they could be sorted and distributed. This added to security issues, such as hospital employees heading to the loading dock area in search of their mail instead of waiting for on-unit delivery.

This facility’s laundry vendor also contributed to inefficient workflows.

Outgoing soiled laundry is brought from in-unit soiled holding rooms to the loading dock’s soiled staging area and weighed prior to being laundered since the hospital system pays for laundry services by the pound. Various items such as baby blankets, patient gowns, sheets, etc. are mixed in the carts as they are brought down from the different units. Contrastingly, when clean linen is returned to the facility, the vendor might return a cart filled with 100 baby blankets but only 10 patient beds’ worth of sheets. This type of disproportionate return leads to overstocking of some items and a deficit of others. Overages of linen would often sit in the hallways for days until the units could take on additional restocking. Shortages of other laundry items may lead to weeks of doing without or additional orders of items to meet the immediate demand; thus, contributing to additional space issues by having more stock than holding area.

10

Strategies for Creating a Resilient Healthcare Supply Chain

Project Specific Goals & Architectural Interventions Page’s approach to the project was to identify client goals through immersion and client interviews, analyze processes, and verify user needs and supply circulation to inform the architectural interventions necessary to meet client goals.

Step 1: Immersion Shadowing with User Departments & Staff Interviews Page spent multiple days interviewing key staff from each department, as well as shadowing operations to fully understand their roles and responsibilities within the facility. Every department that used the off stage corridor for any reason was shadowed and interviewed so we could understand the implications of our interventions and properly address operational changes when determining phasing. The interviewing/shadowing included Materials Management, Environmental Services, Morgue Operations, Emergency Department, and Patient Transport.

3 MORGUE PATHWAY ANALYSIS

LOADING / PARKING

2

1 MORGUE

1 CONNECTING CORRIDOR

Page Southerland Page, Inc.

11

Step 2: Operational Workflow Pathway Analysis Once we analyzed the flow of people, Page created flow charts of our understanding of each department’s workflow, documenting each step for each individual process within its existing state. Not only did we ask, “What are the steps?” but “Do you see your staff continuing to work in this manner?” “Do the steps need to be altered in any way to create a better workflow for your new space?” Understanding the “existing state” of operations helped the design team facilitate discussions around the best “future state.”

EXISTING STATE OPERATIONAL WORKFLOW PATHWAYS

MATERIALS MGMT CORRIDOR

SORT

SORT

SITES

CSC 5:00

CSC

LOADING DOCK

INBOUND STAGING (CLEAN)

RESTOCK + COUNT

CSC 7:00

MATERIALS MGMT STORAGE

CSC

BREAKDOWN

LOADING DOCK

RECYCLE

Step 3: Goal Identification - Architectural Solution Staff immersion, interviews, and operational analysis coupled with the preliminary program information allowed Page to identify and validate with the users the following client goals for the project.

1. Streamline process of deliveries & ensure constant supply stocked in units. This can be done through Operational and Architectural intervention. Identify with the client what may not be solved through construction alone and start conversations about revisions to operational workflows internal and external to the facility.

2. Upgrade and enlarge storage spaces on site by improving space planning and consolidating program functions. This includes some functions or departments moving out of back-of-house areas. Exterior interventions to the building included additional dock leveler bays for more truck access and rearranging existing trash, recycling, and biohazard disposal bins/dumpsters.

3. Secure all storage areas with cameras and card reader access. Additionally, include lockable cage storage within other secure areas and provide a front desk supply counter for material management “transactions” for clinical staff that visit the supply area for additional items required separate from the daily stocking of in-unit clean rooms.

4.

Verify that interior and exterior architecture support the incoming and outgoing supply demands. This is an exercise in space planning, right-sizing rooms and overall room heights for utilities, proper lighting, and potential vertical storage solutions. Are clean and dirty routes clearly separated? Does each space support the different steps of the client’s supply processes?

5.

Maintain 24/7 operations throughout construction through careful phase planning. This involves understanding the construction phasing effects on hospital operations, maintaining all life safety codes and egress pathways, and meeting strict infection control standards through Infection Control Risk Assessment (ICRA).

12

Strategies for Creating a Resilient Healthcare Supply Chain

Step 4: Circulation Analysis by Phase Lastly, once goals have been identified, preliminary layouts designed, and phasing plans established, validate that circulation routes for clean supply, soiled supply, and pedestrians/patients are uninterrupted. This analysis is done phase by phase, with a particular focus on the transitions from one phase to the next.

The diagrams created were used to assure the client that daily operations would be able to continue 24/7, while aiding in detecting any major vs minor disruptions and potential operational changes between phases. This might include moving staff, finding temporary storage, taking an alternate supply route within the hospital, or creating additional ICRA barriers to keep staff and patients protected during construction.

KEY ROUTES LOADING

DIRTY

CLEAN

Ultimately, the physical architectural interventions are straightforward and conventional, using standard construction techniques. The architectural programming analysis for back-of-house operations and supply chain distribution, however, can be quite complex depending on several factors. This includes but is not limited to: quantity of departments involved, amount of total supplies stored in the facility, frequency of deliveries, available square footage, budget, and schedule.

Page was able to use the facility’s existing 19,000 square feet of interior space and rearrange the material management departments to facilitate the delivery, storage, distribution, and disposal of daily supply loads, helping them mitigate the residual and amplified supply logistics challenges of the pandemic and move forward with the tools to establish and maintain a resilient supply chain.

CONCLUSION These project examples show us that now is the time for hospital systems to invest in a more flexible, efficient, and resilient health care supply chain to prepare for future crises, whether natural disasters, war, or pandemic. Healthcare designers and medical planners can aid hospital systems in evaluating their supply needs and operation workflows, determining flexible spaces for supplies and staff on a campus and interdepartmental scale, so they ultimately don’t have to trade efficiency for resiliency.

Page Southerland Page, Inc.

13

Albany Albuquerque Atlanta Austin Boston Charleston Dallas Denver Dubai Houston Los Angeles Mexico City Orlando Phoenix Raleigh Richmond San Francisco Tampa Washington DC pagethink.com