The U.S. Department of Homeland Security’s Office of National Protection and Programs Directorate (NPPD) partners with a local healthcare coalition to identify challenges and dependencies around the flow of medical goods from manufacturer to patient in the nation’s largest city.
New York City and its surrounding region has one of the largest and most complex integrated healthcare delivery systems in the world. The nation’s most populous and diverse metropolitan area has over 100 hospitals and thousands of related facilities, such as ambulatory care sites, dialysis centers, nursing homes, diagnostic treatment facilities and pharmacies.
Over the past two decades, this vast system has endured an onslaught of disasters that have taught lessons and led to increased resilience to challenges such as patient surge and facility evacuation, flooding and power disruptions. But it was the outbreaks of H1N1 in 2009-10 and Ebola in 2014, in particular, that highlighted the need to improve understanding of the healthcare supply chain. Although regional stakeholders, including healthcare providers, suppliers and government, have increased their focus on this topic, there is widespread agreement that more effort is needed. This is especially true in the context of a national, or even global, event that could debilitate supply chains on a scale yet to be witnessed in New York City, or anywhere else.
To increase the focus and action on this crucial topic, the DHS Office of Infrastructure Protection (IP), supported by Idaho National Laboratory, conducted a project under the DHS Regional Resiliency Assessment Program (RRAP) at the request of healthcare representatives in the New York City region. RRAP projects involve cooperative, non-regulatory assessments of infrastructure systems in specific regions in order to better understand critical operations and potential gaps in preparedness and resilience. The RRAP is customized to the local context and priorities. It involves a yearlong process of collecting and analyzing data, meeting with industry experts, and integrating results into various end products that aim to enhance overall infrastructure resilience. An integral part of the process is DHS’s engagement with private and public stakeholders who assist with framing the analysis and end products, and ensuring that project results are accounted for in future plans and resilience efforts.
Overview of Project Activities and Outcomes
The New York City Regional Healthcare Supply Chain RRAP project was requested by the Emergency Preparedness Coalition of Manhattan, or EPCOM, a local coalition of hospitals and healthcare networks, facilities and organizations that is funded through the U.S. Department of Health and Human Services’ (HHS) Hospital Preparedness Program (HPP). EPCOM and its chair organization, New York University Langone Health, along with the Greater New York Hospital Association, the New York City Department of Health and Mental Hygiene, New York City Emergency Management, the New Jersey Department of Health, the U.S. Department of Health and Human Services, and numerous other participants from across the healthcare industry shared insights, concerns and suggestions on how the region can improve its collective resilience to future disruptions to supply chains.
The project culminated in a final report that documented key findings, including important gaps and options for addressing them. Several associated products were also developed, including detailed operational profiles of specific healthcare product supply chains, regional maps highlighting key supply chain infrastructure, a planning resource that walks through key factors that define healthcare supply chain disruption events and a corresponding list of potential scenarios, and an interactive viewer that allows users to navigate throughout various supply chains and explore a variety of risk considerations.
Through this comprehensive, broad-based effort, a number of key themes emerged, including recognition that significant redundancy and resiliency exists within certain aspects of healthcare supply chains. However, the study found that, in other important respects, the complexity, fragmentation, and fragility of many of these supply chains continue to grow. Product movements can span the globe and are vulnerable to a wide variety of risks, including natural disasters, cyber threats, sabotage, and large-scale accidents. At the same time, the margin for error grows ever smaller as the just-in-time imperative shrinks response timelines while life-threatening disasters can appear with little or no warning. Because lives are at stake, solutions must be implemented in hours, not days.
The healthcare and public health sector operates with thousands of independent actors, including manufacturers, shippers, brokers, vendors and wholesalers. While these companies often coordinate during normal and disrupted operations, in general they operate independent of one another. Furthermore, healthcare providers located at the end of the supply chain may have very limited interactions with entities operating further up the chain. Nevertheless, in a crisis these numerous and varied stakeholders will need to come together quickly, not only to create a shared understanding of the problem, but to find and communicate solutions. While some mechanisms for this type of coordinated planning exist in the New York City region, key project stakeholders acknowledged the need for significant improvements in order to deal effectively with a major disruption to healthcare supply chains.
The project found that, from the perspective of patient-care facilities, there is limited visibility “up” the supply chain and improvements to coordination and information sharing are required. For instance, there is no holistic “big picture” view of the healthcare supply chains that serve the New York City region. In the end, most organizations understand only their individual ‘links’ in the supply chain.
The project recognized the vital role of government coordination of mission priorities and information, and highlighted the importance of these activities within the Emergency Support Function #8 (so called “ESF-8”) that focuses on healthcare operations during a disaster. In a large scale operational disruption, shared “problem ownership” between private and not-for-profit sectors will quickly shift to not-for-profit (hospitals) and then to the public sector (government). A major supply chain crisis will require key stakeholders with limited experience to work together and function as a team.
Focus on Specific Product Supply Chains
In addition to the systemic view, the project also focused on the following five specific product categories:
- Pharmaceuticals are one of the top concerns for healthcare providers in terms of supply chain disruptions. They are prone to various supply chain problems, including limited sources, lack of alternatives, time sensitivity, frequent shortages, and very limited on-site inventories.
- The globalized nature of pharmaceutical manufacturing presents a variety of potential risks related to supply chain disruptions and delivery delays. In addition, there are manufacturing and shipment lead-times that limit the ability to quickly ramp up production.
- Each stakeholder along the pharmaceutical supply chain faces challenges with understanding and planning for possible disruptions emerging further up the chain.
- The rapidly expanding use of just-in-time inventory practices by distributors and healthcare customers is creating an increasingly fragile supply-demand balance that could be highly disrupted by a major event either further up the supply chain or within the last mile of delivery in the New York City region.
- In the event of a major oxygen demand increase, oxygen production facilities can ramp up production, but they can also temporarily redirect capacity normally dedicated to customers from other industries.
- One of the only scenarios that would lead to a regionally crippling impact on oxygen production would be the extended loss of normal grid electricity in areas that host production facilities.
- Major disruptions to the road transport of bulk and cylindered oxygen to healthcare facilities could present significant challenges, depending on a given facility’s current oxygen levels.
- Some large oxygen suppliers have capabilities and programs that account for emergency cylindered oxygen needs, including emergency oxygen kits.
- For pre-notice events such as a coastal storm, healthcare facilities can increase their oxygen supplies in advance to ensure at least 3-5 days of on-site supply.
- A common challenge is the overwhelming reliance on foreign sources for “med-surg” products, which can limit supply chain visibility and entail lengthy transit times. In addition, industry consolidation for many med-surg product lines is leading to fewer supply options.
- There are manufacturing and shipment lead-times that limit the ability to quickly ramp up production to meet sudden and significant med-surg product demand.
- Stakeholders at every level of the med-surg supply chain must contend with inadequate transparency affecting their ability to foresee and plan against emerging supply chain problems.
- Regulations at different stages of the supply chain can limit the ability to adjust operations and implement more agile approaches in the face of a major disruption.
- Med-surg product purchases are conducted through electronic, web-enabled systems that are vulnerable to communications problems, cybersecurity threats, and other problems.
- Despite the potential for localized short-falls in donations and spikes in demand, blood products can be sourced from other states and delivered to the New York City region on short-notice.
- While the region has managed past blood product shortages, there is always the potential for a significant and protracted situation, including shortfalls in blood collections and/or large increases in demand in multiple regions around the nation simultaneously.
- There is the risk of major transportation disruptions that could impede both inter-state and last-mile delivery of blood products.
- Temperature control and other special treatment is key for blood products, and loss of such capabilities can jeopardize supplies.
- Healthcare providers can be impacted by disruptions in supply chains for related products, such as blood collection kits, blood bags, and testing machinery, which are often produced overseas.
- Overseas raw material and end product suppliers can face operational disruptions, but the diversity of the global supplier base for linens such bedding, towels and staff apparel provides significant protection against systemic problems.
- There are separate but related linen supply chains serving other industries such as hotels that could cushion against a short-term healthcare linen disruption. In addition, linens could be redirected from other regions in the United States.
- Just-in-time linen deliveries result in a very small buffer against a product shortage situation. A disruption to normal delivery services could quickly result in a shortage at a facility.
- In the case of a large sudden increase in demand for laundry services, there is unused capacity within the region’s laundry industry that could be quickly ramped up.
- An extreme contamination event could prevent laundries from cleaning exposed linens. Even with a high confidence level that laundering could address the contamination, it is likely that companies may choose to incinerate exposed linens due to public concern.
- There is an option to utilize disposable linens. The supply chain for disposables, however, should be more closely examined.
The goal of this project, as with every DHS RRAP project, is to catalyze a sustained cooperative, multi-stakeholder effort to build greater disaster resilience. For the New York City region, among other actions, this means encouraging stakeholder groups and communication pathways to share information during a crisis, a playbook that defines the process to identify and solve healthcare supply chain problems, and exercises to create “muscle memory” around this process. The project already spawned a successful scenario-based tabletop exercise among public, private and not-for-profit stakeholders in early June 2018. In addition, a follow-up DHS RRAP project has started and is focusing on the supply chains for time- and temperature-sensitive medical products that often rely on air transport.
There is a growing emphasis on the need for healthcare providers to anticipate and plan for disruptions to their product supply chains. Many such concerns played in the aftermath of Hurricane Maria, which caused a variety of healthcare supply chain problems due to impacts in manufacturing operations in Puerto Rico, as well as movements of products to patients around the territory. The potential benefits of this project are substantial. Healthcare facility owners and operators can use the insights gained to help identify strategic investments in equipment, planning, coordination, training, and infrastructure. These actions can enhance the resilience of their supply chain operations, and by extension the continuity of critical healthcare operations throughout the New York City region.
At the same time, the project will help drive the private and public sectors into greater coordination and planning to build a more knowledgeable, prepared, and resilient healthcare community in the New York City region.
This project is relevant not only to New York City, but to other regions and healthcare coalitions throughout the United States. DHS will work with HHS and others to share its insights and outcomes in order to advance healthcare supply chain resilience in communities throughout the nation.