Standardizing Response for COVID-19 and Influenza Commingling
As of the end of June 2020 the U.S. has suffered more than 120,000 deaths relating to COVID-19. The first weeks and months of the 2020 pandemic were rife with foreseeable and preventable supply chain related catastrophes. Future research will undoubtedly show the delayed and insufficient governmental responses to medical experts’ requests for help and materials to have cost many innocent American lives. It is paramount for hospitals to never again owe their ability to continue operations to politicians ill-equipped to make proper medical decisions. The iterations of bottlenecked workflow in health care disaster response are being laid bare through the lens of COVID-19 response in America, every one of which demands a more provocative solution.
The focus of this article began by standardizing standard operating procedures (SOP) in disaster preparedness to allow one language to be spoken between departments, hospitals, and governmental agencies. The early stages of this article were designed to ensure continued levels of in-house stock of unique materials; to take the maintaining of acceptable levels of unique materials out of the hands of administrators and into the hands of an algorithm to ensure greater efficacy. The focus of this article changed with the realization of what disaster preparedness professionals experienced during the COVID-19 pandemic response.
Calculating “Golden Ratio Based Iterated Trigonometric Resilience Minimum Standards” for extended and possibly continued production in case of sudden-onset events with multiple sub-events (SOEMS) is a critical success factor for successful navigation of the second wave of the 2020 pandemic. Researching disaster preparedness during one of the greatest pandemics in human history makes for a unique quest and an ever-changing trajectory in a dynamic landscape.
As of June 24, 2020, the predicted second wave of COVID-19 is swelling – more accurately, the first wave of COVID-19 is being reintroduced to the public. The official start of the second wave, as defined by this article, is when the novel coronavirus of 2019 commingles with the seasonal influenza virus in fall 2020. Major changes to supply chain operations and data base communications must be implemented post haste to have any significant impact on the stakeholders during the second wave.
This article puts forward simple to follow SOP which allow extended and possibly continued production of hospitals (and every other supply chain associated business) during the second wave. Using iterated trigonometry and “golden ratio” coefficients to set resilience minimum standards, supplies of critical unique materials (hospital beds, PPE, respirators, gloves, hand sanitizer, staff, doctors) can be maintained at levels conducive to Americans health. As some experts have mentioned; we are “knee-deep” in the reemergence of the first wave, there must be SOP in place to allow healthcare professionals to navigate the case of the second wave, the time when COVID-19 begins to commingle with the seasonal influenza this fall 2020.
The financial strain on hospitals from needing to purchase (stock/restock) critical supplies that became critically low and/or unavailable during the response phase of the disaster cycle during the COVID-19 pandemic has left these hospitals in less than ideal financial shape. Issues with rapid depletion of critical supplies need a better solution than stockpiling due to the longevity and expiration dates to be effective in case of second wave of the pandemic. Both extremes of supply chain collapse and stockpiling must be avoided if production up time is to be maximized.
What are the primary indicators that most accurately predict the efficacy of SOEMS, including pandemic, response, recovery and evaluation, mitigation and preparation? Are these indicators scalable to navigate inner department stock through and including international conglomerate supply chain resilience?
Can an algorithm be developed to allow stakeholders to determine what unique materials should be allowed to be “lean” and which materials must be kept at a resilient level of stock to effectively allow for predictable, repeatable production extension (reduced impact) and possibly continuance (negligible impact) in the case of SOEMS?
The response evaluation of COVID-19 showed that current methodologies are not enough to significantly reduce impacts of SOEMS. It became clear quickly the current supply chain model for personal protective equipment (PPE) acquisition is inadequate for the demands of hospitals during COVID-19. Moving forward, how can hospitals better predict and prepare for the possible second wave of this pandemic? How can communication and data sharing be made more accessible to departments of hospitals and agencies of government in positions to make critical decisions?
Background of LSS
At this point it is prudent to explain and situate Lean Production (or Lean Manufacturing) and Six Sigma in relation to supply chain resilience. Lean Production has been adopted by various industries to reduce production cost, waste and to increase productivity and profits for the stakeholders. The origins of Lean Production are from the Toyota Production System and is associated with Just in Time production. The focus of lean is to reduce the time required for set up and waste costs. The history of Six Sigma can be traced back to Friedrich Gauss as a system of measurement standard in product variation.
LSS is a combination of Lean Production and Six Sigma. LSS is considered a continuous improvement methodology, with a focus on reducing waste of production. The main results claimed are cost reduction and increased quality of products and services. LSS concepts are increasingly popular with large companies due to their positive influence on productivity, quality and financial results. Lean focuses on the “speed” of the process and Six Sigma focusing on the accuracy.
Lean production as a concept can be useful to avoid expiration of stock due to unmonitored stockpiling, especially when the turnover time of unique materials is relatively short, as in the case of many critical unique materials in the healthcare field.
A review of the current literature shows gaps in scalable algorithms and standardized operation procedures (SOP) aimed at extending and possibly continue production of hospitals in case of sudden onset events with multiple sub-events (SOEMS). Contained in this article are instructions for the implementation of “golden ratio based iterated trigonometric resilience minimum standards.” This article is by no means a complete and finished work, rather the SOP developed within are designed as a jumping off point for improvement to hospital supply chain methodologies.
Key indicators and terms:
- CSF – critical success factor
- TAT – turnaround time
- LSS – Lean Six Sigma
- Product decay – length of time for disintegration of product (shelf life)
- Business as usual – normal operating levels
- DMAIC – define, measure, analyze, improve, and control
- Duty cycle – workload flux (can be a positive or negative number, business as usual would have a duty cycle of zero)
- Limiting reagent – a material that will run out first causing an impact on production
- Major incident – any event that has potential to significantly impact business as usual
- Sub-events – subsequent incidents resulting from a major incident (i.e. an earthquake causes a tsunami which causes power outages that cause a disruption in water pumps that cause nuclear reactors to meltdown.)
- Resiliency – pursuit of self-sustainability, all unique materials and resources used to produce unique materials and means to process said resources are contained in house
- Materials stalling – when a material is too Lean and has a negative impact on production, supply chain collapse
- Materials flooding – when a material is too resilient and has a negative impact on production, hoarding/stockpiling materials
- Resilience continuum – a proprietary tool for measurement, used to determine overall and individual material required resiliency to allow business as usual.
- Disaster cycle – mitigation, response, recovery and return to mitigation of future disasters
- Materials level – on hand, use-per-delivery period
- Limiting reagent – any negative (below zero) materials level, the unique material that will run out first
- Duty cycle – workload flux, can be positive for increased load and negative for decreased workload. Business as usual will have a zero-duty cycle.
- Turnaround time – a complete cycle of an SOP
- SOEMS – sudden onset events with multiple sub-events
- RME – resilience minimum equation
- Delivery period – days between deliveries for unique item
- RMS – resilience minimum standard
- Materials atrophy triangle – right triangle used for setting up the resilience minimum equation
- Standard operating procedure (SOP) – rules and guidelines for each task
- Lean Standard – A RMS of 45, just-in-time inventory stocking
- Robustness – strength of the system, ability to resist the impact of a disaster event
- Rapidity – the rate at which a system can recover an acceptable level of functionality.
(Not all terms are used in the current stage of this research.)
By implementing the results of the calculations put forward, hospitals can effectively bolster their critical PPE supplies. At the same time hospitals are setting resilience minimum standards for each unique material, they are increasing communication with other local hospitals and government agencies to allow quicker acquisition in case of SOEMS. Other results of the research showed the dire need for a consolidated data platform for each department in a hospital and government agency to be able to quickly and precisely report and acquire SOEMS related data.
Defining Resilience and Standardizing the Resilience Minimum:
Using a coefficient based on the golden ratio in the iterations of RME – defining and implementing criteria that increase the Theda (reduce the length of the hypotenuse) of the materials atrophy triangle – is the critical success factor to reducing the impact of major SOEMS.
For the purpose of this article, the word resiliency can be defined as “the pursuit of self-sustainability.” The reference point from which all subsequent measurements are derived is now coined the “resilience minimum standard” (RMS). The RMS is designed to expand and possibly continue production in case of SOEMS. This means having access to all necessary unique materials in a partial or complete supply chain collapse.
The ultimate outcome of RMS and the implementation of the RME with the materials atrophy triangle is to have departments in a hospital – and hospitals in a city – realize that healthcare is a team sport. Hospitals in the same city are allies not business rivals and must form a network of interconnected chains of unique materials which allows greater supply chain resiliency due to more entities pooling their resources. Pooling resources allows each hospital in the network to focus on bolstering different unique materials and eliminating unnecessary redundancy. This avoids unique materials expiration from hoarding and loss of production due to prolonged supply chain disruption. One fatal flaw of the U.S. COVID-19 response, is disaster preparedness agencies and elected officials not cultivating teamwork between citizens and agencies, between hospitals and the infected, and most importantly, between citizen and citizen.
Promoting supply chain resilience minimum standards alongside development of inter-hospital networks could extend and possibly continue operations in case of SOEMS. One thing that has been made clear during the first wave of the 2020 pandemic is infections on this level require the entire nation to have a standardized response. If we the people can learn that pandemics are a team sport, we can avoid most of the possible 1918-like morbidities and mortalities of the second wave this fall.
Situating the Resilience Minimum Standard on the Resilience Continuum:
For the purposes of the trigonometric calculations used to find the RMS for each unique material, the scale of the resilience continuum is set from 0 to 90, with 0 being a complete collapse in the supply chain and 90 being complete resilience for each unique material. As a quick example, an RMS of 45 is defined in this article as the “lean standard.” According to the RME, an RMS of 45 denotes a 1-to-1 relationship between days of item stock and days until delivery.
A very interesting concept emerged in the development of the materials atrophy triangle and the resiliency continuum. For reasons that demand further research, the RMS happens at 58 on the resiliency continuum, equating to a 58-degree Theda on the materials atrophy triangle. In short, the RME will predict and set the resilience minimum on-hand stock level for a unique material and establish a baseline reference point to allow for extended and possibly continued operation through a SOEMS.
Using Fig. 1 as a reference, any unique material placed on the resiliency continuum below the 45 mark is a “limiting reagent” and has great potential to halt production.
There are a few given assumptions/guiding principles in the field of disaster preparedness:
- The most recent SOEMS is not the last SOEMS
- Even similar SOEMS require different responses.
It is because of these two principles the “mitigation” portion of the disaster cycle has become the focus of the RME. This research is based on the hypothesis that one of the critical success factors (CSF) in the mitigation of SOEMS impact is having the appropriate level of unique materials to extend operational up-time in case of partial or complete supply chain collapse. The pursuit of self-sustainability is a proactive action, a continuous incremental process using feedback loops to monitor trends in unique material levels in relation to production deviance from “business as usual” due to SOEMS. `
See example below:
Proof of coefficient development using golden ratio equation:
- (a+b)/a = a/b = 1.618…
- If not true, then factor in coefficients
- ((a+b)/a)(Z) = (a/b)(X) = 1.618…
- X = [((a+b)/a)(Z)]/(a/b) or X = (1.618/(a/b))
* (a) = (amount on hand divided by amount used per day), (b) = delivery period
*Setting the equation to (X) will produce the coefficient needed to calculate the proper level for a unique material to be set at to satisfy the resiliency minimum standard (RMS).
*Multiplying (x) by the amount on hand (from (a)) will yield the resiliency minimum standard for amount on hand for the unique material.
Example Calculations using the RME methodology:
Let us say we have 62 rolls of toilet paper on hand. We use eight rolls a day. This would make the calculation for (a) = amount on hand/amount used per day = 62 rolls/(8 rolls/day). Solving for the units we can multiply by the reciprocal. Which gives us (a) = (62 rolls *1 day)/8rolls, which cancels out the “rolls” units giving us 7.75 days of this unique material.
Now, let us say we get our toilet paper delivered every two weeks, and we just received our delivery today. That makes (b) = 14 days.
This shows us we have 7.75 days of toilet paper left and we have 14 days until our next delivery. The industry standard response would be to double the amount ordered for the next delivery and send an employee to the nearest store to bolster supplies. We can do better.
Using the resilience minimum equation (RME): X = (1.618/(7.75/14)) = 2.922 (X is a coefficient so no units)
Now, (a)X = 62X/8, which gives us 62*2.922 = 181.164 is the resilience minimum standard (RMS) for amount of this unique material on hand.
This means at the current usage of eight rolls per day, we have 22.6 days of toilet paper on-hand. This RMS allows for expanded production if a SOEMS were to affect the supply chain.
Keep in mind that 181 rolls on hand is not a standing order, and the surplus does not multiply with each consecutive order. The RMS is a dynamic number based on the delivery period and unique material usage. So, if usage goes up or delivery period increases the golden ratio coefficient will adjust the amount on hand to meet the RMS. The iterations of the RME continually feedback to allow the golden ratio coefficient to keep the unique material at the RMS.
Now, our original Theda = aTan(7.75/14) = 29 degrees. Situating a 29 on the resiliency continuum means this is well below the 45 mark and qualifies as a limiting reagent, which has high potential to negatively impact production.
Using our RMS level of unique material (22.6), we find our Theda = aTan(22.6/14) = 58. The RMS will always have a Theda of 58 and therefore be a 58 on the resiliency continuum.
Explanation of the Resiliency Continuum:
The root of many current systemic issues presenting in healthcare disaster preparedness is the dichotomy of approaches. The “all or nothing” approach to LSS implementation in some industries has yielded poor results and utterly frustrated the workers attempting to abide by such guidelines. This article is focusing on the mitigation portion of the disaster cycle. It is the intention of the researchers to provide a system for use by all industries involving supply chains and production to continuously monitor and align unique material inventory levels to allow extended and possibly continued production in case of SOEMS.
The emergence of LSS has shown many industry sectors the value of “just in time” services. Toyota, for example, has enjoyed great success with the implementation of systems like LSS. Other industries such as restaurants and hospitals have shown mixed results in the development and implementation of LSS systems. The research here will clearly demonstrate and situate the role of LSS in industries with short “turnaround times” in their standard operating procedures.
LSS has a unique ability to thrive during “business as usual,” but any deviation from this duty cycle will cause a drop in the efficacy of LSS. The healthcare industry and specifically hospitals, by their nature and design operate outside of the “business as usual” model, factor in SOEMS and LSS is all but guaranteed to negatively impact production. This article is not arguing the removal of systems such as LSS from the healthcare industry, but instead is providing data and models to properly situate LSS on a continuum to allow extended and possibly continued operation in case of SOEMS.
It is for this reason that parameters must be developed for the continuum to understand why, when, and how systems such as LSS can be implemented and when to avoid them for more resilient and robust systems.
The parameters developed and presented here use supply chain delivery period as a unit domain to situate the necessary amount of unique material on hand. The dichotic extremes of the resilience continuum are supply chain collapse (no ability to receive unique materials, all production ceases) and in-house supply chain (every resource and the ability to process the resources to produce all unique items are available in-house, self-sustained forever). The assumption of the resilience minimum equation is that all standard operating procedures fall somewhere between these two extremes and locating the exact position on the resilience continuum for each unique material might avoid negative impacts to operations.
Sub events and mortality as an indicator:
Mortalities due to SOEMS are one among many indicators of disaster preparedness measurement. Other indicators include country safety, treatment efficiency, and risk ranking. Some analytics groups went as far as labeling 72 unique indicators.
More specifically, pandemic mortalities must not be the sole measure of success for disaster response validation. If available hospital beds are considered a unique material, then prolonged surges of COVID 19 related admittance can be a sub-event which could collapse a specific supply chain.
It is clear the U.S. botched its opportunity to contain the first wave. Containment is no longer our best strategy for response. Available hospital beds have become a limiting reagent. If hospitals remain at surge capacity for extended periods of time disaster fatigue is inevitable.
In the meantime, and until we have a vaccine, our best strategy is to avoid the collapse of the available hospital bed supply chain. America’s divided, late, and poor response has made indicators like “mortality” into collateral damage. We must defend the supply chains if there is to be a recognizable country left to defend.
Moving forward, mortalities must not be our standard of measurement for dealing with COVID 19. Comorbidities, even in asymptomatic individuals, have become a sub-event growing in the shadow of our focus. If resiliency is not cultivated for the available hospital bed supply chain before the second wave, the sub-events from COVID 19 will prove irreversible in terms of scope and damage.
Shortfalls in Absolute Resiliency
The truth is, if it were as simple as hoarding unique materials, the best business to invest in would be warehouse buildings. However, there are glaring deficiencies in stockpiling mass quantities of unused, expiring materials.
In the early, panicked response to COVID-19, many individuals began hoarding rubbing alcohol. A few weeks later, these individuals were either storing the alcohol in their pantries or selling surplus supplies of rubbing alcohol online for many times original market value. While store shelves were bereft of the product, many who needed it and could not afford the inflated prices were forced to navigate a pandemic without disinfectants.
This sub-event perfectly defines the extremes of the resiliency continuum; collapse of the supply chain on one side and utter self-sustainability at all costs on the other. Both extremes are to be avoided if productivity up-time is to be maximized.
Before a proper response plan can be developed in case of SOEMS, where disaster response is becoming ever increasingly resource dependent, there must be a common verbiage and standard set of procedures for each department within a hospital and for government agencies attempting to access hospital databases. Poor communication between hospitals and government agencies was a common theme during the initial COVID-19 response. There must be standardized terms, definitions, and procedures for accurate communication in case of SOEMS.
One of the failures in the American healthcare system made clear by COVID-19 response in case of SOEMS is a lack of communication by systems and departments. Governmental agencies discovered that gathering necessary data from hospitals to form a response plan was incredibly difficult and required countless billable hours and phone calls. If a standardized database were developed and implemented, this would eliminate the issue almost completely.
There are two main issues with setting up SOEMS communication, both micro and macro. The micro aspect of departments within a hospital not being able to communicate properly with each other – and hospitals in the same city using different programs which do not interface – is far outside the scope of this article. However, the macro aspect of communication pertains to governmental agencies being able to accurately, precisely, and consistently access hospital data.
It is necessary for a standardized, consolidated database to be developed and implemented before the 2020 influenza season. There is no need for protected health information (PHI) to be used in the database, so HIPAA is satisfied.
Required data uploaded to the standardized database should include, for example, the number of patients in beds, number of patients tested (including positive tests) for COVID-19, number of respirators on hand (and currently in-use), and PPE on-hand (and currently in-use).
For the purposes of an efficacious response plan, only supply chain data is needed. Other demographic and PHI data will still be recorded by each hospital, but not reported to the standardized database. The database should be equipped with the materials atrophy triangle calculations for each unique material to develop resilience minimum standards.
Top Concerns from Hospital Emergency Management Department
When researching the most important aspects of disaster preparedness the researchers reached out to professionals on the front lines dealing with COVID-19 response, recovery, and mitigation. Denise Bechard of St. Joseph Mercy Hospital in Ann Arbor, Mich., shared some major concerns listed in her after action report with the researchers:
- Electronic Medical Records (EMR) platform-Epic, travel screening (needs to be mandatory field that is asking with every patient encounter moving forward)
- Physician engagement in highly infectious disease planning and exercising (due to time restraints and responsibilities, seeing patients, clinic, etc.)
- Testing- turnaround time for results and shortages of testing supplies. Severe shortages of testing supplies and extended waits for tests results limited hospitals’ ability for quickly monitoring the health of patients and staff.
- The need for stockpiles of PPE and critical supplies was evident in COVID-19 to replenish the rapid depletion of supplies necessary for response. This is a tough one due to longevity of product and expiration dates.
- Several supplies became critically low and/or unavailable during COVID response and recovery – masks, isolation gowns, isolation caddies, ventilators, surgical caps, shoe covers, hand sanitizer, wipes, etc.
- Huge problem with PAPRs and parts used for those who do not pass fit testing for N95s
- The financial strain on hospitals due to COVID-19 has resulted in an additional crisis on healthcare systems. The cost of COVID-19 hospitalizations, the impact of canceled and closed services, and the additional costs associated with purchasing needed PPE, supplies and equipment for response, have left hospitals with lost revenue
- Convincing the public it is safe to seek care in the hospitals
The Current Disaster Cycle Model
In the discipline of disaster preparedness there are no shortage of clever acronyms and cartoon graphics to help practitioners understand and communicate the vital essence contained within the research. Among these tools are the disaster cycle, a four-phase process that is more commonly reduced to just three phases involving mitigation, response, and recovery (mitigation and preparation are often considered the same phase). The disaster cycle operates in a repeating continuous feedback loop. This continuous incremental feedback loop motif is at the core of effective disaster preparedness. The age of “fix it and forget it” management is thankfully coming to an end and being replaced with its more sophisticated, reliable and efficacious counterpart.
The Evolution of the Materials Atrophy Triangle
The materials atrophy triangle has its developmental roots in the resilience triangle, which is another conceptual framework for understanding the flow of the disaster cycle. The resiliency triangle depicts an event occurrence that impacts production and shows the time it takes and the orientation of the recovery process.
The materials atrophy triangle uses the same concept of a case of a SOEMS impacting a critical function, but instead of measuring recovery time, it measures the drain of supply and can predict and suggest a resilience minimum standard for each unique material. The domain for the materials atrophy triangle being “delivery period” gives a unique perspective which states supply chain continuation is equal (if not more important) than production recovery in the event of SOEMS. A system cannot recover if it is not supplied with what it needs to do so.
It is for this exact purpose the materials atrophy triangle was necessary to develop. Creating a resilience minimum standard operating procedure which allows extended and possibly continued production in case of SOEMS gives the disaster cycle the time it needs to successfully navigate the impact. The second necessity for the development of the resilience minimum standard is consistency across disciplines.
Implementing standards in communication which promote geographically local hospitals to operate as organelles of a single cell to form a supply chain super network is part and parcel of the future of disaster preparedness in case of SOEMS. Ensuring a universal database with pertinent SOEMS-related information that is easily accessible to governmental agencies and hospitals is a national priority. Finally, using the resiliency minimum equation and the materials atrophy triangle to establish resiliency minimum standards for all unique materials is a necessary first step to saving lives in case of SOEMS. More precisely these standardizations could allow more Americans to survive the second wave of the 2020 pandemic.