After COVID-19: What Does A Resilient Healthcare System Look Like?

We thought we were planning for resilience. But we weren’t prepared for this.

COVID-19 is an unprecedented global crisis, but epidemics have been increasing in both frequency and reach due to globalisation, greater connectivity and denser cities. The pace at which healthcare systems were able to respond, and the scale of the transformation, are an incredible achievement. But they also serve to highlight how ill-equipped the world was for a pandemic of this kind. COVID-19 has shone a spotlight on systems and processes that had been fine-tuned over many decades, revealing flaws and vulnerabilities that we had overlooked, as well as glaring blind spots in our forecasting.

Most fundamentally, COVID has reinforced the fact that healthcare is a system, and that it will only ever be as resilient as each of its components, however minor a role they may seem to play. Flexibility and agility are essential components of resilience, but these are often value-engineered out of systems optimized for efficiency and minimum cost. If we are to be better prepared in the future, we may need to reconsider our notions of “value” and the potential consequences of leaving so little room for manoeuvre.

“This has shown that resilience isn’t just about being belted and braced for the things you think may happen,” says Suzanne MacCormick, global healthcare lead at WSP. “It’s about being prepared for the things you really don’t have any visibility on at all.”

But perhaps that’s the problem: resilience planning has typically taken place at the level of a single location, healthcare system or hospital, while a pandemic, by definition, has no respect for boundaries.

“Systems tend to operate in relative isolation and they’re designed for disaster in their own bubble,” says Kevin Cassidy, head of healthcare at WSP in Canada. “If there had been an outbreak of COVID in one hospital, they would have been well prepared, especially the newer ones. But this particular virus hit everybody at the same time – not just within a local community or a province or even a country, but the world.” In Canadian building code, hospitals have to be “post-disaster” facilities, says Cassidy. “But when you dig into it, what that really means is that they need to be able to stand up after earthquakes or hurricanes because they are supposed to be areas of refuge.” This is of little value if all the roads that lead to a hospital are not designed to withstand the same level of impact, he points out – a system is only as resilient as its weakest link.

The pandemic presents a more fundamental challenge to this conventional approach to crises, points out Michael Pietrzkiewicz, an electronics engineering technologist at WSP in Alberta, Canada: “A lot of disaster planning is based on having a shelter to protect people from the elements, where we can provide services in one place. But with COVID, we found that we couldn’t mass people together because that’s the way the virus spreads.”

This failure to think holistically – or to plan for a different kind of disaster – has been felt most tragically in the disconnect between health and social care systems. In many countries, a high proportion of COVID deaths have been in care homes for older people, or among those receiving care at home. This is partly because older people are more vulnerable to the disease, but also because of the way that care is funded and, crucially, staffed. Care work is typically low status, poorly paid and insecure, leading to a high-turnover, highly mobile workforce, who often visit multiple locations in a single day – the perfect conditions for a virus with a long incubation period.

“Hospitals are often the focus, but there are many other supporting areas of healthcare,” says Sarah Wallwork, principal consultant in WSP’s UK healthcare advisory team. “Care homes hold considerably more places than hospitals, so if they were better protected, this could stop or slow down hospital admissions and deaths related to COVID or a future pandemic. We need resilience in all of these supporting areas – primary care, mental health, social care, community services – to give us resilience across the whole system.”

Wallwork says that the UK’s healthcare resources were already stretched before COVID, with occupancy of hospital beds usually close to 100%. This is partly because of a significant shortfall in social care funding, which means frail older people are stranded in hospital because there is no care home place available, or no support to help them in their home. Social care is run separately from healthcare, the responsibility of local authorities, though the National Health Service has recently begun to introduce “integrated care systems” to bring together the different service providers in a local area. Joining up the system would improve resilience in various ways, she says – for example, organizations in the care sector might have been better able to access personal protective equipment (PPE) via their healthcare partners: “Acute hospitals already have defined supply chains or may have been able to tap into a central procurement process, but care homes, hospices and carers who go into people’s homes were unable to do this and struggled to procure any.” This strategy was broadly similar among both public systems like the NHS and private healthcare services, based on a survey of WSP’s global client base.

Procurement is one of the areas that has been found most wanting. Global supply chains have been ruthlessly optimized for efficiency, leaving them with little capacity to accommodate sudden fluctuations in demand – as consumers trying to stock up on toilet roll found to their dismay.

Over the last 30 years of globalisation and outsourcing, the world’s manufacturing base has shifted overwhelmingly to Asian countries, particularly China, which makes more than 50% of the world’s PPE. Hubei province, where the virus struck first, is one of the country’s most important manufacturing centres. As governments realised the scale of PPE that would be required, international cooperation broke down. Exporters froze shipments, and buyers found themselves in a desperate scramble for masks, gowns, gloves and goggles, competing with international neighbours and with providers in their own market. In March, the World Health Organization called for a 40% increase in PPE production, and warned that supply chain disruption – “caused by rising demand, panic buying, hoarding and misuse” – was putting the lives of frontline medical workers at risk.

“The global supply chain just stopped because everyone wanted the same product at the same time, even though they didn’t need it at the same time,” says Mathias Elmfeldt, a hospital logistics expert with WSP in Sweden. “That created a lack of trust in the system, and that was right – you can’t trust an imperfect system.” Cooperation failed because the system wasn’t primed for it in advance – once a crisis has hit, it’s too late. This lies partly in the realm of global politics, but a practical stumbling block is that healthcare does not use a common language to describe medical equipment, says Elmfeldt. “You can’t cooperate unless you have full transparency of your supplies. The same tube will have different names, so even though there are a lot of electronic systems, it is impossible to aggregate information on stock levels.” A common language has been developed by GS1, the not-for-profit inventor of the barcode, which covers not only equipment but every kind of information about hospitals, caregivers and patients, and Elmfeldt thinks this could improve efficiency and resilience in many areas. But while the fiercely competitive grocery sector has been using an equivalent for 50 years, healthcare has been slow to implement it.

There are already initiatives to increase regional manufacturing to counter the over-reliance on Chinese healthcare suppliers. Elmfeldt says that taking advantage of advances in digitalisation, automation and 3D printing could make local suppliers more competitive, but that procurement needs to look beyond lowest cost and factor in proximity, lead times and geographic diversity too. Materials requirements planning (MRP) systems could also make better use of artificial, or human, intelligence to forecast the impact of a range of different scenarios, rather than treating the future as a steady continuation of the recent past.

“If you can categorise articles and understand potential demand, then those very important items can be stockpiled and held in reserve, and you can have greater requirements for multiple sourcing and regional manufacturing,” he says. “Before, we just procured from the cheapest company and then everything happened to be manufactured in Asia. Now we might have a requirement to have a supply in Europe or within five hours.” Products coming from Asia via container ship can take two months to arrive, he points out – an unacceptable delay for essential items.

Gearing up local manufacturing industries would also tap into the greatest source of resilience in the system: people. “What I learned is that the people themselves created a lot of the agility, in terms of the fast-moving reaction to COVID, and they were very, very good at doing that,” says Elmfeldt. “That will be the case the next time too.”

Agility has not been sufficiently prized in the past, says Kealy Herman, a specialist in supply chain sustainability with WSP in Denver. “Organizations have been so focused on efficiency that they don’t see the value of flexibility – especially because flexibility often costs money and the return on investment isn’t clear, at least in the immediate term,” she says. “Now it’s becoming very clear that the companies that are more flexible and agile are better able to respond to these types of threats, and there’s a window of opportunity to address some of these issues.”

When they carry out tabletop exercises for clients, Herman and her colleague Emily Wasley find that organizations are frequently unaware just how exposed they are to a single source, not necessarily among their direct suppliers but in the hidden tiers below. “The companies that are faring well right now are the ones that have conducted a supply chain assessment looking at who their critical suppliers are and where they are, and have that relationship with their suppliers – which is huge in itself,” says Wasley, leader of WSP’s corporate climate risk and resilience practice in San Francisco. 

This is borne out by the example of Bon Secours Mercy Health, a healthcare system with 35 acute care locations across the eastern US, from major urban hospitals to much smaller critical access facilities in rural areas. There were capacity issues in some locations, says infrastructure director Jonathan Hunley, but it hasn’t struggled for supplies because of a corporate supply chain initiative that was already underway. “From a supply side, we were actually in very good shape because we had been working to establish warehouses in our markets to create overstock and then use just-in-time deliveries for those supplies,” he explains. “That will create more space inside of our hospitals for clinical functions and it’s whole lot easier to control than storing equipment inside the hospital.” 

Building system maintenance is another Cinderella topic that suddenly everyone wants to talk about, and an area where previous economies may have hindered resilience. “When COVID hit, hospitals that hadn’t been performing preventative maintenance suddenly started looking at their filters or HVAC systems and realised they weren’t good enough,” says Tomer Zarhi, mechanical manager in WSP’s Canadian healthcare team. “The focus is now back on things that have been neglected for many years.” Cleaning air ducts every ten years is a code requirement but it’s never enforced and seldom done, for example. “It’s a big undertaking and it’s very hard to convince a VP of finance to spend $300,000 on something that you can’t see and that isn’t broken.” 

So Zarhi thinks we need to talk about “proactive” maintenance instead: “It sounds very similar, but one is reacting to problems and the other is looking for the problems. There’s a huge difference.” WSP has developed a “risk-informed” facility condition assessment (RIFCA), to better help owners target investment where it is most needed. “A traditional FCA just says ‘your building is collapsing, it’s going to cost you millions of dollars to repair’. With a risk-informed assessment, we can say ‘that air-handling unit is in bad condition, and if it breaks, you will have downtime in surgeries’, so there’s actually a risk class attached to the condition of the asset. Owners want to know what’s going to collapse first and what the risk is.” (We’ll consider how technology can support more effective building maintenance, and much else besides, later in the series.)

If, and it remains a big if, we do act on all of this, COVID should leave us in a better position to weather future crises. This includes the impacts of climate change – another unprecedented global phenomenon with the potential to cause widescale disruption to human and natural systems. “We know there are going to be more extreme weather events, and we have the opportunity to take the lessons from COVID-19 and extrapolate them out so that we are better prepared,” says Kevin Cassidy. “In the grand scheme of human history, this is a short-term problem – we will come through COVID-19, as we have come through previous pandemics. With climate change, we might not.”

At a building level, flexibility is essential for resilience. This almost always adds cost upfront – but it could save considerably more later on, as we’ve seen during the pandemic. In the next part of the series, we’ll take a closer look at exactly what kind of flexibility healthcare facilities really need, and how they can make the economics stack up.