As 2020 began much of the world was watching and waiting as the crisis that would become known as the COVID-19 pandemic started to spread. At Cleveland Clinic, a Critical Incidence team was assembled and a command center created. As early as January, two months before Ohio’s first confirmed case of COVID-19, the team began meeting to ensure the organization was prepared. The interdisciplinary team brought together leaders from Supply Chain, Quality and Safety, Occupational Health, Surgical Institute Chairs and Enterprise Analytics among others. The Critical Incidence team recognized early that protecting frontline caregivers and ensuring they had appropriate and sufficient personal protective equipment (PPE) would be critical.
The organization took a multipronged approach and built a cohort of teams beginning with the Critical Incidence team and expanding to Surgical Services, Philanthropy Institute, Innovations and other departments to ensure the health and safety of patients and caregivers. Supply Chain continued to purchase PPE and maintain on-hand inventory when possible. However, with disruptions to international supply channels, a new process to disinfect and reuse supplies was built, donations were procured of goods and raw materials and a team began to design and manufacture PPE. Staying true to its values, Cleveland Clinic’s response exemplified teamwork and integrity while maintaining a focus on quality and safety through innovation to ensure the highest quality care for patients, caregivers and the organization continued while working in partnership with the community.
Within the United States, approximately 80% of consumer goods and raw materials are imported; worldwide crises like COVID-19, while rare, make evident the vulnerability of the country’s position of being so reliant on offshore goods. As the virus spread and international borders closed, domestic competition for remaining product increased. Traditional supply channels were not just being disrupted nearing a complete shutdown. Simrit Sandhu, Executive Director of Supply Chain, notes what became important was local, last mile supply sources as it “didn’t matter where the product was in the world and how much of it existed. If we didn’t have it in the last mile of our supply chain around our local geography we were ‘supply insecure.’” While early predictive buying was successful and increased inventory on hand from 90 days to approximately 200 days, the organization knew utilization of PPE would increase exponentially as the population of COVID-19 patients grew.
“It didn’t matter where the product was in the world and how much of it existed. If we didn’t have it in the last mile of our supply chain around our local geography we were ‘supply insecure.’” Simrit Sandhu
The Critical Incidence team worked together complete initial background work with the goal to build models and dashboards that gave visibility into the future for expected usage rates on PPE as well of other supplies. As the first COVID-19 cases were admitted into the health system, caregivers were using upwards of 100 sets of personal protective equipment daily for each patient. With no guarantee of what a surge could look like or how long one could last, one of the first tasks was to eliminate unnecessary PPE use. Through real-time observation on nursing units and in ICUs, the team began to reduce consumption.
Understanding that patient care is not one size fits all, the team similarly understood that neither is PPE usage. Supply Chain already practiced inventory management by tracking all incoming and outgoing supplies but how it was distributed and managed once it reached nursing units and other areas was outside their line of sight. Supply chain recognized these limitations and took a hands-on approach to understanding the unique needs of different nursing units by working with clinical partners. A subgroup from the Critical Incidence team, including Aaron Hamilton M.D., Interim Chief Safety and Quality Officer, spent time on nursing units and in ICUs engaging with frontline caregivers to marry the work and insight of non-clinical experts in Supply Chain to that of the clinical teams. As Dr. Hamilton points out, “the biggest thing is we all came together. It wasn’t just a clinical decision, it wasn’t just supply chain. It was something we all did.” Now armed with additional insight and a better understanding of situation-specific variances in required PPE, Supply Chain alongside the Critical Incidence team began building algorithms to differentiate situational use and predict burn rates. While this work was being done, Enterprise Analytics built a sophisticated COVID-19 curve model. By integrating the projects, the team now had the benefit of both a rear- and forward-view into consumption and predicted case volumes which allowed complex models and dashboards to be built. These models and dashboards created guidelines for PPE usage and ensured caregivers would have the protection they needed while the organization continued being good stewards of on-hand supplies.
“The biggest thing is we all came together. It wasn’t just a clinical decision, it wasn’t just supply chain. It was something we all did.” Aaron Hamilton, MD
As the disruption to supply channels continued to escalate alongside domestic competition, the Supply Chain team began to seek products in non-healthcare markets. There are very few, if any, industries that could meet a 15-20 times demand increase and maintain inventory levels through purchasing alone. She notes, “if you can’t buy it outside of healthcare then seek donations from those outside of healthcare who own that product. And then even if that is not enough we actually need to consider making” the products ourselves. Early on, Ethan Karp, President and CEO of MAGNET (The Manufacturing Advocacy and Growth Network), reached out to explore the possibility of making PPE.
While not engineers, or experts in manufacturing, a group from Supply Chain began to dabble in the construction workshop prototyping PPE. Executive leadership was impressed by the idea but knew it could be done bigger, better and at a higher level. Cleveland Clinic was founded in 1921 to provide outstanding patient care based on the principles of cooperation, compassion and innovation. Executive leadership recognized one of our core strengths had not yet been engaged - Innovations. With a renewed energy, Supply Chain partnered with both the Philanthropy Institute to procure donations and Innovations to make PPE . This was the beginning of what would soon become known internally as BUY-MAKE-DONATE, a complement of teams working together to ensure the safety of caregivers and patients.
Conor Delaney M.D., Chair of the Digestive Disease and Surgery Institute, observed Cleveland Clinic’s response to COVID-19 ‘was a real demonstration of the excellence of the Cleveland Clinic team’. The pandemic brought devastation and loss of life that cannot be downplayed or ignored but it also brought people and communities together. As a non-profit organization and a worldwide leader in healthcare, Cleveland Clinic has strong relationships with many philanthropic donors. The Philanthropy Institute, chaired by Lara Kalafatis, was contacted by individuals and corporations offering everything from monetary donations and meals for caregivers to raw materials and manufacturing capabilities. Cleveland Clinic received an outpouring of support with everyone asking the same question – how can I help?
The Philanthropy team set up satellite stations across the region where donations could be dropped off. The community’s response was humbling and heartfelt as 20,000 homemade masks were brought to these locations along with gift cards for caregiver meals and additional supplies. While the community continued finding ways to support the organization, Philanthropy was fielding a myriad of calls and emails from corporations as well as individuals. There were donations flooding in of PPE that non-healthcare companies had on hand and others transitioning entire production lines to meet the rising need for items like hand sanitizer. A COVID-19 Response Campaign was set up and is seeing tremendous support. To date the campaign has raised nearly $14 million to directly support caregivers and advance critical research.
As daily monitoring of the newly built dashboards continued and the uncertainty of COVID-19 remained, masks (N95 and cotton), face shields, and isolation gowns emerged as pain points in the procurement of supplies. The Innovations team, founded in 2000 to promote innovation and expand treatment of the sick through the deployment of Cleveland Clinic technology, was challenged to recreate and build PPE. Understanding innovation can typically take years, asking the team to recreate specs, design, validate and manufacture in weeks was no small ask but they were up for the challenge.
The portfolio of Innovations contains over 1,200 issued patents and an entourage of Innovation Managers with over 300 years combined experience. While there were projects that fell naturally into the lap of engineers with strong backgrounds in product development like N95 masks, there were others, such as isolation gowns and cotton masks, where the team needed to start at ground zero. Innovations brought expertise, scale, and national partnerships to the arena of work already in progress within Philanthropy and Supply Chain. One of the
first national corporations Innovations worked with was Proctor and Gamble (P&G). During an initial call in March both organizations recognized personal protective equipment was outside the normal scope for P&G while also acknowledging manufacturing was at the core. The teams agreed to work together in identifying the right project which matched Cleveland Clinic’s needs with P&G’s capabilities. During this same time Case Western Reserve University’s (CWRU) think[box] began an effort with 2 additional local companies to produce face shields. One day after the initial call between Cleveland Clinic and P&G, the groundwork was laid to expand the CWRU face shield work into a collaboration with P&G. While the team of teams was expanding outside the organization, internally the teams were meshing as efforts to make supplies also procured donations of products, personnel, time, and manufacturing equipment.
As the population of COVID-19+ patients grew and the United States began to see the beginning of a surge in New York, the importance of the work to make PPE became increasingly evident. There was a growing need for additional isolation gowns, impermeable to fluid that are a critical layer of protection for frontline caregivers. Before the real work of manufacturing could begin, a fabric that met specifications needed to be identified. Just as Supply Chain experienced in purchasing off-the-shelf products, the domestic competition was increasing for raw materials like fabric. With the majority of raw fabrics imported, materials were limited to what suppliers had on hand. Although the search was time sensitive, Cleveland Clinic maintained their commitment to caregiver and patient safety by ensuring all potential fabrics were formally tested to guarantee they met or exceeded the same standards as those typically purchased. Distributors bent over backwards to ship fabric samples from all around Ohio and neighboring states, although with widespread disruptions also being seen outside of healthcare even expedited shipping became a challenge. The Innovations team spent countless hours in the car picking up samples, driving them to main campus and ultimately driving those with potential to a materials testing lab in Toledo. As results came back from the lab and the appropriate fabric was identified another challenge emerged. Distributors that had 10-20,000 yards of fabric two days earlier were now stating their inventory was gone. Eventually three sewing companies were sourced to fulfill purchase orders. While none of them had experience sewing gowns they each eagerly transitioned production lines to accommodate the needs of Cleveland Clinic. With each having a network of fabric distributors they willingly joined the search and began making calls to locate fabric. Over approximately 8 weeks, and with no prior experience in textiles, over 40,000 isolation gowns were procured for the organization.
As evidence mounted in support of wearing cloth face masks there was an overnight need to outfit the organization with hundreds of thousands of cloth masks. Similar to isolation gowns, the team needed to identify both material and sewers. Fortunately, with much of the legwork already completed, they were able to quickly partner with the Amish community who offered the assistance of approximately 60 in-home seamstresses. As the frolic, a colloquial Amish term for a group that comes together to complete a large project, began to work the Innovations team also sourced additional partners. Together the efforts produced over 600,000 masks.
In addition to protecting the wider population of caregivers, there were also those on the frontline treating suspected COVID-19+ patients who required a more complex mask. N95 respirators became another work stream among the growing number of projects Innovations was working to recreate. The team was tasked to find second and third sources for Supply Chain to leverage. The N95 project has been a true testament to the talent within Innovations as well as the undeniable benefit of having the right strategic partners. Through reverse engineering, the team is nearing a final design. While the project began on April 1, the team is still engaged in daily phone calls with local manufacturing and design partners. Working tirelessly over the past three months, the new goal is to ensure a validated design exists in the back pocket of Supply Chain should a resurgence of COVID-19 come to Northeast Ohio or a future crisis be faced.
Through their work, over two million pieces of PPE was secured for Cleveland Clinic. Innovations connected Philanthropy with additional donors and opened the door to newly created supply channels. The pandemic affected millions of lives but in Northeast Ohio, and within Cleveland Clinic, it also brought a community together. The world will head towards a new normal post-COVID-19 and global supply channels will reopen but now having insight into the risk of relying solely on global markets there is a renewed passion to create a sustainable local, last mile supply channel. There is now a deeper understanding of the design intricacies of PPE and an opportunity for Cleveland Clinic to continue its long-standing tradition of innovation in a new way. Through strategic partnerships with local manufacturers, distributors, and design companies Cleveland Clinic will continue the pursuit of making PPE better, faster and less expensively. There is no clear end-date for COVID-19 but the lessons learned over the past six months will long outlast its presence. With silos removed, Cleveland Clinic exemplified what it means to be a team of teams.