By Daria Byrne, EdD, MSN, RN; Li Ern Chen, MD, MSCS; and Steve Kiewiet
An immense opportunity presents itself between supply chain and frontline clinical providers in order to support healthcare organizations in their quest to achieve the Quadruple Aim. The Quadruple Aim—which consists of enhancing patient experience, improving outcomes, reducing costs, and improving the work life of staff (Bodenheimer & Sinsky, 2014)—is a pivotal underpinning of a highly effective healthcare system. “To achieve desired outcomes for patients, organizations, and those providing care, effective coordination among care providers is essential,” according to Havens, Gittell, & Vasey (2018). Since the evolution of the Triple Aim to the Quadruple Aim, clinicians and supply chain team members more than ever need a functioning, efficient, and ongoing relationship.
A literature search using the keywords “supply chain,” along with “nursing,” “physician,” or “clinician,” yielded few results focused on the interdependency of these two categories. These findings emphasize the scarcity of literature related to the perceived interdependency of clinicians, specifically frontline clinicians, and supply chain. With intentional focus, researchers proved that collaboration between supply chain and clinical communities—defined as clinical-led, health system-wide, interdisciplinary communities focused on patient safety and quality improvement—realized significant cost savings for the health system (Ishii et al., 2017). Harvey, Smith, and Curlin (2017) described how surgeon engagement could reduce operative cost, and Young, Nyaga, and Zepeda (2016) demonstrated a positive association between hospital physician employment and supply chain performance. Undoubtedly, without intentional and purposeful focus on the relationship between supply chain and clinicians, a gap exists between two of the most critical departments in the healthcare organization.
The intent of this paper is to begin filling the void in the literature as to the importance of the clinician and supply chain relationship and its impact on achievement of the Quadruple Aim, and to make recommendations for alignment between frontline clinicians and the supply chain. This paper will also contend that an “invisible” healthcare supply chain represents a high-functioning, efficient supply chain as clinician needs are being met, resulting in quality care administration among other areas of impact.
The Quadruple Aim and Cost, Quality, Outcomes frameworks
Before the Quadruple Aim, and still today, healthcare organizations focused on achieving the Triple Aim, which at its core emphasizes improving the lives of patients cared for within the healthcare setting (Feeley, 2017). In 2014, Bodenheimer and Sinsky declared provider and staff satisfaction as a prerequisite for attainment of optimum Triple Aim outcomes. As such, a fourth aim focusing on provider and staff satisfaction was proposed. Bodenheimer and Sinsky (2014) asserted there was no path to higher patient satisfaction, improving outcomes, and decreasing costs without an initial focus on clinicians themselves.
In 2013, the Association for Health Care Resources & Materials Management (AHRMM) socialized the Cost, Quality, Outcomes (CQO) framework. “CQO looks at the intersection of, and the relationship between, all costs associated with caring for individuals and communities, care aimed at achieving the best possible health and the financial results driven by exceptional patient outcomes” (Donatelli, 2019). Healthcare leaders use CQO to support multidisciplinary collaboration and organizationwide acceptance to achieve goals by improving quality and outcomes while decreasing costs (O’Connor, 2018). The alignment between the Triple Aim, Quadruple Aim, and CQO frameworks encourages collaboration between clinicians and supply chain organizations to promote a clinically integrated supply chain beyond the traditional approach as defined by value analysis. Nonetheless, while the tenets of the Quadruple Aim and CQO are valued by healthcare leaders and clinicians alike, Nicosia, Park, Gray, Yakir, and Hung (2018) declared, through their own research around Lean process improvement, that a distance between theoretical principles and its application in healthcare settings exists as underlying goals that are “often difficult to achieve in real-world settings.”
The invisible supply chain and its impact
Donatelli (2019) posited “[i]t is no wonder our clinicians are frustrated, burned out and not the Supply Chain department’s best friend” when examining supply chain processes that exist in many healthcare organizations today impacting professional satisfaction, burnout, cost, and quality of care delivery. It could be suggested that frontline clinicians infrequently consider the importance of a high-functioning supply chain organization unless stock room bins are empty or needed equipment is not available. Furthermore, it could be stated that clinicians do not consider supply selection and inventory management as supply chain functions, but rather adopt an overarching mentality of “the supplies I need, when I need them, to best care for the patients I am responsible for.”
A lack of inventory or readily available equipment unnecessarily increases clinician workload, results in time away from care delivery to search for equipment, and may lead to the perception that patient care and caregivers are not important to the organization. Hence, we see the value of an invisible supply chain. In essence, an invisible supply chain is one that is highly functioning and unnoticed in day-to-day practice, yet is appreciated by those who are reliant upon it. The underlying premise for the invisible supply chain is the recognition that the clinician, in addition to the patient, is a key customer who needs to be understood and whose needs must be met. While organizational goals may center around the provision of excellent patient care, supply chain cannot do this directly; the clinician is a customer and, therefore, a necessary partner.
To promote further alignment between the clinical and supply chain departments, the variables included in the Quadruple Aim and CQO frameworks—professional satisfaction, patient outcomes and patient experience, and cost—are discussed in this paper to demonstrate their inextricable link.
“Nursing constitutes the greatest segment of the health care workforce,” wrote Bowles, Adams, Batcheller, Zimmermann, & Pappas (2018). As such, nurses have an immense potential to influence the healthcare environment, patient experience, and influence healthcare quality (Bowles et al., 2018). But, “[w]ithout joy and meaning in work, the workforce cannot perform at its potential,” wrote Sikka, Morath, & Leape (2015). A lack of professional satisfaction leads to constant turnover of nursing staff and significantly impacts finances and quality of care, directly affecting patient outcomes.
In high-pressure, stressful nursing unit environments, frontline nurses continue to do more with less. Nurses, often feeling as if they have failed their patients due to a lack of attentiveness or time spent with individual patients due to high-acuity caseloads, are continuing to retreat from the frontline. Schenk et al. (2017) conducted a time motion analysis of nursing work in ICU, telemetry, and medical-surgical units and discovered a significant percentage of a nurse’s interventions on any given shift occur outside of the patient room. “A separate study of medical-surgical nurses found they walked nearly a mile longer while on than off duty in obtaining the supplies and equipment needed to perform their tasks,” according to the Institute of Medicine (U.S.) & Robert Wood Johnson Foundation (2011). Frontline nurses quantify quality of care delivered based on the time spent with the patient, or the time spent “caring” for the patient. Time away from the frontline—whether spent on documentation, gathering medications or supplies, conversing with pharmacy or lab, or updating providers—is all time away from their assigned patient.
Eight wastes that Lean processes work to rectify can be found as supply chain’s conceptual underpinnings. These wastes include defects, over-production, waiting, confusion, unnecessary motion, excess inventory, overprocessing, and unfulfillment of human potential (Leming-Lee, Polancich, & Pilon, 2019). Unnecessary motion is a contributing factor to professional dissatisfaction as this exemplifies the lack of “necessary materials and equipment … I need to perform my job” (Leming-Lee et al., 2019) by increasing a clinician’s foot traffic to search for and obtain supplies required to care for patients. Specific focus on removing distractions and interruptions, saving the clinician from spending valuable time searching for items, results in a more satisfying work setting, reducing turnover and increasing operational productivity (IOM & RWJF, 2011; Leming-Lee et al., 2019).
Burnout. Burnout is prevalent across specialties (Bodenheimer & Sinsky, 2014). “The extent of burnout in healthcare is daunting: 55 percent of physicians indicate signs of burnout (Shanafelt et al., 2015 as cited in Norton, 2018), 55 percent of nurses worry that their jobs are affecting their health, and 35 percent of nurses hope they will not be working in their job within a year,” according to AMN Healthcare (2017) as cited in Norton (2018). Burnout and dissatisfaction of physicians and healthcare providers were linked to decreased patient satisfaction and health outcomes, as well as increased cost (Bodenheimer & Sinsky, 2014). In fact, physician and nurse burnout costs the U.S. over $30 billion every year (National Taskforce for Humanity in Healthcare, 2018). Clinicians reported the inability to provide patients with quality care was a contributing factor emphasizing the need for healthcare leaders to optimize the time clinicians spend with patients by designing efficient processes (Norton, 2018), thereby improving the efficiency of nursing time and reducing activities not related to patient care.
Burnout and patient outcomes/experience are inextricably linked. “Burnout leads to lower levels of empathy, which is associated with worsened clinical outcomes” (Bodenheimer & Sinsky, 2014). Similarly, Leming-Lee et al. (2019) denoted “[d]istractions and interruptions are frequent contributing factors to medical errors.” Without warning and proper education, new equipment stocked on the units (e.g., nasogastric tubes, intravenous catheters, and defibrillators) can be disruptive to patient care delivery and result in frustration. The patient and/or family can sense this frustration, and the patient experience is negatively impacted. McHugh, Kutney-Lee, Cimiotti, Sloane, and Aiken (2011) discovered patient satisfaction is much lower in institutions where many nurses feel burned out and dissatisfied with their work conditions.
Another contributor to burnout is embedded in a long- established supply chain strategy to lower cost: switching vendors. While this may seem to be successful from a supply spend standpoint, its contribution to burnout has a hidden but significant cost. First, switching products is tiresome to the frontline as it inevitably mandates a change in process and/or practice. This change is often perceived as unnecessary, is unwelcome, and erodes the joy in care delivery. Second, there is a learning curve when a new product is introduced, and while it is challenging to know the number of patients and clinicians who have been harmed as the care team learns to use a new product, every seasoned clinician will have a story to tell. Switching vendors can challenge the “first do no harm” tenet that is at the core of medical care.
Patient outcomes and experience
Supply chain management in the healthcare industry is complex and challenging due to its impact on people’s health, requiring accurate and adequate medical supplies based on the needs of patients (Mustaffa & Potter, 2009). “Patient safety is threatened by nurse dissatisfaction; many nurses report their workload causes misses in important changes in the condition of patients,” wrote Bodenheimer & Sinsky (2014). When new supplies or equipment arrive on the units, with or without proper training, an delay in patient care may occur due to learning curves and the frustration of acclimating to the new supplies. In addition, patient safety is partially dependent on having sufficient equipment to meet the patient’s requirements (Allen, 2013).
“In supply chain efforts, 15% of the savings derive from negotiating better prices, while 85% derive from influencing supply standardization and utilization by providers” (Ishii et al., 2017). Frontline clinicians have not always been accountable for or aware of the healthcare organization’s bottom line. Their focus is the patient’s well-being, and well it should be. However, today, the financial health of a hospital is everyone’s responsibility as research demonstrates the relationship between hospital financial performance and the quality of care administered (Dong, 2015). Frontline clinicians have the ability to impact an organization’s financial status not only by providing high-quality care focused on minimizing risk, but also by simply reducing the waste of resources. Unsurprisingly, frontline physicians and nurses are keenly aware of where the waste is and can play an integral role in informing efforts to lower costs.
Collaboration between clinicians and supply chain is critical for financial success as medical supplies comprise the second largest expenditure in hospitals, after personnel costs (Moons, Waeyenbergh, & Pintelon, 2019). Ongoing collaboration to determine potential opportunities and adapt operational processes accordingly ensures the greatest impact on costs without reducing quality of care. Healthcare organizations must ensure that the hospital has resources available to provide timely and efficient patient services.
Through recommendations designed to impact organizational culture, there is opportunity to narrow the gap between frontline clinicians and the supply chain. These recommendations are intended for organizations who acknowledge that the bidirectional relationship between the supply chain and clinical departments is critical to achieving the Quadruple Aim. Such a relationship results from reciprocal trust where frontline clinicians view supply chain as their ally, and supply chain views frontline clinicians as its customers.
First, a shared purpose and common vision must be instituted where objectives are defined and results are measured. A mutually agreed-upon definition of customer service and patient experience should be transparently conveyed to the organization. Organizations should identify clinical champions who can socialize the value of the supply chain and clinical department to others within their department using common, familiar nomenclature to ensure consistency and standardization. Further, the identified clinical champions must deliberately and transparently communicate to the frontline clinicians regarding how and when equipment and supplies are selected.
Second, in order to truly achieve a collaborative environment, frontline clinicians beyond those responsible for value analysis processes must also have a seat at the supply chain table to support decision-making. Nurses, as “creatures of habit who thrive on the predictable and comfortable to minimize stress” (Sherman, 2017), become accustomed to specific supplies used in providing patient care. Even the slightest change in supplies can be distracting and impact patient outcomes and experience.
Third, there must be a mutual understanding of clinician and supply chain workflow. An emphasis on information technology implemented on clinical units to manage inventory levels must be reinforced. Clinicians must know that documentation accuracy drives the supply chain. Specific examples of how missing inventory charges impact care delivery should be articulated to garner awareness.
Finally, frontline clinicians often do not learn about the supply chain function in medical or nursing school. In fact, clinicians are never encouraged to review of The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) criteria, which provides the curricular elements and framework for supply chain interdependency,. The lack of supply chain exposure within these professional curricula requires healthcare organizations to provide education and expose novice providers to the importance of supply chain in achieving clinical safety and quality.
Opportunities for future research
A strong research need has surfaced based on further investigation of this topic and an obvious paucity of literature. Specifically, research should be conducted to understand the frontline clinician’s perceived awareness of supply chain, its function, and its impact on cost, quality, outcomes, and work life. Further research is also suggested to infuse supply chain best practices into clinical workflow by continual education and re-assessment of the interdependencies of these two departments. In addition, it will be of interest to chart healthcare’s progress toward achieving the Quadruple Aim as supply chain matures alongside the clinical integration journey.
“We need to develop efficient processes and decision making that is based primarily on the needs of our patients and secondarily on the need of our practitioners to deliver optimum care for the best outcomes at the most feasible cost,” wrote Donatelli (2019). We propose that the function and principles of supply chain should be purposefully addressed at each stage of a clinician’s education and career. Although the working supply chain should function almost invisibly, it is paramount that clinicians have an appreciation for the selection, obtainment, purchasing, and logistics of medical supplies necessary to provide the utmost care for patients. *
Allen, L. (2013). Role of a quality management system in improving patient safety—laboratory aspects. Clinical Biochemistry, 46, 1187-1193.
American Association of Colleges of Nursing (2008, October). The essentials of baccalaureate education for professional nursing practice. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12, 573-576.
Bowles, J., Adams, J., Batcheller, J., Zimmermann, D., & Pappas, S. (2018). The role of the nurse leader in advancing the quadruple aim. Nurse Leader, 16(4), 244-248.
Donatelli, D. (2019). In pursuit of the Quadruple Aim. Healthcare Purchasing News, 43(3), 52.
Dong, G. (2015). Performing well in financial management and quality of care: Evidence from hospital process measures or treatment of cardiovascular disease. BMC Health Services Research, 15, 45.
Feeley, D. (2017, November 28). The Triple Aim or the Quadruple Aim? Four points to help set your strategy. IHI Improvement Blog. Retrieved from http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy
Harvey, L., Smith, K., & Curlin, H. (2017). Physician engagement in improving operative supply chain efficiency through review of surgeon preference cards. Journal of Minimally Invasive Gynecology, 24(7), 1116-1120.
Havens, D., Gittell, J., & Vasey, J. (2018). Impact of relational coordination of nurse job satisfaction, work engagement and burnout. Journal of Nursing Administration, 48(3), 132-140.
Institute of Medicine (U.S.) & Robert Wood Johnson Foundation. (2011). The future of nursing: Leading change, advancing health. Washington, D.C.: National Academies Press.
Ishii, L., Demski, R., Lee, K., Mustafa, Z., Frank, S., Wolinsky, J., … Pronovost, P. (2017). Improving healthcare value through clinical community and supply chain collaboration. Healthcare, 5(1-2), 1-5.
Leming-Lee, T., Polancich, S., & Pilon, B. (2019). The application of the Toyota production system Lean 5S methodology in the operating room setting. Nursing Clinics of North America, 54(1), 53-79.
McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., & Aiken, L. H. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs (Project Hope), 30(2), 202-210.
Moons, K., Waeyenbergh, G., & Pintelon, L. (2019). Measuring the logistics performance of internal hospital supply chains—A literature study. Omega, 82, 205-217.
Mustaffa, H., & Potter, A. (2009). Healthcare supply chain management in Malaysia: A case study. Supply Chain Management, 14, 3, 234-243.
National Taskforce for Humanity in Healthcare. (2018, April). Position paper: The business case for humanity in healthcare. Retrieved from http://healthcareexcellence.org/wpcontent/uploads/2018/04/NTH-Business-Case_2018.pdf
Nicosia, F. M., Park, L. G., Gray, C. P., Yakir, M. J., & Hung, D. Y. (2018). Nurses’ perspectives on Lean redesigns to patient flow and inpatient discharge process efficiency. Global Qualitative Nursing Research.
Norton, J. (2018). The science of motivation applied to clinician burnout: Lessons for healthcare. Frontiers of Health Services Management, 35(2), 3-13.
O’Connor, C. (Ed.). (2018). The healthcare supply chain: Best practices for operating at the intersection of cost, quality, and outcomes (2nd ed.). United States: GNYHA Ventures, Inc.
Schenk, E., Schleyer, R., Jones, C., Fincham, S., Daratha, K., & Monsen, K. (2017). Time motion analysis of nursing work in ICU, telemetry and medical-surgical units. Journal of Nursing Management, 25, 640-646.
Sherman, R. (2017). Transcending your comfort zone. American Nurse Today. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2017/09/ant9-Comfort-Zone-824.pdf
Sikka, R., Morath, J., & Leape, L. (2015). The Quadruple Aim: Care, health, cost and meaning in work. BMJ Quality & Safety, 24, 608-610.
Young, G., Nyaga, G., & Zepeda, E. (2016). Hospital employment of physicians and supply chain performance: An empirical investigation. Health Care Management Review, 41(3), 244-255.