Healthcare supply chain risk management in Rio de Janeiro,Brazil: What is the current situation?

Abstract

BACKGROUND:

Public hospital managers in Rio de Janeiro must deal with severe budget costs, which is the only source of income of public hospitals. In this sense, systematic supply chain risk management can contribute to identifying such risks, assessing their severity, and developing mitigating plans, or even revealing the lack of such plans. Private hospital networks must also map their risks since they are facing a diminishing of demand given that unemployment in Brazil, which is growing in the past years, generates an impossibility of affording private healthcare.

OBJECTIVE:

The purpose of this paper is to investigate how supply chain risk management is being applied in healthcare supply chains from Rio de Janeiro – Brazil. This study considers supply chains located in the state of Rio de Janeiro. To accomplish this objective, we provide answers to two Research Questions: RQ1 - Is SCRM known as a concept among Rio de Janeiro healthcare supply chains? RQ2 - How are risk identification, risk assessment, and risk mitigation being implemented by companies from the healthcare supply chains in Rio de Janeiro – Brazil?

METHOD:

Our research design is based on four steps: i) Research design; ii) Case selection: iii) Data collection (11 cases selected); iv) Data analysis.

RESULTS:

The interviews revealed that SCRM is an entirely unknown concept among healthcare supply chains from Rio de Janeiro – Brazil. Managers have empirical knowledge of the risks, and they can identify the most hazardous risks and can come up with solutions to mitigate them, nevertheless, in many situations they do not have the authority or the manpower to implement the solutions, at most, managers implement local risk mitigation initiatives that do not consider the supply chains broader context.

CONCLUSION:

The healthcare organizations studied by this paper do not apply SCRM. They only apply local isolated solutions not considering a supply chain scope. This can become hazardous since isolated risk mitigation initiatives are often innocuous and have the potential to generate other risks.

Keywords

Supply chain risk resilience qualitative study qualitative data

1 Introduction

Different types of crisis, such as operational crisis, financial crisis, wars, or even humanitarian crisis strike healthcare organizations of all types around the world. This obligates the supply chains, which are exposed to multiple high-magnitude risks [1] to maintain a posture of resiliency for crisis mitigation [2]. This statement is supported by Khalili [3], which affirms that supply chains (SC) are increasingly exposed to operational, and disruption risks threatening their business continuity. Also, when dealing with healthcare supply chain (HCSC) risks, it often means that either a medication or a bandage is missing, the wrong treatment is applied, or even the team was unable to save the patient’s life [3]. Therefore, literature analysis leads to conclude that it is crucial to identify, assess and mitigate not only healthcare organizations risks, but risks concerning their whole SC as well. The identification of risk is more than a list of threats, furthermore, the sooner a risk is managed, the less it will negatively impact an organization [4]. In terms of mitigation, Wieland and Wallenburg [5] propose two main risk-mitigating constructs: robustness (proactive strategy) and agility (reactive strategy). Although there are many papers applying means of identifying and confirming risks to most different supply chains such as apparel [6], automotive [7], clothing [8], courier [9] and papers approaching multiple segments [4]; Wieland and Wallenburg [5]; Kern et al. [10]; Cantor et al. [11]; Fan et al. [12]; Sreedevi and Saranga [13], the literature shows a gap in supply chain risks identification related to healthcare.

The next logical step after risk identification would be how to assess/measure these risks. Perfor-mance management is considered an always challenging issue, besides, there are significant adverse outcomes associated with reduced use of performance management systems in public services, particularly adverse effects on staff morale managers [14]. Such inadequate use or even the total absence of performance indicators is responsible for jeopardizing improvement initiatives, as it is almost impossible for managers to improve a process that is not being measured. In areas such as finance, insurance, crisis management and healthcare, the importance of considering risk is already broadly acknowledged. In addition, well-elaborated concepts and approaches for risk management have been developed, stating how supply chain resiliency (SCRes) is crucial ([15]; [2]). In this paper we consider SCRM the process of identification, assessment, mitigation, and monitoring risks that generate ripple effects to one or more supply chains.

This study focused on the SCRM in the healthcare sector of Rio de Janeiro – Brazil, for four main reasons. First, the recent increase in the supply of new materials and technologies in the scenario of budget restriction and great pressure of market forces, is imposing great challenges to the healthcare supply chain in Rio de Janeiro – Brazil, as well as to the whole country’s healthcare supply chain. Thus, this makes the healthcare supply chains of Rio de Janeiro – Brazil, worth studying. Second, disruptions in the Rio de Janeiro healthcare sector often mean that patients will receive unsatisfactory service that can result in surgery delays, lack of medications, which in worst cases can be fatal for patients. Third, with population ageing in Rio de Janeiro, healthcare costs are constantly increasing, making it imperative to offer increasingly better services with the same or even lower costs. Fourth, literature contribution. There are very few studies investigating how SCRM can be applied to healthcare organizations. In addition, no studies were found contemplating healthcare SCRM in Rio de Janeiro. Therefore, there is an opportunity for generating technical literature, which would benefit scholars interested in generating furtherstudies.

In this sense, the objective of this study is to investigate how supply chain risk management occurs in healthcare supply chains from Rio de Janeiro – Brazil. This paper is organized as follows. This section is introductory. Section 2 shows the background of healthcare in Brazil and data to illustrate the healthcare panorama. Section 3 conducts a literature review discussing the main concepts worked in the paper. Section 4 details the research methodology. Section 5 discusses the data revealing how the organizations of this study are identifying, assessing, and mitigating risks. Section 6 proposes a general discussion. Finally, section 7 closes the paper with the conclusions.

2 Theoretical framework

Although Brazil is the 12^th world economy considering Gross Domestic Product (GDP) [16], families in Brazil live (on average) with a per capita income of 1,380.00 BRL per month, which means about 250.00 USD [17] of per capita income per month. Considering that a private healthcare insurance average cost is around 2,000.00 BRL per month for people over 60 years old and can cost over 9,000.00 BRL per month [18], most Brazilians depend on publichealthcare.

Therefore, the already insufficient public healthcare must deal with a demand growth that generates queues for surgery that take longer than six months depending on the medical specialty and location [19]. In this sense, considering that Brazilian public healthcare system is already unable to meet an increasingly growing demand; process improvement, cost-cutting, and risk mapping measuring and mitigation are crucial for the survival of healthcare (HC) organizations as well as their SC.

3 Literature review

This section presents a literature review on supply chain risk management (SCRM) and healthcare SCRM (HCSCRM), to ground our research performed in Rio de Janeiro – Brazil. Section 3.1 presents SCRM in general and Section 3.2 presents HCSCRM.

3.1 Supply chain risk management (SCRM)

Today’s business world comprises supply chain networks that are becoming increasingly prone to uncertainties [20]. The topic is currently considered one of the most attractive to researchers in the supply chain field [21]. Disasters that cause disruptions are well-documented in the literature. For example, fire in microchip powerplants [22] and the earthquake in Japan [23]. In this sense, the application of supply chain risk management has received increased attention in recent years, aiming to protect supply chains from disruptions by identifying, assessing, and mitigating their adverse effects [24]. Moreover, supply chain stability has a significant and extensive effect on both operational performance and customer experience value [25].

Considering the broad scope of applications, SCRM is being applied to agricultural supply chains [25, 26], chemical supply chain [27] and fast-moving consumer goods manufacturer [28]. Considering techniques, Sawik [29] implemented a multi-period stochastic programming model to prevent disruption management. Yan et al. [25] applied the conditional value-at-risk (CVaR) model to establish a risk loss function and a genetic algorithm to identify the optimal risk control portfolio. Snoeck et al. [27]; Sawik [29] stochastic program-ming models and Trapero et al. [28] utilized a GARCH (Generalized Auto Regressive Conditional Heteroscedasticity) model to deal with demand uncertainties.

Considering the studies by Cunha et al. [30] and Busse [31], the SCRM body of knowledge is still incomplete, lacking aspects such as social supply chain risk management (SSCRM), which considers the image and financial damages to companies that are causing social risks. Another stream of literature which is lacking research is supply chain risk management applied to healthcare organizations (HCSCRM). SSCRM and HCSCRM are well related in Rio de Janeiro, since Brazil offers universal healthcare coverage via its unique healthcare system, called “Sistema Único de Saúde” (SUS). Job losses generate impact in public healthcare offer since the unemployed population loses the capability of affording private healthcare. In this sense, HCSCRM in Rio de Janeiro is strictly related to SSCRM. The next section reviews the concept of HCSCRM, while the concept of SSCRM is out of the scope of this work.

3.2 Supply chain risk management in healthcare (HCSCRM)

Risk’s literature provides a wide variety of tools that are adapted supply chain management [32]. In the last five years, studies about SCRM have been growing, nevertheless, studies considering HCSCRM are lacking.

To the best of our knowledge, we were only able to find few studies that concern HCSCRM. None of these few studies were explicitly applied to either Latin America or Rio de Janeiro – Brazil. These few papers can be classified into two types: (i) papers which formally apply SCRM to HC organizations and (ii) papers which eventually discuss solutions to problems that consist in major risks and may cause service rupture.

Vanvactor [2] highlights the importance of disaster mitigation to prevent SC breakdown and draws attention to crisis mitigation concepts. Vanvactor [2] defines healthcare SC resilience (SCRes) as a capability to be responsive to disasters, as well asSC breakdowns, and still being able to provide a full continuum of services to all patients arriving at a facility for care. Eiro and Torres Junior [33], bring cases of healthcare organizations that implemented Total Quality Management (TQM) and Lean through the implementation of tools like Value Stream Map (VSM) and Failure Mode and Effect Analysis (FMEA). These techniques and concepts can improve processes and have been used in the last decades to mitigate undesired intra organizational effects.

Rakovska and Stratieva [34] mention that pharmaceuticals and medical devices are of particular interest because they must meet specific requirements of several clinical departments and therefore, present significant risks of stockout Mandal and Jha [35]; Niemsakul et al. [36] analyze the role of collaboration considering hospital-supplier, which helps mitigate risks related to demand changes. We identified seven papers that formally apply SCRM to healthcaresupply chains: i) Jaberidoost et al. [37] – Literature review; ii) Jaberidoost et al. [38]– Analytic Hierarchy Process (AHP); iii) Elleuch et al. [39] – Failure Mode and Effect Analysis (FMEA), AHP and Design of Experiments (DOE); iv) Zamora Aguas et al. [40]– System Dynamics; v) Zepeda et al. [41] – Econometric methods; vi) Riley et al. [42] – Structural Equation Modeling (SEM); vii) Boonyanusith and Jittamai [43] – House of Risk (HOR) model. Analyzing these seven papers, we conclude that there are no case studies, frameworks or studies that diagnose the current state of SCRM concerning healthcare supply chains, which consists in an important literaturegap.

Jaberidoost et al. [37] present a literature review focused on a pharmaceutical original equipment manufacturer (OEM). The authors identify five major risk categories: i) Supply & suppliers’ issues, ii) Organization & strategies issues, iii) Financial, iv) Logistic, v) Market, vi) Political, and vii) Regulatory. The authors affirm that risks in this SC are responsible for impacting the quality, the quantity and their delivery in the right place and time demanded by the customer. The authors conclude affirming that risk identification and mitigation can optimize the supply chain management as well as improve performance measures such as accessibility, quality and affordability.

Jaberidoost et al. [38] is a study that assesses supply chain risks using Analytic Hierarchy Process (AHP). The authors could identify 86 main risks distributed into 11 categories. The top risks were the financial and economic parameters, politics and then the government. The results show that in Iran pharmaceutical industry and supply chain were affected by the political conditions. The financial function was highlighted by the authors as the priority to manage in the pharmaceutical industry. More than 50% of the mapped risks were external from the supply chain.

Elleuch et al. [39] combine tools in a framework for systematic approaching SCRM including: i) Failure Modes, Effects and Criticality Analysis (FMECA), ii) Design of experiment to design risks mitigation and action scenarios, iii) Discrete event simulation to assess risks mitigation action scenario, iv) AHP to evaluate risk management scenarios, and v) desirability function approach to minimize the risk. The authors validate their methodology in a pharmaceutical supply chain case. Although the authors present a robust empirical methodology, the study does not make an in-depth discussion concerning risk identification.

Zamora Aguas et al. [40] carry on a supply chain risk analysis applying System Dynamics to the Colombian oncological medicine supply chain. The authors assess for a given set of conditions the cost of risks and logistic operations. The authors indicate that some of the main problems in the Colombian health system are related to inadequate supply and availability of essential medicines. Risk management was carried out from a framework including: i) Contextualization – including the identification of internal risk factors and external risk factors, ii) Assessment – including valuation and analysis, and iii) Decision and Feedback – Including evaluation of management strategies that result in implementation, monitoring, and control, resulting in acquired knowledge.

Zepeda et al. [41] focus on hospital inventory costs investigating the potential mitigating effects of affiliation with multi-hospital systems. The authors mapped some critical factors and tested which of these factors could either lower or generate inventory. The authors showed a notable relationship between demand uncertainty for a hospital’s clinical requirements and a hospital’s inventory costs.

Riley et al. [42] set as a premise that organizations should leverage supply chain agility principles and develop capabilities like internal integration, information sharing, training, therefore, enabling the organization to address and react to supply chain anomalies. The authors conduct a survey where they test the assumptions: i) Does the hospital’s internal integration result in improved warning and recovery capabilities? ii) Does enhanced information-sharing competences result in improved warning and recovery capabilities? iii) Does enhanced training competences result in improved warning and recovery capabilities? Also, iv) Does enhanced warning and recovery capabilities result in improved performance? The authors found evidence suggesting that internal integration could be used to enhance organizations’ SCRM capabilities.

The blood supply chain studied by Boonyanusith and Jittamai [43] presents a set of unique features since it must confront not only blood demand and supply uncertainties but also complexities in blood inventory management. Therefore, the authors propose risk identification in the blood supply chain using a risk management tool called HOR model. As the main results, Boonyanusith and Jittamai [43] highlight 30 risk events and 16 risk agents identified and assessed in the case study.

Concluding this section, it is important to mention that no papers regarding HCSCRM were explicitly applied to Latin America and, in this case, Rio de Janeiro – Brazil. In this sense, our work brings a unique contribution. Next section depicts the methods used in our work.

4 Methods

Our research methodology framework is based on Yin [44] and is summarized in Fig. 1.

Fig. 1

Research methodology.

4.1 Research design

The first step is to build the research design following five steps: i) Formulate research questions; RQ1 - Is SCRM known as a concept among Rio de Janeiro healthcare supply chains? RQ2 - How are companies from the Brazilian healthcare supply chains implementing risk identification, risk assessment, and risk mitigation? ii) Formulate propositions: PR1 – HCSCs do not apply SCRM as most market-oriented SCs do, PR2 – HCSCs apply risk identification, assessment and mitigation not systematically; iii) Identify analysis units, a case study, can be an individual. We selected 11 cases, which were guided by the professionals that returned our calls. iv) Assess the logic connecting the cases to the propositions; our criterion consisted in carrying out a qualitative analysis from the interviews. v) Establishing criteria to interpret the findings, – Yin [44] affirms there is no precise way of establishing a criterion for such discoveries. Therefore, the authors of this paper assessed the findings and discussed about the data collected.

4.2 Case selection

The following criteria were considered: i) Organizations should be based in Rio de Janeiro – Brazil; ii) The organizations should be part of a healthcare supply chain; iii) We did not require that the professionals have supply chain risk management knowledge, we wanted to hear their perception and then cross-validate with the literature.

Our final sample included different professionals (nurses, administrators, engineers, pharmacists and psychologists) belonging to various organizations (army, navy, airborne, private and public healthcare organizations and industry). We summarized the interviewee’s profile in Table 1. Figure 2 shows the conceptual design of the supply chain formed by the interviewed professionals. In next section, we describe the data collection method used in our study.

Table 1
Interviewee’s profile

Professional Job description/Formation Supply chain tier

PROF A National logistics manager of private hospital chain (PrHC) - Administrator Hospitals, warehouses (supply, procurement)

PROF A.1 Logistics analyst of PrHC - Industrial engineer Hospitals

PROF A.2 Logistics analyst of PrHC - Industrial engineer/Pharmacist Hospitals

PROF B Supply manager of public federal hospital (PuFH) - Administrator Hospital

PROF B.1 Nurse at PuFH Hospital

PROF C.1 1st lieutenant pharmacist - Airborne (Airb) Hospital

PROF D.1 1st lieutenant pharmacist - Navy (Nav) Hospital

PROF E.1 Production and planning control analyst - Industrial engineer - Private OEM (PrMOEMl) OEM

PROF F.1 Production and planning control analyst - Industrial engineer (PrMOEM2) OEM

PROF G.1 Logistics analyst - Nurse/ Industrial engineer (LogAn) Distributor of pharmaceutical products

PROF H.1 Therapist in public clinic (PuCL) - Psychologist Clinic

Professional	Job description/Formation	Supply chain tier
PROF A	National logistics manager of private hospital chain (PrHC) - Administrator	Hospitals, warehouses (supply, procurement)
PROF A.1	Logistics analyst of PrHC - Industrial engineer	Hospitals
PROF A.2	Logistics analyst of PrHC - Industrial engineer/Pharmacist	Hospitals
PROF B	Supply manager of public federal hospital (PuFH) - Administrator	Hospital
PROF B.1	Nurse at PuFH	Hospital
PROF C.1	1st lieutenant pharmacist - Airborne (Airb)	Hospital
PROF D.1	1st lieutenant pharmacist - Navy (Nav)	Hospital
PROF E.1	Production and planning control analyst - Industrial engineer - Private OEM (PrMOEMl)	OEM
PROF F.1	Production and planning control analyst - Industrial engineer (PrMOEM2)	OEM
PROF G.1	Logistics analyst - Nurse/ Industrial engineer (LogAn)	Distributor of pharmaceutical products
PROF H.1	Therapist in public clinic (PuCL) - Psychologist	Clinic

Fig. 2

Healthcare supply chain considering the interviewees.

4.3 Data collection

Our data collection method consists of semi-structured interviews. This approach had a good fit with our method, because it guides the interview allowing the researcher to explore interesting answers and obtain even better results than the expected [45]. The interviews were conducted in loco, by telephone, or by e-mail (all the options were given to the interviewee who could freely choose, although the researchers preferred the in loco interviews). The interviews were recorded in audio files (when carried in loco) with the interviewee’s consent, contributing towards an accurate and unbiased record ([46, 45]). The interview protocol was piloted with one interviewer and no secondary data was used (Appendix).

4.4 Data analysis

We analyzed the data by listening to all the interviews or reading the reports provided by the interviewees. Nevertheless, to preserve the privacy of the interviewees we did not transcribe the interviews. Instead, we selected the most vital information for further analysis. In this sense, we summarized the literature consensus concerning SCRM analyzing the data from the interviews following in the light of the framework.

5 Results

SCRM deals with the identification, analysis and mitigation of risks that affect the whole supply chain network [47]. Different authors propose steps and phases that if logically followed result in a promising way of managing risks. For example, Sinha et al. [48] identified five steps for mitigating supplier risks: (1) identify risks, (2) assess risks, (3) plan and implement solutions, (4) conduct failure modes and effect analysis, and (5) continuously improve. Based on an extensive literature review, Sodhi et al. [49] summarized four key sub-processes for managing supply chain risks: (1) risk identification, (2) risk assessment, (3) risk mitigation, and (4) responsiveness to risk incidents. This stream of research has generated valuable insights on the SCRM processand has offered significant implications for practitioners.

Nevertheless, Sodhi et al. [49] show that the major understanding of SCRM literature consists in approaching SCRM with three main elements: identification, assessment and mitigation. As already shown, some authors bring four or even five or more elements [49]. Considering the available frameworks, this work adopts the major understanding of considering the framework composed by identification, assessment and mitigation, considering that all other steps proposed are embedded within these three. Figure 3 shows the framework that based our analysis.

Fig. 3

SCRM framework (Senna et al. [50]).

5.1 Risk identification

In general, professionals showed detailed visions of the risks even describing concrete mitigation plans. Sustainability risks pointed out by professionals A and B included cardboard boxes, chemicals, overdue products and medicine, prostheses, and orthoses. In terms of procurement risks, PROF C.1 affirms that even if the company has a terrible reputation (wrong delivery, quality issues, etc.) public procurement cannot prohibit the company to take part in the procurement process and if the company has the lowest price, answers to all specifications, and presents all documents, the company will win the bidding. In terms of financial risks, only PROF E.1 and PROF A.2 highlighted this as an issue, mentioning for example changes in currency rates (imported raw materials for example). Concerning lack of efficiency, PROF A, PROF A.1 and PROF B.1 highlight how manual are the processes. Thus, both private and public healthcare professionals highlighted how manual are the process, what generates mistakes and broken information flows. In addition, these professionals related problems concerning inventory checking. For example, imagine that a bin has 1,000 medicine ampoules with different due dates. The employee checking the ampoules must store them using a First-in First-out (FIFO) logic. OEM professionals stated that there are opportunities of improving the information sharing along the supply chain where OEM professionals work in a business-oriented logic. In this sense, they tend to have a clear understanding of the importance of supply chain management and supply chain risk management, while healthcare professionals (namely, professionals working directly with patient care) tend to have less understanding. In terms of demand risks, PROF E.1 highlight the existence of meetings to determinate whether there are risks of real demand overcoming the forecast, thus avoiding backorders. Concerning distribution risks, PROF B.1 highlights that a significant risk consists of delays in deliveries. PROF D.1 affirms that other issues that affect an SC are the excessive number of documents (bureaucracy, slow processes, etc.) and lack of management, inventory planning. Professionals A and B highlight that Clinical Engineering (CE) plays a significant role in HCSC. Clinical engineers have a tremendous potential to give consultancy and generate savings in the SC. CE is an SC tier that is responsible for approving a 100,000 USD equipment or diagnose that the same equipment can be repaired for half the cost; therefore, it is a company that is also responsible to bridge the gap between management and giving patients better quality of care. HRO and HRN provide principles that converge to the generation of SCRes and the generation of resilience in HCSC.

Deepening the discussion concerning HCSC risk identification, PROF A highlights that there is no formal risk identification method, the manager affirms though, that there is an assessment of the resupply policy to avoid rupture. The inventory control planning is not integrated, there are several different local spreadsheets and inventory conference depends on the analyst ability. Supply delays are registered in a list, which generates an alert. Then, there will be an investigation to discover which order did not arrive. This information will also go to a technical sector, which will assess whether there is or not the possibility of substituting the product. In case the disruption is confirmed (i.e., the order is already delayed) the planning sector contacts the supplier and asks if they will deliver the order. The supplier then, may either deliver with delay or not deliver the order at all (the supplier may be experiencing severe ruptures as well, such as fires, strikes, etc.). In case there is already a substitute homologated, the product is replaced. The document containing these pieces of information shows what is delayed, and a critical list shows, which orders are in imminent rupture. There is a corporate procurement department that buys stockable products for CE, and the CE department is responsible for buying the more technical types of equipment such as tomographs. CE is also responsible for managing equipment being responsible for its depreciation and replacement. These items are considered non-stockables. Hospitals from the private hospital network (PrHN) do not have facilities departments, and so each hospital executes maintenance via its building maintenance department.

Other hospitals from the private network of Rio de Janeiro must deal with risks related to health insurance as is the case of the network of private hospitals called D’Or network. This network of privatehospitals litigated with one of the main health insurance companies in Rio de Janeiro, called (AMIL). AMIL argues that the D’Or network is overcharging the procedures. They could not reach an agreement [19]. It is important to mention that neither the D’Or network nor AMIL figured as the company of any interviewees from the interview performed in this work.

PROF A.1 highlights that another significant risk is the low inventory accuracy. PROF A.1 is ananalyst that already worked in retailer warehouse and affirmed that the inventory accuracy in the PrHN is considerably lower than the average retailer inventory accuracy. To preserve the companies, the number cannot be disclosed. The analyst discusses that HC is a very normative sector, needing a thorough medicine due to date control. In most of the retailers, inventory is conducted at about three times a year while in HC, the inventory is continuously checked. Inventory checking is also very challenging because after the conference, the analysts often do not restore the medicine in a FIFO due date logic. The company does not have an appropriated inventory system, and it cannot electronically check a bar code. Instead, the system prints a list, and the employee does a manual check and then compiles (manually) into the system. In an emergency, low inventory accuracy may result in not having a vital medicine in stock. PROF A.1 also mentions culture problems. In general, it is incredibly challenging to convince HC professionals that they also play a major role in logistics. In overall, healthcare professionals excel at medical care, but they lack logistic skills. There are issues concerning doctors that only use one determined kind of medicine (even if there are equivalent substitutes). The fact that there are doctors who do not use the standard hospital medicine or equipment obligates the hospital to keep a minimal stock of that medicine. This is also incredibly challenging because of the huge variety of medicines.

PROF B highlights, in the public hospital network (PuHN), the unstandardized demand flows at the municipality level. Each hospital has a demand for a different period. At the federal level, hospitals have their information systems and thus it is easier to consolidate demands, in opposition to municipality level, where each hospital has its own scattered spreadsheets. Private pharmaceutical companies also have difficulties with all levels of the government that often delays payments, generating considerable struggle for companies to fulfill public hospitals orders. There are also private pharmaceuticalcompanies with still an influential family culture, lacking business-orientation and often losing deadlines and accumulating backorders. There are many quality issues, such as wire sutures that depending on the quality may result in the death of patients. In the PuHN, quality mostly means “complying with the laws”. A wire suture can be considered an A-class product (considering a price ABC classification) and has a very complicated purchase process due to relying on an outdated licitation process. Diapers (mostly in either B or C category) are considerably cheaper, having a high volume. Nevertheless, if the quality is too weak, it may result in using greater number of the product, resulting in a hard to balance trade-off.

Still according to Professional B, suppliers use to deliver a lot of non-conforming products. Taking into consideration the Brazilian Supply Federal Law (Lei 8.66/93), that regulates the purchase in the public sector, there is a clause in such law that gives the possibility of provisionally receiving the order. This clause gives managers some time to execute quality control. Concerning technology change, a careful cost-benefit analysis should be carried out. In terms of clinical equipment, there is a CE company contracted to carry out this analysis. The CE companies are responsible to map materials and equipment and to manage equipment maintenance. The recent increase in cargo theft in the last three years (mostly in Rio the Janeiro), is responsible for an increase in suppliers’ prices. The reverse logistics process of prostheses and orthoses are also very costly, as they must be incinerated. A mitigation strategy for this problem consists of reselling silver components that most hospital equipment has. Therefore, managers can negotiate a discount on future purchases if the suppliers can receive these silver components.

Professional B.1 highlights the problems of quality that often affect the recovery of patients. For example, inadequate quality bandages can lead to non-healing of an injury, increasing patient discomfort, increasing infection risks, aggravating their clinical condition. This situation also leads to a cost increase for the hospital as the patient eventually will have a more extended stay, generating a bed deficit. Another major problem is when a poor-quality sterile procedure glove is purchased. The gloves can rip during a procedure generating risks to both HC professional and the patient.

PROF H.1 is a therapist professional with experience in treating schizophrenia, bipolarity, among other severe mental illnesses. The professional cites how important it is for the patients and the treatment team to choose together which vegetables and fruits they want in the patient’s meals. This kind of choice is made during what the professionals call assemblies. The assemblies join all patient treatment stakeholders (family, friends, neighbors, etc.) and it is where they discuss actions. Thinking about their own food gradually leads the patient to make decisions. Assigning responsibilities plays a major role in the treatment. The heavy drugs that psychic patients must consume most of the times generate other health problems such as obesity, cholesterol, diabetes, which reinforces the need of a healthy food supply, which often does not occur. The hotel sector also should not be “too standard”. White sheets and white beds compose a context that is similar to asylums. Therefore, the treatment consists in doing the opposite, having colored furniture, sheets and other furniture that relieves this stigma. In this sense, a simple solution would be to integrate this network of clinics in a system and consolidate the needs, in this way it would be possible to keep the individual choices and still have scale gains since the needs from clinic to clinic would not be so different.

PROF E.1 (PrMOEM1) highlights that raw materials delivery may cause a severe impact in planning and production scheduling and hence, in product availability. Therefore, for the OEM, the major risks are (i) fail to deliver the orders and (ii) production capacity constraints, which may generate backorders. The most critical suppliers are raw materials suppliers and packing suppliers. Raw material suppliers are even more critical because they may impact hospital patients. The suppliers and the OEM do not have a functional integration, mostly because they are from other Brazilian states or even other countries and cannot evaluate how a wrongly emitted invoice may impact or delay delivery. In the analysis of PROF E.1, this relationship still must be improved.

PROF F.1 highlights that many important procedures are not documented, resulting in a bad knowledge management. For instance, when a procurement professional leaves the company, such professional usually carries away all the technical knowledge about that specific purchase the professional used to perform. The professional PROF F.1 also highlights that his team works in almost a Make-to-Order logic and do not have a reasonable safety stock.

PROF G.1 points out the vision of the distributor and highlights that the suppliers often present quality problems, which result in failure to fulfill orders they receive and cause an impact in competitive pricing. Professional G.1 complements affirming that these risks could be mitigated if there were more involvement of the supplier in understanding the clients’ needs.

In this sense, the interviewed professionals present an empirical understanding of the risks. Nevertheless, they do not map these risks systematically nor implement continuous risk management initiatives. Although, risk identification consists in a crucial phase of SCRM, it is still not sufficient. Generally, managers and employees do not have enough time to equally create and execute detailed mitigation plans, in this sense, it is vital to prioritize which risks are urgent and which ones can be dealt with in a near future. Therefore, the next logical step is to assess the previously mapped risks via key performance indicators (KPIs). Table 2 presents the healthcare supply chain risks identified by Senna et al. [50] mentioned by the interviewed professionals.

Table 2
Risks mentioned in the interviews

Risk category Risks Professionals

Environmental Disasters

Environmental risks

Flood

Government risks PROF B, PROF B.1, PROF A.2

Hazardrous wastes risks PROF A, PROF A.1, PROF B, PROF B.1

Legal risks PROF B

Sustainability risks PROF A, PROF A.1, PROF B, PROF B.1, PROF E.1

Deliberate threats Corruption PROF B

External pressures Purchasing cost higher than expected PROF B, PROF B.1

Insufficient e-government services PROF B

Lack of health service supply chain design PROF B

Lack of macro-ergonomics conditions in HCSC

Procurement risks PROF B, PROF B.1, PROF C.1

Technology risks PROF A.1, PROF B

Organizational/resource limits Blood wastage

Capability

Costs PROF A.1, PROF B, PROF E.1

Culture risks PROF B

Drug recalls management

Excess of packaging material PROF A, PROF B

financial risks PROF E.1, PROF A.2

No comprehensive e-procurement system

Institutional pressures (coercive, mimetic, and normative, endogenous pressures) PROF B

Internal conflicts, PROF B

IT risks PROF A.1, PROF B, PROF E.1, PROF F.1

Lack of efficiency PROF A, PROF A.1, PROF B

Lack of executive support

Lack of expertise

Lack of product rotation PROF A, PROF A.1, PROF B

Lacking provision of dressings to nurses

Long waiting times,

Misalignment of priorities

Prescription errors PROF A, PROF A.1, PROF B

Time waste (from non-value-added activities)

Turnover

Sensitivity Expired drug management PROF A, PROF A.1, PROF B

Huge variety of drugs,

Management of product expiration date PROF A, PROF A.1, PROF B

Performance measurement risks PROF A, PROF A.1, PROF B

Network Communication risks PROF A, PROF A.1, PROF B

Credibility risks PROF B, PROF B.1

Data management risks PROF A.1, PROF B

No integrated and unified information system between hospital and its suppliers PROF A.1, PROF B

No information-sharing between hospital and its suppliers PROF A.1, PROF B, PROF E.1 -

No collaboration PROF A.1, PROF B, PROF E.1, PROF F.1

Information risks

picking risks PROF A.1

Relationship risks PROF B, PROF F.1, PROF E.1

Warehouse management risks

Supplier/customer disruptions Demand risk PROF A, PROF A.1, PROF E.1

Distribution risks PROF A, PROF A.1, PROF B, PROF B.1, PROF D.1, PROF E.1, PROF A.2, PROF F.1, PROF G.1

Hospital–supplier integration - mitigators

Quality risks PROF B, PROF B.1, PROF D.1, PROF E.1, PROF A.2, PROF F.1, PROF G.1

Supply risks PROF A, PROF A.1, PROF B, PROF C.1, PROF D.1, PROF E.1, PROF F.1, PROF B.1

Risk category	Risks	Professionals
Environmental	Disasters
	Environmental risks
	Flood
	Government risks	PROF B, PROF B.1, PROF A.2
	Hazardrous wastes risks	PROF A, PROF A.1, PROF B, PROF B.1
	Legal risks	PROF B
	Sustainability risks	PROF A, PROF A.1, PROF B, PROF B.1, PROF E.1
Deliberate threats	Corruption	PROF B
External pressures	Purchasing cost higher than expected	PROF B, PROF B.1
	Insufficient e-government services	PROF B
	Lack of health service supply chain design	PROF B
	Lack of macro-ergonomics conditions in HCSC
	Procurement risks	PROF B, PROF B.1, PROF C.1
	Technology risks	PROF A.1, PROF B
Organizational/resource limits	Blood wastage
	Capability
	Costs	PROF A.1, PROF B, PROF E.1
	Culture risks	PROF B
	Drug recalls management
	Excess of packaging material	PROF A, PROF B
	financial risks	PROF E.1, PROF A.2
	No comprehensive e-procurement system
	Institutional pressures (coercive, mimetic, and normative, endogenous pressures)	PROF B
	Internal conflicts,	PROF B
	IT risks	PROF A.1, PROF B, PROF E.1, PROF F.1
	Lack of efficiency	PROF A, PROF A.1, PROF B
	Lack of executive support
	Lack of expertise
	Lack of product rotation	PROF A, PROF A.1, PROF B
	Lacking provision of dressings to nurses
	Long waiting times,
	Misalignment of priorities
	Prescription errors	PROF A, PROF A.1, PROF B
	Time waste (from non-value-added activities)
	Turnover
Sensitivity	Expired drug management	PROF A, PROF A.1, PROF B
	Huge variety of drugs,
	Management of product expiration date	PROF A, PROF A.1, PROF B
	Performance measurement risks	PROF A, PROF A.1, PROF B
Network	Communication risks	PROF A, PROF A.1, PROF B
	Credibility risks	PROF B, PROF B.1
	Data management risks	PROF A.1, PROF B
	No integrated and unified information system between hospital and its suppliers	PROF A.1, PROF B
	No information-sharing between hospital and its suppliers	PROF A.1, PROF B, PROF E.1 -
	No collaboration	PROF A.1, PROF B, PROF E.1, PROF F.1
	Information risks
	picking risks	PROF A.1
	Relationship risks	PROF B, PROF F.1, PROF E.1
	Warehouse management risks
Supplier/customer disruptions	Demand risk	PROF A, PROF A.1, PROF E.1
	Distribution risks	PROF A, PROF A.1, PROF B, PROF B.1, PROF D.1, PROF E.1, PROF A.2, PROF F.1, PROF G.1
	Hospital–supplier integration - mitigators
	Quality risks	PROF B, PROF B.1, PROF D.1, PROF E.1, PROF A.2, PROF F.1, PROF G.1
	Supply risks	PROF A, PROF A.1, PROF B, PROF C.1, PROF D.1, PROF E.1, PROF F.1, PROF B.1

In a list of 54 risks there are 35 risks corroborated by the professionals (about 64.8% ), in this sense, most part of risks identified in the literature are also mentioned by HCSC professionals.

5.2 Risk assessment

PROF A affirms that the stock levels are analyzed in the light of their previously defined inventory policies and they use either three or four different statistical methods to conduct the analysis (the methods were not detailed during the interview). A 24-month sample defines the product stock turnover, and minimum and maximum quantities. The main objective is never to have supply disruptions, which may result in losing patients’ lives.

PROF A.1 affirms that the storeroom has an adequate inventory control. The major consists in keeping track of nursing units’ inventory. If the nursing unit needs a medicine with urgency, the storeroom often dispenses the medicine promptly not keeping track of it in any system, to guarantee the quick dispensation. Nevertheless, this practice generates low inventory accuracy issues if the stockman forgets to keep track of the medicine later. Another necessary process is to map the homologated medicines and products in order to register the consumption and calculate their minimum and maximum quantities.

The labeling process has the objective of providing traceability. The hospitals from the PrHC have one warehouse in which the labeling process is already fully automated. This labeling process is particularly important because it gives visibility of product information, for example, when the product must be dispatched. Among the main indicators, Professional A.1 and Professional A highlight i) Product receipt service level; ii) Dispensation time; iii) Stock turnover of storeroom; iv) Nursing units’ stock; v) Cleaning and organization; vi) On Time in Full (OTIF). Supply assessment is responsible to define which is the optimum products mix for the hospital. The lack of an integrated system generates KPIs that are locally visualized via spreadsheets only. The managers know that a high inventory level means a low level of working capital that could be invested in either more beds or more hospitals. The planning analysts consult the pharmacists and nurses to validate the supply planning.

PROF B highlights that compliance is a critical process (PROF B defines compliance as the fulfillment of laws and conducts) to help mitigating supplier-related risks. In the PuFH there is no standard purchasing process, thus the purchasing depends on the ability of the current manager.

PROF E.1 highlights that the departments of quality and procurement works to continually evaluate their suppliers. In terms of assessment, if PrMOEM1 incorporates a new production line, they open a “Change Control” process to evaluate whether the changes are being positive. This assessment has the objective of helping to mitigate supply chain risks. Table 3 shows the summary of the assessment practices.

Table 3
Assessment practices

Risk assessment measure Remarks Professional

Statistical methods The statistical methods estimate minimal and maximum quantities to avoid rupture PROF A

Manual checking for inventory control The medicine dispensed without the proper control PROF A.1

Automated labelling process Labeling process provides information of when the product was dispatched PROF A.1

KPI measurement system KPIs mentioned: i) Product receipt service level; ii) Dispensation time; iii) Stock turnover of storeroom; iv) Nursing units’ stock; v) Cleaning and organization; vi) On Time in Full (OTIF). PROF A.1

Compliance Compliance helps to mitigate supplier-related risks PROF B

Suppliers’ quality assessment The departments should continuously assess the quality of suppliers PROF E.1

Risk assessment measure	Remarks	Professional
Statistical methods	The statistical methods estimate minimal and maximum quantities to avoid rupture	PROF A
Manual checking for inventory control	The medicine dispensed without the proper control	PROF A.1
Automated labelling process	Labeling process provides information of when the product was dispatched	PROF A.1
KPI measurement system	KPIs mentioned: i) Product receipt service level; ii) Dispensation time; iii) Stock turnover of storeroom; iv) Nursing units’ stock; v) Cleaning and organization; vi) On Time in Full (OTIF).	PROF A.1
Compliance	Compliance helps to mitigate supplier-related risks	PROF B
Suppliers’ quality assessment	The departments should continuously assess the quality of suppliers	PROF E.1

The professionals did not emphasize risk assessment practices. This outcome is consistent with the lack of risk assessment studies in SCRM literature. There is a significant literature gap concerning which KPI should be used to evaluate risks and evaluate risk mitigation practices.

5.3 Risk mitigation

PROF A highlights the importance of listing the critical items. In the PrHC the items with coverage equal or smaller than seven days are flagged as critical. The team keeps a continuous work of homologating possible substitute products to build a substitute catalog. This work is sustained by the competence of pharmacists and nurses who attest the quality. Nevertheless, the ideal would be that such standardization to be performed in a network level; nowadays, it is still performed locally.

The PrHC already has a unitizing medicine machine, which can meet at about 80% of the demands of hospitals. The machine can automatically cut and pack pills. In terms of automation, they have KPIs automated via updated commercial software, which allows information to flow faster along the supply chain. In terms of sustainable risks mitigation, the PrHC has 100% of its hospitals in compliance with the law. The manager highlights the importance of having one employee to inspect the waste disposal personally. In Rio de Janeiro, as well as in the whole country, if the third-party company contracted to dispose the waste does not comply with the law, the hospital network is still legally accused of notcomplying with the law. The cardboard boxes (containing mainly food) also pose a sustainability problem in healthcare units. The manager highlights that all the cardboard boxes stay in the warehouse and the nutrition department; the food supplies are disposed of as if they were in a supermarket shelf and so, the patients do not have any contact with the cardboard boxes, which can be vectors of diseases.

PROF B shows the PuHN side and the management differences, in the public sector procurement has strict regulation. The manager affirms that an essential risk mitigation strategy to comply with the law is to map and standardize the demand flows and to establish an annual procurement calendar organizing all demands. If the public managers strictly comply with the law, the private suppliers also start to have fairer prices and create a trend of reducing costs in this chain. Respecting the combined payment dates with suppliers is also crucial. Constant delays in payment generate mistrust by the suppliers and prices raise. The CE department plays a major role in costs mitigation, avoiding hospitals insolvency. The manager describes an example where a contract of about 150,000 BRL was cut to 50,000 BRL due to a detailed CE study about the lung ventilators maintenance contracts. The CE department can also precisely tell when new equipment must be bought. Nevertheless, if a partnership culture with the suppliers could be created, the SC would benefit muchmore.

PROF B.1 affirm that the network should always incorporate new technologies. Nevertheless, it should follow some logical steps: i) Professional training before using the new equipment, ii) Test phase, to evaluate performance, quality, and the benefits, iii) approving or not the equipment, based on the test phase and benefits evaluation.

PROF F.1 shows the vision of an OEM and highlights the importance of continually monitoring possible changes in product forecast. In this case, a long-term stable relation with the suppliers isessential to obtain flexibility. Such stable relation must be tailored with more than one supplier, to mitigate supply risks. This integration and relationship must be supported by integrated systems, which facilitate the demand understanding and lead times, avoiding excessive stock, delays and guarantees that the right quantities of the right products are bought.

PROF H.1 also highlights the crucial importance of Supplier-buyer integration to avoid supply problems. When a “win-win” relationship is developed, the negotiation is more natural and avoids SC disruptions. Table 4 summarizes the risk mitigation practices highlighted by the professionals.

Table 4
Mitigation practices

Risk categories Risks Risk mitigation practice Professional

Environmental Sustainability risks Inspect waste disposal PROF A

Organizational/resource limits Lack of expertise Professional trainning before using new technology PROF B.1

Supplier/customer disruptions Demand risk Map and standardize demand flows PROF B

Quality risks Preventive maintenance PROF B

Demand risk List critical items for mapping substitutes PROF A

Distribution risks Using a unitizing medicine machine PROF A

Network and supplier/customer disruptions Information risks, Demand risk Monitore changes in the demand forecast PROF F.1

External pressures, supplier/customer disruptions Procurement risks, Supply risks Organize procurement calendar PROF B

Network No collaboration Long-term stable relation with the suppliers to obtain flexibility PROF F.1

No integrated and unified information system between hospital and its suppliers, Supplier integration supported by integrated systems PROF F.1, PROF H.1

Risk categories	Risks	Risk mitigation practice	Professional
Environmental	Sustainability risks	Inspect waste disposal	PROF A
Organizational/resource limits	Lack of expertise	Professional trainning before using new technology	PROF B.1
Supplier/customer disruptions	Demand risk	Map and standardize demand flows	PROF B
	Quality risks	Preventive maintenance	PROF B
	Demand risk	List critical items for mapping substitutes	PROF A
	Distribution risks	Using a unitizing medicine machine	PROF A
Network and supplier/customer disruptions	Information risks, Demand risk	Monitore changes in the demand forecast	PROF F.1
External pressures, supplier/customer disruptions	Procurement risks, Supply risks	Organize procurement calendar	PROF B
Network	No collaboration	Long-term stable relation with the suppliers to obtain flexibility	PROF F.1
	No integrated and unified information system between hospital and its suppliers,	Supplier integration supported by integrated systems	PROF F.1, PROF H.1

6 Discussion

6.1 General discussion

In the next ten years, businesses will have to reinvent themselves, reaching new quality levels, while reducing costs to provide healthcare to an increasingly elderly population, providing mass healthcare. Human resources will have to adapt to these changes and training programs will have to update their syllabus to include at least the basics of how to deal with such technologies. Supply chain integration will increasingly become a mandatory feature. If an OEM is fully automated but the systems do not couple with the wholesaler or the retailer, the benefits of such automation will be reduced or in last analysis will not even be noted. To fully reach SCRM, it is essential at one hand to identify, assess and mitigate risks and on the other hand, to increase supply chain resilience.

Moreover, new concepts are emerging in the industrial and healthcare sectors. For instance, industry 4.0 applied to healthcare is still a new concept that needs further definition. The lack of papers applying 4.0 techniques to healthcare organization makes it difficult to measure the benefits (or hazards). How the human factors discussed in Senna et al. [51] will relate to the 4.0 environment? Therefore, empirical validation is required. Concerning HCSC automation, is it always viable? Which processes can be automated, and which ones should remain strictly made by humans? What is the human factor role in a hospital 4.0? These questions still require validation. There is also a possibility of medical impacts on patients. Therefore, there should exist a multidisciplinary team, including engineers and doctors, to measure the impacts for the treatment when the patient must deal with a machine instead of a human.

To obtain maximum profit from automation, processes must be optimized (or discontinued if the diagnosis shows that they do not add value to the client). If the machine or the process is defective, a good practice would be to combine automation with traditional process improvement methodologies such as Lean/Six-Sigma and Business Process Management. With respect to healthcare organizations, there are some extra difficulties. For example, healthcare professionals do not have training in management or risk mitigation techniques. Moreover, concepts like Lean, Six-Sigma, Business Process Management, and efficiency are often seen as the precariousness of work and associated with job losses, which characterizes a cultural barrier not easy to transpose.

Companies should not only develop solitary risk management initiatives and suppose that the SC is profiting from them. There should be a robust SC-level risk mitigation culture, which permeates the entire chain, developing strategic partnerships with vendors searching where the opportunities for cutting costs are. Concerning process automation, The OEM must analyze whether it is better to buy new machinery or automate the existing ones.

Which risks a fully automated SC could mitigate and which risks may be generated it is still unclear. Many papers converge to a framework that includes identification, assessment and mitigation as a way of building SCRM, nevertheless, what is the importance of each phase and the importance of the variables that build the constructs? Papers usually do not formally highlight integration in the identification, assessment and mitigation framework; nevertheless, integration is essential to mitigate, for example, the bullwhip effect. Literature still does not discuss enough whether a risk mitigation strategy can become a risk itself. For example, the safety stock. It can prevent rupture and delivery fails; nevertheless, the literature lacks to mention the risks of maintaining too much safety stock. Studies in SCRM are increasing in both quantity and quality. Nevertheless,there are still not many case-studies about risk culture implementation in SC-level. Moreover, risk management approaches are either too general or require pieces of information not regularly recorded by organizations [52].

6.2 Theoretical implications

Supply chain risk management applied to healthcare supply chains belong to a research field that lacks studies. In this sense, our paper brings relevant and unique empirical contributions since we were not able to find any similar studies. Considering our first research question (Is SCRM known as a concept among these organizations?) the evidence indicates that the concept is not widespread. Managers and healthcare professionals have only limited understanding of the risks and do not have a solid knowledge about supply chain practices. In addition, the interviewed professionals do not have the visibility as whether a local risk have the potential to generate ripple effects throughout all the supply chain or not. Nevertheless, the individual interviews contribute with risk identification and even mitigation techniques that contribute to generate knowledge for healthcare supply chain professionals about the subject. The suggestions and issues listed by the professionals should be considered together to obtain a global optimum along the supply chain and to construct a unified framework that addresses risk identification, risk assessment and risk mitigation.

6.3 Managerial implications

Brazil is experiencing severe budget cuts in education that impact public healthcare since some of the main Brazilian universities have hospitals that serve as internship and residence for doctors. Considering public healthcare, many of these hospitals are suffering from lack of insulin, air-conditioners among other problems that affect the well-being of the patients. In this sense, systematic supply chain risk management can contribute to identifying such risks, assessing its severity, and developing mitigating plans, or even revealing the lack of such plans, since public hospital managers have the government as its only source of income. This budget cut results in an increase of patients in the public system since Brazil is also suffering from unemployment, which limits the capability of paying private healthcare insurance.

Private hospital networks must also map their risks, since they are facing a diminishing of demand given that unemployment generates an impossibility of affording private healthcare. In this sense, for both public and private healthcare networks, SCRM can generate mitigation of these risks.

7 Conclusion

This paper had the objective of analyzing how the current state of SCRM in a healthcare Brazilian supply chain is. Our research revealed that there are only seven papers applying SCRM to healthcare supply chains. Among these papers there are no case studies, frameworks or studies that conducts interviews to diagnose the current HCSCRM situation. This objective was addressed from 2 research questions: RQ1- Is SCRM known as a concept among Rio de Janeiro healthcare supply chains? RQ2 - How are risk identification, risk assessment, and risk mitigation being implemented by companies from the Brazilian healthcare supply chains? Which generated two propositions: PR1 – HCSCs do not apply SCRM as most market-oriented SCs do, PR2 – HCSCs apply risk identification, assessment and mitigation not systematically. The interviews revealed that SCRM is an entirely unknown concept among Brazilian HCSCs. The OEM managers still have intrinsic knowledge of risks, although they promote no systemic risk management initiative. The second research question was addressed by session five detailing which initiatives could fit in each phase of the framework proposed. Proposition PR1 was validated, although the literature does not provide examples of SCRM applications in most economy segments. Proposition PR2 was validated since they have empirical knowledge of the risks, they can identify the most hazardous risks and can come up with solutions to mitigate them. As main limitations we highlight that the research was carried on in Rio de Janeiro/RJ, which is part of the southeastern region of Brazil. In addition, the results are specific to the selected cases, in this sense, since Brazil is a continental country, the results of this research cannot be generalized for all regions and all states. Nevertheless, this first study constitutes a very important evidence, that can be further discussed with studies conducted in other regions and countries. As a future research agenda, we recommend that more cases in different regions of Brazil are conducted and then compared to our data aiming to conclude which of the results can be generalized to the whole country. We also recommend that managers implement SCRM in a supply chain level, and automate the framework proposed by our paper.

Conflict of interest

None to report.

Footnotes

Appendix

Interview protocol

Interview questions	Authors
General background
Overview of purpose of study	Gaudenzi et al. [53]
Confidentiality assurance permission to audiotape	Gaudenzi et al. [53]
Background on organization, position, job title and responsibilities	Fan and Stevenson [54]
What is your understanding of buyer-supplier relationships, SCR and risk identification in particular?	Fan and Stevenson [54]
Supply chain risks and risk identification strategies
Which of the following SCRs are most relevant to your company?	Fan and Stevenson [54]
Inability to meet quality requirements;	Fan and Stevenson [54]
Inability to adapt to required product design or technological changes;	Fan and Stevenson [54]
Failures to make delivery requirements;	Fan and Stevenson [54]
Cannot provide competitive pricing (including sudden hike in costs);	Fan and Stevenson [54]
Supplier opportunism (including intellectual property risk);	Fan and Stevenson [54]
Contractual agreements;	Fan and Stevenson [54]
Single source of supply;	Fan and Stevenson [54]
Selection of wrong partner;	Fan and Stevenson [54]
Financial instability, including bankruptcy;	Fan and Stevenson [54]
Lack of supplier involvement;	Fan and Stevenson [54]
Sustainability related problems.	Fan and Stevenson [54]
Are there any other SCRs (not listed) that are relevant to your company?	Fan and Stevenson [54]
What strategies has your company used to identify risks, and how effective have these been?	Fan and Stevenson [54]
Types of BSR, SCR and risk identification
What are the different types (characteristics) of working relationships with your suppliers? How critical is a supplier in each type to your overall business?	Fan and Stevenson [54]
How do the types of relationships you have with suppliers affect the SCR?	Fan and Stevenson [54]
How has working with your suppliers (with examples from different types of relationships) influenced risk identification?	Fan and Stevenson [54]
How would you evaluate your working relationships with your suppliers regarding SCRs and SCRM?	Fan and Stevenson [54]
Final comments
Are there any further comments that you think are relevant to this research that either affect the company now or may do in the future?	Fan and Stevenson [54]

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