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The influence of supply chain risk management in healthcare supply chains

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The influence of supply chain risk management in

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Pedro Senna, Augusto Reis, Lino Guimarães Marujo, Julio Cesar Ferro de
Guimarães, Eliana Andréa Severo & Ana Carla de Souza Gomes dos Santos

To cite this article: Pedro Senna, Augusto Reis, Lino Guimarães Marujo, Julio Cesar Ferro
de Guimarães, Eliana Andréa Severo & Ana Carla de Souza Gomes dos Santos (2023): The
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PRODUCTION PLANNING & CONTROL
https://doi.org/10.1080/09537287.2023.2182726

The influence of supply chain risk management in healthcare supply chains

performance
Pedro Sennaa , Augusto Reisb , Lino Guimar~aes Marujoc , Julio Cesar Ferro de Guimar~aesd ,
Eliana Andr
ea Severod and Ana Carla de Souza Gomes dos Santose
a
CEFET/RJ – COPPE/PEP UFRJ, Rio de Janeiro, Brazil; bCEFET/RJ, Rio de Janeiro, Brazil; cCOPPE/PEP UFRJ, Rio de Janeiro, Brazil; dUFPE DCA,
Recife, Brazil; eIFRJ, Rio de Janeiro, Brazil

ABSTRACT ARTICLE HISTORY

The challenges imposed by the business environment increasingly obligate supply chains to seek Received 21 December 2021
lower costs while maintaining high service levels. Healthcare supply chains face additional challenges Accepted 13 February 2023
since their main indicator is to save lives and provide care, nonetheless, keeping the revenue flow to
KEYWORDS
support the activities. The covid-19 pandemic evidenced that a severe rupture in healthcare chains
Healthcare SCRM; supply
generates rupture in all other supply chains. In this sense, our paper has the objective of presenting a chain resilience; SEM;
conceptual healthcare supply chain performance framework empirically validated by structural equa- COVID-19
tion modelling. Our survey data were processed through the covariance-based structural equation
modelling method, adopted for assessing the causal connection among the constructs. The paper
revealed a relationship of supply chain integration, supply chain risk management, and supply chain
4.0 (antecedents) with healthcare supply chain performance (consequent). The literature contributions
of this paper are (i) developing and validating a new scale for each construct; (ii) finding evidence of
the causal relationships between the factors; (iii) measuring how the constructs influence the health-
care supply chain performance in both public and private healthcare sectors and providing discussion
and tools to improve these results; (iv) this work empirically tested a theoretical framework; (v) the
study reveals that the sector (public or private) has a moderating effect on all the constructs.
Furthermore, the results of this study help to address some literature gaps identified by scholars hav-
ing the potential to serve as a guide to organisations that are willing to implement these practices.
Lastly, we recommend that HC supply chain managers consider the implementation of robust initia-
tives regarding SCRM, SCI, and SC40.

1. Introduction do not usually need to worry about bankruptcy, neverthe-

Today’s business environment is increasingly obligating sup-
ply chain managers to cut costs while maintaining high ser-
vice levels. These ‘lean’ and high-performance supply chains
became lucrative, but also very prone to systemic risks, that
affect not only one company, but often the whole supply
chain. In this regard, scholars and supply chain practitioners
already recognise the significance of risk management and
integrative practices in supply chains to deal with the com-
plexity and uncertainties faced (Munir et al. 2020). In this
sense, developing multiple security initiatives to increase
security and resilience capability without affecting efficiency
became a mandatory feature for global chains (Yang and
Hsu 2018). Risk analysis should consider the whole Supply
Chain to provide the desired results, in this regard, supply
chain risk management constitutes a concept that aims to
manage risks that affect the whole supply chain instead of
an individual link. (Juttner, Peck, and Christopher 2003;
Waqas et al. 2019).
Healthcare organisations can be either public or private
(depending on the country). Public Healthcare organisations
less, they still must deliver healthcare services to the tax-
payer with an adequate service level (Senna, Da Cunha Reis,
et al. 2020). Healthcare supply chains can be defined as sup-
ply chains that prioritise saving lives and providing quality
care to the population (Abdulsalam et al. 2015; Rakovska and
Stratieva 2018). The COVID-19 pandemic generated severe
ruptures such as shortages of respirators and beds, reinforc-
ing the need for healthcare supply chains resilience (Senna,
Da Cunha Reis, et al. 2020). Among the examples of supply
chain risks are disruptions to material flows, information
flows, knowledge flows, and control and coordination flows
(Ancarani and Di Mauro 2012).
Nowadays, supply chains are globalised and leaner, in this
regard, becoming vulnerable to natural and man-made disas-
ters and bullwhip effects (Soni and Jain, 2011; Dolgui,
Ivanov, and Rozhkov 2020). Resilience must be pursued by
supply chain managers to achieve competitiveness, more-
over, SCRes is a way of dealing with the inevitable ruptures,
predicting when the risks will occur and, ultimately, a matter
of survival (Barroso et al. 2010; Barroso, Machado, and Cruz

CONTACT Pedro Senna pedro.sennavieira@gmail.com CEFET/RJ – COPPE/PEP UFRJ, Rio de Janeiro, Brazil
ß 2023 Informa UK Limited, trading as Taylor & Francis Group
2 P. SENNA ET AL.
Machado 2011; Carvalho, Azevedo, and Cruz-Machado 2012;
Mancheri et al. 2019).
Supply chain risk literature provides many different types
of risks, nevertheless, epidemics/pandemics papers are lack-
ing in SCRM literature. pandemics may become more fre-
quent. Due to the lack of sustainable practices and damage
dealt to the environment, in this sense, supply chains should
be more resilient to respond to healthcare demand quickly.
Regarding pre-COVID-19, there were only three papers in
SCRM literature mentioning pandemics. Oke and
Gopalakrishnan (2009) identify the pandemic risk as a natural
disaster mentioning the avian flu, while Mavi, Goh, and Mavi
(2016) classify it as an exogenous social risk. However,
whether a pandemic is a natural disaster, or its causes can
be traced to human behaviour can be debated. The study of
VanVactor (2011) affirms that pandemics are unexpected
events that require preparedness and mitigation strategies.
Supply chain uncertainties and risks have significant impacts
on logistics performance (M. Wang, Jie, and Abareshi 2018),
however, there is still not much empirical evidence.
Considering healthcare supply chains, which consider
patient care in addition to profit, it is even harder, and the
literature does not provide a vast number of frameworks
detailing the variables responsible for measuring healthcare
supply chains’ performance (Senna et al. 2023; Tortorella
et al. 2019). Although supply chain 4.0 and healthcare 4.0
are becoming consolidated concepts, 4.0 technologies
applied to healthcare supply chains can be viewed as ran-
domly conceived and still lacks both academic and manager-
ial guidance grounded on the literature. Moreover, Iftikhar,
Purvis, and Giannoccaro (2021) indicate that the number of
studies encompassing supply chain resilience, and reviews of
the antecedents and outcomes of resilience is limited.
Agreeing with this vision, our research did not find any study
that proposes a framework to investigate the antecedents of
a healthcare supply chain, in this sense, this work is unique.
In addition, scholars are still trying to understand the rela-
tionship between supply chain risks and firm performance
(Chen 2018). In this sense, the literature presents significant
gaps, summarised by the following research questions: RQ1)
Which are the antecedents of healthcare supply chain per-
formance? RQ2) What is the impact of SCRM on healthcare
supply chain performance? To obtain answers to the research
questions, this paper has the objective of identifying the
antecedent factors of healthcare supply chain performance
and proposes an empirical validation of the framework using
structural equation modelling (SEM). SEM is being success-
fully used by researchers as a means of testing theoretical
frameworks. Hu et al. (2020) use SEM to investigate the rela-
tionship between international asset dispersion, SCRM, sup-
ply chain integration, and operational performance. Ali and
Go €lgeci (2021) propose a framework that tests the impacts
of social capital and climate risks in small-medium enter-
prises. Sreedevi, Saranga, and Gouda (2021) propose a frame-
work based on the constructs: External integration, supply
chain risk perception, and objective supply chain risks and
logistics performance index. Measuring supply chains’ per-
formance can be a very difficult task.
Our results lead to five major literature contributions: (i)
developing and validating a new scale for each construct; (ii)
finding evidence of the causal relationships between the fac-
tors; (iii) measuring how the constructs influence the health-
care supply chain performance in both public and private
healthcare sectors and providing discussion and tools to
improve these results; (iv) this work empirically tested a the-
oretical framework; (v) the study reveals that the sector (pub-
lic or private) has a moderating effect on the constructs.
Moreover, we organised this paper is organised as follows;
besides this introductory section, Section 2 presents the lit-
erature review, Section 3 presents the research methodology,
Section 4 presents the empirical analysis, Section 5 presents
a thorough discussion about the findings and Section 6
closes the paper with the conclusions and future trends.
2. Theoretical background and literature review
2.1. Contingent resource-based view (CRBV)
The resource-based view (RBV) theory affirms that each firm
is unique and capable of processing resources and capabil-
ities that form the backbone of its competitive advantage
(Iftikhar, Purvis, and Giannoccaro 2021). Moreover, it affirms
that each firm has a unique bundle of resources and capabil-
ities that form the source of the firms’ competitive advan-
tage (Iftikhar, Purvis, and Giannoccaro 2021).
The resource-based view states that firms must gain and
sustain competitive advantages by developing resources and
capabilities (M. Wang and Jie 2019). The development of
flexible capabilities is a way of responding to adverse circum-
stances, and the competitive advantages generated by the
development of these resources are important to improve
firm performance (Iftikhar, Purvis, and Giannoccaro 2021).
Organisations are always part of an environment that con-
sists of an internal and a contingent external context, more-
over, Contingency Theory (CT) affirms that there is not a
single best way to establish processes of decision-making
and leadership since different environments provide different
antecedents (Gro €tsch, Blome, and Schleper 2012). In addition,
CT indicates in which particular conditions firms would
obtain superior performance.
To be competitive, firms must be cohesive and acknow-
ledge the specific context in which they operate while being
adaptable to the market dynamics, in this sense, this theory
provides a way for supply chains to minimise disturbances
(Gro €tsch, Blome, and Schleper 2012). Therefore, the contin-
gent resource-based view (CRBV) states that the usual contin-
gencies of the business environment can affect the
usefulness of different resources and capabilities to achieve
resilience (Iftikhar, Purvis, and Giannoccaro 2021). The main
idea of CT is that firms should adapt and configure them-
selves under the environment in which they operate (Iftikhar,
Purvis, and Giannoccaro 2021).
The HC SCRM definition (Senna et al. 2023) highlights ele-
ments that present clear links between HC SCRM and CRBV.
First, flexible capabilities imply that companies must con-
stantly adapt to the needs of their customers. In this sense,
companies should seek to integrate their processes so the

suppliers can understand how to adapt to their customer’s
needs. Second, due to the uniqueness of the HC supply
chains, the resources needed to obtain a competitive advan-
tage, as well as their definition of competitive advantage
along the supply chain differs, since, for hospitals and clinics,
the competitive advantage includes, in addition to revenue,
the capability of providing care. Third, CRBV theory states
that for each company, there must be particular conditions
to obtain high performance. In terms of HC SCRM, depend-
ing on the diagnostic, a particular action plan can be either
a risk mitigation strategy or a risk source. For example, on
one hand, if a Healthcare facility often lacks some medicine
of high demand, they need to find ways of having more
safety stock, on the other hand, if the HC facility suffers from
medicine expiration and shortness of cash flow, the solution
is more likely to consider a plan to reduce the safety stock.
In other words, each organisation in a HC supply chain must
create its processes of risk identification, risk assessment, and
risk mitigation to identify the best risk strategies to stay
competitive, being aligned with practices seen in Norrman
and Jansson (2004).
2.2. Healthcare supply chain integration (SCI)
Healthcare supply chain integration (SCI) is stated as an
important characteristic of resilient supply chains (Senna
et al. 2023). Collaboration is an essential feature of SCRM
and improves Supply Chain visibility and understanding
(Friday et al. 2018; McCullough 2014; Senna et al. 2023). In
an integrated supply chain, companies share information
about sales forecasts, production plans, production progress,
and stock level. Relevant information should be shared with
the purchasing department (Chaudhuri, Boer, and Taran
2018), with key suppliers (Cagliano, Grimaldi, and Rafele
2016; Senna et al. 2016; Chaudhuri, Boer, and Taran 2018),
and key customers (Chaudhuri, Boer, and Taran 2018;
Barroso et al. 2010; Muriana et al. 2017). In addition, supply
chain integration in HC supply chains is an essential risk miti-
gation strategy to comprise with laws and can help to map
and standardise the demand flows and establish a way of
periodically organising all demands (Senna et al. 2022).
After being integrated, companies must apply joint deci-
sion-making with the purchasing department about demand
forecast, production plans, and stock level (Chaudhuri, Boer,
and Taran 2018; Lin and Ho 2014), key suppliers, product,
process, quality improvement, and cost control (Lin and Ho
2014; Turhan and Vayvay 2012) and key customers about
product design/modifications, process design/modifications,
quality improvement and cost control (Chaudhuri, Boer, and
Taran 2018; Soni and Jain, 2011). For Hospitals and clinics
these features are also essential since they must know their
demand for medicines, equipment, and services (Senna et al.
2022).
Companies must seek collaborative approaches with key
customers and key suppliers, and long-term agreements
(Chaudhuri, Boer, and Taran 2018; Iakovou, Vlachos, and
Xanthopoulos 2007). The integrated SC must seek coupling
with key customers and key suppliers, for example via
PRODUCTION PLANNING & CONTROL 3
vendor-managed inventory, just-in-time, Kanban, and con-
tinuous replenishment (Chaudhuri, Boer, and Taran 2018;
Cagliano, Grimaldi, and Rafele 2016). The existence of sup-
plier risks obligates managers to enhance supply chain inte-
gration to achieve supply chain resilience (Brusset and Teller
2017).
2.3. Healthcare supply chain 4.0 (SC40)
The 4.0 revolution is supported by technologies such as
blockchain and the Internet of Things IoT, which can also be
applied to Healthcare SC. Blockchain is a digital ledger that
records transactions using a cryptographic hash function that
is resistant to modification (Mylrea and Gourisetti 2018).
Network-connected devices are used in industrial machines,
household devices, and Healthcare management systems in
the Internet of Things (Martınez-Caro et al. 2018). Healthcare
4.0 includes advancements such as cloud computing for data
storage and IoT for data collection (Kumari et al. 2018). The
implementation of IoT has the potential to optimise proc-
esses (Roy, Abidi, and Abidi 2017; Griggs et al. 2018).
Moreover, IoT in the Healthcare context is defined by
Rodrigues et al. (2018) as the Internet of Health Things
(IoHT). Patient data collection supported by IoT devices can
help improve the quality of care (Javdani and Kashanian
2018; Rodrigues et al. 2018). HCSC Processes obtain more
compliance and security when supported by blockchain
(Mylrea and Gourisetti 2018; Kumari et al. 2018) and IoT
(Kouicem, Bouabdallah, and Lakhlef 2018; Griggs et al. 2018;
Hiromoto, Haney, and Vakanski 2017).
2.4. Healthcare supply chain risk management (SCRM)
A Healthcare unit can be defined as a facility that offers dir-
ect or indirect services to provide healthcare to all individu-
als (Macedo et al. 2016). Compared to most of the segments,
healthcare supply chains face even more complicated chal-
lenges since they must pursue traditional supply chain indi-
cators and deal with a very sensitive service that involves a
great deal of subjectivity that is providing affordable quality
care in a context where costs are always increasing
(Chakraborty, Bhattacharya, and Dobrzykowski 2014). In add-
ition, cost containment is of the most important challenges
in healthcare, therefore, network relationships become cru-
cial, by offering extensive opportunities to explore hospital-
supplier relationships (Chakraborty 2018). Healthcare supply
chain managers daily deal with the dilemma of mitigating
risks costs versus costs and losses caused by the risks, in
addition, managers must consider that minimising costs can-
not result in lesser care for the patients (Senna, Da Cunha
Reis, et al. 2020). In this sense, supply chain management is
crucial to maintain affordable healthcare services (Beir~ao,
Patrıcio, and Fisk 2017; McColl-Kennedy et al. 2017).
A hospital is more than a simple link in a complex Supply
Chain, in this regard, it would be a natural consequence to
invest in control towers that can manage all KPIs and data
science applications to always and automatically identify,
assess, mitigate, and monitor risks (Senna, Da Cunha Reis,
4 P. SENNA ET AL.
et al. 2020). Healthcare supply chains (HCSC) have an import-
ant difference compared to most segments since their main
objective is to save lives (Abdulsalam et al. 2015; Rakovska
and Stratieva 2018).
Applying SCRM to healthcare is very rare in the literature
the only formal definition of healthcare supply chain risk
management is found in Senna, Reis, et al. (2020), which
stated as follows: ‘The process of identifying, assessing, miti-
gating and monitoring supply chain risks aiming to provide
the best quality of care through SC processes integration,
with sustainable profit avoiding supply shortage, valuing HC
and clinical engineering professionals, having in consider-
ation that local actions may generate hazards to all HCSC
generating SCREs and high-reliability healthcare networks’.
SCM can be highlighted as one of the best means to
improve the performance of organisations and supply chains
(Teller, Kotzab, and Grant 2010). However, healthcare supply
chains are even more complex than regular supply chains
(Senna et al. 2023), due to population ageing and other fac-
€hme et al. 2013), in this regard, they require other
tors (Bo
building blocks such as SCRM (Senna et al. 2023; Brusset and
Teller 2017), supply chain integration (Senna et al. 2023;
Brusset and Teller 2017) and supply chain 4.0 (Senna et al.
2023). Supply chain resilience allows a supply chain to recon-
struct itself and be stronger than before (Brusset and Teller
2017). Moreover, while SC disruption in a commercial envir-
onment may cause a loss of revenue, in healthcare the
stakes are much higher, putting lives at risk (Scala and
Lindsay 2021).
It is crucial that firms can identify capabilities that help
mitigate the negative impacts of disruption risks (Singh and
Singh 2019). In addition, the supply chain’s success depends
on its resilience and ability to meet the challenges of the
internal and external environment (Abeysekara, Wang, and
Kuruppuarachchi 2019). SCRes and SCRM must be supported
by a culture of identifying, assessing, mitigating, and moni-
toring risks (Senna, Reis, et al. 2020). Scholars argue that by
responding to supply chain disruption events, firms can build
institutional memories related to response strategies. (Singh
and Singh 2019). Additionally, there is evidence of the posi-
tive effects of SCRes on firm performance and competitive
advantage (Abeysekara, Wang, and Kuruppuarachchi 2019).
Moreover, Scala and Lindsay (2021) affirm that SCRes is a
central element in supply chain risk management as a strat-
egy to protect against risks and disruptions.
One of the most crucial strategies to improve patient
safety is to develop systems that will reduce the probability
of error and improve the probability of safety (Fukuda et al.
2008). Organisations should promote continuous education
programs along all the SC (David, Jaramillo, and Stiefel 2008;
Oumlil and Williams 2011), to build a multi-skilled workforce
(Ali, Nagalingam, and Gurd 2018). Robust collaboration
mechanisms with government agencies are important to
mitigate risks (Cavalieri, Guccio, and Rizzo 2017; Ali,
Nagalingam, and Gurd 2018). A SC must develop good qual-
ity management systems to become resilient (Ali,
Nagalingam, and Gurd 2018; B. Wang et al. 2013; Sullivan
et al. 2016). Robust quality management systems often
include accreditation or other quality certificates (Ali,
Nagalingam, and Gurd 2018; Sullivan et al. 2016).
Implementing supply chain risk management is a key man-
agerial challenge that affects the performance of organisa-
tions with features such as tighter collaboration, increased
complexity, reduced inventory levels, and ever-wider geo-
graphic dispersion (Brusset and Teller 2017).
The HCSCs 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 bene-
fits, (iii) approving or not the equipment, based on the test
phase and benefits evaluation, in addition, it is important to
motivate supplier-buyer integration to avoid supply prob-
lems. When a ‘win-win’ relationship is developed, the negoti-
ation is easier and avoid HCSC disruptions (Senna et al.
2022).
2.5. HC supply chain performance (SCP)
Supply chain risk management is considered very strategic
because of its impacts on the operational, market, and finan-
cial performances of a firm (Narasimhan and Talluri 2009).
HCSC Performance means that healthcare supply chains
often also must profit to survive, nevertheless, its primary
objective is to save lives and provide good quality care.
Capable leadership is essential to obtain HCSC performance
(Chiarini and Vagnoni 2016). HCSC must obtain low levels of
SC vulnerability, good security levels, low probability of cargo
misuse, and good capability to detect defects in parts/prod-
ucts (Lu, Koufteros, and Lucianetti 2017). Supply chains must
build practices that reduce theft/loss of products and the
potential for drug smuggling (Lu, Koufteros, and Lucianetti
2017). HCSC must develop growingly patient satisfaction
(Cochrane et al. 2017; Woodhouse et al. 2016).
The conceptual model indicates that three supply chain
constructs are important to achieve healthcare supply chain
performance (SCP). We have identified three constructs that
function as antecedents of SCP, and based upon these fac-
tors, three hypotheses have been proposed and shown in
Figure 1.
Resilience is considered a set of capabilities that a SC has
of going through a disturbance and returning to the former
performance level or even an improved level (Carvalho,
Azevedo, and Cruz-Machado 2012). HC resilience can profit
from the broader SCRes theoretical background, with one
particular detail, the performance of the supply chain must
measure the ability to provide the best care for the patients.
The development of SCRes through SCRM helps the SCs to
regain performance levels quickly (Blackhurst et al. 2018).
The increase in global competition and the risk of SC failures
increase the likelihood of not achieving the desired (SC) per-
formance (Tummala and Schoenherr 2011). In terms of HCSC,
organisations have the challenge of offering care to an
increasing elderly population, controlling costs while improv-
ing the level of care.
The literature has evidence attesting to the undesirable
effects of SC disruptions and ripple effects (Ivanov, Das, and

Figure 1. Conceptual framework to show the hypotheses.
Choi 2018) on operational and financial performance with
both immediate and long-term effects (Deane, Craighead,
and Ragsdale 2009; Blackhurst, Dunn, and Craighead 2011).
The absence of supply chain risk management generates
financial losses, reductions in product quality, delivery delays,
and loss of reputation in the eyes of customers and suppliers
(Hendricks and Singhal 2003; Finch 2004). SCRM is consid-
ered to influence on Supply Chain Performance (Wagner and
Bode 2008). The COVID-19 pandemic can be considered a
HCSC risk that generated a ripple effect that propagated to
all other chains. The number of sick people overcame the
hospitals’ capacity, leading governments to declare lock-
downs, affecting nearly all the supply chains’ performances.
Therefore, proposition 1 implies that there is a positive rela-
tionship between SCRM and SCP.
H1. The SCRM positively influences SCP
Disruptive innovations such as digitalisation and Industry
4.0 influence the development of new paradigms, principles,
and models in supply chain management (SCM) (Ivanov, Das,
and Choi 2018). Since digital technology influences SCM and
SCM are influenced by disruption risks, it is logical to expect
interrelations between digital technology and SC disruption
risk management (Ivanov, Das, and Choi 2018).
Industry 4.0, and SC 4.0 are concepts that still require
more formal definitions and are becoming Panacea.
Although a Fully automated SC can generate efficiency and
minimise several risks, it may as well create others. For
example, it is charging the devices (battery autonomy).
Additionally, it requires a considerable amount of initial
investment, high-qualified workforce, among other features.
PRODUCTION PLANNING & CONTROL 5
As a clear example of 4.0 technology applied to HCSC,
Tseng, Liao, and Liao (2018) suggest a blockchain as the
base of the data flow of drugs to create transparent drug
transaction data and improve SC performance. Software,
hardware, and Radio Frequency Identification (RFID) technol-
ogy strengthen the tracking and trace of drugs in the supply
chain and are considered relatively mature and easy to adopt
(Mackey and Nayyar 2017).
Blockchain technology could create an encrypted, distrib-
uted, and immutable data ledger with the possibility of
being applied in the healthcare sector, including sharing of
information with stakeholders while ensuring data integrity
and protecting patient privacy (Tseng, Liao, and Liao 2018).
Literature still lacks studies concerning more 4.0 technologies
applied in HCSC although there is some evidence. Therefore,
Proposition 2 suggests a positive relationship between SC40
and SCP.
H2. The SC40 positively influences SCP
Supply Chain Integration allows firms to be more efficient
by exchanging information and coordination between
internal activities and external partners (Ellinger et al. 2015).
SCRM includes coordination and collaboration among the
supply chain partners to ensure profitability and continuity
(Tang 2006). In this respect, collaboration and coordination
are the outset premises for SCRM. Supply Chain Integration
is a crucial feature needed by companies to manage an
increased level of complexity (Wiengarten et al. 2016).
Supply chain integration can be considered a predecessor to
achieving synchronisation. The firms must integrate internal
functions, suppliers, suppliers’ suppliers, customers, and
6 P. SENNA ET AL.
customers’ customers (Brusset 2016). Such integration is
achieved by integrating information through the capture of
demand information, the transmission of information to the
whole supply chain, and virtual connection (Brusset 2016). By
integrating internal and external processes with suppliers
and customers, supply chains generate a competitive advan-
tage (Ellinger et al. 2015). Before process automation, compa-
nies should map their processes, or the automation will
accelerate low-value-added processes that could even be dis-
continued. In this regard, supply chain integration means
that companies must structure cross-functional inter-organ-
isational knowledge and information sharing, which mitigate
the effects of SC disruptions while improving performance
(Ellinger et al. 2015). Integrating internal processes with sup-
ply chain firms requires coordination, information, and con-
trol of suppliers and downstream partners, moreover, such
integration is needed to obtain agility (Brusset 2016).
Moreover, SCI is the existence of organisational culture,
alignment of strategies, involvement, good cooperation, and
easy access to information (H€ useyinog lu, Kotzab, and Teller
2019). SCI is increasingly related to firm and supply chain
performance, in addition, the research front is encapsulated
within the resource-based, transaction cost, and contingency
theory (Kotzab, B€aumler, and Gerken 2020). Senna et al.
(2022) state that HCSC integration must be supported by
integrated systems, moreover, long-term relationship with
suppliers is crucial to obtain flexibility.
Therefore, H3 implies that there is a positive relationship
between SCI and SCP:
H3. The SCI positively influences SCP
Intervening variables may generate moderating effects in
the dependency relations between the constructs. In this
study, we noted evidence that the sector in which the
respondents work (public or private) could interfere with the
intensity of the relationships, which alters the influence of
SCRM, SCI, and SC40 on supply chain performance.
The companies that integrate healthcare supply chains
can be either public or private. In that context, the hypothe-
ses of the moderating effect of the sector (H4a, H4b, H4c)
were evaluated:
H4a. The sector has a moderating effect on the relationships
between SCI and SCP
H4b. The sector has a moderating effect on the relationships
between SC40 and SCP
H4c. The sector has a moderating effect on the relationships
between SCRM and SCP
3. Method
We used a quantitative (survey) methodology and descriptive
research adapted from Guimar~aes et al. (2021). Moreover, we
used multivariate statistical methods and techniques, among
which are descriptive statistics, Cluster Analysis, Exploratory
Factor Analysis (EFA) using SPSSV (v.21) software, and
R
Covariance-Based Structural Equation Modelling (CB-SEM)
using AMOSV (v.21) software. If the research objective is the-
R
ory testing and confirmation, then the appropriate method is
CB-SEM (Hair et al. 2017) which is the case of this paper, as
we are testing part of the theory seen in Senna et al. (2023).
The survey was carried out during the period from
January 2020 to January 2021 and was applied to a non-
probabilistic sample, for convenience, to recollect and ana-
lyse a large volume of data, and to identify the opinion of a
statistically significant number of respondents (Hair et al.
2014). The data were collected in Brazil, we sent the ques-
tionnaire using an electronic form from Google Docs. We
used the snowball method for data collection, the form was
sent to the researcher’s contacts, which, then, were asked to
send it to other respondents (healthcare professionals),
resulting in 221 responses.
The questionnaire deployed involved several statements
(see Appendix A – Table A1), for each of which the respond-
ents chose, according to a 5-point Likert scale, the alternative
that best represented the situation of their company.
Initially, 3 specialists read the questionnaire to report
ambiguous questions and any other possible improvements.
Next, pre-testing was performed with a sample of 25
respondents to evaluate respondents’ general understanding
of the issues addressed in the research. The selection of
which companies/clinics or Hospitals to contact was made at
random, during the data collection. Following the Data
Cleaning process (Figure 2), which led to the elimination of 7
cases considered invalid. It is feasible to use Structural
Equation Modelling (SEM) analysis with a sample size of 214
since the sample number exceeds the recommended range
of 200–400 cases (Hair et al. 2014; Kline 2015).
The methodology used in the research is detailed in
Figure 2, including a description of the following steps: (i)
Definition of Observable Variables; (ii) Data Collection; (iii)
Data Cleaning; (iv) Scale Validation; (v) Structural Equation
Modelling (SEM) – Hypothesis Testing; (vi) SEM – Framework
Evaluation.
4. Data collection and results
The questionnaire was addressed to the healthcare supply
chain professionals, including employees from suppliers, dis-
tributors, and OEM (upstream) and healthcare professionals
from hospitals and clinics (downstream). The questionnaires
were distributed via e-mail and message applications, out of
which 221 filled-in responses were received. During analysis,
it was found that 214 responses were valid. Hair et al. (2014)
recommended a minimum sample size of 50 for multivariate
data analysis. PCA helps to identify features and understand
the relationships between the factors that contribute to SCP.
We performed a PCA using varimax rotation to determine
the constructs.
In line with Iftikhar, Purvis, and Giannoccaro (2021), this
study used Harman’s single-factor test to examine whether a
single factor emerges from principal component analysis, or
if one factor represents most of the covariance among the
variables in unrotated factor analysis. The results indicated
that more than one factor emerged to explain the data

Figure 2. Method design.
variance. Hence, CMB was not a problem for the current
research. The proportional variance found was 0.37, less than
the threshold of 0.5.
We performed a t-test to verify non-response bias (Iftikhar
et al. 2022; Brusset and Teller 2017). Following the method
seen in Brusset and Teller (2017) we used a ‘time trend
extrapolation test’ in which we compared ‘late’ versus ‘early’
respondents, in addition, the t-tests conducted showed no
significant differences between ‘early’ and ‘late’ respondents
PRODUCTION PLANNING & CONTROL 7
along any of the key study variables. Table 1 presents the
constructs and their constituent factors.
SEM is a very important technique that relates independ-
ent variables with dependent variables in successive analyses
(Hafeez, Keoy, and Hanneman 2006; Tripathy, Ray, and Sahu
2011). In our study, healthcare professionals work either in
the public or private sector. In this respect, we created a
path model represented by Figure 3, which considers all pro-
fessionals surveyed in this study.
8 P. SENNA ET AL.

Table 1. Factor analysis.

Constructs and constituent factors with notations Mean SD Factor loading Cronbach’s alpha Standardised regression weight
INTE1 4.51 0.786 0.417 0.913 0.543
INTE2 4.21 0.984 0.726 0.868
INTE3 4.20 1.048 0.744 0.916
INTE4 4.14 1.080 0.811 0.904
INTE5 4.04 1.113 0.601 0.721
INTE6 4.12 1.039 0.704 0.670
INTE7 4.09 1.001 0.722 0.605
INTE8 4.00 1.081 0.589 0.667
INTE9 4.13 1.025 0.690 0.557
SCRM1 4.41 0.866 0.472 0.751 0.458
SCRM2 4.50 0.786 0.593 0.801
SCRM3 4.54 0.760 0.733 0.551
SCRM4 4.67 0.662 0.791 0.522
SCRM5 4.50 0.798 0.544 0.727
SC401 3.99 1.041 0.695 0.905 0.689
SC402 4.21 0.971 0.680 0.791
SC403 4.05 1.003 0.773 0.895
SC404 4.10 1.094 0.843 0.842
SC405 4.19 1.024 0.543 0.599
SC406 4.11 1.019 0.751 0.830

Path analysis focuses on the relationship among the pre-
dictors for the model. Our model shows different relation-
ships between HCSC performance and the three factors –
SCRM, supply chain 4.0, and, supply chain integration, with-
out considering the latent variables. The preferred path is
based on a standardised regression weight that provides the
causal connection between the set of variables. The higher
the value of the path coefficient, the more the chance of
selection of that path for the acceptance of the hypothesis.
We used AMOS 4.0 package; the values are significant
with p < 0.01 in each case. We validated the model using the
fit statistics shown in Table 2. Columns 4, 5, and 6 are
respectively the comparative fit index, normalised fit index,
and root mean square error, which indicates that the predic-
tion of the relationships among the constructs is adequate.
Table 2 shows that v2/df is less than 5, which is a com-
mon benchmark (Muduli et al. 2020). The CFI is greater than
0.90 which indicates a good fit (Schumacker and Lomax
2010). RMSEA is between 0.05 and 0.08 which indicates a
good fit (Xia and Yang 2019).
We based the rejection or acceptance of the hypotheses
on the standardised regression weights seen on the branches
of the path diagram of Figure 3. We rejected the hypotheses
that weighted less than 0.1 following the criteria found by
Hung and Lu (2008); Lattin, Carroll, and Green (2009) and
Muduli et al. (2020). Table 3 shows all of our hypotheses.
Table 4 shows hypotheses H4a, H4b, and H4c. The t-test
(Zhang and Wang 2017) revealed that the sector is a relevant
moderating effect considering a significance of 5%.
5. Discussion
This paper contributes to research by proposing and empiric-
ally testing a holistic framework demonstrating the effects of
SCI, SC40, and SCRM on SCP to develop theoretical and man-
agerial implications. Although H2 and H3 have results that are
in line with the theoretical framework, the H1 hypothesis was
not supported. This situation may happen for some reasons,
SCRM is a concept that is increasingly becoming more popular
among scholars and managers, nevertheless, we still perceive
that it is not completely understood. In Brazil, there are only a
few courses that mention SCRM, and even fewer disciplines
that exclusively approach SCRM. The lack of SCRM courses
implies that it would be very difficult to build a broad SCRM
culture in Brazil since most professionals are not familiar with
the concept. Roscoe et al. (2020) affirm Contingency variables
can be grouped into four broad categories: national context
and culture, firm size, strategic context, and other internal
organisational context variables, therefore, Brazilian public
healthcare is lacking an important contingency variable.
In this sense, there is a considerable lack of knowledge of
the concept among professionals. When it comes to health-
care supply chains, the situation worsens. Considering the
complexity of the healthcare supply chains, the upstream
side encompasses professionals that are business-related and
interact with supply chain concepts. Nevertheless, healthcare
professionals such as physicians and nurses, usually, do not
receive supply chain or SCRM training and possibly have no
knowledge of which are the supply chain risks. Moreover,
automation and integration are words that can easily be
understood as work facilitators, therefore, receiving higher
scores among all professionals. In addition, this paper
revealed that the sector moderates the relationships
between SCRM, SCI, and SC40 with SCP. This constitutes an
important contribution to both academia and practitioners.
In terms of literature, we provide insights that build upon
resilience and SCRM in supply chains. Through this research,
we could corroborate that supply chain resilience consists of
a major source of competitive performance. This paper is in
line with the findings of Brusset and Teller (2017), which
affirm that only integration positively affects the resilience
level and performance of a supply chain. In addition, we par-
tially confirmed the theoretical framework of Senna et al.
(2023) identifying that SCI and SC40 positively influence SCP.
Moreover, SCRM’s influence on SCP depends on the sector.
5.1. Theoretical implications
According to Strategic Management, the definition of CRBV
is that the usual contingencies of the business environment

Figure 3. Structural model (framework).
Table 2. Model fitting parameters.
v2 df v2/df CFI NFI RMSEA
267.301 129 2,072 0.909 0,892 0,060
can affect the usefulness of different and unique resources
and capabilities to achieve resilience. This uniqueness implies
that each supply chain has its features, furthermore, to
obtain HCSC performance we must identify the antecedents
and mediators. In our paper we found evidence of antece-
dents and variables composing these constructs, that may
imply that companies must develop these capabilities, there-
fore, our paper is aligned with CRBV theory. Since we did
not identify any paper that made such a contribution, this
highlights a unique contribution of this paper. In addition,
we concluded that the HC SCRM definition seen in Senna
et al. (2023) offers a path to bridge the gap between CRBV
theory and generic SCRM. In Figure 4, we illustrate the con-
nections between the three theories, the constructs, and the
healthcare supply chains.
Supply chain resilience (SCRes) is obtained through oper-
ational capabilities that help a broken supply chain return to
a more desirable state than before the disruption (Brusset
and Teller 2017).
PRODUCTION PLANNING & CONTROL 9
Scholars have continuously suggested managing supply
chain risk management (SCRM) proactively to avoid their
occurrence, although business practice seems to fail with this
task (Gro€tsch, Blome, and Schleper 2012). In this regard
knowing HCSC performance’s antecedents has the potential
of helping the anticipation of risks, allowing managers to
avoid them, in this regard, our paper converges with the
vision of Gro€tsch, Blome, and Schleper (2012) affirming that
CT forms a backbone for proactive SCRM.
Considering SCI, this paper revealed that it can be consid-
ered an important construct that positively influences SCP. In
line with Iftikhar, Purvis, and Giannoccaro (2021), SCI is a
relational resource that generates a competitive advantage,
considering the RBV perspective, additionally, SCI activities
result in a more organised response to market disruptions
and changes and are considered an antecedent for disrup-
tion mitigation. Moreover, better control of external resour-
ces reduces uncertainty as well as vulnerability and enables
a company’s risk mitigation capability (Spieske et al. 2022). In
addition, our study found that the sector (public or private)
has a moderating effect considering a 5% significance
(hypotheses 4a, 4b, and 4c). Besides, if we consider a signifi-
cance of 1%, the moderating effect of the sector applies only
to hypothesis H4b. It is important to highlight that other
samples may reveal different results.
10 P. SENNA ET AL.

Table 3. Results of the hypothesis tests – consolidated model.

Hypotheses Description Standardised regression weights – consolidated model Inference drawn
H1 The SCRM positively influences SCP 0.13 Not supported
H2 The SC40 positively influences SCP 0.45 Supported
H3 The SCI positively influences SCP 0.31 Supported

Table 4. Moderating effects.

Public Private T test
Hypotheses Description sector SE sector SE (p-value) Inference drawn
H4a The sector has a moderating effect on the relationships between SCI and SCP 0.21 0.41 0.047 Supported
H4b The sector has a moderating effect on the relationships between SCRM and SCP 0.15 0.17 0.001 Supported
H4c The sector has a moderating effect on the relationships between SC40 and SCP 0.44 0.39 0.042 Supported

Figure 4. Connection between theories, constructs and healthcare supply chains.

The work of Marques, Martins, and Arau jo (2019) draws
some major gaps in healthcare supply chain literature: (i)
lack of network-level studies; (ii) an imbalance of research
attention regarding the various types of supply, namely
health services, medicines, medical supplies, and blood sup-
ply; (iii) lack of theoretical lens in healthcare SCM studies.
Given this context, our paper provides a network-level study,
providing a conceptual model with empirical validation sup-
ported by a robust theoretical framework.
5.2. Managerial implications
This research reveals managerial implications that have the
potential to assist practitioners to understand the role of
SCRM, SCI and, SC40 in healthcare organisations. The results
considering the influence of SCRM in SCP require deeper
analysis since they are not totally in line with the literature.
Managers and organisations are seeking to develop response
capabilities that can mitigate the disruption impacts of risk
events (Singh and Singh 2019). Considering the private sec-
tor, SCRM has a positive influence on SCP. In Brazil, private
healthcare organisations tend to assume the role of supply
chain managers, especially big private hospital networks.
Such practices often include lean/six-sigma, and business
process management, among many other process improve-
ment and risk mitigation techniques. Therefore, even if those
professionals do not have formal SCRM training, risk manage-
ment is already very disseminated, albeit informally and still
lacking a full understanding of SC ripple effects. Public
healthcare organisations tend to have minor integration with

their suppliers since public procurement is ruled by strict
laws and carried on by online auctions, where the company
that provides the best price with the minimum quality
requirements must be chosen. At a first glance, this seems
very logical, nevertheless, SCRM practices that include secur-
ity measures, environmental issues, and supplier sustainabil-
ity, are often not considered in these companies, making
their price lower, but generating supply chain risks in the
long run. Analysing the supported hypotheses, we note that
supply chain integration and supply chain 4.0 are features
that promote healthcare supply chain performance improve-
ment in Brazil.
Scala and Lindsay (2021) highlight the importance of col-
laboration as a key mechanism for resilience in public sector
networks. Our paper presents important findings and builds
upon Mandal (2017) which affirms that SCRes research is also
lacking in the context of healthcare.
Another important issue is how to deal with the ripple
effect. Dolgui and Ivanov (2021) state that the ripple effect is
a specific area of SC disruptions and a strong stressor to SC
resilience, moreover, the ripple effect propagates through
the supply chains and impacts its resilience and perform-
ance. The findings of our paper indicate that due to more
SCRM proneness, the private healthcare sector has more
tools to deal with the ripple effect, while the public sector
still must develop an SCRM culture. The industry is increas-
ingly emphasising the application of SCRM tools, building a
holistic approach that must consider the level of various sup-
ply chain risks that companies are exposed to, as well as the
different strategies available to mitigate risks (X. Wang,
Tiwari, and Chen 2017). In this sense, it is imperative to map
the antecedents of SCRM and its measuring variables. Our
study identified information sharing as an important variable
of SCI, Furthermore, our study is in line with Yaroson et al.
(2021), which affirm that information sharing is an effective
strategy used in recovering from a disruption. More specific-
ally, the adoption of 4.0 technologies facilitates the shift
from hospital-centered to patient-centered organisations
(Tortorella et al. 2019). In exclusively business-related supply
chains, integration is still very difficult to obtain. In HCSCs
the difficulty increases since most healthcare professionals in
hospitals and clinics do not have supply chain and business
process training and work with individual efforts without a
proper understanding of the processes and the benefits of
integration. Private healthcare organisations already promote
lean/six-sigma and business process management training to
create a process improvement culture while in public health-
care organisations, such practices are almost inexistent.
Nevertheless, SCRM training is still not seen in either public
or private organisations. Public HC organisations should work
closely with the government and public universities to
develop risk mitigation practices at a supply chain level.
According to the results of the study, we recommend that
HC supply chain managers consider the implementation of
robust initiatives regarding SCRM, SCI and SC40. Full automa-
tion techniques, which are the basis of industry 4.0 are hard
to implement mostly because of the high costs.
Nevertheless, supply chain integration and supply chain risk
PRODUCTION PLANNING & CONTROL 11
management initiatives can be considerably cheaper and
consistent results can be obtained from short trainings
including supply chain and supply chain risk management
basic concepts. Regarding supply chain integration, compa-
nies should promote integration events, which nowadays,
are somehow easy to organise due to presential constraints
imposed by COVID-19. The seminars can include best practi-
ces and debates about process improvement initiatives.
Given this context, this study has the potential of helping
organisations that are willing to implement these practices.
6. Conclusions
This research had the objective of presenting a conceptual
healthcare supply chain performance framework empirically
validated by structural equation modelling. The paper
revealed a relationship between supply chain integration,
supply chain risk management, and supply chain 4.0 (antece-
dents) with healthcare supply chain performance (conse-
quent). The literature contributions of this paper were (i)
developing and validating a new scale for each construct; (ii)
finding evidence of the causal relationships between the fac-
tors; (iii) measuring how the constructs influence the health-
care supply chain performance in both public and private
healthcare sectors and providing discussion and tools to
improve these results; (iv) this work empirically tested a the-
oretical framework; (v) considering healthcare supply chains,
there is a different perception of risks between public and
private sectors. Moreover, the major contribution of this
study was to find empirical evidence for the impact of sup-
ply chain 4.0, supply chain risk management, and supply
chain integration on healthcare supply chain performance. In
addition, we show the direct relationships among the con-
structs and identify the conceptualisation of the backbone of
healthcare supply chain performance by identifying its ante-
cedents, which are currently under-researched in the
literature.
This study addressed a very important literature gap
regarding the measurement of the influence of SCI, SC40,
and SCRM on SCP. In a broader context, this research can go
a long way to not only solving nationwide problems but also
providing guidelines to the researchers and practitioners to
address supply chain risks in a more systematic manner. To
the best of our knowledge, this paper is the first to empiric-
ally analyse the fit of a theoretical framework by measuring
the weight of each construct. therefore, this paper provides
a unique contribution.
Another notable result of the study is the moderating
effect of the sector. This has the potential to generate further
research and investigation to answer research questions such
as (i) What are the reasons for this difference? (ii) Does this
difference of perception happens in all countries, or it is a
specific case in Brazil? (iii) If the basics of SCRM are included
in the curriculum, would the results be different? (iv) Are
there other constructs that impact healthcare supply chain
performance? These questions require further studies to
receive proper answers.
12 P. SENNA ET AL.
The framework developed in this research significantly
contributes to the advancement of science, by providing aca-
demic studies with a clearer view of the background of
HCSC performance, which contributes to improving the qual-
ity of management decisions in the public and private
healthcare sectors.
As a limitation, we can cite that the use of subjective
measures (collected through questionnaires) may allow the
occurrence of Common Method Variance and the formation
of response biases, resulting from a wrong generalisation
effect (Halo). We performed statistical tests to avoid these
limitations and proved the effectiveness of the scale.
The proposed theoretical framework was tested among
healthcare supply chain professionals in Brazil, in this sense,
other countries can obtain different results. We identified
three main constructs that function as antecedents of SCP,
nevertheless, they may not be the only antecedents and
more constructs can be incorporated based on other experts’
feedback. The data collection process was also challenging in
terms of cost issues and time consumption. As future
research opportunities, we recommend that researchers test
other constructs.
Notes on contributors
Dr. Pedro Senna holds a doctoral degree from the
CEFET-RJ, in Industrial Engineering at the CEFET-RJ,
Brazil. He has experience in the area of Supply Chain
Management, Supply Chain Risk Management and
Data Science. Professor at CEFET-RJ, Postgraduate
Programme in Production Engineering and Systems
(PPPRO), Department of Industrial Engineering
(DEPRO). He is currently a postdoctoral researcher in
industrial engineering in COPPE/PEP UFRJ under the
supervision of professor Lino Guimar~aes Marujo.
Dr. Augusto Reis has a degree in Business
Administration from PUC-Rio (2006) master’s at
Industrial engineering from PUC-Rio (2009) and doc-
torate at Industrial engineering from PUC-Rio (2013).
Now, he is a professor of Production Engineering
Department at CEFET/RJ. He has experience and
focuses on the following subjects: supply chain man-
agement, product variety management, healthcare
logistics and reverse logistics.
Dr. Lino Guimara ~es Marujo received a B.Sc. degree
in industrial metallurgy engineering from the Federal
Fluminense University, Volta Redonda, Brazil, in 2000.
He was awarded an M.B.A. from Get ulio Vargas
Foundation, Sao Paulo, Brazil in 2002, and an M.Sc.
in Operations Research and Technology, from
CEFET/RJ, Rio de Janeiro, Brazil, in 2003. His doctor-
ate was completed in 2008 in naval engineering
from COPPE/UFRJ, Rio de Janeiro, Brazil. He has
been coordinating a research track with SCALE-MIT focussed in sustain-
able supply chains, He worked as a Visiting Scholar with Megacity
Logistics Lab at MIT, Cambridge, MA in 2014–2015, developing models
to assess cargo freight over public transport networks. He is currently an
Associate Professor of Logistics and Simulation with the Department of
Industrial Engineering at Polytechnic School of UFRJ, Brazil. He is also a
Professor with Operations Research Program and collaborate with the
Transportation Engineering Program at COPPE/UFRJ, Rio de Janeiro,
Brazil. His research focuses on stochastic modelling, optimisation via
simulation, data-driven decision making, and uncertainty quantification.
The application areas of interest include supply chain management,
logistics and transportation, urban operations research, health care serv-
ices, and sustainable operations management.
Dr. Julio Cesar Ferro de Guimara~es holds a Post-doc-
toral degree from the University of Caxias do Sul
(UCS), PhD in Business Administration at the
lica of Rio Grande do Sul
Pontificia University Cato
(PUC-RS) and University of Caxias do Sul (UCS),
Brazil. He has experience in the area of Business
Administration, emphasis in management of innov-
ation, business competitiveness and Cleaner
Production. Professor is currently researcher and
Federal University of Pernambuco (UFPE), Post-Graduate Program in
Hospitality and Tourism (PPHTur/UFPE), Post-Graduate Program in
Management, Innovation and Consumption (PPGIC/UFPE), Department
of Administrative Sciences (DCA/UFPE), Centre for Applied Social
Sciences (CCSA/UFPE).
Dr. Eliana Andrea Severo holds a Post-doctoral
degree from the University of Caxias do Sul (UCS),
PhD in Business Administration at the Pontificia
lica of Rio Grande do Sul (PUC-RS)
University Cato
and University of Caxias do Sul (UCS), Brazil. She has
experience in the area of Business Administration,
with emphasis in environmental management,
innovation and entrepreneurship. She is currently
researcher and professor at the Federal University of
Pernambuco (UFPE), Post-Graduate Program in Management, Innovation
and Consumption (PPGIC/UFPE), Department of Administrative Sciences
(DCA/UFPE), Centre for Applied Social Sciences (CCSA/UFPE).
Dr Ana Carla de Souza Gomes dos Santos holds a
Ph.D. in Industrial and Systems Engineering at
Federal Centre for Technological Education Celso
Suckow da Fonseca (CEFET/RJ) in the lean healthcare
line of research and a professor at the Federal
Institute of Education, Science, and Technology of
Rio de Janeiro (IFRJ), campus Nitero i. Her general
field of research and experience is in Industrial
Engineering, focussing on Production Management,
Lean Managment, Lean Healthcare, and Service Quality.
ORCID
Pedro Senna http://orcid.org/0000-0003-2501-2203
Augusto Reis http://orcid.org/0000-0002-3200-8096
Lino Guimar~aes Marujo http://orcid.org/0000-0002-0355-6501
Julio Cesar Ferro de Guimar~aes http://orcid.org/0000-0003-3718-6075
Eliana Andrea Severo http://orcid.org/0000-0002-5970-4032
Ana Carla de Souza Gomes dos Santos http://orcid.org/0000-0002-
6205-7454
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Appendix A

Table A1. Questionnaire.

Observable variables Reference
Supply chain integration
INTE1) I consider it a good practice to share information with the Chaudhuri, Boer, and Taran (2018)
purchasing department (e.g. demand forecast, production plans,
production progress and stock levels).
INTE2) I believe there should be information sharing with key suppliers Cagliano, Grimaldi, and Rafele (2016); Chaudhuri, Boer, and Taran (2018);
(e.g. on sales forecast, production plans, order tracking, delivery status Tang (2006); Barroso et al. (2010); Barroso et al. (2010)
and stock levels).
INTE3) I believe organisations should develop collaborative approaches Chaudhuri, Boer, and Taran (2018); Soni and Jain (2011)
with key suppliers (e.g. supplier development, risk/revenue sharing,
long term agreements etc.).
INTE4) I believe there should be joint decisions with key suppliers (e.g. Koufteros, Vonderembse, and Jayaram (2005)
on products, processes, quality improvement, cost control etc.).
INTE5) I consider it essential that information systems are integrated with Cagliano, Grimaldi, and Rafele (2016); Chaudhuri, Boer, and Taran (2018)
key suppliers (e.g. supplier-controlled inventory – VMI, Just-in-Time,
Kanban, continuous replenishment).
INTE6) I find it relevant to share information with key customers (e.g. Chaudhuri, Boer, and Taran (2018); Tang (2006); Barroso et al. (2010);
sales forecast, production plans, order tracking, delivery status and Barroso et al. (2010)
stock levels).
INTE7) There should be collaborative approaches with key customers (e.g. Chaudhuri, Boer, and Taran (2018); Iakovou, Vlachos, and Xanthopoulos
risk/revenue sharing, long-term agreements, etc.). (2007); Soni and Jain (2011)
INTE8) I consider it essential that information systems are integrated with Chaudhuri, Boer, and Taran (2018)
key customers (e.g. supplier-controlled inventory – VMI, Just-in-Time,
Kanban, continuous replenishment).
INTE9) I consider it a good practice to make decisions together with the Chaudhuri, Boer, and Taran (2018)
purchasing department (a good practice e.g. demand forecast,
production plans, production progress and stock levels).
SCRM
SCRM1) I believe that the organisation where I work should have Ali, Nagalingam, and Gurd (2018)
accreditation or other quality certificates.
SCRM2) I believe there should be joint decisions with key customers (e.g. Chaudhuri, Boer, and Taran (2018); Soni and Jain (2011)
product design or modification, process design or improvement,
quality improvement, cost control, etc.).
SCRM3) I believe the organisation I work for should have a quality Ali, Nagalingam, and Gurd (2018)
management system.
SCRM4) I believe that a resilient organisation must have continuing Authors
education programs.
SCRM5) I believe my organisation would benefit from a well-structured Guha and Kumar (2018)
database (containing information about patients, suppliers, customers
or patients)
HC SC 4.0
SC401) I believe that our supply chain processes would have greater Mylrea and Gourisetti (2018); Kumari et al. (2018); Griggs et al. (2018);
compliance and security if they were supported by blockchain Hiromoto, Haney, and Vakanski (2017)
SC402) I believe that implementing IoT (Internet of Things) devices would Roy, Abidi, and Abidi (2017); Griggs et al. (2018); Javdani and Kashanian
optimise our processes. (2018); Rodrigues et al. (2018)
SC403) I believe our supply chain would be more efficient if it had IoT Roy, Abidi, and Abidi (2017)
and Blockchain support
SC404) I believe that implementing IoT devices can help improve patient Martınez-Caro et al. (2018); Griggs et al. (2018); Javdani and Kashanian
care. (2018); Rodrigues et al. (2018)
SC405) I believe it is essential that the organisation has a strong Ali, Nagalingam, and Gurd (2018)
mechanism for collaboration with government agencies.
SC406) I believe IoT would make our supply chain safer Kouicem, Bouabdallah, and Lakhlef (2018); Griggs et al. (2018); Hiromoto,
Haney, and Vakanski (2017)
HC SC performance
HSCP1) Our organisation has had better patient satisfaction over the past Ali, Nagalingam, and Gurd (2018)
3 years.
HSCP2) I believe our organisation is experiencing a reduction in theft. Lu, Koufteros, and Lucianetti (2017)
HSCP3) The organisation I work for has improved its ability to detect Lu, Koufteros, and Lucianetti (2017)
counterfeit parts or products.
HSCP4) I believe the likelihood of our supply chain being compromised Lu, Koufteros, and Lucianetti (2017)
(e.g. disruptions, disasters, or events that cause rupture) is small.
HSCP5) I believe our probability of supplies misuse is small. Lu, Koufteros, and Lucianetti (2017)
HSCP6) I believe we have low levels of vulnerability in the supply chain. Lu, Koufteros, and Lucianetti (2017)
HSCP7) I believe we have achieved a reduction/smaller potential for drug Lu, Koufteros, and Lucianetti (2017)
trafficking.

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