Scenario Planning: Designing Resiliency into Operations

The minute health systems started shutting down services at the start of the COVID-19 pandemic, reality hit that something was broken.

It was more than the supply chain, which forced the rationing of personal protective equipment. It went beyond cleaning protocols as facilities tried to mitigate infection spread. It was greater than a need for more ICU beds and negative pressure rooms available to treat infected patients.

It was everything, from surge capacity to traffic flow, technology to staffing, The strain of closed clinics and operating rooms proved to be greater than many had anticipated, and coupled with overtime for other staff, and expenses for quick room conversions for negative air flow, the situation elicited one large question: “How did we get here?”

For more than a decade, the planning for healthcare organizations has been guided by the Institute for Healthcare Improvement’s Triple Aim – to improve the experience of care, population health, and the cost associated with care. That pursuit of the aim led to campuses and facilities that are more intuitive for patient-families, more efficient for staff, and more cost effective to operate…all in normal operations.

While an understatement, COVID-19 proved to be anything but normal, and in its sweep across the nation, it exposed a deficiency in our collective healthcare system. Missing from the Triple Aim was “resiliency,” a word often applied to physical structures, not so much to operations. As organizations pursued the Triple Aim, with a strategic and structural shift from inpatient to outpatient care, facilities and campuses reflected that shift, designed for consumers of care with a focus to keep the community healthy and reduce the need for hospitalization.

The flood of need for hospitalization in the pandemic isn’t an indictment that the previous pursuits were wrong. Rather, in exposing the gaps in healthcare operations, the pandemic has revealed the need to evolve our planning approaches. More than answering how organizations got here, the question is, “How do we move from here?”

A New Planning Approach

The scenario laid out by the pandemic is that: a scenario. On its own, COVID-19 represents a national event whose scale and impact has little precedent. However, in the past 15 years, the coronavirus spread is one of many unplanned events that have challenged both large and small organizations, alike. MERS, SARS, mass shootings, 100-year floods, tornadoes – the scenarios that strain the resources of hospitals, clinics, and the communities that they serve occur at a greater frequency that ever before.

Through that lens, we can both critique the plans that put organizations where they are now and evolve the process to find a resilient path to managing through these scenarios. Simply called Scenario Planning, this new approach to the traditional master planning process aims to mitigate the impacts scenarios can have on operations and facilities.

Most campuses and facilities have been programmed through a master planning process, a practice that usually relies on observed trends to forecast a probable future. What the current pandemic has shown is that the scenario under which the plans are crafted focus on a desirable future, one predicated that the future will be similar to the past. The master planning process often assumes an environment that operates business as usual, and the facilities and infrastructure are designed accordingly.

Scenario planning takes the planning process to a new level. More than planning for a worst-case scenario, scenario planning puts the integrity of an organization’s operations at the center of the planning process. A dynamic approach to planning, the planning process enables organizations to understand the possible effects unplanned, adverse events could have on their personnel, supplies, and facilities.

Where vision drives much of the master planning process, scenario planning complements that vision through a segmented analysis of the drivers of an organization’s operations. By studying the impacts scenarios have on each part of an organization’s operations, the organization is forced to consider enterprise-wide how it can respond to adverse conditions demanding rapid attention and adaptation. Beyond the response, the analysis concentrates the planning on how organizations can pivot facilities, technology, and personnel in a moment while protecting its ability to operate at optimum levels.

Resiliency Redefined

Scenario planning combines the vision of where organizations want to go under controlled conditions with an approach that examines that resiliency of the vision in the face of uncontrolled conditions. It takes the idea of resiliency in operations to expand its definition beyond recoverability. Instead of analyzing how quickly a normal state of operations can return after those operations are disrupted, scenario planning allows teams to consider how well the organization can absorb a disruption to maintain continuous operations.

Facilities and infrastructure are then designed for disruption absorption – alternative care sites, alternative care delivery methods, flexible mechanical systems, adaptable spaces, alternative traffic flows, as well as support for staff wellness under unrelenting stress. By creating a dialogue between all the various parts of an organization, a dynamic plan is shaped to help organizations maintain the integrity of their operations through adversity.

According to a report from the American Hospital Association, shuttered and modified operations in response to COVID-19 has resulted in a 19.5% drop in inpatient volumes at non-federal hospitals, and an additional 34.5% drop in outpatient volumes. Losses from the first four months of the pandemic plus projected continued losses, even after services come back online, are expected to exceed $323 billion in 2020. (Click to read the report.)

The current pandemic represents a real existential threat for many healthcare organizations. The look of hospitals, clinics, and their operations after the pandemic will be different from what it was before the pandemic. However, “different” must be “better.” While COVID-19 provides a better understanding of how a pandemic can impact operations, it is only one of many scenarios that force organizations to deviate their operations from normal. Disruptions to operations will continue. Only through a better planning process can we mitigate the impacts those disruptions can have on the integrity of the whole healthcare organization.

Download BWBR’s white paper, “Scenario Planning: How to be Resilient in Design and Operations,” for more detail about the Scenario Planning process.

Mike Boldenow is a principal at BWBR who has spent much of his career working with healthcare organizations to develop facilities that enhance the services they provide in both small communities and large metropolitan regions. Mike can be reached at or 651.290.1996. Scott Holmes, RA, ACHA, LEED AP, is a retired principal and healthcare planner who has worked with organizations from large health systems to critical access hospitals to program spaces that increase efficiencies and improve the delivery of care.

BWBR Rankin Hall Renovation Earns Carroll University’s Second LEED Certification

A nationally registered historic lab and classroom facility at Carroll University has earned LEED® certification, making it the second campus facility to attain LEED certification in two years.

Rankin Hall’s 26,500-square-foot renovation completed the third and final phase of a BWBR-designed campus capital plan to improve academic spaces focused on science and health programs. Previous phases included Carroll University’s first LEED certified project, Hastad Hall, which also features Waukesha’s first green roof, and Jaharis Science Laboratories.

The renovation includes nine classrooms and labs, 25 faculty offices, three new psychology testing rooms to perform research, and additional open, flexible spaces that inspire a collaborative learning environment.

The project focused on using historically appropriate, environmentally friendly, long-lasting materials and design strategies. Those included clay tile roofing, zinc flashing and downspouts, and a low-VOC historically appropriate paint palette. Energy efficiency and indoor environmental improvements were made with sensitivity to the historic masonry and wood structure. Strategies included spray foam insulation added in the roof joints, LED lighting, and new systems for heating and cooling, in addition to refinishing the wood floors.

Exterior detail of the revitalized historic wood windows.

The original wood windows were removed, restored, and then replaced to maintain the historic character of the building from both the inside and outside. New insulated windows were installed on the outside of the original windows. These windows were thermally broken, with low-e coating and argon fill. To maximize the ability to see the original windows from the exterior of the building, the window frames are as narrow as possible with low iron glass for extra clarity.

Rainwater run-off from Rankin Hall is directed to bioretention ponds built as part of the Jaharis Science Laboratories project. Moving beyond LEED, an added exterior ramp, new elevator, and gender-neutral bathrooms improved the building’s accessibility and inclusivity.

“The ability to reuse and improve existing structures is a key sustainability strategy. The historic nature of Rankin Hall made LEED certification a welcomed challenge,” said Sara Curlee, AIA, LEED AP, senior project architect at BWBR and the project’s LEED project administrator. “Rankin Hall’s design helped to set the tone for the campus aesthetic more than 100 years ago, and it’s gratifying to see the facility continue to reflect that tone while influencing future generations of students in a safe, accessible, and sustainable environment.”

Named for Carroll University’s second president, Rankin Hall, located in a National Historic District, is listed on The National Register of Historic Places and the Wisconsin Register of Historic Places, and is designated as a City of Waukesha Landmark. In 2019, the project received the George Gunn Award for Excellence in Architectural Preservation and Historic Restoration by the City of Waukesha Landmarks Commission.

With 40 LEED accredited professionals currently working at BWBR, the firm is one of the leading advocates for sustainable high-performance design, incorporating green design strategies into complex environments like academic facilities, R&D centers, and hospitals. As part of a global movement to design smarter, BWBR is a signatory to the AIA 2030 Commitment which challenges architects and engineers to make buildings carbon-neutral by 2030.