The Next Evolution: Scenario Planning

In this episode, we’re talking about the Next Evolution: Scenario Planning.

Why an evolution?

The pandemic exposed gaps to the way our industry planned campuses and facilities, from hospitals to academic centers. 

Traditionally, a master planning process guided project developments, driven by both vision and an assumption that the future would reflect more of a normal operational environment. 

The pandemic upended any sort of normality, but it also showed where that traditional master planning process failed to help organizations navigate through deviations from normality.

Scenario Planning evolves that approach, looking at an organization’s operations through various lenses to create options that promote resiliency through various scenarios.

Talking about Scenario Planning, what it is and how it can be applied to organizations, especially those in health care, are three people who bring unique lenses to the subject.

Sophia Skemp is a medical planner and architect who has provided planning and programming services for regional and critical access hospitals and ambulatory centers across the Plains and Upper Midwest. She has a master’s degree in architecture, with her studies crossing the boundaries between design research and health care architecture. 

Mike Boldenow is a principal at BWBR with more than three decades of work with health care organizations and corporations creating campuses and facilities that elevate operations and help organizations effectively serve their stakeholders.

David Voller is senior operational planner who brings experience as a facilitator and operations leader with a demonstrated history working inside health systems evaluating operations, revenue, strategic goals and building cultures.

Hosted by James Lockwood.

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Transcript

James Lockwood  0:09  
Hi, and welcome to Side of Design podcast from BWBR. For those new to our podcast, Side of Design is an exploration of the topics and issues affecting how we heal, learn, work, research, play and pray, in essence, how we live. Twice a month, we are bringing you engaging conversations with those who are passionate, curious, and obsessed about the performance of organizations, and the people and facilities that power them. All with a Side of Design. 

I'm James Lockwood, your host for this episode. 

Today, we're talking about the next evolution: Scenario Planning. 

Why an evolution? The pandemic exposed gaps to the way we planned campuses and facilities, from hospitals to academic centers. Traditionally, a master planning process guided project developments driven both by vision and an assumption that the future would reflect more of a normal operational environment. 

The pandemic upended any sort of normality. And it also showed where the traditional master planning process failed to help organizations navigate through deviations from normal. Scenario planning evolves this approach, looking at an organization's operations through various lenses to create options that promote resiliency through any number of scenarios. 

Joining me today to talk about scenario planning, what it is and how it can be applied to organizations, especially those in healthcare, are three people who bring unique lenses to the subject. 

Sophia Skemp is a medical planner and architect who has provided planning and programming services to regional and critical access hospitals, as well as ambulatory centers across the Plains and Upper Midwest. She has a master's degree in architecture, and her studies cross the boundaries between design research and health care architecture. 

Mike Boldenow is a principal with BWBR who brings more than three decades of experience to working with healthcare organizations and corporations, creating campuses and facilities that elevate operations and help organizations effectively serve their stakeholders. 

Finally, David Voller is a senior operational planner who brings experience as a facilitator and operations leader with a demonstrated history working inside health systems, evaluating operations, revenue, strategic goals, and culture. 

Welcome to all of you. And as we kick off this discussion, I'll start with you, Sophia. 

Sophia Skemp  2:33  
Sure. 

James Lockwood  2:34  
You've had an integral role in starting the development of scenario planning here at BWBR. What was the genesis that spawned this thinking? And what need is it filling?

Sophia Skemp  2:45  
Great question. I would say going back to March 2020, so almost a year ago now, really started it all. COVID was becoming widespread, and our first shut down here in the Twin Cities was just about to happen, and a lot of our health care projects were quite suddenly put on hold. And also, at the same time, our office, like many other offices, in the Twin Cities, was being directed to start working from home full time. 

So it was this awkward transitional period. For us, as a firm, especially at the beginning, it felt like all we could do, and personally, all we had time for was talking about this pandemic and what is happening, and as it relates to design. And I would say this led us to start organizing some internal working groups within our office centered around this very topic. It was just a great way, for a dedicated time, for our health care group to come together as an office and, one, connect with each other, because, you know, all of a sudden, we weren't with each other seeing each other every day. But also to brainstorm topics around the pandemic, give client updates to the group, you know, just just keeping each other in the loop. 

And I would say during these meetings, the more earlier conversations at the beginning were centered more around immediacy. So immediate needs, and immediate solutions. So this client needs this area to be converted into storage, or this client needs X amount of patient rooms now to be negative pressure. Okay, go. Like, What's the need? What's the solution? 

And then over time, the group conversation started to be more focused on preventative measures, and what does that look like in the design process, so just recognizing that everything that the world was going through, you know, we really can't end up here again. So how do we do that? How do we plan for the unpredictable? 

So that was really the genesis, you know, planning for the unpredictable. To your question more specifically, what need is it fulfilling? Scenario planning is trying to, as much as possible, prevent health systems from experiencing the ramifications that they went through in 2020 and are continuing to go through today and 2021. What are those? One, being cost. You know, yes, the, we all think of the personal protective equipment, the PPE shortage, which led to the stopping of non-emergent procedures and elective surgery, which, that is a huge revenue stream for health facilities. So cutting that off temporarily was a huge financial blow. So we don't want that to happen again. 

And while that is important, I think we all want to stress, as a group that, that scenario planning is not just focused on that. It's not just addressing financials. It's also thinking about experience of care. So you think about the patients and the family experience that, you know, it was recently occurred in 2020 family members who are not allowed in the hospital and, in some heartbreaking instances, could not say goodbye to loved ones. Is there anything that could have been done? 

Experience of care also applies to the community at large. So thinking about the fear that COVID instilled in people, some instances, hospitals actually saw a decrease in emergency department and urgent care visits because people were afraid to, to come to the hospital for a moment in time.

And it's interesting, on that same note, we're doing some post occupancy evaluation for a birth center, and interviewing one of the midwives, she noticed, over the summer, specifically a decrease in her patient population. So healthy mothers opting for home births, or going to birth centers not directly physically tied to a hospital system. So just that fear and experience of care from the community lens. 

But it's also about staff, thinking about their health and their safety. Thinking about, and I don't think we as a group can stress enough, their mental health and their safety. As a side note, we can all agree that most times on projects, when it comes down to reevaluating the budget and spaces that we need to squeeze, or take out, staff areas are typically the ones offered up first. So scenario planning, I think, has brought to light that we should really start reevaluating those conversations, and maybe push back on that a little bit. So, those are the needs that scenario planning is seeking to fulfill. It's, yes, it's about cost, but it's about people, their experience of care, the health of your community, and what can we do as designers to make those more resilient.

James Lockwood  8:50  
That's a great synopsis. I appreciate the details in that.

Mike, bringing you into the conversation here. You know, through out the decades of service that you've had in the design industry, you've worked in many planning processes, and most of these probably have been defined as master planning. How is the scenario planning that Sophia described actually differing from a traditional master planning process? And I'll even add on to that, something that Sophia said that really piqued my interest: She talked about fear really driving utilization or lack thereof. In a traditional master planning process, would fear ever be part of that conversation? And does scenario planning actually give you the ability to start to incorporate some of those anxieties into the planning process? 

Mike Boldenow  9:46  
Well, that's an interesting way to look at it. You know, the fear, we all fear the unknown, right? And I think that that in itself is what we're talking about here. The traditional masterplan we and our peers across the world have been involved with has really been more about the known, right? We're going to help a client or a campus or a system, evaluate their infrastructure, their facility condition, the data, looking at business plans about where growth and contraction might be. So it was based on data. 

So it was very known. There was very little fear there. Our clients generally knew what we were doing, we were just projecting that data out across anywhere from 1 to 20 years. So they could plan ahead and not paint themselves in a corner. 

So back to your point about fear, what we've decided back in the spring, as Sophie had mentioned to you, is really address the unknown, right? We weren't prepared, as Sophie said, we being collectively. Whenever I say, "We," we are going to be talking about the design field, A's and E's, as well as our clients, the healthcare systems, hospitals. We weren't prepared to deal with disruption. We weren't prepared to help facilities be resilient for many of the aspects that Sophie had mentioned. 

So therefore, what scenario planning is doing is, as you mentioned earlier, James, we're evolving the process. We're evolving it to include information, to gather information, to ask questions that help our clients and systems prepare for those disruptions that we don't know will ever happen. The pandemic, we're not, we're not planning for another pandemic. Although what we've learned has been applied to helping us be more resilient, whether it's a mass casualty event, a facility threat, a natural disaster. 

So again, I think we're trying to alleviate the fear of the unknown, and move forward confidently with solutions that are really going to be more operational solutions than they are physical or infrastructure based solutions. So I think that's where David can kind of help, maybe help me out. Say that, you know, we've been dealing with the physical, right, the known the controlled conditions. Now we need to lay their inner feather in the uncontrolled operational aspects and be prepared.

Sophia Skemp  12:12  
Can I just add, add one thing on to that I've been thinking about this and preparing for this conversation. It was helpful for me to just reiterate that they're different, but they're not so different. They're working, they're working together, they're complementary. So master planning, like you said, Mike, is, it's designing for where you are headed, based on data volumes, all that good stuff, or where you want to head, you know, we want to start attracting a certain amount of physicians to come here. 

Scenario planning is helping to make sure that that is still possible, in addition to maintaining your baseline operations. So just just helping the typical master plan along the way, that it's resilient in the face of a tornado. The next COVID, for example. 

Mike Boldenow  13:09  
It's meant to be flexible enough that it doesn't necessarily have to be applied to, or be part of, a master plan. There's many aspects of this, questions we can ask, data we can gather, conversations we can have with our clients that can be applied to projects, right? Whether it's medical a office building, and starting to talk about adaptability and flexibility in the infrastructure and keeping it safe. It could be a remodeled lobby or front entry to a facility. 

And knowing what we know, we want to be able to design that in a way and ask the right questions to keep it safe. We've even had principals in our office under other sectors, like higher education, saying, you know, we could really apply a lot of these principles to a new academic center or a dormitory. So I think it's really going to evolve, at least at BWBR, as something that's more than just a healthcare evolution in the master planning into scenario planning.

James Lockwood  14:09  
And one of the things I really liked the way you're describing Mike, is this idea that you're taking a systemic approach to planning, rather than, as you mentioned, just a facility approach to planning. 

You know, David, you've spent a career studying and developing systems, mostly within healthcare for organizations like Mayo Clinic. You know, how does this systemic focus to scenario planning help organizations navigate all these scenarios that Mike highlighted? And you know, how do these scenarios, you don't want to call them disasters, but more that they're just deviations from normal? You know, how does this scenario, systemic approach help them navigate these deviations?

David Voller  14:52  
Yeah, you know, it's interesting because this feels like the classic chicken-and-egg kind of question per se. And you know, if you really take from the perspective and in the background I've had in my career, it truly is that form follows function, right? And I think it really becomes the start of the opportunity in understanding function. Right? Is it, what is it really that we're trying to achieve? Do? What are? What is that aligns? Or how does that align with your goals, your strategic plan, and you start to use some of that.? 

What I really like about scenario planning, and the way we did it, is that it brings up a broader, probably more holistic look at every aspect of what you want to do and try to do in an organization. And you, Mike talked about the we earlier, and it's, it's really important to understand that we think because it is really through various lenses, that being of the client, that being of the architectural firm, and, you know, some of the question of how did we get here, and how I say we, I'm going to infuse both lenses, but we got there because it's systemic, from the traditional way that healthcare organizations, constrained by whatever resource that they had, guided them in a direction to try to achieve most optimally, those elements related to their goals and strategic plan. 

So, whether it was a capital limitation, it was a space limitation, it was a staff resource limitation, those were all the things that we were designing, and we're designing around optimizing it, especially in normal. The pandemic, I think, really unearthed or exposed us in a way that said, "I gotta be thinking about this bigger and broader." We've got to look at it from more lenses than just normal. Because unfortunately, and Mike mentioned earlier, we did paint ourselves per se into corners, whether that was limiting the number of accesses into physical space, or how we created that flow through space, limiting the amount of storage because we went to just-in-time inventory systems, how we defined staff to optimize them and have them work as optimally as possible, in a way that they maybe we weren't able to flex into other areas of need. And all of a sudden we're finding, we're flexing nurses into clinical areas where maybe they wouldn't have normally practiced. 

So you know, the systemic-ness of all of this, based on its roots or where it came from, to where we're at today. Really, I like this way scenario planning is going to shape a more broader perspective, it's a more holistic look at really, how do we need to be prepared for running our operations and become more flexible, become more adaptable. And really, Sophia really hit on nicely too, and that is that resiliency of how our staff perform and can perform and at the end of the day, feel like they were successful.

James Lockwood  17:51  
You know, you hit on a word there that I was wondering if the three of you could maybe expound upon, and that is the word resilience. You know, the word resilience seems to be at the center of scenario planning. Why that word?

David Voller  18:09  
You know, it didn't come from a medical perspective. The resiliency just ties back to the importance of, we know that there's a direct correlation when you have high staff satisfaction, that correlates to higher patient satisfaction. And so in those that it's critical, right? It's critical from so many different angles. So that's this clinical lens or the perspective from healthcare, is we want our staff to be resilient because they can perform better but Sophie you ...

Sophia Skemp  18:40  
No, that, that that was a great description, David, it's being able to recover and maintain form while under pressure. So how can your facility maintain operations while under the external pressure of a pandemic, a severe weather event, mass casualty, you know, its resilience. It's the definition that's at the heart of scenario planning.

James Lockwood  19:08  
Mike, typically, resilience has been applied in a physical sense, you know, like a natural disaster. Sophia seems to be suggesting that maybe we should be applying the word in a more holistic sense. In your experience, has the word resilience really been applied to either operations or even financials?

Mike Boldenow  19:33  
No. To tag on to what David was just mentioning, we tried to lean ourselves or our designs to meet a demand to lower healthcare costs, and that had to deal with reducing space and try to be more efficient, which is good, don't get me wrong. We weren't focused on the big picture and, the big picture again was the fear of the unknown. We don't know what we don't know. 

But now that we've gone through something like this, I think it's helping us to open our eyes a little bit. You know, this isn't really a bricks and mortar solution, what we're talking about here, it's really an operational solution. We're not trying to design bigger hospitals with more beds, in the chance that there might be a mass casualty event, or another pandemic. We're not trying to do that at all. We're trying to either design new facilities or adapt existing facilities just for that purpose to be flexible, whether that's the mechanical electrical systems. Before we were trying to get them more energy efficient. Now we're trying to make them more energy efficient, and be able to flip the switch and go from normal HVAC air changes to something whether negative or positive, depending on the situation. 

We just are trying to think ahead. We're not trying to, again, design more beds. We just want to make sure that, say, in a bed ward, in a med surg unit, maybe we design in some flexibility with slightly larger rooms that can take a second bed and maybe have the ability to have additional med gases or emergency powers associated with them. So that they can be adapted. 

We're looking at outpatient facilities and see how could they be used in an event, such as we just had during a surge, to take on sick patients. Or, by removing outpatient procedures and visits from the hospital setting off site, are we now creating that separation and keeping business as usual in the next situation where sick patients, there's a surge or a pandemic in the hospital, we don't have to shut down business for other procedures, other elective patient care, that can still be maintained as long as we can separate sick from healthy. 

And so I think, again, this isn't a bricks and mortar solution, I've said that. It's really just having a conversation to make sure that we're really thinking about the building, the facility, the site differently, so that it can be adapted to, to be, to help our clients be resilient. To still treat the sick, treat the not sick, and make sure that patient care goes on as usual.

Sophia Skemp  22:27  
I think this is a great question to bring up because if people are hearing about scenario planning for the first time, I can see the immediate jump or the assumption to perhaps it leading to more square footage or a larger scope. But, like Mike said, it's not always necessarily a bricks and mortar solution. And, and I'm not sure that that's necessarily the case, either. 

An example that came to mind while Mike was talking, in addition to mechanical and electrical, you know, just technology and think about the boom that technology has had in healthcare, especially within this last year. IT, connecting in-patients with family members. Protecting the health of the community with telehealth and virtual care visits. Protecting people within the actual building with technology advancements and infection control. You know that, technology is a key driver for operational resiliency. And, I am not a technology expert, but I would think that that doesn't necessarily, drastically increase your scope or like double the size of your building. 

So, or like Mike said, maybe just reassigning circulation flows that are already in place, you know, thinking about a common lean concept: on-stage off-stage. You know, separating staff versus patient flows. Can you just pivot that during a pandemic and have it sick versus well, you know. I just, I, I am not, I'm not certain we've lean processed ourselves into a corner, or that scenario planning is automatically means building the church for Easter Sunday. So, but I don't know yet. You know, where there's still time to figure it, it would be interesting to start taking, Mike and David, some of the projects that we did do this past year for our clients where we were like retrofitting lobbies and clinic spaces for pandemic scenarios and see what that difference in scope was. And if it was a huge, huge Delta, but I ...

David Voller  24:55  
You know Sophie, I can, I can tell you we're already starting to see some of that. And whether, you know, play in the technology driver. I think it's important that we understand that in part of the way that we do our process for scenario planning is that we certainly start to identify, you know, what are the various scenarios that could potentially put an organization at risk. And then, what are those key drivers? And you kind of hit on that, right? Technology being the driver in an environment. And how is that going to inform us a little bit different about how we can practice and use space.

And, Mike hit this on thinking about acuity, adaptive hospital rooms, and you hit on it with a tele-med visits and all that. And that is actually really starting to re-inform us in a way that we can design hospital rooms to be more flexible, more adaptable. Whether it's an acuity level kind of thing, or flexing a room in the space of a hospital that might have originally been like an 80-bed hospital, but really could be maybe closer to a 45-bed or 46-bed hospital. But, could we make those rooms just a little bit bigger and make them a new occupancy if you needed to? The technology one is really fascinating, I think with all that's been happening, especially around telehealth care, and that's going to transition to all your agent play strategies, your remote monitoring, your classic virtual visits, all that kind of stuff. 

Taking that patient away from having to be in that brick-and-mortar space, it does start to say, "What might that do to utilization?" Do we need as many exam rooms if 20% of our business no longer need to be in person? What might that be? So I think we're gonna see a lot of really informed approaches and intentional opportunities to really size things, right, but do it in a more mindful and intentional way. And, and in, in the end, really more flexible, more adaptable. So I think it really does lend well. I will say we were actually are working with a client right now where we have done this and we are seeing, when I talked about an 80-bed to a, probably, 40-bed hospital, that's exactly what we're doing. And it became really informed through running our tool and our system for that.

James Lockwood  27:07  
You know, so many people have talked about this new normal going forward. My question, though, actually is, are we really experiencing a new normal, or has COVID-19 just really opened our eyes to how we should have been approaching planning for operations, and organizational resiliency. I mean, COVID-19 is just one of three pandemics that we've actually experienced in the past few 15 years, if you consider SARS and MERS. Weather events, you know, the, Nebraska alone, the flooding that they experienced, I can't remember if it was last year or two years ago, mimicking some of the floods that we've seen up in North Dakota. And you know, that doesn't even begin to talk about, you know, the mass casualty events where, if we haven't experienced it, regionally, we've definitely seen it nationally. So, are we in a new normal? Or are we just becoming smarter about the way we're defining normal?

Sophia Skemp  28:07  
That is the new normal, we're just becoming smarter. It's just opened our eyes to the importance of planning for, for the what ifs. I, I mean, Mike and David, correct me if I'm wrong, but scenario planning is not necessarily a brand new way of thinking. It just has not been very top of mind. And now it is. And we need to be more diligent about incorporating it into our design process as a service to our clients. You know, it's helped us realize we need to be more intentional, like David said.

David Voller  28:48  
I agree with Sophia. I think, you know, you know, we all get kind of caught in these little whirlwinds of focus and priority. And I think, from the healthcare organization perspective, we all were really thinking, how do we optimize our organizations? Lean was absolutely the front of mind on many things, and we did use baseline normal as our guide. And unfortunately, it just, it's just, you just get kind of stuck in a cycle of thought and direction. And, you know, the new normal is, I don't think it really is.

I think you really hit on it, James, and that is that it's always been there. I think we just got lost, and the pandemic was a good reminder that we need to be thinking more holistically. And we have to not lose sight of all these variables that can enter into the equation and coming back to our very beginning of our conversation, right? We want to think about how do we keep us from getting into a situation where we, whatever, the whatever the scenario that limits us from having to shut down operations; that puts our staff in a position of being and feeling burnt out; that puts our community at additional harm's way because we haven't thought about how they operate in that physical space. So I agree with Sophia and I just, in a way, there's been a breath of fresh air with the pandemic and what I think it's doing for us as a world as a society. It certainly has had its catastrophe as well, and we can't lose sight of that, unfortunately,

James Lockwood  30:23  
Mike, as someone who has facilitated so many of these planning processes, what's exciting you about this opportunity that David's highlighting to to do better?

Mike Boldenow  30:32  
Well, you know, we've always been striving to be trusted advisors to our clients. And I think where many of my clients, I'll speak for myself, are looking at us more, is really helping their leadership come together, and have these conversations where they have never had this kind of conversation before, right? So I think they appreciate bringing us in early, right? Just to facilitate those conversations and get them talking amongst themselves. 

It was just this fall that I was sitting in a room with a CEO of a, a healthcare provider group. And I asked Matt, I said, "How many times have you had your physicians at the table talking about this?" And he said, Never. So well, there we go. This is the first thing we're going to do, is get you together, and not just talk about how many exam rooms you want. Again, not just talking about the baseline, and you want a window in your office. We have to have several conversations. And we want all of your providers to be listening to each other and sharing for the first time, as you're telling me first time ever. That's what makes me excited. That's what we want to be is that trusted advisor, that facilitator. So at the end of the day, we are moving in a direction that is strategic for our clients, and resilient, of course.

James Lockwood  31:53  
Thanks, Mike. It's refreshing to hear such excitement in your voice, and to know that organizations are positioning themselves for what's next in this uncertain time. 

I want to thank our guests, Mike Boldenow, Sophia Skemp and David Voller for sharing their thoughts today. We know coming out of the pandemic, there will be many questions about organizational preparedness. And it's encouraging to hear how some of that analysis is already in play, and the innovative thinking that's occurring to mitigate impacts going forward. There will be significant planning in the near future, and these scenarios, we're sure, will play a huge role. 

If you want to read more details in the thinking behind scenario planning, Mike, Sophia and David co-authored a white paper on the subject. It can be found on BWBR's website at BWBR.com\research. There you will find a tab for our white papers. 

And let us know what you're thinking on the subject, as well as other design thinking topics that would make a great conversation. Email us at SideofDesign@bwbr.com. Until our next episode, see you on the other side.