Highlights
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• Tabletop exercises can be valuable means of learning theoretical concepts about and raising awareness of business continuity management, but their effects on business continuity plans have not been determined.
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• Business continuity planning processes help respond to and recover from crises, such as blackouts or cyberattacks.
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• Disaster simulations are an effective and highly appreciated form of continuing education for hospital pharmacy staff.
Introduction
Disasters1 put health care systems under pressure for several reasons. These include massive influxes of patients,2 direct physical damage to health infrastructure,Reference Carlton and Bringle3–Reference Paudyal, Cadogan and Fialová6 and vulnerability to technological disruptions.Reference Julliand7–Reference Ramakrishnan, Poojari and Rashid9 Major events can severely disrupt hospital institutions’ normal operations, including hospital pharmacies (HPs). However, health care providers must be able to maintain a minimum level of services and ensure the provision of “routine” care.Reference Khorram-Manesh10–Reference Bierenbaum, Neiley and Savageau12 This can be greatly aided by having a business continuity plan (BCP). Business continuity is an organization’s ability to maintain its essential functions during and after an event seriously disrupting its normal activities.Reference Khorram-Manesh10 This is a major step in the preparation for and subsequent management of crises,Reference Hatton and Brown13, Reference Gerard and Malarkey14 and BCPs should define all the measures to be taken to that end.Reference Coursaget and Haas15, 16
HPs’ processes rely on several upstream necessary elements17; disruption of one or more of them can lead to the interruption of potentially essential operations, preventing HPs from fulfilling their missions. This includes lack of human resources (e.g., staff shortages during the COVID-19 pandemic), the loss of essential external partners (e.g., drug suppliers), critical equipment failures (e.g., ventilation in a sterile manufacturing laboratory), problems with public infrastructure (e.g., power outages), and information technology (IT) breakdowns (e.g., cyberattacks).Reference Paudyal, Cadogan and Fialová6, Reference Santalo, Perez and Lorich18–Reference Cueno20 The latter represent major and current threats to modern health care systems that rely increasingly on electronic patient records and various critical software.4, 21 Furthermore, hospitals’ heavy reliance on technology makes them vulnerable to major geopolitical upheavals or extreme climatic events, as the global supply of goods (e.g., drugs) or energy (e.g., gas, electricity) can quickly be disrupted.Reference Ramakrishnan, Poojari and Rashid9, 22 When these events occur, BCPs enable the activation of strategies that can help maintain essential operations and minimum necessary levels of service.17 The recent power outage in Spain (2025 Iberian Peninsula blackout) demonstrated the importance of hospitals being resilient.Reference García Rada23 Furthermore, the 2026 major geopolitical upheavals in the Middle East and the blockade of the Strait of Hormuz illustrated once again the heavy reliance on strategic supply chains,Reference Wang, Fan and Liu24 with a marked rise in energy prices and growing concerns about fuel and energy shortages.Reference Khader, Bashier and Al Nsour25
Disaster preparedness is to be encouraged among all health care providers.Reference Gowing, Walker and Elmer26–Reference Aruru, Truong and Clark28 Simulation exercises familiarize staff with crisis plans, help them to react better, and test their organization’s resilience to disasters.Reference Khorram-Manesh10, 16 They also contribute directly to defining, validating, and improving plans.Reference Hatton and Brown13, Reference Coursaget and Haas15, 17 Simulations are pedagogical tools imitating reality and safely training participants in practical response processes. The choice of the exercise run depends on the resources available and the skills to be trained.29 One way of preparing for a crisis is using tabletop exercises (TTXs). TTXs are discussion-based and frequently used by managers and decision-makers.30, Reference Wallace, Bollfrass and Cooper31 They use a simulated emergency scenario to get participants to familiarize themselves with existing plans, to consider the potential impacts on capacity, and to identify gaps in their plans and devise improvements.29 Participants are asked to describe the actions they would take in such a stressful situation, but here in a calm environment.29, 32, Reference Castro Delgado, Fernández García and Cernuda Martínez33 A TTX requires little equipment, time, or money.29, Reference O’Reilly and Brandenburg34 However, this format precisely fails to replicate the sense of urgency felt during real crises and does not engage as many of the resources as an operational exercise would. Another option, therefore, is using full-scale exercises (FSXs). These are means of more faithfully replicating a disaster scenario, with the aim of assessing response efficiency by mobilizing both personnel and their equipment. This is the most intense form of simulation as it creates a more realistic level of stress and provides a tangible estimate of a plan’s actual efficiency.35 Schumacher et al. demonstrated the usefulness of FSX in Swiss HPs for improving disaster response.Reference Schumacher, Senhaji and Gartner36 However, its greater investment in time and organization prompted a search for other forms of simulation that could test organizations’ BCPs, including TTXs.
Disaster TTXs are already used in various pharmacy contextsReference Nybo, Klepser and Klepser37–Reference Salimnejad, Schultheis and Wolcott40; nevertheless, no published studies have evaluated the use of TTXs that seek to improve HPs’ BCPs. This study aimed to assess a resource-limited TTX’s impact on the quality and content of HPs’ BCPs and on the link between business continuity preparedness and the concrete crisis responses observed in a subsequent FSX.
Methods
Study Design and Participant Recruitment
A pre–post-intervention study among HPs recruited through French-speaking Switzerland’s Hospital Chief Pharmacists Group (Groupement des Pharmaciens-chefs des Hôpitaux Romands; GPHR) was conducted. Each hospital’s chief pharmacist was required to agree to run the exercises. Participating HPs were asked to provide baseline data—including demographics, instances of previous real or simulated disaster management activities, and current business continuity management (BCM) preparedness—via the REDCap® online survey platform (REDCap, Vanderbilt University, Nashville, TN, USA; www.redcap-ispso.unige.ch). HPs whose chief pharmacist declined to participate or who had been involved in the design of the exercises were excluded. The Swiss Armed Forces Pharmacy (SAFP) also ran a complementary simulation exercise.
Each HP participated in 2 different disaster simulations focusing on an interruption to their internal activities. The first, a TTX, served as the study intervention. Six to 9 months later, the second exercise, an FSX, tested the HP staff’s response to a simulated major disruptive event. Both exercises had been tested in a pilot HP (Pharmacy T) before being used in the study. The SAFP only ran the TTX.
Both scenarios were designed for pharmacy staff working in hospital or military settings and were structured using simulation guidelines.29, 41 Each exercise concluded with a 3-phase “hot debriefing”Reference Schumacher, Senhaji and Gartner36 of all participants involved in the simulation. Within a month, a written report summarizing the exercise assessors’ comments was used as feedback in a “cold debriefing.” Participants also completed a written questionnaire regarding their satisfaction with the exercise and their confidence in their abilities to face a major business disruption. HP managers were encouraged to incorporate any knowledge gained into their BCPs.
Hypothesis and Outcomes
Two hypotheses were tested. Hypothesis 1: TTXs could have a positive impact on the quality and content of HPs’ BCPs. Thus, the primary outcome was the evolution of HPs’ BCP scores, from before to after the TTX. Before each exercise, BCPs were collected from either their chief pharmacist or their quality assurance manager. These were provided together with a non-exhaustive list of examples of documents that might go into a BCP (e.g., risk analysis matrices, disaster management plans, standard operating procedures [SOPs]). BCPs were evaluated in a structured manner by a single assessor using a grid adapted from the Harvard School of Public Health’s Emergency Exercise Evaluation Toolkit32 and developed using relevant literature on BCPs (see Appendix A).Reference Hatton and Brown13, Reference Coursaget and Haas15–17, 27, 42–Reference Ridgway-Green, Doulags and Clark44 This grid was previously reviewed by three independent experts working in the fields of energy supply, crisis management consulting and military HP. It was structured according to the “all hazards” approach for preparing for major events,35 was divided into the “4Rs” categories (risk Reduction, Readiness, Response, and Recovery)45 and contained 48 items in total. This “4R” framework follows the principles of preparing for major events and emergency situations, while encompassing several terms from the Sendai Framework.46 The “Reduction” phase refers to a thorough analysis of threats and vulnerabilities and the means to reduce them; the “Readiness” phase to the ability to maintain trained staff and up-to-date plans; the “Response” phase to crisis management; and the “Recovery” phase to the return to normal. This offers a straightforward and accessible approach to disaster risk management, particularly for those unfamiliar with BCM concepts. BCPs’ evaluations involved listing the items one might expect to find in each “4Rs” category and assessing whether they were present (yes/no). The quality of each item present (yes) was scored on a Likert scale ranging from 1 (= not at all sufficient) to 5 (= excellent), with a rating of 3 (= sufficient) representing what might reasonably be expected of a HP’s BCP (see Table 1). Scores were not communicated to participants in their written report, to avoid their attention being focused on achieving higher ratings rather than on improving and understanding BCM principles.Reference Lamba47 For confidentiality reasons, BCP of the SAFP was neither collected nor evaluated.
Evaluation grid of BCP items—Illustration of the Likert scale
Table 1. Long description
Table illustrating the Likert scale used in the evaluation grid of BCPs items. Likert scores were 1 ("Not at all sufficient"), 2 ("Not sufficient"), 3 ("Sufficient"), 4 ("Good") and 5 ("Excellent"). For each score, the table describes its interpretation by the evaluator and shows an example for the item “IT backup procedures”. For each item, scores were assigned based on the level of preparedness expected of a hospital pharmacy in the face of a severe business disruption.
BCP = business continuity plan; IT = information technology.
Hypothesis 2: the HPs with the highest BCP quality and content scores would respond better to a major event impairing their usual operations. Thus, the secondary outcome was a comparison of the HP’s response to the FSX with its BCP score at that time, using its level of preparedness as a proxy. Details on the conduct and assessment of the FSX are presented below.
Scenarios and Settings
Exercise scenarios and settings are presented in Table 2. All the exercises took place inside the participating HPs’ premises. For their FSX, each HP site had one local “accomplice” who secretly prepared the simulation facilities. Just before the FSX, chief pharmacists informed the heads of their pharmacy units, enabling them to ensure routine activities and patient safety during the simulation.
Exercises’ scenarios and settings
Table 2. Long description
Table describing the details of the scenario and the settings of both exercises (TTX and FSX). The following aspects are detailed: “Exercise’s purpose”, “Scenario”, “Scenario construction”, “Local preparation”, “Timing”, “Conduct of the exercise” and “Exercise evaluation”.
Abbreviations: BCP, Business continuity plan; FSX, full-scale exercise; HP, hospital pharmacy; TTX, tabletop exercise.
The FSX simulation was evaluated by four assessors: an investigator, a local “accomplice,” and one employee each from the local institution’s quality assurance and IT departments. Evaluations were done by direct observation of each assessor’s area of activity: disaster management; logistics; clinical pharmacy and pharmacy manufacturing activities; crisis communication.Reference King, Battles and Baker48 Assessors used an adapted version of the Harvard School of Public Health’s Emergency Exercise Evaluation Toolkit,32 which provides qualitative and quantitative methods of measuring and evaluating participants’ actions. Briefly, expected actions at each stage of the scenario were listed, evaluated as having been “performed or not,” and then rated on a Likert scale ranging from 1 (= not at all satisfactory) to 5 (= excellent), with a rating of 3 (= satisfactory) representing what might be expected in that situation. If an expected action was not performed, it was given a score of 1. Assessors could leave comments or recommendations that were used to structure both the “hot debriefing” and the subsequent written exercise report.
Data Collection and Analysis
Data collection ran from February 2023 to February 2024. No patient data were collected, and the exercises did not disturb HPs’ routine operations. The research protocol was presented to the Canton of Geneva’s Research Ethics Committee, which waived the requirement for approval.
All data from HPs’ BCPs and the information collected by the FSX assessors were compiled for statistical analysis. Raw data were exported into Microsoft Excel® 2013 software (Microsoft Corporation, Redmond, WA, USA). Descriptive statistics and pre–post-intervention comparisons were calculated using McNemar’s test and the Wilcoxon signed-rank test. P-values <0.05 were considered statistically significant. An R2 coefficient of determination was used to determine the correlation between each HP’s responses to the FSX and its second BCP score.
Results
Five of the 11 HPs headed by members of GPHR were enrolled. Three HPs declined, 2 did not reply, and 1 was used to initially test the exercises (Pharmacy T). HPs A and B belonged to university hospitals with ≥1,000 beds each, and HPs C, D, and E belonged to regional hospitals with 200-1,000 beds each. HPs A, B and E reported having experienced a situation that had threatened their business continuity within the past 5 years (not including the COVID-19 pandemic), mainly a lack of staff or the failure of important electronic devices. At the time of their recruitment, these HPs declared that they already had a BCP (A and B) or were in the process of establishing one (E). HPs C and D had no formal BCP, mainly due to a lack of resources. HPs A and B had already trained with their BCPs in exercises prior to this study.Reference Schumacher, Senhaji and Gartner36
The TTXs were conducted between 27 February and 29 March 2023, and the FSXs were played out between 10 October 2023 and 30 January 2024. BCPs were collected and analyzed before each exercise. The mean time between BCP analyses was 9.3 ± 0.7 months, corresponding to the time dedicated to improving HPs’ plans based on the knowledge gained during their TTX. The results of each BCP’s evaluation according to the “4Rs” categories are shown in Figure 1.45 The mean percentage of expected key items observed in HPs’ BCPs rose from 47.9% to 54.2% between the two analyses (P < 0.01). Mean overall BCP scores increased by 8.6% (from 1.74 ± 0.15 to 1.89 ± 0.16; P = 0.03). When considering only the items present in the BCPs, mean scores did not significantly increase (from 2.50 ± 0.30 to 2.58 ± 0.32; P = 0.31).
Business continuity plan (BCP) evaluation before and after the tabletop (TTX; scores shown for the overall analysis and just for the items found to be present in them).
Figure 1 Long description
Mean HPs’ BCP evaluation before and after they performed the TTX. The vertical bars represent the mean scores for the 5 HPs, and the diamonds represent the average percentage of items searched for and found in the BCPs provided by the HPs. Hatched areas indicate evaluation results before the TTX, and solid areas indicate results after the TTX. Light colors indicate the overall assessment of the BCPs, while dark colors indicate the assessment of only the items found in the BCPs. The results are stratified by category according to the 4R model (risk Reduction, Readiness, Response and Recovery). We observe that scores tend to increase between before and after TTX, but modestly and with wide confidence intervals. On the other hand, the increase in the percentage of items present in the BCPs is more pronounced, particularly in the “Reduction” and “Response” categories.
HPs’ response to their FSX was evaluated as described above. Table 3 shows each HP’s results, and Figure 2 shows the correlations between individual FSX results and individual BCP scores. An R2 = 0.78 was calculated when considering the whole group’s overall BCP scores, and R2 = 0.76 when considering only the items present in their BCPs.
Comparison between hospital pharmacies: FSX results and second BCP evaluation
Table 3. Long description
Table showing the hospital pharmacies’ (HPs) results of their response to the FSX and their second BCP evaluation (at the time of the FSX). The 5 HPs are labelled from A to E. HPs A and B were university hospitals, while HPs C, D and E were regional hospitals. The time spent between the two exercises (TTX and FSX) ranged from 7.4 months to 10.2 months. The number of actions rated during the FSX ranged from 164 to 191, while the percentage of those actions accomplished during the FSX ranged from 54% to 82%. On a 1-5 points scale, their mean score of their response to the FSX thus ranged from 2.1 to 3.1. At the time of the FSX, their mean overall BCPs scores ranged from 1.4 to 2.5, while their mean BCPs scores considering only present items found in the BCPs ranged from 2.2 to 3.1.
Abbreviations: BCP, Business continuity plan; FSX, full-scale exercise; R, regional hospital; TTX, tabletop exercise; U, university hospital.
Correlations between individual hospital pharmacies’ full-scale exercise (FSX) response scores and their individual business continuity plan (BCP) scores (scores shown for the overall analysis and just for the items found to be present in them).
Figure 2 Long description
Correlations between individual hospital pharmacies’ FSX response scores and their individual BCP scores. Light colors indicate BCPs’ scores coming from the overall assessment of the BCPs, while dark colors indicate the assessment of only the items found in the BCPs. Although the sample of hospital pharmacies is small (n = 5), the graph suggests a positive correlation between the quality of their BCPs and their ability to cope with an event severely disrupting hospital pharmacy operations. This correlation appears to hold true whether considering the overall BCPs’ scores (R² = 0.78) or the scores of only the items present in the BCPs (R² = 0.76).
Table 4 summarizes the BCM aspects that were insufficiently or sufficiently developed in the BCPs overall, as identified by the BCP evaluators. Participants’ satisfaction questionnaires after both simulations were completed by 29 and 49 staff members, respectively (Figure 3).
Insufficiently developed and well-developed aspects of BCM in participants’ BCPs
Table 4. Long description
Table showing the insufficiently developed and well-developed aspects of BCM in participants’ BCPs after their evaluation. The observation are stratified according to the 4R model categories (risk Reduction; Readiness; Response; Recovery). Following this model, the insufficiently developed BCM aspects observed were: Formal business impact analysis, agreements with helpful external partners; Education, training and BCP evaluation; Management of activities in case of business disruption, and business continuity objectives; Gradual resumption of activities, tools for crisis analysis and experience feedback. The well-developed BCM aspects observed were: Process mapping, minimum human resources needs, paper documents as a backup; Defined responsibilities for updating SOPs; Existence of downgraded SOPs and of a disaster plan for mass casualty incidents; Identification of the command chain for deciding that crisis is over.
Abbreviations: BCM, Business continuity management; BCP, business continuity plan; HP, hospital pharmacy; SOP, standard operating procedure.
Individual participants’ level of satisfaction with the exercises and their confidence in their ability to respond to a crisis after the tabletop exercise (TTX) and the full-scale exercise (FSX).
A: “The exercise was well structured and organized.” B: “The scenario was realistic.” C: “The pre-exercise briefing was useful and properly prepared me for the exercise.” D: “I did not feel stressed during the exercise.” E: “The format of the exercise was appropriate.” F: “The duration of the exercise was appropriate.” G: “The format of the exercise helped me to identify the key points in our BCP.” H: “The debriefing was useful and helped me to understand what was at stake.” I: “The exercise improved my understanding of hospital pharmacy business continuity issues and the risks associated with business interruptions.” J: “The exercise effectively tested the plans and procedures for responding to an event disrupting my hospital pharmacy’s activities.” K: “The exercise enabled us to identify our BCP’s strengths and weaknesses.” L. “The exercise gave me a good overview of our plans and procedures.” M: “The exercise gave me a good estimate of our ability to continue operations in the event of a real crisis.” N: “I think the exercise will be useful for improving our BCP.” O: “At the end of the exercise, I feel I’m better prepared to respond to a major event and keep my hospital pharmacy running.”
Limitations
Firstly, BCP evaluations were highly dependent on participants’ perceptions of what is required of a BCP and, therefore, on the provided documents for initial analysis. This analysis may thus not have reflected the HPs’ true states of procedural readiness, as participants may not have identified all their relevant documents. Conversely, this may be the precise result of a lack of BCM knowledge. An exhaustive audit could have been carried out to inventory every document, but this would have been time-consuming and discouraging for HPs. Secondly, HPs A and B could have benefited from previous disaster simulationsReference Schumacher, Senhaji and Gartner36 that may have influenced their baseline documentation, their potential to learn from the TTX, and their ability to respond to the FSX. Thirdly, the sample size limited the statistical analysis (n = 5), and confounders prevent these findings from being generalizable (no control group, recruitment based on chief pharmacists’ motivation, limited geographical spread). Nevertheless, in agreement with previous findings such as planning influence on crisis responseReference Hatton, Grimshaw and Vargo43 or satisfaction with simulations,Reference Watson, Waddell and McCourt38, Reference Pate, Bratberg and Robertson39, Reference Fregeau, Cournoyer and Maheu-Cadotte49 investigators’ observations support TTXs as an adequate form of disaster preparedness training. Fourthly, BCPs were assessed by a single evaluator, and the subjective use of Likert scales could have been supplemented by inter-rater reliability tests to ensure consistency. However, having a single assessor may favor reproducibility between measurements. Furthermore, using a grid that had been reviewed by external experts provided a standardized means of evaluating BCPs and consistent, rules-based means of scoring them. However, this grid was developed from general BCM guidelines since there were no specific recommendations for HPs at that time. Finally, external factors may have increased participants’ willingness to improve their BCPs—such as energy shortages,Reference García Rada23, 50 cyberattacks on European hospitals,4, 21 or global drug supply issuesReference Ramakrishnan, Poojari and Rashid9—thus confounding the true impact of the TTX. Nevertheless, exercise scenarios were aligned with these threats, helped to raise HP staff’s awareness, and promoted the need to improve their planning processes.
Discussion
Two complementary types of disaster simulations focusing on HPs’ serious business disruptions were developed. Combining different types of exercises is useful for training and testing different skills.29, Reference Skryabina, Reedy and Amlôt51 The TTX intervention helped pharmacy management and team leaders to raise awareness about the need for BCM, while the FSX enabled entire pharmacy teams to test their responses to a business interruption. Both scenarios were relevant for HPs because they involved credible threats regularly observed throughout the world and were based on recommendations from other HPs, making them as realistic as possible. Despite the small number of volunteering HPs, those enrolled provided a mix of university and regional hospitals. A pilot intervention at Pharmacy T allowed us to adjust the exercises and train investigators before involving the study participants, which was very valuable.
Hypothesis 1 was not fully supported. Nine months after the initial intervention, a slight but significant improvement in the HPs’ BCPs as per the scoring grid was measured. However, the quality scores for items found in the initial BCPs did not increase after the TTX, raising questions about its significance. The nine months allocated for HPs to act may not have been sufficient; improving plans and processes takes time, and leaders’ willingness and involvement in BCM is essential for this,Reference Hatton and Brown13, 42 so the TTX was principally targeted at them. This study focused on simulations because of their advantages over passive learning—encouraging participants’ involvement, teamwork, discussions, critical thinking, and greater aid to the assimilation of information, to say nothing of the “fun factor.”Reference Torralba and Doo52–Reference Masters54 Watson et al. showed that a TTX could improve pharmacy staff’s understanding of disaster management activities.Reference Watson, Waddell and McCourt38 Thus, the TTX may have provided participants with some valuable new information, but other factors (e.g., lack of a BCM culture or staff dedicated to this task, insufficient time provided between the analyses)Reference Hatton and Brown13, Reference Awang Ali, Hanafiah and Mogindol55 may have limited its translation into actionable procedures.
Whether this resulted from external factors or specific aspects of the intervention, like knowledge gained during the TTX or report recommendations (cold debriefing), is difficult. Risk “Reduction” (e.g., a business impact analysis or having key procedures) and “Response” (e.g., having a disaster plan or communication tools) were the main “4Rs” categories that improved, maybe reflecting the TTX scenario. Indeed, it covered several aspects of business disruption, such as infrastructure, human resources, and communication issues. Inversely, “Readiness” (e.g., BCP testing or audits) and “Recovery” (e.g., “back to normal” plans or structured feedback) were mostly discussed during the “hot debriefing” and in the written report, which may have had less impact on participants. Most of the documents laid out at the TTX were not formally grouped in a single BCP but were more often provided separately from one another. HPs appeared uncertain about which documents could form a BCP (see Table 4). However, the rise in provided documents and items found between analyses suggests the TTX still increased participants’ awareness of BCM requirements.
Hypothesis 2 was confirmed, as the HPs with the best BCP scores also exhibited the best FSX responses. Disaster preparedness is an essential aspect of risk management, and it could be tempting to infer the positive impact of the TTX. However, numerous factors could have influenced this correlation (e.g., participation in previous disaster simulations, presence or absence of the chief pharmacist during the FSX, number of participants, subjective assessors’ evaluation).Reference Schumacher, Senhaji and Gartner36 Furthermore, important BCM information not being in a plan did not mean participants were unaware of it.Reference O’Reilly and Brandenburg34 Having BCPs is a significant milestone in risk management processes,Reference Asgary, Anjum and Azimi56 but data regarding their true efficacy in major disasters are scarce.Reference Hatton, Grimshaw and Vargo43 Hypothesis 2 stated that a TTX could encourage pharmacy managers to improve their BCPs and thus enhance their crisis response capacity. Although this relationship is not guaranteed, results supported previous findings on how business continuity planning processes helped disaster recovery.Reference Hatton, Grimshaw and Vargo43
Participants expressed high satisfaction with both exercises and greater confidence in their abilities to respond to a future disaster. This was consistent with previous literature, indicating that simulation training should be promoted.Reference Castro Delgado, Fernández García and Cernuda Martínez33, Reference Watson, Waddell and McCourt38, Reference Sena, Forde and Yu53 They enjoyed the evolving tempo of the TTX (“[I liked] the exercise’s ‘dramatic’ and sequential structure, and its level of realism.”) and its structure (“A simulation of this form is quite an original way of making you think; there’s no stress like there is in a disaster exercise; there are clear instructions. It quickly revealed our deficiencies.”). They also appreciated the FSX’s topic of a cyberattack21 (“We know it’s something that can and will happen.”). Some comments indicated a preference for the FSX with regards to planning and problem-solving, due to its immersive and realistic nature (“Doing the exercise in ‘real life’ enabled us to better anticipate problems and confronted us with concrete decision-making.”). However, discussion-based exercises complement operations-based exercises because they have different objectives and do not require the same skills level29, 32 (“I think it’s great to prepare both the executive format (tabletop exercise) and the [operational] format.”). TTXs are well received as means of transmitting knowledge and raising participants’ awareness.Reference Watson, Waddell and McCourt38, Reference Pate, Bratberg and Robertson39, Reference Fregeau, Cournoyer and Maheu-Cadotte49 They also require less time and resources than operations-based exercises, making them easier to set up.29, Reference Wallace, Bollfrass and Cooper31, 41 This supports the notion that TTXs are appropriate simulation models and can be used as a low-resource method of disaster preparedness education.
The evaluation of a training program’s impact can be classified into four gradual, educational categories: reaction, learning, behavior, and results.Reference Smidt, Balandin and Sigafoos57 Investigators directly evaluated participants’ reactions using a satisfaction questionnaire. They indirectly evaluated their knowledge gain, as BCP evaluations were used as a surrogate for knowledge retention about BCM. Nevertheless, an increase in knowledge does not automatically imply the development and improvement of BCPs. Similarly, during a disaster event, the availability of BCPs does not necessarily make staff actions and responses more efficient—some training is surely also necessary.Reference Schumacher, Senhaji and Gartner36 Despite using a Likert-scale rating system, individual scores were not communicated to participants in the written reports; this decision was part of the investigators’ objective to continuously improve BCPs regardless of the score obtained. Furthermore, as Goodhart’s law emphasizes, a metric that becomes a target can lose its value as an effective indicator.Reference Lamba47 Instead, priority has been given to realistic scenarios during simulations, structured discussions during the hot debriefing, and qualitative feedback in the cold debriefing, enabling the formulation of tailored and actionable recommendations to strengthen participants’ BCPs beyond their initial level. Investigators did not evaluate HPs’ BCPs at a third time-point after the FSX, as this study focused on the TTX; it would have been interesting to estimate the effects of an operations-based exercise complementing a discussion-based TTX.Reference Schumacher, Bonnabry and Widmer58 Likewise, given the rapid development of virtual reality (VR) technologies, future evaluation of VR-based TTXs would be worthwhile, as they are highly immersive and cost-effective for disaster training.Reference Alshowair, Bail and AlSuwailem59
The absolute BCP scores on the grid were relatively low and had wide confidence intervals, reflecting the variability in HPs’ levels of preparedness. Some observations about their state of preparedness can be made, nonetheless. Although staff were able to identify their HPs’ critical processes, these were neither systematically analyzed nor amalgamated into overarching BCM strategies. HPs had several sets of SOPs that were interpreted as being equivalent to parts of an overall BCP. These mainly focused on equipment failures, staff shortages, or IT malfunctions. In contrast, the overall BCPs mostly lacked concepts involving BCM and other business continuity objectives, and were not incorporated into a single, formal, centralized BCP that could be easily found and used by all pharmacy staff. Focusing on vulnerabilities rather than risk scenarios when developing BCPs is recommended, as it prevents redundant work and avoids demotivating managers, even though key risks should still be addressed.17 The present study observed how many downgraded procedures used during simulations were treated separately rather than through generic BCM strategies based on the pharmacy’s key functions and vulnerabilities. Although each BCP must be adapted to its local context,Reference Hatton and Brown13, Reference Coursaget and Haas15 there remained a lack of literature on requirements for BCPs in HP settings at the time of this study, in contrast to community pharmacies.Reference Ridgway-Green, Doulags and Clark44, 60 Recent studies have been conducted to fill this gap.Reference Le Bloc’h, Schumacher and Kessler61
The TTX was also conducted with the SAFP (data not shown), enabling the investigators to test their training format in another setting. The scenario was slightly modified to the military context, but the main themes remained, demonstrating TTXs’ flexibility and ease of use. However, the significantly different setting would have made it impossible to compare BCPs since this institution’s missions are so distinct (e.g., manufacturing specific medicines or supplying drugs and medical materials to troops in the field). Nevertheless, investigating the expertise of active military pharmacists could provide precious added value, as their activities are more likely to directly involve disasters and conflicts than are civilian HPs’ activities. Internal reorganization to ensure essential operations is almost certain to occur. As observed in HPs, participants relied on their knowledge and experience (particularly the COVID-19 pandemic); however, military pharmacists put crisis management tools and concepts (e.g., immediate measures, situation reports, or informing staff)17, Reference Schumacher, Senhaji and Gartner36 to work more quickly, revealing how this was routine for them. Participants also quickly identified their critical electrical equipment in case of a power cut or their external partners likely to help them (e.g., military resources, laboratories, drug suppliers). Conversely, the formal management of critical and non-critical activities during business disruptions was hardly discussed (see Table 4), illustrating the need to also firmly embed a culture of BCM.Reference Hatton and Brown13, Reference Hatton, Grimshaw and Vargo43 TTXs are, therefore, helpful for military pharmacy staff as well, as ensuring critical functions is essential during conflicts or disasters. Joint exercises and experience sharing could also create opportunities to establish a dialogue between civilian HPs and military pharmacies to mutually reinforce BCPs.
Conclusion
Strong BCM is crucial for HPs. This study examined the importance of HPs having BCPs to enact during crises and highlighted the value of disaster simulations in improving preparedness. A discussion-based TTX was tested to improve the quality and content of HPs’ BCPs. The statistical effects were modest, probably due to the limited time allocated to the whole approach, and confounding factors diminished the attribution of those effects to the TTX alone. Nevertheless, a correlation was found between the quality of BCPs and the HPs’ ability to respond to an operation-based FSX, thus highlighting the need to strengthen crisis procedures. Participants highly appreciated both exercises, underscoring the pharmacy teams’ interest in disaster simulation and the value of this type of training. Theoretical BCM concepts should be shared within every HP to enhance their disaster preparedness, and this can be achieved through low-resources simulations such as TTXs. Further studies should be conducted to determine the European HPs’ level of compliance with recent recommendationsReference Le Bloc’h, Schumacher and Kessler61 regarding their BCPs content for HPs.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2026.10424.
Data availability statement
Both scenarios will be freely available in French on the Specialised Centre for Emergency and Disaster Pharmacy’s website (http://www.disaster-pharmacy.ch/).
Acknowledgments and affiliation
The authors would like to acknowledge the French-speaking Switzerland’s Hospital Chief Pharmacists Group (Groupement des Pharmaciens-chefs des Hôpitaux Romands) for allowing to recruit hospital pharmacies for the study and thank the experts who reviewed and validated the BCP’s evaluation grid (anonymized). The authors are grateful to all those who contributed their expertise in exercise simulation, their accounts of power shortages or cyberattacks, and all the excellent advice they shared, thus enriching the exercises’ scenarios. The authors warmly thank all the pharmacy teams trained and all the exercise assessors for their active participation. The authors gratefully acknowledge the support of the Competence Center for Military and Disaster Medicine of the Swiss Armed Forces (Bern, Switzerland).
Author contribution
Ferdinand Le Bloc’h: Conceptualization, methodology, formal analysis, resources, writing—original draft. Laurence Schumacher: Conceptualization, methodology, supervision, writing—review and editing. Pascal Bonnabry: Conceptualization, funding acquisition, supervision, writing—review and editing. Nicolas Widmer: Conceptualization, funding acquisition, supervision, writing—review and editing.
Funding statement
The present study was funded by the Centre of Competence for Military and Disaster Medicine, Swiss Armed Forces, Bern, Switzerland.
Competing interests
The authors declare that they have no competing interests other than those resulting from the study’s funding and no affiliations with the pharmaceutical industry.
Ethical standards
The research protocol was presented to the Canton of Geneva’s Research Ethics Committee, which waived the requirement for approval. All hospital pharmacies involved in this study participated on a voluntary basis.
Open access
