The old adage that hindsight is 20/20 is often tinged with feelings of regret. In our last article, “Research in Practice: Lesson 3—Testing Innovation Through Simulations and Mock-ups,” we shared the importance of simulation techniques for visioning how designs will perform.

But a simulation without performance metrics collected from field research (actual walking distances, direct patient care time) is analogous to a cartoon—entertaining, but not reality. In this fourth article, we give a reason to celebrate and embrace hindsight with the post-occupancy evaluation (POE).


What is POE?
In practice, there are two types of POEs. One is more surface level and involves looking at a space and assessing whether it meets the specification and performance metrics for which it was designed following a facility’s occupation. The second, more progressive, definition is research-focused and looks beneath the surface to understand the impact of the built environment on users.

These more-rigorous evaluations can use advanced statistical methods to tease out the impacts of design interventions on outcomes such as occupant satisfaction, safety, health, and well-being.

POE evaluations are a type of field study, and field studies represent a paradox. On one hand, they’re limited in the amount of control the research team can have over the study’s variables. With true experiments, a researcher can theoretically control all variables, plan for the perfect sample size, and generalize findings. This level of control is difficult to achieve in a POE.

On the other hand, these POE limitations are also a blessing because we’re interested in how clinicians and patients will act in real-life settings. Properly conducted POEs have practical implications for solving complex design and operational problems for specific clients and afford exploration as the basis for innovation.

Each facility is different and may require a specific solution for a universal problem (for example, excessive walking by staff). Finally, with these studies, the design research net can be cast broadly at less cost and effort when compared to a true experiment.

What follows are some examples of POEs and their practical implications for inpatient unit layouts and decentralized care delivery. With these examples, we’ll illustrate the dynamics of a POE and the tangible benefits.


Destination bedside: Meaningful use at the Miriam Hospital
A Lifespan partner, The Miriam Hospital in Providence, R.I., has 247 inpatient adult medical-surgical beds and is recognized by the ANCC Magnet Recognition Program. Following the addition of a new inpatient floor incorporating decentralized nursing care (including dual-sided nurse servers with accessibility inside and outside of patient rooms, and workstations-on-wheels), the hospital conducted a POE to assess the impact of the design on health information technology, medical equipment, and supply usage. Results would guide design implications for future inpatient units proposed for the campus.

The work sampling data collected from the nurses through personal digital assistant (PDA) devices allowed researchers to analyze circulation patterns, congestion, and space utilization on participating units. The nurses also wore pedometers to keep track of walking distances. Questionnaires assessed the patient and staff experience. Adverse events data helped determine the impact of layout, furnishings, and cabinetry on patient-centered care.

Though the results of the POE validated a design innovation like the nurse servers, they also demonstrated some ongoing challenges. Nurses were using workstations-on-wheels in the hallways away from patients. Centralized medication cabinets at the main nurses’ station contributed to increased walking distances and concerns for patient safety.

After gathering the POE results, the team attended a design charrette with Miriam Hospital nursing staff, during which the nurses reacted to the results with ideas for new and improved units. One idea was to have a dedicated clinician zone, or “porch,” for each patient room.

Work sampling data collected during the POE afforded the researchers an opportunity to simulate how a new inpatient unit would perform with the clinician porch. Conservative simulations demonstrated that nurses on just one 36-bed inpatient unit with clinician porches would save more than 5,500 miles in walking distance a year.

Given these findings, the hospital was able to go ahead with feasibility analyses for inclusion of decentralized medication cabinets and bedside computers for each patient room, and the addition of pharmaceutical technicians to stock the servers.


Looking ahead at Leonard Morse Hospital
Leonard Morse Hospital (LMH) in Natick, Mass., part of the Metro-west Medical Center and Vanguard System of hospitals, had a goal to differentiate itself against formidable competitors in the Boston suburban market. A site visit immediately revealed that LMH should find ways to maximize an existing hillside campus site. This aim in mind, a POE was conducted to evaluate the existing inpatient units.

LMH used the same toolkit as the Miriam Hospital, including PDAs, pedometers, and questionnaires. Though the sample size from the unique intensive care unit was small, a careful examination of the work sampling and questionnaire data revealed that a family zone and hallway with seating wrapped around the perimeter of the inpatient rooms was ideal for visitors but competed with staff workflow.

Visitors brought furnishings in and out of an ICU room through the “back door” of the room (accessible from the family zone and hallway) and propped the door open. Additionally, there were concerns for patient privacy that necessitated solid walls and the drawing of blinds at the back of the patient room.

The darkness of the ICU prevented maximum visibility of patients. Finally, staff didn’t have enough surfaces, decentralized spaces, and provisions for documentation.

For the medical-surgical inpatient units, the statistics revealed that the organization should invest in balanced headwalls, handrails, improved over-the-bed lighting, decentralized medication strategies, nurse servers, and glass doorways. All of these interventions on the small units would bring nurses closer to the patient bedside and improve nurses’ vigilance over patients showing signs of delirium, visibility across the unit, staff response time, staff efficiency, patient safety, and patient satisfaction.

Currently, the hospital is trialing various design interventions for their efficacy and potential roll-out throughout the Vanguard system of healthcare facilities and exploring a renovation of the existing ICU.


No regrets with POE
The road for POEs is paved with strong precedents like those above. If you’re going down this road for the first time, often the hardest parts are getting started and taking the time to prepare.

Nowadays, numerous conferences, groups, and publications speak to facility evaluations in and outside of healthcare design. For example, the Environmental Design Research Association’s (EDRA) POE/Programming Knowledge Network mentors people specifically interested in POE. Additionally, the EDRA annual international conference is replete with POE research on a variety of environments.

Also, The Center for Health Design’s (CHD’s) Pebble Project is advancing a consulting effort to perform these services. Many design firms now have in-house resources and external partnerships with universities or other organizations to conduct effective, impartial facility evaluations. These are done at a minimal fee as part of, or separate from, building project delivery. The benefit of working directly with firms with in-house research expertise is that results are expediently and cost-effectively translated into design decision-making, along with detailed benchmarking.

The business case for POE is not complicated. In her 2011 book “Healthcare Facility Evaluation for Design Practitioners,” Mardelle Shepley cites an estimate that in 2001, a POE study cost $40,000. Some quick math and appraisals from our experiences show that a high-end, comprehensive study on a $150 million healthcare project is significantly less than 0.001% of the project’s budget.

Moreover, Shepley shares research that indicates that what would have cost $1 to correct in programming may cost $10 in schematic design and design development, and $100 to correct during construction administration.

Requests for proposals (RFPs) and project contracts often allude to an enthusiastic desire for design research services such as POE on building projects. But they fail at articulating concrete and actionable scopes that spell out responsibilities and accountabilities for each party involved. It’s not enough for the team to have EDAC qualifications, as these don’t provide a person with a license to perform credible POEs.

Some rules of thumb for design research in RFPs include a priori identification of the setting to evaluate the timeframe for results to inform design decisions, meaningful outcomes to be measured, and any permissions needed for conducting research.

Additionally, a portion of the interview process should be dedicated to design research as represented by the organization’s researchers and those they work closely with on the design team. A design researcher with a doctoral degree ensures that the researcher has experience and expertise with implementing original research like POEs.

In design research, it’s important to be mindful of steps that aren’t typically encountered in current building project delivery. These include human subjects review requirements, training needs, sample size goals, literature review, pilot testing, and research instrument development and modification. It’s important to the success of the design research that a project manager allocates the time needed to go through human subjects review process and conduct pilot testing.

As we saw in “Research in Practice: Lesson 2,” pilot testing of your research instruments will go a long way toward training your data collectors, establishing trust, testing methods, and catching any quirks.

And every end has a beginning. Although the focus of this article is POE, there’s also a second type of facility evaluation, referred to as pre-occupancy evaluation (PROEs). PROEs are performed at an existing facility at least three months prior to moving and serve as a baseline to compare with POE data collected six to 12 months after the new building is occupied.

PROEs are a valuable complement to inform strategic planning, programming, and schematic design. The comparison between pre- and post-data reveals the new design’s contributions and loose ends. Pairing these studies reduces cost because they involve the same methods and instruments.


The deep end of the ocean
Most of us spend the majority of our lives inside buildings, and yet we may know more about outer space and the depths of the ocean than we do about the impact of buildings on health. In a 2008 Health Environments Research and Design Journal article, Roger Ulrich and colleagues found by their standards only an estimated 460 credible published studies of healthcare design and its impact on human health. By studying your facility, you’re not only contributing to your own project but to the greater body of knowledge by publishing the results in peer-reviewed publications.

As seen in our examples, properly performed facility evaluations are ideal for immersing the team into the deep end of the ocean of design research and innovation. Here, rigorous diagnostics are performed and design ideas and future projects are inspired by the results. For example, a post-occupancy study can also serve as a pre-occupancy diagnostic for a future renovation, building project, or design guide update. On top of these opportunities are innovative ways to automate data collection to improve research quality and allow more resources to be invested on applying the research findings to design.

In our last contribution to this series of articles, we’ll dive into the veritable ocean of opportunity afforded by POE and other design research. We’ll critique the current state of design research in practice and then point toward the future.

To read the first three installments of this series, plese follow the links below:

Research in Practice: Lesson 1
Research in Practice: Lesson 2
Research in Practice: Lesson 3

Nicholas Watkins, PhD, is HOK’s director of research and innovation. Erin Peavey, Associate AIA, LEED AP BD+C, EDAC, is a researcher and medical planner within the healthcare group at HOK. Derrek Clarke, AIA, LEED AP BD+C, is an architect with HOK. The authors would like to thank contributing team members and colleagues including Chris Korsh, Richard Saravay, Mary Mullany, Tim Jones, Mary Kennedy, Maria DuCharme, Nelson Lee, John Lyon, and Suzy Genzler. Nicholas Watkins can be reached at