Post-occupancy evaluation (POE) of building performance is the process of systematically and rigorously evaluating buildings after construction and occupancy, and providing feedback. As one of the key components of continuous improvement of the built environment, the POE process has been widely adopted by both the public and private sectors for the assessment of many building types as a means and offers significant benefits in the short-, medium-, and long-term.

In recent years, there’s been a rapid growth of community clinic and health center renovation and construction. However, there’s very limited empirical knowledge from research and best practices available to inform design decision-making for these projects. This is partially due to the lack of standardized evaluation tools and platforms for sharing results. Even though some POEs have been conducted by individual clinics and design firms, different approaches are often used and outcomes often aren’t shared outside of those individual organizations.

Recognizing this urgent need in the field, a research team at The Center for Health Design, supported by the California HealthCare Foundation, and the Kresge Foundation, has engaged in an effort to develop a standardized clinic design POE tool and a database for information sharing and benchmarking. The development and pilot testing of this tool was an 18-month project that took place from 2011 to 2013.

The tool was developed in several main steps: (1) literature review and conceptual framework development, (2) paper tool development and testing, and (3) online tool development and pilot testing. During the development process, a 15-member multidisciplinary advisory council provided guidance and feedback, and facilitated site visits to clinics to test the tool. An in-depth review of the research literature and best practices was conducted around key topics in clinic design, post-occupancy evaluation, and the performance outcomes impacted by design. Based on this literature review as well as expert opinions, a conceptual framework was created to better understand the major factors related to community clinic design and to guide the development of the POE tool. A series of matrices were then created to develop questions and rating items for the POE based on the conceptual framework, and a first draft of the tool was developed on paper.

The tool is customizable based on individual construction project goals and design intents. This allows:

  • The tool to be more relevant to individual clinics by narrowing down the built environment features that are more closely related to what a clinic wishes to achieve through a construction project
  • The tool to be shorter and easier for self-administration by clinic representatives
  • The results to be more pertinent for individual clinics in order to fine-tune and improve building performance
  • Participation from clinics to increase, so that sample size may grow more quickly and information databases may become more robust for benchmarking and research.

The paper POE tool was then tested at three clinics and revised after each visits, based on testing results. Because the tool includes patient and staff surveys, as well as outcome data collection, institutional review board (IRB) approval was obtained so that human subject data can be collected and shared as aggregated results on CHD’s clinic design website.

The next step involved transferring the paper tool to an online interface integrated in the clinic design website and testing the new online tool at two additional clinics. Survey data was also collected at all five clinics after IRB approval. Finally, preliminary data analyses were conducted and the findings were reported to individual clinics. Currently, the web interface is undergoing additional improvement.

The POE tool
The resulting POE tool includes five main parts, each of which includes a series of interactive and customizable web pages. The first part is the key for customization. Clinic representatives are first asked to select three to five high-priority goals and design intents, and to provide demographic information about the organization, clinic, and construction project. Parts 2-5 of the tool will then be customized based on the design intents selected.

The second part is the environmental audit, and is organized by major spaces (including building exterior, overall interior, waiting and check-in, patient-clinician interaction spaces, checkout, and staff areas) to facilitate the process of walking through the facility and conducting observation and evaluation. Users are asked to go through a list of design features relevant to the selected design intents, verify whether these design features were implemented, and rate how well the implementation of the design features meets certain criteria on a scale of 1-5.

The third and fourth parts are simple anonymous paper questionnaires to gather information regarding patient and staff perception of the clinic environment, service quality, and work experience. Individual facilities may choose the best methods of administrating the patient survey (paper format distributed during clinic visits or online format completed by patients after clinic visits). The staff survey is in an online format.

An outcome data collection form that includes outcomes typically collected in clinic operations (but usually for other purposes), such as staff turnover rate and clinic cycle time, as well as technical measurements, such as lighting and sound levels, makes up the fifth and final part. Standard measures in the industry are included. Only those outcomes related to the selected design intents will be included in the customized tool.

In addition to the five main parts, the tool also includes a checklist for taking and uploading photos as well as a process guide created to help users as they conduct the POE, from organizing the project team, completing each part of the tool, to reporting the results.

Preliminary findings from pilot testing
Because of the small sample size, there’s little to share in terms of definitive findings. A few things of note, however: First, among the 14 possible design intents, improving patient flow and throughput was selected by all five clinics in the pilot testing. Reducing patient anxiety and enhancing patient-staff communication were the next most commonly selected design intents and chosen by four facilities.

An interesting finding consistent across different clinics was that staff typically rated the physical environment lower than patients. This probably reflects the fact that most clinics pay more attention to front-end patient areas than back-end staff areas during construction and maintenance. Another potential factor is that because staff members typically are in the environment longer than patients, they’re more likely to find problems in the built environment.

Lessons learned
Several lessons were learned during the process of developing and testing this tool, including:

  • Because the POE process typically requires coordination between different departments in an organization, support from an organization’s administration is essential for success
  • The POE tool will be very valuable for organizational learning when one organization engages in multiple construction projects in a short time period; lessons learned at one facility can be quickly applied to other new construction projects
  • The tool provides a flexible structure for customization to fit needs of individual clinics, and the content of the tool will be regularly updated based on emerging design intents and features.

It’s intended that the POE tool will enable
a more standardized evaluation of the community clinic built environment and benchmarking between facility designs. The continuing optimization and use of the tool is essential for the generation of new evidence for examining the impact of building design on community healthcare outcomes. The complete online version of the tool will be accessible from CHD’s website in near future.

Xiaobo Quan, PhD, EDAC is a research associate at The Center for Health Design. He examines the impact of the built environment on human behaviors and healthcare outcomes. Xiaobo focuses his efforts on special research projects, as well as The Center’s major research initiative, the Pebble Project. He can be reached at

Acknowledgment: The Center for Health Design would like to thank the California Healthcare Foundation, the Kresge Foundation, the five pilot-testing sites, all patients and other staff who facilitated or participated in the POE tool pilot testing, the Forum One team responsible for the online interface improvement, the advisory council members, and the CHD team members, including Anjali Joseph, Ellen Taylor, Catherine Ancheta, and Alan Puccinelli.