by Jane Rohde


A concurrent theme throughout this year’s Environments for Aging (EFA) held in Savannah, Georgia included ‘what are your lessons learned?’ Even with the most careful and stringent functional and physical space programming process, there are always design and operational adjustments that would be improvements for the next project – with the same or different client. Completion of a post occupancy evaluation is key in raising the bar for better environments designed for aging.

Functional Programming Process

It still surprises me that often providers, as well as designers, do not utilize the opportunity prior to beginning the actual design process to completely vet and understand the proposed care model, the resident desired outcomes, and all the operational flows that are required to deliver a specific care model. As the long-term care world moves away from institutionalized care to person-centered care models, there are all types of operational concerns that need to be addressed for the environment to fully support both the resident and staff needs. The overview of changing from a centralized culture to a decentralized process needs to be fully evaluated; including staff understanding and agreement of the execution of services. As part of a successful person-centered care model, the staff need to fully embrace the concepts in turn supported by the physical environment. The two areas that are the most problematic for change tend to be the decentralization of dining services and the training of universal or shared services staff that are empowered to be self-directed. We have found that facilitating workshops, focus groups, developing resident profiles, and laying out mock-ups to be informative for decision making – allowing changes to occur during the planning and program phase, instead of during the construction and soft opening phases. All changes made during construction are going to cost more and could potentially negatively impact other operational flows and resident outcomes as an unintended consequence. I have received inquiries as to how to gather and use information effectively. We use spreadsheets, icons, and notes for our collection and recording of data. Alberto Salvatore, a healthcare architect, is currently completing a white paper about the functional programming process and the integration on the environment of care. When this is completed, it will be available through the Facility Guidelines Institute’s website. Another initiative is the Functional Program Toolkit, which is being championed by the Environmental Standards Council, a group of volunteers that supports the development of the toolkit as part of the work of The Center for Health Design. The functional programming process is essential in completing a successful project and is required by jurisdictions that have adopted the various Guidelines developed by the Facility Guidelines Institute as licensing code.

Post Occupancy Evaluation

A Post Occupancy Evaluation (POE) is “the process of evaluating buildings in a systematic and rigorous manner after they have been built and occupied for some time.”[1] Once a project is completed and operational, a POE provides information that prevents designed projects from perpetually including design flaws that can negatively impact staff and residents in senior living and other types of healthcare settings. If a Functional Program is detailed and documented, it can provide the framework for the pre-occupancy assumptions and detailed decision-making process; in addition to providing the framework and documentation format for completing a POE. The information gleaned from doing surveys, observations, interviews, and comparisons to the initial project assumptions and owner program requirements (OPR) informs future designs. Front line staff, residents, patients, and families can all provide first hand experiences within the designed environment. Some of the feedback that we have heard includes “need to have point of service storage for all activities and services,” “walking distances are too far – spending less time with patients or residents, and too much time getting to destinations,” and “grab bars located in the wrong places and not supporting safe independent movement by residents/patients.” In senior living, food and the dining experience (or lack of experience) is a major focus for residents. Providing adequate time for them to order, select, dine, and converse are often cut short by staff-driven models. Variety of foods and times for eating are also often discussed during focus groups. One setting made the timing flexible, and found satisfaction to be much higher, no long lines, and adequate space for assistive devices – normalizing the dining experience versus artificially controlling the ‘dinner hour.’

Post Occupancy Evaluation and Sustainability

Post Occupancy Evaluations are very similar to completing commissioning as part of continuous performance improvement for sustainable buildings. Some colleagues refer to the POE as “operationally commissioning” of the physical environment – seeking not only issues with the design of the physical spaces, but also adjustments to operations that can improve quality of life and outcomes for all endusers. In working with the trend toward Health and Wellness in all settings, an intervention is strongest when a physical building element is coupled with an operational policy, procedure, or process.


The phases of architectural and interior design start with the programming and planning needs of a healthcare project – identifying and involving all stakeholders from the beginning, which provides an opportunity for the completion of a much more successful project. Completing the post occupancy evaluation provides a means for both physical space and operational continual improvement, but also provides the ground work for future projects – improving quality of life through a higher quality of design for all generations!

Blog was written for Sunbrella.

AuthorLauren Erickson

By Jane Rohde

Lighting Research

Research regarding natural light and older adults has been championed by the Lighting Research Center at Rensselaer Polytechnic Institute’€™s Mariana G. Figueiro, PhD and Mark S. Rea, PhD.  There is general research and lighting principles for older adults available at Changes occur to the visual systems as residents age and can decrease ability to see, impact balance and stability, and impact the circadian system as it relates to the quality of sleep. Utilization of daylight and artificial sources of light can be used to stimulate the circadian rhythm to improve sleep, increase visibility while completing tasks, and reduce fall risk. There is a resource based upon the research completed called Lighting Patterns for Healthy Buildings that can be utilized by design professionals to improve their lighting design and placement for positive outcomes by residents, patients, and staff.  For example, for a nursing station there is a Base Case provided for reference, and two redesigns with descriptions; one with Circadian Stimulus (CS) that is static and one that is color tunable. The information on the website ( is available for various types of senior living, healthcare, and educational spaces.

With the on-set and popularity of a health and wellness focus for workers, as part of the sustainable design of buildings, the General Services Administration (GSA) has completed research on circadian light that found that office workers who received the most circadian stimulation at work during the daytime, slept an average 30 minutes longer at night.[1] This in conjunction with a recent RAND study on sleep estimated that the US loses an equivalent of about 1.23 million working days per year due to sleep loss, translating to an economic cost of $9.9 million per year.[2]  These data could support a business case for investing in circadian effective light in daytime work environments – including healthcare settings. With the high turnover and stress for healthcare workers, the provision of circadian effective light could support staff through various shifts for better performance and healthier individual outcomes.

The two popular rating systems used for the evaluation of Health and Wellness attributes including daylighting and access to views are the WELL Building Standard® and FitwelSM.  WELL is available through the International WELL Building Institute and administered through GBCI, the certification and credentialing organization for USGBC (LEED®).  FitwelSM was developed by the Centers for Disease Control and Prevention (CDC) and GSA.  After the completion of over 80 pilot projects, FitwelSM is now administered by the Center for Active Design. As of the beginning of November 2017, there are 59 current projects certified or in-progress and over 600 committed projects anticipate in 2018.

Standards and Guidelines

There has been an update to the Illuminating Engineering Society’s Standard Lighting and the Visual Environment for Seniors (IES RP-28-16) that includes guidance as well as recommended foot candle levels for designing of various types of spaces within a senior living setting.  The companion standard, Lighting for Hospitals and Health Care Facilities (IES RP-29-16) has also been updated and includes guidance and foot candle levels for spaces found in hospitals and outpatient facilities.  Both standards are referenced in the three 2018 Facility Guidelines Institute (FGI) books; Guidelines for the Design and Construction of Hospitals, Guidelines for the Design and Construction of Outpatient Facilities, and Guidelines for the Design and Construction of Residential Health, Care, and Support Facilities.

Within all types of healthcare settings, most users are over the age of sixty-five.  When designing environments for those with low-vision, the outcomes are good for all users of a setting – including such attributes as reduction of glare by using indirect lighting solutions, providing even lighting on all types of walking surfaces, and providing adequate light levels to easily read and understand information provided by healthcare practitioners. The recommended resource available as a free download is the Design Guidelines for the Visual Environmentcompleted by the National Institute of Building Sciences (NIBS).  This document is also referenced by the FGI’s Guidelines for Design and Construction of Residential Health, Care, and Support Facilities and recommended by the Mayer-Rothschild Foundation.

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Design Guidelines for the Visual Environment from the National Institute of Building Sciences (NIBS).



Research is having an important impact on lighting design for healthcare environments. Coupled with the development of tunable LEDs, sensors to control daylighting within healthcare spaces, and designing buildings with easy and safe access to outdoor areas, the opportunity to improve patient, resident, and staff outcomes is clear!  Become a champion of good lighting design€“ as it supports quality of life!


[1] Figueiro MG. (2017). The impact of daytime light exposures on sleep and mood in office workers.

Sleep Health. 2017 Jun;3(3):204-215.

[2] RAND Corporation, 2016.  Why Sleep Matters: The Economic Costs of Insufficient Sleep

Blog was written for Sunbrella.

AuthorLauren Erickson