Sarah Markovitz

Sarah Markovitz

Principal, NBBJ
Sarah is a principal and healthcare architecture practice lead with NBBJ in Boston. She has dedicated her career to improving healing environments and performance metrics in healthcare design. Sarah has brought laser focus to infection prevention in all recent NBBJ projects, including the Lunder Building at Massachusetts General Hospital, which is the recipient of multiple national and local awards, and has received recognition in leading publications such as Modern Healthcare and Healthcare Design. As much as Sarah loves beautiful buildings, she prefers to be outdoors, whether walking 20,000 steps daily or hiking the national parks.

Faster and More Efficient: How the Pandemic Has Sparked Project Delivery Innovation

December 1, 2021

Principal, NBBJ

Editor’s Note: We believe that strong project management drives great design. In this four-part series, we will explore four different and important aspects of project management. The first post in the series—which was originally published by Project Management Institute—focuses on accelerated and innovative delivery methods.  

This post was co-authored by Sarah Markovitz and Kwang Lee.

One of the challenges facing hospitals across the country has been the urgent need for space due to the Covid-19 pandemic and increased emergency psychiatric visits. In this context, it is especially important to deliver projects as quickly as possible, all while maintaining social distancing measures during design and construction. According to a Health Facilities Management survey, almost a third of recent hospital projects have been fast tracked. This critical need for faster delivery has spurred new virtual and logistical approaches to project management, including our work with Massachusetts General Hospital on its 7,050 square foot Acute Psychiatry Service project.

The project team, led by NBBJ (design) and Walsh Brothers (general contractor), worked with a compressed schedule which enabled Mass General to finish the project more than 30% faster than initially planned, while accommodating changes requested by the hospital during construction. From this experience we have distilled three key strategies, described below, that can deliver projects faster and more efficiently—streamlining the request for information and user engagement process, developing Building Information Models (BIM) in collaboration with engineers and consultants early in the design process, and using platforms like Open Space to rapidly track on-site progress virtually.

Streamline the Request for Information (RFI) and User Engagement Process
Needing to quickly create new psychiatric space to shift psychiatric patients out of a cramped emergency department, Mass General developed a compressed project timeline. Accommodating this schedule required NBBJ to develop a new process for responding to construction related questions and reviewing submittals. Typically this takes one to two weeks and involves several engineers sending documents back and forth to identify and work out design and technical issues.

To keep to the compressed schedule, NBBJ committed to a one day RFI response time and introduced group Zoom calls with the relevant project team members—from engineers and equipment suppliers to security contractors and door consultants—to quickly coordinate live comments.

A similar Zoom-based approach was used to streamline the user engagement process. The Mass General Emergency Department staff wanted to participate in the construction meetings to check the construction process and to relay last minute design change requests. This virtual meeting enabled the project team and client to communicate quickly while maintaining social distancing measures and also allowed a range of stakeholders to participate even at the peak of the pandemic period.

Develop Collaborative BIM Models Early On
With a compressed schedule, it was important to ensure early coordination between the design and construction team. Recognizing the need for more accurate bids to save time and money, the team invested in earlier, more complete BIM development, coordinating with engineers in the BIM model before they would typically be engaged in the design process. As a result of this approach, the project received far more accurate bids and minimized the amount of changes needed during construction, enabling a faster timeline.

Early BIM development was particularly important as a portion of the project is located in a building built in the early 1800s, with a very low ceiling. NBBJ collaborated closely with a mechanical engineer as well as the construction team to find the right routing for a new mechanical system in the tightly packed ceiling space.

In the same spirit of collaboration, the design team worked more flexibly with the general contractor on construction material selections, recognizing the need for substitutions on certain items due to their impact on the schedule. With widespread material shortages, especially for items with microchips or items coming from overseas, it was critical to both order materials early and be flexible with substitutions in order to maintain the project’s tight schedule.

Use Virtual Platforms to Track On-Site Progress
Given the pace of the project schedule, it was critically important to maintain a high level of coordination among all team members to identify clashes and track on-site progress. The team used Navisworks, a design collaboration tool, to coordinate with engineers and mechanical subconsultants to identify any conflict between existing and new mechanical systems weeks before they would typically be discovered. The team also held weekly meetings to review clashes and find alternate solutions.

This process was greatly enhanced through the use of virtual platforms like Open Space, which maps live jobsite photography to plans. Using Open Space, construction team members were able to to walk through the construction site with a camera that takes pictures at regular intervals, creating a point-to-point virtual 3D model of the project. This enabled the team to quickly identify, collaborate and resolve issues, and create a visual reference model that was readily accessible online. It also reduced on-site visits, which saved time and reduced infection risk.

Open Space was particularly useful for this project as the team had to work in a highly coordinated fashion to adhere to the project timeline. On a typical construction project, the trades would work sequentially, moving from work like MEP ductwork and electrical to finishes and flooring. But to maintain Mass General’s schedule, the trades worked more concurrently—adapting measures like installing and protecting flooring so that other trades could continue work. This required the design team to push forward on submittals and order materials early. Using Open Space reduced the number of people working on and visiting the site and enabled faster coordination.

While these project management strategies may not be applicable to every project, they can help to streamline the design and construction process—particularly when the schedule is an overriding concern. Given the ongoing restrictions to in-person collaboration and collocation due to the pandemic, and the critical need for more clinical space, the adaption of virtual tools and strategies like these will likely gain traction as clients look to complete projects quickly, safely and more efficiently.


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A Quiet Building is a Healthy Building

Because noise disrupts productivity and elevates stress, strategies to reduce it can lead to healthier outcomes.

October 11, 2021

Principal, NBBJ

A version of this post initially appeared on Forbes. This post was co-authored by Sarah Markovitz and Ryan Mullenix.

Despite the fact that the pandemic has pushed many of us to embrace the outdoors in new ways—whether to safely meet with friends, family and colleagues, to exercise, or to embrace a new hobby—we still spend the vast majority of our lives (over 90 percent!) indoors. This reality points to the importance of healthy buildings, the impact of which reaches beyond physical or environmental factors, affecting not just individuals, but also organizations.

Elements such as noise, access to light and views, thermal comfort, the incorporation of nature, and healthy materials are shown to increase cognitive function, resulting in improved productivity among workers, higher test scores for students and quicker recoveries for patients. A healthy building can also impact a business’s bottom line—from energy reduction to more efficient and engaged employees. According to a recent World Green Building Council report, 69 percent of owners report improved worker satisfaction due to their healthier building investments, and 46 percent of commercial building owners say that they are able to lease space in buildings with healthy features more quickly.

Acoustics are one of the major contributing factors to a building’s overall health. While all building types are affected by acoustics, their effect is felt most strongly in workplace and healthcare environments. In the workplace, noise pollution leads to decreased productivity, absenteeism and dissatisfaction among employees, resulting in a massive financial burden for companies; whereas in hospitals, noise negatively impacts both patient recovery as well as staff performance and satisfaction, taking an enormous toll on patients, families and staff. This post explores the implications of noise in the design of workplace and healthcare environments.

Noise Reduction in the Workplace: Counteracting the Sound of the Human Voice
At the most basic level, we cannot ignore the sound of the human voice—it’s a survival mechanism. However, research tells us that voices over 55 decibels (roughly the sound of a loud phone call) can cause measurable stress. In the office, it is almost impossible to tune out the various conversations, phone calls and Zoom meetings. Because we often hear only one side of a conversation, our brain works tirelessly to fill in the other half—a concept called a “half-alogue” that can be even more distracting than other disruptive office noise. By contrast, a modest level of unintelligible background noise actually helps concentration in the workplace. So rather than aiming to reduce all noise, focus on materials and systems that specifically dissipate speech sounds. Here are four ideas to do so:

  • Build it in: Think about sound reduction strategies that can be built directly into a space. For example, we worked with the University of Washington* to develop an acoustic panel system that can be embedded into concrete and mass timber structural systems. Shaped like empty bottles, these sound dissipating systems muffle noises and are highly effective at trapping low-frequency, intelligible sound due to their narrow necks and wide empty cavities. Tests of prototypes measured noise reductions of around 13 decibels, the equivalent of wearing noise-canceling headphones. Alternatively, consider prefab: conference rooms and other spaces that are regimented in size can be prefabricated to include acoustic solutions rather than relying on materials applied post-construction. Because each module is prepared as a separate unit with its own walls, floor, and ceiling, panels can be fabricated or milled in advance to directly address the preferred room acoustics and reduce both time and waste.
  • Isolate the noise: Create insulated quiet zones within work areas, each with a target decibel level based on the type of work being done there. Nooks made of soft materials such as felt, or phone booths with soundproof glass can serve as quiet areas within a larger, more open office, and adding transitional cues through materials, light and volume reinforces the intent for each zone.
  • Incorporate biophilia: Not only does being around nature improve our mood and make us more productive, but plants are also incredible natural sound absorbers. While a green wall is excellent for capturing sound, even greenery dispersed throughout the office can help mitigate noise.
  • Not all noise is bad noise: While spaces that are too loud can be stressful and distracting, those that are too quiet can feel awkward and uncomfortable — or even drive you crazy. Aim for the din of a coffee shop, where noise is ambient but not distinguishable.

Noise Reduction in Healthcare Environments: Promoting an Atmosphere of Rest and Focus
As in the workplace, heightened noise levels in healthcare settings have a strong negative effect. Researchers at Johns Hopkins University found that excessive noise not only hindered patients’ ability to rest, but also increased the likelihood of medical errors and contributed to stress-related burnout among workers. One example of noise reduction that has stood the test of time is Massachusetts General Hospital’s Lunder Building, which was completed in the 2000’s. The building combines design innovation with changes in clinical practice to reduce average noise levels by 35 percent as compared to the worldwide average. To design quieter healthcare environments, consider these five solutions:

  • Move activity away from patient rooms: Many challenges related to noise in healthcare environments have to do with issues of proximity and speed. Caregivers need to be close to patients, teams and families to provide the highest quality of care, so while it is beneficial to design units that place patients near caregiver teams, it is equally important to remove other sources of noise—such as mechanical equipment, closing doors, ice machines and cart traffic—from outside patient rooms.
  • Tailor clinical team work spaces for appropriate visibility and noise levels: In hospitals, clinical teams on patient floors are getting larger, there are more interactions happening amongst various care team members—both in-person and remotely—and information is constantly being updated. Caregivers must be able to focus, pivot and think on their feet to stay on top of their tasks and patients. By providing enclosed team work areas and space for heads-down concentration, while ensuring that staff can still see their patients and converse, caregivers are able to perform at a high level without noisy distractions.
  • Remove rounding teams from corridors: In academic medical centers, rounding teams often conduct impromptu conversations or teaching moments in corridors outside patient rooms. And while these types of walking meetings are beneficial for many reasons, the noise that comes with them is not. Designing alcoves that take teams out of earshot helps to maintain an impromptu, informal atmosphere while increasing privacy and significantly reducing noise.
  • Take cues from lighting: Ambient lighting is an unexpected way to suggest how quiet or noisy a particular area should be. The way that corridors and nurse stations are lit during certain times of day—for example, brighter in the morning and dimmer at night—can indicate the appropriate voice level to staff, in addition to supporting staff members’ circadian rhythms and creating a more calming atmosphere, both of which are important in managing stress.
  • Explore materiality: Absorptive materials are often overlooked in healthcare settings because they may appear difficult to clean. However, rubber flooring, antimicrobial fabric panels or even quieter cart wheels can all help to dissipate sound.

Designing a healthy and acoustically sound environment is a delicate balance of transparency and privacy, concentration and energy. By creating thoughtful spaces that consider how noise affects rest, stress and productivity, we can achieve buildings that are healthier for those that occupy them.


*Copyright 2022 Acoustical Society of America. This article may be downloaded for personal use only. Any other use requires prior permission of the author and the Acoustical Society of America. This article appeared in The Journal of the Acoustical Society of America 151, 457 (2022) and may be found at

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Rethinking Healthcare Hubs In The Post-Covid Era

Three ways technological advances will shift healthcare delivery, from the traditional hospital to at home services.

November 2, 2020

Principal, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Sarah Markovitz and Ryan Hullinger.


The explosion of telehealth prompted by the COVID-19 pandemic has accelerated a shift in care delivery away from the hospital and clinic and into homes and communities. While hospitals have historically been the main hub of care, technology and new care models are enabling a different approach to care delivery. Rather than episodic preventative care, in which a patient periodically goes to a physician or hospital with a health concern, this new model of care is continuous and ubiquitous — with ongoing care reinforced in the home, office, school and throughout the community. There are three key aspects to this shift: advancing technology, new care settings, and the future evolution of hospitals.


Advancing Technology

Healthcare may follow a familiar path blazed by online retail. It was not that long ago that virtually everyone preferred in-person retail experiences to shopping online. The technology that would later make online shopping experiences superior to brick and mortar just didn’t exist. Telehealth, by comparison, is still in the dial-up days. It’s difficult to imagine now, but based on the patterns we have seen clearly in other technology sectors, it’s probable that some healthcare experiences will be better remotely than in-person—more convenient, and less stressful and time consuming. The technology that will transform telehealth is on the horizon. It will take several R&D cycles, but it will come. In fact, there’s evidence that in areas like behavioral health telehealth is already comparable in efficacy to in-person care.

What might the next generation of telehealth look like? For one, rather than sequential visits with separate specialists, patients may be able to connect to a suite of caregivers, all working collaboratively to provide more coordinated, effective care. The type of continuous, convenient touch-bases and flow of information enabled by telehealth and wearable devices could be particularly effective for the elderly and those with chronic conditions, where communication and ensuring compliance with medication and preventive care are often an issue. There will also likely be an expansion in the types of care and services that can be provided, including everything from post-surgical appointments, to ED triaging, and eventually more complex tests as new diagnostic technologies emerge.

Automated technologies and artificial intelligence will also play an increasingly vital role in improving health throughout the community. AI technologies are being used to scan patient records, identify patients with hypertension and diabetes, and remind physicians to check in regularly with them. Hospitals have already shown good results using telehealth, texting and improved monitoring to help vulnerable populations and those with chronic conditions. Improved telehealth and health data capabilities could extend widescale efforts like these, improving population health efforts.


New Care Settings

With technology acting as a facilitator, more and more forms of care, especially routine procedures, will migrate away from hospitals and clinics. The home could become the new healthcare hub, with prefabricated telehealth units for the home that integrate medical technologies with telehealth capabilities. The explosion of smart home, home health and health monitoring devices, encompassing everything from sensors that detect sudden falls to smart watches that monitor heart rate and O2 levels, is only the tip of the iceberg. With the ability to monitor health data and communicate effectively with caregivers, the home could be a crucial site for preventive medicine, chronic disease management and ongoing care.

The home health model is only one possible model—the technologies that enable it may have shortcomings, or prove unaffordable to large segments of the population, further exacerbating health inequities and the digital divide. But healthcare can still be provided in a wide range of locations distributed throughout communities. Libraries, schools, community centers, homeless shelters and pharmacies could become hubs for telehealth resources and care, serving a vital role in improving the health of communities. A key consideration will be access and location—ensuring that healthy equity and care for vulnerable populations drives where these new care hubs emerge.


How Hospitals May Evolve

As care becomes increasingly continuous and ubiquitous, the role of the hospital may evolve. Rather than serving as a destination for all patient types, it will become increasingly specialized and streamlined, focusing on high acuity cases. They may expand their capabilities and efficiency in areas like perioperative and high-end imaging that are not available in community settings. In the process, hospitals are likely to become more compact, high performing and efficient by narrowing their focus. As part of this evolution, hospitals may also need to bolster their ability to expand capacity by 50-100% in anticipation of emergencies like epidemics, mass casualties and weather-related crises.

In the last 20 years, many hospitals have invested heavily in improving patient comfort and satisfaction, and have even borrowed processes and designs directly from the hospitality industry—creating patient environments that nearly resemble hotel lobbies and guestrooms. Patient satisfaction will continue to be a driver, but the environments that promote satisfaction are likely to change drastically. New environments that convey a sense of safety and cleanness will begin to feel more comfortable than the hospitality-informed designs of the past.

As this shift and gradual downsizing takes place, there may be opportunities to adapt existing space for other uses. The COVID-19 pandemic has demonstrated the dramatic impact of stress on healthcare workers. Hospitals now have an opportunity to provide sufficient and appropriate space for staff, helping to build resiliency to counter staff burnout and ensure the well-being of these truly essential workers. Hospitals could also aim to provide more community, patient and staff resources, such as spaces to demonstrate telehealth technologies and how to use them, or new hybrid offices equipped for telehealth.

As technologies, new care settings, and hospitals evolve, care will become more embedded in our daily lives. The pandemic may have spurred new interest in telehealth, but the trends shaping the future of care predate social distancing. They will continue to transform how and where care is delivered, ushering in a new era of ubiquitous healthcare.


How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at

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