Once the need was identified to expand cardiac and surgery services at this growing regional medical center, Kootenai Health retained Bouten and the architect to assist with establishing a budget, securing board approval, and beginning the design process. It soon became apparent the scope would involve several complex phases, including two vertical expansions (one above the kitchen and the other above the occupied emergency department), a three-story addition over major buried utilities, and multiple remodeling phases of occupied space. And all of this would occur during rapid inflation, a global pandemic, and significant supply chain issues. In the end, the project was completed on time and within budget.