Building from scratch would have been the simplest way to provide Holdrege, Nebraska with a critical access hospital to replace the one that had been serving the community for nearly 45 years. But it would have cost an estimated 50% more to accomplish than the innovative replacement-in-place strategy that combined 102,000 square feet of new construction with 61,000 square feet of renovations. A strategic approach to sequencing allowed the team to work around the constraints of the existing buildings, the city block, and required set-backs to shuffle existing departments, add new ones and create appropriate department adjacencies. The result is a state-of-the-art facility that will serve the community well for the next 45 years.