Designing for Resilient Healthcare Facilities

Designing in the Face of Disaster

Recovery Strategies for Healthcare Facilities

EDR PRINCIPAL MARK RIPPLE’S HOME POST KATRINA | NEW ORLEANS, LOUISIANA

Mount Carmel Academy (New Orleans)suffered extensive flooding damage due to Katrina. EskewDumezRipple began the diagnostic assessment of Mount Carmel’s 100,000+ square feet of flood-damaged facilities in October of 2005, and completed the full restoration scope, inclusive of the creation of a new central plant, in time for a January 2006 re-opening.

Recovering from Disaster There are few communities in the world who have not experienced natural disasters. When disasters like this happen, little is often left behind to salvage. Such trauma leaves behind open wounds, and in efforts to heal, developers and other well-meaning urban planners swiftly turn their attention to quickly rebuilding. While this expediency results in the replacement of infrastructure and other civic necessities, the end result is often a foreign place when compared to the one residents previously knew.

We play an indispensable role—as designers, planners, leaders, and advocates—in realizing a more equitable future for these communities. While the need to rebuild presents an obvious opportunity to redraw the physical landscape, this opportunity should be approache d with c aution. C ontex tual understanding and careful interventions—driven by community—are key to realizing a place that emerges stronger than it was before—and not merely an empty substitute.

New Orleans, much like other cities in recent history, is a place recovering from trauma. In the Post-Katrina landscape, EskewDumezRipple dedicated itself to rebuilding New Orleans with projects focused on recovery, resilience, and community. What we quickly learned is a resilient community is never achieved via a single design intervention, but from community efforts working in tandem. Simply put, rebuilding functions best when it grows from its roots.

We’ve since brought this message global. Beyond recovering, New Orleans is today, in many ways, thriving. Tourism is booming. Health outcomes are improved. Air quality is getting better. Urban development is charging along at an unprecedented rate. Of course, every community is different, and we would never be so bold as to suggest a carbon copy of the vision applied in New Orleans. But our experience in our own home has provided us with a remarkable toolkit that we believe can help other communities. We know what it means to come back from the brink.

Rebuilding for Resiliency | A Brief History Hurricane Katrina resulted in one of the largest disasters in American history and led to the loss of approximately 1,800 lives and nearly $200 billion in damages along the Gulf Coast. In the wake of the storm, numerous efforts focused on rebuilding New Orleans aimed not simply to rebuild, but build better. Lessons provided by the storm afforded us the opportunity to reexamine traditional ways of building. New Orleans is a city built on land that simply didn’t exist 20,000 years ago. Constructed on an alluvial deltaic plane, the city maintains a fragile and delicate relationship with the land it occupies. Nowhere is this tenuous relationship more visible than from space. resulting dirt to make the land useable, and planting landscaping and trees to provide a natural, retentive barrier to hold the banks in place.

We have water all around us, it is what we live with and what defines us; and in 2005 we had water inside the city.

How did we arrive at such precipitous conditions?

In the early days of the city’s development, we worked with the natural environment, rather than in opposition. We responded to its existing conditions, showing remarkable flexibility and resiliency in dealing with water, particularly in the 19th century. Wonderful examples exist in some of the beautiful parks found throughout New Orleans that were built along originally low-lying swampland. The effort undertaken to construct them represents a simple, but appropriate response for dealing with challenging, waterlogged infrastructure – digging out a low lying area from the swamp for a pond, piling up the

All of this changed in the 20th century, when architects and civil engineers posited that technology had advanced enough to afford us the ability to conquer nature, bending and shaping it to meet our demands. Driven in part by the great flood of 1927, which encouraged the channelization of the Mississippi River, the city began drafting the beginnings of its new plan to wrangle nature – massive pumping technologies that aimed to pump the entire city dry. What resulted was a city beholden to infrastructure, massive drainage stations traversing its neighborhoods like a spider web. As we pumped the city free of water, it collapsed, just as a wet sponge shrinks as it dries, sinking into what many affectionately now refer to as “the bowl.”

In doing so, we created an infrastructure dependent on technology—giant walls intended to hold water out—with the hope that such barriers would persist forever. When in fact they couldn’t, and didn’t.

Painfully, what we learn from such catastrophes is that most aspects of infrastructure and design are completely invisible – until they fail, and their shortcomings become all too apparent.

Rectifying these shortcomings requires a mutual understanding of three fundamental fallacies in 20th Century thinking:

Of course one might suggest we continue to build higher—wall ourselves in from the onslaught of natural forces.

1. Nature will cooperate.

2. Manmade systems can be made failsafe.

3. We are addressing a static condition.

Nature almost never cooperates, man by his very nature is fallible, and the reality of addressing the presence of water involves hitting a moving target. Events are getting worse, storms stronger.

We must change the way we define the problem before attempting to solve it.

There is nothing more sobering than seeing such conditions graphically. New Orleans is losing its natural barrier, the wetlands, at an astonishing rate. These images show the loss of wetlands from 1930 to 2005, and projected to 2050—the city of New Orleans persisting as nothing more than an island in the Gulf of Mexico.

1930

Such efforts represent an exercise in futility.

A seasoned perspective, one recognizing the numerous failures of city infrastructure over the years, might offer an alternative: living with nature, rather than attempting to control it. For us, that implies technology can no longer be thought of as mono-technic. It can no longer do merely one thing. We are building such infrastructure in the middle of cities.

First and foremost, we must understand such infrastructure is, by its very existence, a social construct, driven by cultural, environmental, and programmatic conditions. And a response should include an answer not to simply stall the flood of water, but an opportunity to build community.

2005

2050

Climate risk is not a static condition. Storm strengths are increasing. For our hospitals to maintain a truly resilient framework, it’s imperative design teams address threatening natural disasters as a moving target.

PERIODS:

EMERGENCY

CAPITAL STOCKS:

Damaged or destroyed

Patched

Rebuilt (Replacement)

Major Construction (Commemoration, Betterment, Development)

Ceased or Changed

Return and Function

Return at Predisaster Levels or Greater

Improved and Developed

NORMAL ACTIVITIES:

RESTORATION

RECONSTRUCTION 1

RECONSTRUCTION 2

COPING ACTIVITY

MAXIMAL

MINIMAL DISASTER EVENT

.5

SAMPLE INDICATORS:

1

2

3

4

5

10

20

Completion of search and rescue

Restoration of major urban services

End of emergency shelter or feeding

Return of Refugees

Clearing rubble from main arteries

30

40 50

100

200

Attain predisaster level of capital stock and activities

300 400 500

Completion of major construction projects

Rubble cleared

This chart modeling the cycle of disaster recovery activity is a product of a research project sponsored by the U.S. National Science Foundation in the mid-1970s. While the researchers concluded that recovery is “ordered and predictable� it does not include the nuances of recovery: who is involved, what is rebuilt, who is left out.

Disaster Response Cycle Although each natural disaster is inherently unique, its impact on comunities is often predictable, following a specific pattern of emergency/triage, restoration, and reconstruction.

Community planning efforts must reflect an understanding of the physical, social, and financial needs of the community at each stage of recovery.

Community Response Physical reconstruction is only one of multiple challenges facing communities in the first year after a disaster. In New Orleans, the hurricane and subsequent flooding raised critical questions about the appropriateness of reinhabiting the city after and responsibility for the cost of recovery.

At its core, it challenged the notion of individual rights versus the responsibility to serve the greater good of the community. It also exposed underlying issues of race and class throughout the city.

Neighborhood users protesting the razing of their Broadmoor neighborhood.

New Orleans Mayor LaToya Cantrell standing in the finished library and community center in Broadmoore that served to revitalize the devastated neighborhood (Designed by EDR).

Disaster Impact on Healthcare Facilities All major hospitals in the city were taken out of commission:

• • • •

Veterans Administration (VA) Hospital Charity Hospital New Orleans East Hospital Baptist Memorial Hospital

This left tens of thousands of citizens stranded without emergency services, and those that stayed in the city had no access to basic care. Hospital facilities were not designed for a major disaster, and emergency preparedness procedures were woefully inadequate.

New Orleans East Hospital inundated by water.

Major Lessons Learned 1. Facilities were poorly designed for major disaster: generators in basement, inadequate building envelope, no means of efficient evacuation in a flood, insufficient redundancy features in place.

2. Exposed fundamental flaws in emergency preparedness protocols, particularly the orderly, timely evacuation of patients.

3. Hospitals are often seen as a “refuge of last resort” by the community, even if they are not designed or operated as such. None of the hospitals were prepared for the onslaught of citizens looking for a place of refuge.

Understanding Disaster Response In order to create resilient healthcare facilities, the response to disaster must occur at two levels:

• The physical parameters of design • The operational considerations of the facility Based on the lessons learned of Katrina, we now recognize that there are essentially four disaster levels associated with hurricanes, and each requires a unique physical and operational response.

Perhaps most importantly, it is necessary to make strategic decisions about whether, in the event of a major disaster, the facility will be designed for Level 3 “Orderly Evacuation and Shut Down,” or for Level 4 “Defend in Place.” This decision has huge consequences on the design and operation of the facility.

The physical parameters of resilient design can be grouped into three categories: site response, hardening and system redundancy:

Disaster Levels

• The site response utilizing green infrastructure as a tool that supports the protection of not just buildings, but communities.

• The creation of friendly fortresses, robust, hardened buildings that are beautiful, open and inviting.

• The consideration of mission critical facilities and their location, providing sufficient system resource redundancy, tethered to a plan for disaster operations.

A Times Picayune map showing the flood depth in various neighborhoods in New Orleans following Hurricane Katrina

Site Response One of the lessons learned from a disaster is the empirical data gained from the event, which can inform land use planning during the recovery. The first, most obvious response is to build critical facilities on the high ground!

Secondly, create stormwater infrastructure which has the ability to retain water naturally, thus reducing the reliance on man-made technologies.

A/C A/C A/C

N

A diagram of water management strategies introduced in various capacities at the New Orleans Bioinnovation Center

Site Strategies Stormwater design strategies can also be effective tools for disaster protection at the scale of the campus or building site.

At the BioInnovation Center, designed by EskewDumezRipple, the design feeds all rainfall from the roof into a prominent water feature whose depth fluctuates with the rains, allowing for biofiltration through water plants, then overflowing into a vegetated swale, detention in the parking lot subbase, and percolation back into the soils. The water feature is also fed by the AC condensate (up to 20,000 gallons per week) which provides all landscape irrigation (the only use currently allowed for captured water by state regulation).

Pervious pavers and/or concrete is used in all parking locations and in the landscaped courtyard allowing inf iltration and greater reduction of runoff.

The courtyard at the New Orleans Bioinnovation Center

Hardening: Design and Construction Resilient design moves beyond a bunker mentality.

Major Planning & Design Considerations • Reliability of municipal facilities and services • Building code upgrades pertaining to disaster

While locating critical functions in bunkers as part of a ‘hardening’ strategy may be part of resiliency design, we can’t live and work in an actual bunker.

Beyond their denial of the human need for beauty and connection to nature and each other, bunkers are difficult to adapt to changing needs or threats.

Bunkers are very good at protecting against one known threat, but can be vulnerable towards others—it’s hard to think of a ‘nimble, reactive bunker.’ The balance of brute strength, beauty, and adaptability is at the core of resilient design.

7 6

protection

• Base flood elevation responses: 100-year storm, 500-year storm, Category 5 storm surge

• What are considered “Critical facilities” in disaster-prone areas?

Ability to stabilize/evacuate/shut down “Refuge of Last Resort” Requirements.

Robust wind load requirements Large missile impact criteria for building envelope • Stormwater mitigation/retention • Physical access to and from facility before, during, and after the event.

• • • •

9

5

8

3

4 1

2

Resiliency Strategies at the Veterans Administration Hospital, New Orleans 1. Rooms can be converted to double-occupancy in an emergency. 2. Building envelope can withstand at least a Category 3 storm.

3. Raised mission-critical components. 4. Raised primary utility distribution. 5. Million-gallon rainwater storage. 6. 320,000 gallons of fuel, enough to generate one week of power. 7. A 6,000-square-foot emergency storage warehouse. 8. Emergency department ramp/boat launch. 9. The parking garage/helipad.

EskewDumezRipple and Guidry Beazley Architects Joint Venture designed this National Weather Forecast Office in Key West, Florida. The Southernmost of 121 weather forecast offices established by the National Weather Service throughout the United States, this structure is capable of withstanding a Category 5 hurricane and includes an upper air helium weather balloon launch.

System Redundancy

Emergency Preparedness

Resilient design employs systems that allow for continued occupancy of the building in the face of a threat via redundant systems and the ability to island. Resiliency planning is planning for the worst-case scenario. Often disasters reduce or destroy traditional operational building systems such as power or water. Sustainable design often employs passive strategies to reduce everyday energy use; resilient design takes advantage of this to promote ‘passive survivability.’

Resilient design considers both short-term known emergencies and long-term contingencies.

Energy efficient buildings require less backup capacity than traditionally designed buildings, and so redundancy will always be more affordable when the building has incorporated sustainable practices. This combination of efficiency and redundancy creates a more resilient building that is more likely to remain operational during and after an event.

Emergency preparedness is part of resiliency planning, but it’s not the whole story. Emergency planning is about anticipating or responding to the immediacies of events (“How can we get through this?”). Resiliency seeks to lessen the impact of events but focuses on longer-term realignments (“How do we come back?”). The simplest elements of emergenc y prepare dnes s—generator s, flashlight batteries, bottled water, fire drills—are just the beginning. Resiliency requires more than planning for the known, short-term problems; it requires that we play ‘spot the assumption’.

Resilient design involves playing out the scenarios, deciding what is truly mission-critical to any organization.

Focus on Critical Facilities Even the best-maintained utility grids in coastal communities will face periodic power outages due to high winds. If a freezer containing biomedical research samples fails, a decade’s worth of research can be compromised.

The emergency generator for the building is typically sized to support such freezers during power outages, but is not large enough to support the full air conditioning system. In the aftermath of Katrina—a period of time lasting weeks—facility managers were able to obtain fuel to keep generators running, but the heat from all the equipment in the building raised internal temperatures above 110°F, and some freezers failed.

Research Facilities), the design incorporated an array of ‘Freezer Farms’ (each accommodating up to a dozen freezers), complete with its own independent cooling system. During power outages, the freezers and the rooms they are in stay cool. Researchers are not forced to store their samples in place, but they know they are taking a substantial risk if they do not. The Farms operate as lifeboats for researchers’ samples, and their use every day means that no special emergency procedures relocating samples are required.

But what if the emergency power generator fails too? As an extra layer of security, each freezer farm is equipped with compressed gas cylinders that can keep freezers cool for several days.

As part of a renovation for J. Bennett Johnston L abs ( par t of Tulane Univer sit y’s Health

OFFICE

OFFICE

OFFICE

OFFICE

OFFICE

Freezer FREEZER FARM Farms

LAB

LAB SUPPORT

LAB SUPPORT

LAB SUPPORT

LAB SUPPORT

LAB SUPPORT

LAB

LAB SUPPORT LAB SUPPORT

LAB SUPPORT

LAB SUPPORT

A floorplan showing the “Freezer Farms” at Tulane’s JBJ Labs in their Health Research Program. The design incorporated an array of freezers (each accommodating up to a dozen), complete with its own independent cooling system. During power outages, the freezers and the rooms they are in stay cool, keeping priceless health samples safe from harm.

BIOINNOVATION CENTER | NEW ORLEANS, LA

Selected Healthcare Projects

New Orleans East Hospital New Orleans, Louisiana

EskewDumezRipple led the development of the $63M reconstruction/ expansion following Hurricane Katrina. A disaster plan redistributing various functions was developed for the new facility to maintain operations and the safety of patients and personnel in the event of a ‘worst case scenario.’

Because New Orleans East did not have the available funds to accomplish a “defend in place” strategy, the team devised a 72-hour orderly evacuation and shutdown strategy, one that provided sufficient time for hospitals to remove and escort patients to a more secure location elsewhere and shut down the hospital. That decision entailed numerous difficult decisions regarding what facilities to keep and which to remove.

The team decided to keep the newest piece of the hospital, the in-patient facility, and demolish everything else. This clean slate accomplished several things. It allowed the hospital to take the central power plant off the first floor and completely rebuild it on the roof, isolated from any standing storm water event. The team elevated, not only the emergency department, but all critical care facilities, starting at floor 2 and up. As a result, all “sacrificial facilities,” those facilities unnecessary for critical care (such as cafeterias and lobbies), occupy the first floor.

And because the hospital site is eight feet below sea level, it was impractical to pump water offsite, therefore, the site design incorporates on-site retention facilities for stormwater storage.

KEY ATTRIBUTES • “CRITICAL” SERVICES ABOVE FIRST FLOOR • ED AND ACCESS RAMP AT SECOND FLOOR (WHICH CAN BE USED AS BOAT RAMP DURING CATASTROPHIC FLOOD) • PLACEMENT OF CENTRAL PLANT ON ROOF • REPURPOSING OF OLD CENTRAL PLANT • HARDENING OF EMERGENCY SYSTEMS • ENVELOPE MEETS LARGE MISSILE IMPACT CRITERIA • CATEGORY 3 STORMRESISTANT ENVELOPE

PROGRAM REQUIREMENTS: NEW ORLEANS EAST HOSPITAL • • • • • • • • • • •

A diagram showcasing water management on site

14 BEDS ICU 10 BEDS INTERMEDIATE CARE (STEP DOWN) 26 BEDS MEDICAL SURGICAL 10 BEDS PEDIATRIC UNIT 20 BEDS LTAC SHORT STAY UNIT - 15 ROOMS EMERGENCY DEPARTMENT - 20 E X AM ROOMS IMAGING SUITE – MRI, CT, RADIOLOGY SURGERY SUITE – 4 OR’S, 1 CATH LAB PT / OT / CARDIAC REHAB SUITE KITCHEN & DINING AREAS

The hospital inundated by water following Hurricane Katrina

6

PT / OT / Cardiac Rehab Unit

5

Long Term Acute Care

4

Medical / Surgical Unit

3

Short Stay Unit / Pharmacy / Lab

2

Intensive Care Unit

1

Central Equipment Plant

Atrium / Elevators

Lobby / Dining / Kitchen / Reception / Chapel / Administration

EAST TOWER (EXISTING)

Surgical Suite / Endoscopy / PACU Emergency Dept / Imaging Admin. Support / Materials Management / Loading

PATIENT PAVILION (NEW)

“Mission Critical” Facilities Above First Floor

Veterans Affairs Hospital New Orleans, LA

EskewDumezRipple, as a joint venture partner with NBBJ, designed the $995M VA Replacement Medical Center in the newly expanded Medical District of New Orleans following Hurricane Katrina. At the VA, 1.4 million square feet of clinical space drove a number of other considerations, beyond what is traditionally considered. Most notably, as a federal mission critical facility, the hospital was required to meet anti-terrorism force protection requirements. Thus the challenge arose in creating what the team coined a “friendly fortress”—an entity robust enough to withstand hurricanes and terrorist attacks, but still open, inviting, and welcoming.

A second euphemism emerged early in the design process: the “upsidedown” hospital. Usually, in such large-scale operations, the facility will have a service spine traversing the basement. We flipped this paradigm, inserting it as an elevated spine, located on the 4th floor, out of harm’s way. Similar to our project for New Orleans East Hospital, the facility was designed with all mission-critical facilities starting on the 2nd floor. A one million gallon reservoir sits onsite, to assist in cooling for the chillers for the central plant. The rooftop serves as a Blackhawk helicopter landing area. The complex can shelter in place, in the event of a catastrophic storm for five days, and holds 320,000 gallons of fuel for generators, provisions, and accommodations for over 1,000 staff and patients.

KEY ATTRIBUTES • CATEGORY 3 STORM – RESILIENT ENVELOPE • “MISSION CRITICAL” FACILITIES LOCATED ABOVE FIRST FLOOR • EMERGENCY DEPARTMENT RAMP AS EMERGENCY BOAT LAUNCH DURING STORM • MILLION-GALLON RAINWATER RESERVOIR • BLACKHAWK HELICOPTERLANDING • FIVE DAYS UNINTERRUPTED DISASTER OPERATIONS • 320,000 GALLON FUEL FOR GENERATORS • DISASTER RESPONSE CENTER IN FACILITY

A diagram showcasing the elevated service spine of the redesigned hospital.

Community Engagement He drew a circle that shut me out — Heretic, rebel, a thing to flout.

But love and I had the wit to win: We drew a circle and took him in!

— Edwin Markham Edwin Markham’s poem above succinctly de scr ib e s t wo view s of how c ommunit y engagement is typically approached. On one hand, there is the view that disaster response planning and design are solely the domain of the “expert”—the out-of-town consultant who brings the requisite expertise to solve the problems facing the community. Likewise, there are community members who feel they have been misled one too many times by developers and designers unaware of the neighbors they affect. In short, designers draw circles around themselves to protect the precious process of design, while the community draws circles around themselves to protect against what they see as an unpredictable and siloed development process.

social, cultural, economic and political conditions which may greatly affect outcomes. Often, community members feel dismayed, frustrated and even insulted when outside consultants offer solutions without really understanding the underlying issues affecting their community.

In order to ensure successful outcomes, the entire community engagement process must be centered around consensus-building, driven by the idea that every citizen has a voice in the rebuilding of their community. However, structuring an engagement process which achieves this goal requires intentionality, as well as sensitivity to the emotional and physical state of the residents and stakeholders.

Building Consensus Having experienced the consequences of disaster planning and design solely by outside experts, it is clear that successful planning MUST be centered around the community, and include multiple voices: residents, local businesses, community leaders, faith-based organizations, stakeholders and the like. While experts often bring a technology-based focus to the issues at hand, they may not understand the underlying

Challenges abound: if the focus is on input through “town hall” resident meetings, how will dislocated residents participate in the process? Knowing that residents often need an outlet simply for “sharing of grievances,” will the engagement process accommodate those needs? How might meetings be structures to truly accommodate all voices, rather than just the loudest voices in the room?

How might conflicting priorities be mediated, and who will do the mediating?

Tools of the Trade

EDR Principal Mark Ripple at a community meeting held to solicit input for a new park Master Plan in New Orleans, LA

There is obviously no shortage of methods and tools available to practitioners looking to get stakeholders involved in their projects. In 2014, our EskewDumezRipple Research Fellowship program helped us codify what we’ve learned over the last two decades into a set of tools for community engagement that we now share with the profession. These help capture the huge

A community meeting led by Allen Eskew intended to solicit input from the public

range of techniques available to support different kinds of conversations at different scales.

T he b ar r ier to inc or p orating me aning ful engagement in the design process is more often the time available to plan and a willingness to share decision-making power, rather than access to information about methods. The four major motivations for stakeholder engagement

(a desire to bring transparency to the process, to help make decisions, to promote a specific design agenda, and because it builds the firm’s reputation and connectivity) and the four main methods of engagement (speaking from the stage, asking questions, facilitating discussion, and conducting workshops) provide a baseline for engagement as it is practiced at EskewDumezRipple.

Culture of Giving Back The firm is nationally recognized for employing architecture as a catalyzing force for civic and social good. In January of 2015, EskewDumezRipple launched its Day of Service, an annual firm-wide initiative that simultaneously strengthens its commitment to building community and honors the legacy of Martin Luther King Jr. Each MLK Day the firm donates the services of its entire staff to amplify the capacity of organizations working to better the New Orleans community.

The day is an opportunity to concentrate the skills and interests of the entire studio towards assisting larger ongoing community efforts, and

enables community organizations to participate in a collaborative design process, one adapted to their particular design challenge. This exchange of knowledge benefits the firm—constructing a deeper understanding of community needs— and benefits the partner organization in further realizing their mission via design excellence.

Challenges can be tackled through a wide range of services including building and landscape design, graphic advocacy, branding, marketing and communications planning, and urban engagement at a range of scales.

365 Canal Street, Suite 3150 New Orleans, LA 70130 504.561.8686 | eskewdumezripple.com

1989

YEAR FOUNDED

52

NUMBER OF EMPLOYEES

47

UNIVERSITY PROGRAMS REPRESENTED

70%

LEED ACCREDITED TECHNICAL STAFF

46%

LICENSED PROFESSIONAL STAFF

2014

WON THE AIA NATIONAL FIRM AWARD

EskewDumezRipple is a nationally honored architecture, interiors and urban planning firm recognized for producing innovative projects grounded by a strong understanding of context, culture, and environment. We build across the country and around the world, with the goal of integrating beauty and performance.

From the firm’s inception, we have been driven by four enduring core values: Design Excellence, Environmental Responsibility, Community Outreach, and Client Commitment. Every aspect of the practice has been structured to support these ideals. The resulting body of work – ranging from intimate interiors to large urban planning projects with numerous stakeholders – reflects our aspiration for building community, regardless of project scale, budget, scope or complexity.

Our practice’s commitment to culture and civility places public participation at the center of what we do. We work to integrate many voices alongside the constraints of climate, place, and budget to deliver projects that provide the greatest positive impact for the owner, for the user, for the community, and for the planet.