The design of the new Cowichan District Hospital reflects a deep respect for the land, air, water, and life, and was shaped through engagement with the Cowichan Tribes. Recognizing the cultural and ecological significance of water to the Cowichan people—whose traditions and livelihoods are closely tied to local waterways—our team made water central to the design process. Early watershed analysis revealed that the site spans two sub-watersheds that splits the flow to Averill Creek and the culturally important S’aumuna marsh, challenging prior assumptions and engineered reports. By identifying overlooked wetlands and natural drainage systems, we were able to protect vital aquatic habitats and improve site-wide hydrologic function. These findings not only influenced the hospital’s sustainable landscape design—including wetland retention and redefined flow paths—but also led to municipal recognition of these features, ensuring their integration into future surrounding developments. Through this process, our design honours Indigenous knowledge, supports traditional relationships with water, and helps sustain the natural systems that support life.