Context: Surgical services are frequently unavailable in rural American communities. Therefore, rural residents often must travel long distances to receive surgical care. Rural hospitals commonly have difficulty providing surgical services despite potential economic benefits. Purpose: The purpose of this project was to identify the key challenges and describe the initial outcomes experienced by Harney District Hospital (HDH), a rural critical access facility in Oregon, as it develops a surgical program. Since few models exist, this information will be valuable for those considering offering surgical services in a rural setting. Methods: This project employed a single case study design. Qualitative information was gathered from semi-structured interviews, a focus group, reviews of historical documents, and informal observations. Quantitative data sources included HDH financial and utilization records, US Census records, and economic and demographic statistics from the state of Oregon, Harney County, and the city of Burns. Findings: HDH is learning that initiating a change such as expanding surgical services within an organization is a challenging process requiring collaboration among the administration, staff, and community. Preliminary findings indicate that the new surgical program has resulted in significant financial gains for the hospital. Conclusions: While starting a rural surgery program is a complex undertaking, there are benefits for the hospital. If a rural hospital is to be successful in this mission, collaboration and adaptability must be key components of the process.