Background: Georgia’s Critical Access Hospitals (CAHs) face increasingly complex threats to financial sustainability, as demonstrated by the disproportionally high number of closures in comparison to other states in the nation.

Methods: Financial performance measures (including profitability, revenue, liquidity, debt, utilization, and productivity), site visits, key personnel interviews, and a revenue cycle management assessment were used to assess the strategic landscape of CAHs in Georgia, analyze financial and operational performance, and provide recommendations.

Results: For CAHs in Georgia, financial and operating performance indicators, interviews, and assessments depict a challenging operating environment, but opportunities for improvement exist through implementation of a Lean Six Sigma program and improved benchmarking processes.

Conclusions: Georgia’s CAHs operate in a challenging environment, but operational improvement strategies (such as a Lean Six Sigma program) and benchmarking directed towards business processes, including revenue cycle management, provide opportunities for sustainability in the future.