If you lead a rural health care facility, you need to read this. And if you have ever led or are going to lead a building project, you definitely need to read this. As health professionals know, critical access hospitals (CAH) are unique. CAH facilities are not simply smaller versions of their urban counterparts. They are unique in two fundamental ways—their economics and their culture. It’s an understanding of both economics and culture that determines the success of critical access health care building projects. This article discusses the economic and cultural realities of CAH facilities, specifically as they relate to successful building projects. The considerations of phased building projects—projects that are done in multiple stages and sometimes over multiple years—are detailed as an effective response to these realities. Finally, the article also describes some of the characteristics of the right project team that helps ensure a successful building project.