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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Smart Strategies Help Health Systems Navigate Crises, Prevent Surgery Cancelations
Sheila Lai, MA
March 4, 2026
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Days after Hurricane Helene made landfall in northern Florida in September 2024, communities and hospitals impacted by the Category 4 storm faced the daunting task of rebuilding and maintaining patients’ access to care. More than 200 people died across seven states, and widespread flooding, power outages, and road closures impacted the lives of residents for months.1
Several hundred miles north of Florida, catastrophic flooding from Helene overwhelmed Baxter International’s manufacturing facility in western North Carolina. The facility, which produces roughly 60% of the country’s prepackaged IV fluid products essential for surgeries, was severely damaged, triggering a national IV fluid shortage and forcing hospitals nationwide to postpone elective surgeries.2,3
While Hurricane Helene exemplifies the large-scale domino effect disasters can have on healthcare systems, more routine challenges also can disrupt healthcare delivery in less catastrophic, though still frequent and significant, ways. These challenges may range from transportation barriers that prevent patients from arriving on time to appointments to operational deficiencies that lead to last-minute surgery cancelations.
No matter the cause of disruptions, experts emphasize that implementing proactive strategies is essential to keeping hospital systems resilient and ensuring continuous access to care.
“There are so many different things that can cause disruptions in healthcare and missed appointments. Roads may not be passable after a significant storm, staff may not be able to reach a facility in emergencies, or a lung cancer patient may not be able to go outside because of wildfire smoke, making it unsafe for them to travel,” said Leticia Nogueira, PhD, MPH, scientific director of Health Services Research at the American Cancer Society.
Dr. Nogueira is one of several researchers and clinicians working to understand the causes of healthcare disruptions, determine when and how they may occur, and how to help healthcare systems best prepare for them.
Solutions to disruptions and missed appointments depend greatly on context and identifying the root cause. Three ongoing projects highlight the distinct ways healthcare can be disrupted at the system, patient, and operational levels—and the individualized solutions to each.
Preparing for the Unexpected
At the broadest level, large-scale crises reveal critical weaknesses and opportunities to strengthen hospital workflows and emergency responses. A 2021 analysis published in the Annals of Surgery found that hospitals lost more than $20 billion in revenue nationally from elective surgeries canceled between March and May 2020, which triggered a backlog of delayed procedures. Elective surgeries also can include time-sensitive procedures, such as biopsies, hernia repairs, or valve replacements, according to the study, noting that delays in these appointments, though categorized as elective, can worsen patient outcomes.4
While the COVID-19 pandemic was unprecedented in scope and scale, it mirrored what often happens during any large-scale emergency: patients are left without access to critical services, and hospital revenue is strained.
A collaboration between the ACS and the American Cancer Society aims to develop strategies to better prepare cancer centers for events that can trigger large-scale disruptions, including climate-related disasters and health emergencies such as the COVID-19 pandemic.5
“We’re trying to make sure hospitals don’t have to reinvent the wheel every time a disaster or disruption happens, and that as a community, we’re better prepared to handle these disruptions,” said Dr. Nogueira, one of the key leaders of the collaborative.
The initiative recently launched a baseline survey to identify current barriers that centers face, including the impact of recent disasters and centers’ preparedness to manage challenges, to inform the development of targeted support tools (e.g., facility-wide educational materials, automated messages, information on health risks of different hazards). The survey is available at https://redcap.facs.org/surveys/?s=H44W8EDP39EFRAFL.
Also important is gaining firsthand knowledge from healthcare systems affected by prior disasters to foster greater collaboration.
“Many times, the most relevant expertise comes from people with lived experience. Healthcare providers in places like Puerto Rico and the Virgin Islands, where resources may be limited, often develop the most innovative solutions,” Dr. Nogueira said.
Patient Factors Contributing to Missed Appointments
Even without major disruptions, many patients encounter personal challenges in their daily lives that can lead to missed appointments and canceled surgeries.
The root causes of these disruptions often vary widely based on personal factors and access to care. Transportation is one major source of disruption for patients and healthcare systems, contributing to missed appointments, including surgeries, and reduced outcomes. Researchers estimate that between three and six million people annually delay healthcare due to a lack of transportation, and a disproportionate number live below poverty levels and have chronic health conditions.6 Other patient-specific factors—such as financial concerns and insurance barriers—also can contribute to delayed care.7 For oncologic patients in particular, missed or delayed appointments can be especially detrimental to health, increasing rates of morbidity and mortality.8
Breaking Barriers, a national quality improvement project launched by the ACS, identified the main barriers cancer patients face during time-sensitive radiation treatment. The topic of missed radiation appointments was selected after surveying cancer centers about a common source of disruption that affects patients and their health systems. Barriers were wide-ranging, with transportation (62%) and illness unrelated to cancer treatment (37%) most often causing patients to miss three or more radiation appointments.9
Importantly, barriers were not uniform across patients seeking cancer treatment, even if they fell within the same category. Illness, for example, was not always due to a virus or other physical condition and was often related to untreated depression or anxiety that caused significant symptoms. Access to transportation also was highly dependent on the region. In an urban setting, not being able to afford a bus pass may be a more significant obstacle than distance, whereas in more rural areas, distance and the inability to secure a ride may prevent patients from completing treatment. Even outside of cancer care, travel time can significantly impact surgical outcomes across other specialties. Research shows that patients with emergency general surgery conditions who have a travel time of 60 minutes or longer are more likely to require operative interventions and have extended inpatient hospital stays.10
Due to the wide variety of barriers, solutions must be tailored to the specific population. For the Breaking Barriers project, the most successful strategies involved technology-based solutions (automated patient reminders), designating patient navigators to provide additional support to vulnerable patients, and improving scheduling and follow-up workflows. Project leaders noted that assigning a designated staff member to follow up with patients may help prevent future missed appointments, and using fractionated radiation treatment schedules to reduce the number of visits required may be appropriate for some patients, especially those at risk of disruptions.11 Thanks to these Breaking Barriers strategies and a universal toolkit that guided centers in effective solutions, participating centers reduced missed radiation appointments by 40%.
“Centers found that asking patients about the reasons behind missed appointments or screening them beforehand for potential barriers could make a meaningful difference in helping them adhere to their treatment schedule and allow hospitals to develop system-wide solutions,” said Laurie J. Kirstein, MD, FACS, Chair of the ACS Commission on Cancer and a breast surgical oncologist at Memorial Sloan Kettering Cancer Center in New York, who led the Breaking Barriers project. “Participating centers also reported significant benefits from collaborative sessions, where they learned from one another about solutions.”
Preventing Day-of-Surgery Cancelations at the Hospital Level
In the absence of major crises or transportation barriers, gaps in communication or workflow processes can still disrupt healthcare, even for scheduled surgeries.
Across the US, rates of day-of-surgery cancelations vary widely, driven by factors such as patient no-shows, preoperative noncompliance, and scheduling challenges.12 Research on the causes of surgery cancelations is limited predominantly to hospital-level case studies.
A 2012 retrospective review of canceled outpatient pediatric urology procedures at Children’s Hospital Colorado in Aurora found that while cancelations from illness and other factors are not always preventable, up to a quarter of cancelations were due to insurance-financial issues, preoperative fasting violations, or other issues the authors noted could potentially be prevented. They also observed that improved hospital interventions, such as enhanced processes for evaluating insurance status and ensuring effective preoperative parental education, could reduce cancelations.13
Another review of canceled elective outpatient surgeries at Tulane University Medical Center in New Orleans, Louisiana, found that institutional issues—such as a lack of available beds or equipment—contributed to nearly one-third of cancelations.14 Patient inability to comply with preoperative instructions or delays in arrival, caused by transportation problems, confusion about the date of surgery, or other reasons, also were notable causes of surgical cancelations across the hospital system.15 The study authors estimated that average revenue lost ranged from $1,325 to $5,962 per cancelation.
For healthcare systems, delving into the specifics of their patient populations can yield solutions. For instance, the Tulane study found that patients who completed a preoperative visit with an anesthesiologist were far less likely to have their surgery canceled compared with those who did not (4% vs. 11%).
More recently, a multidisciplinary team at Cincinnati Children’s Hospital Medical Center in Ohio led a quality project to address preventable day-of-surgery cancelations, which averaged about 15 per week across all locations and predominantly affected patients with government insurance.
While the financial impact of canceled surgeries was initially the primary concern, analyzing the reasons for missed appointments revealed opportunities to improve patient access to care, noted Norm Honecker, MBA, RN, vice president of perioperative services administration at Cincinnati Children’s Hospital Medical Center.
Honecker presented at the 2025 ACS Quality and Safety Conference, highlighting a hospital-wide effort to identify the causes of day-of-surgery cancelations among pediatric patients and develop solutions to prevent them.
Through an analysis, Honecker and his team found that language barriers, inconsistent reminders, and poorly communicated surgery preparation instructions frequently led to preventable cancelations on the day of surgery.
“Communication was probably the number one factor,” Honecker said. “Oftentimes, before surgery, we handed families a large folder—more than they ever would need—and didn’t have consistent methods to make sure we were communicating with them effectively.”
Honecker and a team developed a revised preop schedule and implemented other solutions to reduce missed appointments.16 Some of the most successful interventions focused on increasing support and enhancing communication processes for patients at risk of cancelations:
Early verification of contact information: Before surgery, a team screens parents or caregivers for the best contact phone numbers, as well as alternative numbers the care team can use.
Proactive reminders 72 hours before surgery: The revised system includes structured ways to follow up with families who cannot be reached by phone, including assigning a call lead who can employ different methods of contact if needed (e.g., MyChart, seeking alternative phone numbers).
Automated reminders translated into a patient’s native language: Through an analysis, the team identified language needs for patients who spoke Spanish and Arabic. Reminders are now translated for these patients.
Patient navigators: Patient navigators are assigned to patients who need additional assistance—whether related to transportation issues or understanding preoperative instructions.
The project resulted in a decrease in day-of-surgery cancelations from 15 per week to about eight, according to Honecker, and provided the care team with actionable plans to address the barriers many patients face in obtaining necessary medical care. However, identifying the root causes of cancelations and maintaining lower cancelation rates will be an ongoing process.
“A lot of projects get started, make a dent, and then are pushed aside,” he said. “We’re trying to make sure this one is sustainable.”
Sheila Lai is the Senior Public Information Specialist in the ACS Division of Integrated Communications in Chicago, IL.
References
Hagen A, Cangialosi JP, Chenard M, Alaka L, et al. National Hurricane Center Tropical Cyclone Report: Hurricane Helene. 2025. Available at: www.nhc.noaa.gov/data/tcr/AL092024_Helene.pdf. Accessed January 9, 2026.
Wolfe MK, McDonald NC, Holmes GM. Transportation barriers to health care in the United States: Findings from the National Health Interview Survey, 1997–2017. Am J Public Health. 2020;110(6):815-822.
Ratnapradipa KL, Jadhav S, Kabayundo J, Wang H, et al. Factors associated with delaying medical care: Cross-sectional study of Nebraska adults. BMC Health Serv Res. 2023;23(1):118.
Ohri N, Rapkin BD, Guha D, Haynes-Lewis H, Guha C, et al. Predictors of radiation therapy noncompliance in an urban academic cancer center. Int J Radiat Oncol Biol Phys. 2015;91(1):232-238.
Clark NM, Hernandez AH, Bertalan MS, Wang V, et al. Travel time as an indicator of poor access to care in surgical emergencies. JAMA Network Open. 2025;8(1):e2455258.
Ghimire A, Maves GS, Kim SS, Raman VT, et al. Patient characteristics associated with NPO (Nil Per Os) non-compliance in the pediatric surgical population. Pediatric Health Med Ther. 2022;13:235-242.
Pohlman GD, Staulcup SJ, Masterson RM, Vemulakonda VM. Contributing factors for cancellations of outpatient pediatric urology procedures: Single center experience. J Urol. 2012;188(4S):1634-1638.
Campbell C, Mora A, Russo S, Abdur-Rahman N, et al. The financial burden of cancelled surgeries: Implications for performance improvement. American Society of Anesthesiologists’ Practice Management Conference 2011.
Honecker N. Decrease preventable day of surgery cancellations. Presented at the ACS Quality and Safety Conference, July 17-20, 2025, San Diego, California.
