As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

This case describes the challenges facing Jon Moussally, the CEO of TraumaLink, a four-year-old social venture that provided trauma first aid to victims of traffic injuries in Bangladesh, a country that had some of the most dangerous highways in the world but no formal emergency response system. Jon, a practicing emergency room physician and public health student, had been shocked by the chaotic traffic that he observed during a trip to Dhaka, Bangladesh, for a course on global health issues. Over the next 18 months, Jon and three partners-two fellow students and the Bangladeshi head of a local social venture organization-decided on a three-pronged approach: they would train community-based volunteers who lived or worked close to the highway to provide free basic trauma first aid; they would develop an easy-to-use 911-type software system to deploy volunteers quickly to a crash scene; and they planned to raise operating funds by selling advertising or subscriptions to companies in Bangladesh whose workers travelled the dangerous highways daily. By the fall of 2017, TraumaLink had been successfully launched along two sections of particularly dangerous highways. Their trained volunteers had been able to quickly and effectively provide first aid to victims of traffic injuries. The software had worked well to notify and deploy volunteers and collect data. However, Jon and his partners had not yet found sustainable, long-term sources of revenue, despite almost four years of trying. After an initial pilot phase in November 2014, the organization had been awarded $142,500 by the US Agency for International Development, but these funds would run out by the end of 2018, with little chance of another round. TraumaLink had proven that they could deliver emergency services and save lives, but could Jon and his partners figure out how to become financially sustainable so that they could continue to support and expand their services within Bangladesh and possibly beyond?

Doing a breakeven analysis for Carlsbad Home Care helped Director Louise Tucker better understand how many more visits she needed to eliminate her deficit. However, she wasn't sure that there was really demand in the community for more nursing, physical therapy or social service visits to allow her to increase visit volume. She also knew that negotiating a higher per visit price from their affiliated HMO was highly unlikely. If increasing volume and raising the price for visits were not feasible, she wondered what else she should be thinking about. She decided she should explore alternatives that would look at her specific programs, staffing approaches, and general expenses. In discussions with her controller, she arrived at five alternatives for consideration.

Physician Moka Lantum was ready to try his hand as a social entrepreneur, aiming to improve healthcare for an underserved population in rural Kenya, where access to clinics was difficult, curable diseases flourished, maternal and child mortality rates were high, and dangerous counterfeit drugs flooded the market. Lantum began to develop a technological solution that could address multiple public sector healthcare problems through a single IT tool, ZiDi, a cloud-based system that could process a wide array of information, from individual patients and their symptoms to drug supplies, the utilization rate of individual clinics, or staff absenteeism. Lantum and a Kenyan partner incorporated MicroClinic Technologies Inc. (MCT), launching ZiDi in August 2012. Lantum's goal for MCT was to demonstrate that ZiDi could improve maternal and child health in rural clinics and dispensaries, and persuade the government to buy it. Over the next two years, ZiDi proved useful, and MCT won endorsements and awards-but no government contract, not even a request for proposal (RFP). By August 2014, the slow pace of government decision-making was threatening MCT's existence. Lantum had to decide: stay the public sector course or diversify into an uncharted market segment with its own unknowns?

In mid-September 2014, the Executive Director of the Health Policy Commission (HPC), an independent state agency in Massachusetts, assessed the proposals submitted by 27 hospitals for projects to be funded from $60m available under Phase 2 of the Community Hospital Acceleration, Revitalization, and Transformation (CHART) Investment Program. The HPC needed to fund projects that would meet the requirements of the CHART program: "to support the Commonwealth's goals to improve the health of its residents, improve the access and quality of care, including patient experience, and reduce the health care cost growth." The HPC had tried to help the eligible community hospitals develop strong, clearly defined projects for Phase 2, building on what they had learned during Phase 1 of the program. The RFP itself contained more detailed requirements than the earlier RFP, and the agency had tried to provide additional guidance by developing FAQs and holding information sessions during the RFP preparation period. Had it worked? What options did the HPC have at this point in the granting cycle to tighten up these projects and ensure that the funds would be used effectively and well?

As CEO Rick Siegrist signed the paperwork to dissolve his three-year-old startup Cambria Health, he pondered what had gone wrong. He had started the company to provide a turnkey software and technical solution to health care organizations that wanted to introduce shared medical appointments to improve patient care. But after several successful beta sites, the company was not able to achieve sufficient traction to continue. After over a year of inactivity, he decided to officially "pull the plug." Rick had previously co-founded three successful healthcare software companies before starting Cambria Health. He wondered what was different with Cambria. Was it a failure related to the idea or vision? Was it the strategy or business model of the company? Execution? Other reasons? Rick knew that he and fellow entrepreneurs liked to talk a lot about their successes, but not much about their failures. Perhaps there was more to learn from those failures regarding future opportunities.

Thandeka Sisulu had just been hired as the new administrative director for the Eastern Cape Clinic, located in the outskirts of the South African city of East London. The Clinic had opened about 18 months ago with support from the government and from two anonymous donor groups. Those funds would soon run out and Thandeka faced the dual challenge of helping the Clinic become self-sufficient and dealing with the long wait times for patients to be seen. She knew that the budget for this year projected a loss, so she decided to better understand the financial problem first.

Thandeka Sisulu had just been hired as the new administrative director for the Eastern Cape Clinic, located in the outskirts of the South African city of East London. The Clinic had opened about 18 months ago with support from the government and from two anonymous donor groups. Those funds would soon run out and Thandeka faced the dual challenge of helping the Clinic become self-sufficient and dealing with the long wait times for patients to be seen. She knew that the budget for this year projected a loss, so she decided to better understand the financial problem first.

Thandeka Sisulu had just been hired as the new administrative director for the Eastern Cape Clinic, located in the outskirts of the South African city of East London. The Clinic had opened about 18 months ago with support from the government and from two anonymous donor groups. Those funds would soon run out and Thandeka faced the dual challenge of helping the Clinic become self-sufficient and dealing with the long wait times for patients to be seen. She knew that the budget for this year projected a loss, so she decided to better understand the financial problem first.

Dr. Osnat Levtzion-Korach was the newly appointed Director of the Hadassah University Hospital-Mt. Scopus, a 350-bed academic community hospital located in the crowded, ethnically mixed neighborhood of northeastern Jerusalem. Mt. Scopus was one of two hospitals in the Hadassah Medical Organization; the larger 850-bed hospital, Ein Kerem, was located about 30 minutes away across Jerusalem. In the past, the two Hadassah hospitals had been centrally managed with the two on-site directors acting primarily as COOs. A new Director General of the system now wanted to de-centralize responsibilities, and Osnat, the first female head of a Hadassah hospital, had been promised much greater control over the finances and management of the hospital than her predecessor had enjoyed. The staff at Mt. Scopus pinned a great deal of hope on their new director to bring resources and a renewed sense of vision to the hospital, but Osnat knew her ability to do this depended in large part on her ability to manage costs as well as change a culture that had always prided itself on providing the best care but had not been held accountable for monitoring expenses or budgets.

John Leader, president of Simsbury Children's Hospital, was reviewing the recommendations put together by his senior management team to resolve the growing problems his hospital was facing. The recommendations, totaling some $10 million, could put the hospital back on a sound financial footing. But John was unsure which of the recommendations made sense and should be implemented. He was particularly interested in understanding the financial, operational and political impact of each one. He was due to meet with the senior management team that afternoon to develop an action plan.

Dr. Casey had just come out of a long meeting with his business manager, Linda Baker, and he was quite concerned. She shared with him that his practice was losing $10,000 a month on monthly revenues of approximately $90,000. Just six months ago he had opened a new office and expected his profit to be growing rather than shrinking. Did he make the wrong decision? He wondered what he should be doing to at least get back to a breakeven level for his practice as a whole.

Lucy Normen, Chief Operating Officer of Sweetbriar Hospital, had just gotten off the phone with her Emergency Department Director, Dr. Max Warner. He was very upset with the present situation in the ED: people currently boarding in the ED hallways because there were no open inpatient beds; some patients waiting over 24 hours to be admitted; stressed out medical staff." Dr. Warner worried about possible mistakes-and likely drops in patient satisfaction scores. Lucy was puzzled. They had just spent millions of dollars on expanding the hospital's emergency department, yet in the three months since it re-opened things had gotten worse rather than better. She had a strong feeling that her problems were all related to inefficient patient flow throughout the hospital, but didn't quite know how to address them.

Lucy Normen, Chief Operating Officer of Sweetbriar Hospital, had just gotten off the phone with her Emergency Department Director, Dr. Max Warner. He was very upset with the present situation in the ED: people currently boarding in the ED hallways because there were no open inpatient beds; some patients waiting over 24 hours to be admitted; stressed out medical staff." Dr. Warner worried about possible mistakes-and likely drops in patient satisfaction scores. Lucy was puzzled. They had just spent millions of dollars on expanding the hospital's emergency department, yet in the three months since it re-opened things had gotten worse rather than better. She had a strong feeling that her problems were all related to inefficient patient flow throughout the hospital, but didn't quite know how to address them.

Lucy Normen, Chief Operating Officer of Sweetbriar Hospital, had just gotten off the phone with her Emergency Department Director, Dr. Max Warner. He was very upset with the present situation in the ED: people currently boarding in the ED hallways because there were no open inpatient beds; some patients waiting over 24 hours to be admitted; stressed out medical staff." Dr. Warner worried about possible mistakes-and likely drops in patient satisfaction scores. Lucy was puzzled. They had just spent millions of dollars on expanding the hospital's emergency department, yet in the three months since it re-opened things had gotten worse rather than better. She had a strong feeling that her problems were all related to inefficient patient flow throughout the hospital, but didn't quite know how to address them.

Jane Leader, president of Simsbury General Hospital, was reviewing the recommendations put together by her senior management team to resolve the growing problems her hospital was facing. The recommendations, totaling some $10 million, could put the hospital back on a sound financial footing. But Jane was unsure which of the recommendations made sense and should be implemented. She was particularly interested in understanding the financial, operational and political impact of each one. She was due to meet with the senior management team that afternoon to develop an action plan.