The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care's Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department. The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center.

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?

This case focuses on the challenges of keeping a collective impact program-the Tackling Youth Substance Abuse (TYSA) program on Staten Island-focused and effective over time, a problem faced by many collaborative community-based efforts. The TYSA program was founded in 2012 as a cross-sector collaborative response to the alarming rates of substance abuse on Staten Island, using a collective impact framework. In the four years since its founding, TYSA had accomplished a great deal. But by October 2016, when the case opens, many of the original members of TYSA's steering committee-most of whom had been high-level decision-makers in their organizations-were delegating their spots to mid-level staff who were not empowered to make organizational decisions. In addition, TYSA's early successes against prescription drug abuse were increasingly overshadowed by a growing opioid problem on the Island and by a continuing culture of alcohol abuse by underage teens. A subtler challenge was that, in the Staten Island community, TYSA was over-identified with Adrienne Abbate, TYSA's Project Director, herself; how could TYSA shift the community's perception to demonstrate the program's value beyond its leader? Project Director Adrienne Abbate decided to pull TYSA's executive leadership and staff together to discuss strategies to reinvigorate the program and to sustain the momentum they had fought so hard to create.

As Angela Laramie compiled her thirteenth annual report on sharps injuries (SIs) among hospital workers for the Massachusetts Department of Public Health's Occupational Health Surveillance Program, she noted that the prevalence of injuries had remained at the same level for six years in a row. From 2002 through 2009, the SI rates had trended downward as hospitals implemented sharps injury prevention plans, but starting in 2009, the decline in rates and number of sharps injuries appeared to have stalled. Angela hoped to evaluate the reasons for the apparent lack of progress over the last few years, and to reassess the state's approach: were the data they had been collecting adequate to meaningfully capture the sources and incidence of SIs in Massachusetts hospital workers? Did it clearly indicate where interventions should be targeted? Were there other data that could help her better understand the flat trend line? What did the data tell her, and what more should she know?

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?

Southcoast Health System consists of three hospitals in southeastern Massachusetts: St. Luke's in New Bedford, Charlton Memorial in Fall River, and Tobey in Wareham, as well as numerous affiliated entities. But how did the merger that created the Southcoast system came about? "Basically, we merged because we wanted to, not because we needed to," said John Day, President and CEO of Southcoast Health System (formerly the CEO of St. Luke's Hospital). "We wanted to avoid a divide and conquer situation. As community hospitals, we needed to be able to serve the long-term interests of our communities." "We decided it was ridiculous to be competing with each other," added Ron Goodspeed, MD, President of Southcoast Hospitals Group and Executive Vice President of Southcoast Health System (formerly the CEO of Charlton Memorial). A mix of events and environmental conditions set the stage for the three hospitals to consider merging. One of the most critical of these was a turnover in Charlton's CEO position. Meanwhile, the health care environment was becoming increasingly volatile and competitive, and the focus in the business community was shifting away from city-specific planning and toward developing the larger southeastern area of the state. The predominant goal of the management and boards at all three hospitals was to find a way to best serve the interests of their communities. They decided on a full asset merger: building a single executive management team and board of trustees to oversee the organization.

In early 1996, Charlton Memorial, St. Luke's, and Tobey Hospitals were contemplating a full asset merger, something that had never been done before in Massachusetts. The logistics of the merger and its impact on the finances of the hospitals were among the many unknowns that the boards of trustees and management were facing. But, as Ron Goodspeed, MD, CEO of Charlton at the time, explained, "We had a fundamental desire to make it work. We expected hurdles - we knew there would be difficulties - but that is not a reason to back away...We took one step at time, taking care of hurdles as they appeared."

On November 15, 1996, Stanford's Board of Trustees and the University of California (UC) Board of Regents voted to merge their two academic medical centers; on November 1, 1997, the merger became official. However, less than two years later, in October 1999, the merger came to an abrupt end. Was the merger an ill-conceived "snakebit venture" or a reasonable response to the environmental and economic pressures of the time that fell apart in its execution? Would the same ills have befallen Stanford and UCSF regardless of the merger?

Dr. Laurie Gianturco ("Dr. G."), Chief of Radiology at Baystate Health and President of the private imaging practice Radiology & Imaging, Inc. ("R&I"), and her partner for this project, Suzanne Hendery, VP of Marketing & Communications at Baystate Health, considered their new assignment. With Baystate leadership's full executive sponsorship and support, but no additional budget, they were tasked with consolidating two competing practices-one operated by R&I, the other by Baystate Medical Center-to form a new breast services center under the Baystate umbrella. The consolidation would simplify redundant Baystate-affiliated breast services offerings, making the system less confusing for patients and providers while giving Baystate the opportunity to offer more patient-centered services as well as reducing its operating costs and boosting revenues. They knew it would be a complicated project, involving two competing physician practice cultures, three clinical specialty orientations, the potential disruption of existing referral networks, and the merger of imaging services for healthy women along with treatment for women with breast cancer. Despite these challenges, they banded together to define a patient-driven culture, create an integrated program, and build a strong brand anchored by the new facility. Their goal was to gain a competitive advantage by developing a relationship-based approach that would exceed customer (patients and referring physicians) expectations for service. "The financial argument was the easy part," Dr. G reflected. "How to actually design a model of care is where we came to an impasse."

After extensive negotiation, Baystate Health (BH) and the private Radiology and Imaging (R&I) hammered out a clear business plan to consolidate their two practices in a new breast center in a new location. Despite a clear business plan, however, tensions among the two staffs remained high. Project leaders Dr. Gianturco and Suzanne Hendery carefully crafted an internal communication and implementation plan, detailed to the hour, and enlisted a consultant to help to unify the "warring factions." The consultant worked with Dr. G and Ms. Hendery to plan and hold a retreat with all of the stakeholders-clinicians, management, and staff-from all locations and from both legacy organizations, with the goals of constructing a new cultural blueprint and designing a new patient experience.

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.

This case presents organizational challenges facing a physician champion of the Patient-Centered Medical Home (PCMH). Dr. Julian Kuffler, working with his employer, the Mount Desert Island Hospital System (MDI), hoped to persuade the primary care physicians in the system to embrace the PCMH care model. Physician resistance was strongly opposed to some of the key principles of PCMH, such as managing the health of a defined population, standardizing chronic care management protocols, delegating patient care tasks to non-physician members of a care team, and to having strong physician leadership at the system level. At the same time, MDI was a small rural "critical access hospital" with declining admissions, predominantly outpatient-based revenues, and deteriorating finances. MDI leadership viewed high quality primary care to be essential for MDI to be able to attract the best health system partner with which it could affiliate to become part of a larger, more financially viable organization. MDI leadership also hoped to find a partner that could also support its participation in new population health arrangements such as accountable care organizations.