Carmen’s alarm jarred her awake at 6 a.m. She remembers a time when she woke up each morning with renewed energy and enthusiasm, eager to take on the many tasks ahead of her. Today, like so many other mornings in the last year, she has to drag herself out of bed. Within an hour, she will be at her desk in a small office, overflowing with file folders, located down the hall from the Acute Care Unit (ACU) at Saint Theresa Hospital in Queens, NY. This would likely be the fifth day in a row that she would work a 14-hour day, slogging through heaps of paper work, heading off conflicts and dust-ups, and even pitching in to ease her staff’s patient overload. Beyond fatigue, she was beginning to feel overpowered and beaten by the ACU’s problems. About Carmen Carmen Ortega was proud to have fulfilled her immigrant parents’ dream that she graduate from college and become a successful professional. She loved nursing, a field she has worked in for eight years. Most of the eight years she worked in Brooklyn General’s surgery unit, progressively assuming more responsibility, and gaining the respect of her coworkers and superiors. For a thirty-year old, Carmen has lived up to her reputation as a fast-track professional making the most of a burgeoning, competitive health care industry. She jumped at the opportunity to apply for the ACU Nursing Supervisor position at Saint Theresa. Although currently one of the oldest, least modern, and most in-demand hospitals in New York City, the institution and its staff are greatly admired for its persistence in meeting trauma and inner-city health care challenges. Saint Theresa was built in the early 1900s to care for immigrants and remains a valued resource for Queens’ multi-ethnic community. Although the facility has seen better days, the organization’s human capital and reputation clearly make it an attractive target for a corporate take-over. It’s no secret that Saint Theresa’s board has been looking for ways “to save our venerable institution,” and is expected to deliver on short- and long-term plans that include construction of a cutting edge facility with state-of-the-art medical and health care technology—exciting, hopeful prospects in Carmen’s opinion. Rumors fly that a Swiss-based multinational company will buy Saint Theresa as part of that transformation. Carmen’s former nursing school prof and mentor, Michaela Robinson, now Director of Nursing at Saint Theresa, actively encouraged Carmen to take the ACU supervisor job. Michaela candidly described the demands of the job, as well as Saint Theresa’s and the ACU’s need to deal with the organization’s behavioral, structural, and technological problems, adding that she believed Carmen was up to the task, and had every confidence that she would contribute to an improved future. Ambitious, self-directed, and drawn to a worthy cause, Carmen was honored by Michaela’s confidence and stood ready to embrace what lay ahead. About ACU But when Carmen bega ...

1. Carmen’s alarm jarred her awake at 6 a.m. She remembers a
time when she woke up each morning with renewed
energy and enthusiasm, eager to take on the many tasks ahead of
her. Today, like so many other mornings in the last
year, she has to drag herself out of bed. Within an hour, she
will be at her desk in a small office, overflowing with file
folders, located down the hall from the Acute Care Unit (ACU)
at Saint Theresa Hospital in Queens, NY. This would
likely be the fifth day in a row that she would work a 14-hour
day, slogging through heaps of paper work, heading off
conflicts and dust-ups, and even pitching in to ease her staff’s
patient overload. Beyond fatigue, she was beginning to
feel overpowered and beaten by the ACU’s problems.
About Carmen
Carmen Ortega was proud to have fulfilled her immigrant
parents’ dream that she graduate from college and become a
successful professional. She loved nursing, a field she has
worked in for eight years. Most of the eight years she
worked in Brooklyn General’s surgery unit, progressively
assuming more responsibility, and gaining the respect of her
coworkers and superiors. For a thirty-year old, Carmen has
lived up to her reputation as a fast-track professional
making the most of a burgeoning, competitive health care
industry. She jumped at the opportunity to apply for the ACU
Nursing Supervisor position at Saint Theresa. Although
currently one of the oldest, least modern, and most in-demand
hospitals in New York City, the institution and its staff are
greatly admired for its persistence in meeting trauma and
inner-city health care challenges. Saint Theresa was built in the
early 1900s to care for immigrants and remains a

2. valued resource for Queens’ multi-ethnic community. Although
the facility has seen better days, the organization’s
human capital and reputation clearly make it an attractive target
for a corporate take-over. It’s no secret that Saint
Theresa’s board has been looking for ways “to save our
venerable institution,” and is expected to deliver on short- and
long-term plans that include construction of a cutting edge
facility with state-of-the-art medical and health care
technology—exciting, hopeful prospects in Carmen’s opinion.
Rumors fly that a Swiss-based multinational company
will buy Saint Theresa as part of that transformation. Carmen’s
former nursing school prof and mentor, Michaela
Robinson, now Director of Nursing at Saint Theresa, actively
encouraged Carmen to take the ACU supervisor job.
Michaela candidly described the demands of the job, as well as
Saint Theresa’s and the ACU’s need to deal with the
organization’s behavioral, structural, and technological
problems, adding that she believed Carmen was up to the task,
and had every confidence that she would contribute to an
improved future. Ambitious, self-directed, and drawn to a
worthy cause, Carmen was honored by Michaela’s confidence
and stood ready to embrace what lay ahead.
About ACU
But when Carmen began her new supervisory role in the ACU,
she quickly confronted a deeper reality—the reality of
managing within a changing, unstable, severely understaffed
organization. Ten registered nurses (RNs) and five nurse
aids struggle to deliver competent, efficient, and compassionate
care to ACU patients and their grief-stricken families,
despite the out-of-date, cramped facility, and gross
inconveniences—poorly located nurse stations, lack of file
storage,
aging computer terminals to name but a few. Only leaked
recently, Carmen’s predecessor, Crystal, was fired for

3. falsifying time sheets and patient records. Three RNs quit
shortly before Carmen started as ACU’s Nursing
Supervisor. Recognizing the dire need to replace the nurses,
Carmen was astonished when Saint Theresa’s new CEO,
Roman Garvey (“you may call me Dr. Garvey”) a European-
trained West African with an MD and MBA, hired to
increase the institution’s efficiency and profitability, announced
plans to “rightsize” staff and freeze new and
replacement positions.
Back in the ACU trenches, nurses and aids scurry from one
crises to another, lacking backup support, quick access to
needed records, and feeling the pinch of specialized skill sets
that walked out the door when co-workers quit. ACU staff
absenteeism is at an all-time high. Productivity and morale are
at an all-time low. Patient satisfaction ratings are barely
average. Most patients don’t bother to fill out the survey cards
in their discharge packets. Not only is job turnover up
and job satisfaction down, the ACU’s reputation for “shady”
hiring, playing favorites, and “not walking the talk” made
recruiting top-notch candidates very difficult. While the
apparent loyalty of the semi-skilled nurse aids is a relief,
frustrated, overworked RNs continue to ask (in some cases,
angrily) for one-on-one meetings with Carmen. RN’s
complaints cover the gamut—long hours, confining work space,
lack of proper work stations, “buggy” electronic
medical records software, ineffectual job appraisal system, and
unmet promises for adequate training and career
development. Trust in upper and middle management has
eroded.
Last week, a few doctors grumbled during a staff meeting

4. (passed on to Carmen via Michaela) that ACU patient
medication errors were up and the unit’s senior nurse tended to
“drop the ball” when it came to following orders. Dr.
Aazim Al-Jahari, who heads the Ethics and Quality Control
Task Force, was dumb-founded and exasperated by the
news. Helen Connors, the senior nurse in question, has worked
at Saint Theresa her entire career. She burst into tears
when Carmen asked about the doctor’s “observations.” To top
it off, Graciela Rojas, hired a year ago—and among the
hardest working, clearly gifted care givers, and most affable and
skilled communicators on the ACU nursing staff—
suddenly left work a few days ago citing a family emergency.
Rumors quickly spread that Graciela’s departure
suspiciously overlapped with increased investigations by federal
agents of Queens’ hospital employees. Carmen
wonders how Saint Theresa will be able to live up to its mission
and vision, which emphasize compassionate, high-
quality patient care, clinical excellence, and the importance to
be the hospital of choice for professionals in social
medicine and urban health care.
The Challenge—Learning to Lead Change
Carmen’s boss, Michaela Robinson, is deeply concerned about
ACU’s ever-worsening situation, and has requested a
study and status report be done within 30 days. The report will
identify and explain ACU’s problems and causes,
systems affected, alternative measures, and make
recommendations. Clearly, Carmen’s work is cut out for her.
It’s no surprise that Carmen had to drag herself out of bed this
morning!
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