The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

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 efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods. 

For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

In October 2008, Dr. Richard Mgaga, Head of the Malaria Control Programme in Uganda reviewed the monthly malaria statistics report for the district of Apac, which in April of 2008 had undergone a pilot indoor residual spraying (IRS) program using DDT in a campaign to prevent mosquitoes from biting and spreading malaria. The campaign was halted by a court injunction requested by organic farmers, exporters and environmentalists in May 2008, and the injunction was upheld by the High Court in June. In early August, the Uganda Health Ministry began spraying a pyrethroid insecticide in place of DDT. Meanwhile the Ugandan Attorney General was challenging the High Court’s decision.  Dr. Mugaga was under pressure by the Presidential Malaria Initiative (PMI) to undertake a full program of IRS in 300,000 households in the northern districts of Uganda, including Apac. However, he was unsure whether to proceed, given the opposition and apparent problems that surfaced when the Apac pilot was implemented.

Colburn University is the largest private university in the fictitious state of Columbia and is often recognized by people from distant parts of the country for its award-winning Division I athletic teams. That’s why when athletic director Harry Ritchie makes an offhanded comment about Colburn student-athletes with eating disorders, the press pounces. This incident coupled with a complaint from a parent draws the attention of Dean Francis Reilly, who finds himself needing to peel back some of the layers embedding college athletics on the issue of eating disorders among athletes. Throughout the narrative, different perspectives on sports and eating disorders are revealed from top-level administrators, like Dean Reilly, to the student-athletes themselves. As the story concludes, the conversation about eating disorders has begun, but questions still remain on how to make Colburn University a healthy environment for its student-athletes.

This case traces the story of Malala Yousafzai who has advocated passionately for girls’ right to education. In October 2012, a militant group with ties to the Taliban shot 14-year-old Yousafzai in the head as she was riding the school bus home after a day of classes. Yousafzai recovered and became the youngest recipient of the Nobel Peace Prize in 2014. This case explores the social factors that made such an attack possible and why there continue to be such barriers to educational opportunities for girls. "Malala Yousafzai: A Young Female Activist" is a part of a case series on violence against women that illustrate the critical role for leadership through an examination of how factors within a society influence women’s health. Students analyze the situations described by considering the circumstances that placed each protagonist in vulnerable positions. Participants examined the commonalities and differences of these situations in an effort to understand the circumstances that affect women’s well-being. Additionally, using the cases as a framework, students analyzed the connections between collective outrage, reactive action, and leadership. 

This case describes efforts to balance public health concerns with religious and cultural practices of religion pilgrims in India. The Kumbh Mela festival, the largest mass gathering in the world, takes place every 12 years in Allahabad, India. Pilgrims at the 2013 festival followed toilet and water sanitation practices common in South Asia, practicing defecation in both designated areas (contained squat toilets and private “flag” areas for open defecation) as well as public defecation in the sand or by the riverbanks. The construction of the site - and organization of the facilities to support it - follow a detailed system that has developed over decades of close collaborations with national, state, and regional governments and religious leaders, and includes the provision of clean drinking water and public toilets. This case describes efforts by government officials during the 2013 festival to ensure and maintain adequate and appropriate sanitation facilities (toilets and the use of safe drinking water) and the long-term impact of the observed practices on the physical environment. The case introduces students to the conditions and challenges of water and sanitation as it relates to cultural issues (social determinants of health) in global communities with limited resource for optimal health governance.

This case explores Nigerian attorney Hauwa Ibrahim’s defense of a woman charged with adultery by Islamic Shariah law. One of Nigeria’s first female lawyers, Ibrahim develops a strategy to defend a young married woman, Amina Lawal, against adultery charges that could potentially, if the court judged against her, result in her death. While many Western non-governmental organizations and advocacy groups viewed Lawal’s case as an instance of human rights abuse and called for an abolition of the Shariah-imposed punishment, Ibrahim instead chose to see an opportunity for change within a system that many – especially cultural outsiders – viewed as oppressive. Ibrahim challenged the dominant paradigm by working within it to create change that would eventually reverberate beyond one woman’s case. Willing to start with a framework that saw long-term opportunity and possibility, Ibrahim developed a very measured change approach and theory framed in seven specific principles. Additionally, Ibrahim’s example of challenging her own internal paradigms while also insisting that others do the same invites students to examine their own internal systems and paradigms.

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

Many millions of people around the world experience the pervasive, and often painful, societal messages of colorism, where lighter skin tones are asserted to be more attractive and to reflect greater affluence, power, education, and social status. Even in places where the destructive effects of colorism are fairly well understood, far less is known about the problem of skin-lightening (really, it’s “skin bleaching”) creams and lotions, and the health risks that consumers assume with these products. In this teaching case, the protagonists are two women who have recently immigrated to the United States from Nigeria and Thailand, both with a life-time of experience with these products like many of the women of their home countries. As the story unfolds, they struggle along with the rest of the characters to copy with the push and pull of community norms vs. commercial influences and the challenge of promoting community health in the face of many societal and corporate obstacles. How can the deeply ingrained messages of colorism be effectively confronted and transformed to advance social change without alienating the community members we may most want to reach?

The SALUDos program began in 2008 as a response to an influx of migrant seasonal farm workers (MSFWs) at a mobile medical unit serving homeless persons in Santa Clara County in Northern California. The program offered patients free and low-cost primary care services, linkage to resources, and advocacy.  As the farm workers involved in this program became more involved in their primary care, they advocated for evening hours, transportation, linkage to coverage programs, and health education resources to better understand their medical and psychological conditions. During continual modifications of the SALUDos program, the team sought to understand and address large-scale social forces affecting migrant health through interventions to mitigate health inequities.