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This case presents an operating challenge: how does an organization sustain the initial progress achieved through its new quality-improvement system. Nurses and other clinical staff feel that the culture does not support the acknowledgment of mistakes, and the operations manager is trying to ascertain whether this 'blame-game' environment is the cause of the improvement slowdown or whether there are other factors. Students are asked to apply systems-thinking tools to reveal their hypotheses of the causes of the improvement problem and to create a stock-flow map of the system structure. A systems-dynamics model can be used in class or as a preparation assignment. The simulation model enables students to develop a deeper understanding of the systems-dynamics behavior. The subsequent cases in the series (UVA-OM-1043 and UVA-OM-1044; UVA-OM-1045 is an abridgement of the A, B, and C cases) provide students with opportunities to practice the quantification of systems relationships (dominated by soft variables) and to develop a simulation model.