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This case, an abridgement of the A, B, and C cases (UVA-OM-1042, UVA-OM-1043, and UVA-OM-1044), 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 critique one representation of the underlying 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. This case is best used in a class where the emphasis is on systems mapping and not on simulation modeling. It can be used to discuss and critique how the hospital manager has tackled the improvement problem and developed a model representation of the system. It can also be used to discuss how a manager assists in the quantification of systems relationships (dominated by soft variables) and in the development of a simulation model.