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Supplement to the A case. For nearly three months, John Carter, a vascular surgeon by training, had been studying a variety of clinical processes at Deaconess-Glover Hospital in Needham, Massachusetts. Carter was looking for an opportunity to test the applicability of Toyota Production System 'Rules-in-Use' in the health care context. After several weeks of increasing focus, he had found a particular process medication administration to test his ideas. He had just suggested to John Dalton and Julie Bonenfant, the hospital's president and vice president, that they create a learning unit or model line within one of the nursing wards to begin conducting experiments. Dalton and Bonenfant received his modest proposal negatively. They complained that his proposal seemed remarkably unambitious, yet, paradoxically, they complained that creating a dedicated learning unit within the larger nursing ward would be infeasible. Carter struggled to explain how they could react simultaneously with such seemingly contradictory sentiments.