State of Emergency at Mercy Hospital

9-409-048
REV: JUNE 28, 2010
THOMAS J. DELONG
CHIRAG SHAH
State of Emergency at Mercy Hospital

Dr. Scott Gabu, chairman of the Emergency Department of the world-renowned, university-based
Mercy Hospital, was deeply disturbed when he read the letter that arrived in January 2002 from the
family of John Samson, a patient who had come to the emergency room one week earlier. In the letter
(Exhibit 1), Tara Samson, the patient’s daughter, described an incident that occurred at the hospital in
which Dr. Jason Diliper, the attending chief resident in charge of Mr. Samson, irresponsibly
threatened Mr. Samson’s health by leaving his bedside while Mr. Samson was having difficulty
breathing. Additionally, Diliper made an insulting and unprofessional comment suggesting that Mr.
Samson, an elderly man who frequently came to the hospital with trouble breathing, deserved the
poor treatment. Tara, who was with Mr. Samson at the time, found Diliper’s behavior reckless and
inexcusable. The Samson family was seriously considering taking legal action against the Emergency
Department for violating their father’s patient rights.
After training at Mercy Hospital as a resident in emergency medicine for over three years, Diliper
had been appointed chief resident in June 2001 because of his exceptional clinical record. Throughout
his residency, he had received significant recognition, including being awarded the prestigious Peer
Award from the department during his second year for outstanding patient service. In recent
months, however, there had been several anecdotal reports that Diliper had been acting increasingly
unprofessional. In the first instance, he was reported to have examined a female patient with the
curtains open, exposing her to the staff and other patients. Several weeks later, a neurologist
consulting in the emergency room saw Diliper embarrass a medical student in front of a patient for
taking too long with a physical examination. Although these incidents were troubling, the reported
actions surrounding the incident with Samson had escalated Gabu’s concern to another level. Gabu
reflected on the most recent event as he started his patient rounds of the morning and wondered how
to approach the situation.
Dedication to Service
Diliper and Gabu had known each other for a long time. Diliper was the son of a fellow
university professor, and Gabu vividly remembered the day he offered to help the shy, intellectual
college freshman in considering a medical career. Gabu had arranged for Diliper to sit at the patient
reception desk in Mercy’s Emergency Department on a busy Friday night during his Winter break to
help him experience patient care firsthand. Diliper found the experience to be both shocking and
strangely intoxicating. While he had to admit that the sight of an incoming trauma had made his
________________________________________________________________________________________________________________
Professor Thomas J. DeLong and Chirag Shah (MBA 2003) prepared this case. The hospital mentioned in the case is entirely fictional. HBS cases
are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of
effective or ineffective management.
Copyright © 2008, 2010 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-
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digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.
This document is authorized for use only in Professor Maria Angelica B. Lleander's SEELL - June 2022 The Medical City Junior Executive Development Program (4) at Asian Institute of
Management from Oct 2022 to Apr 2023.
409-048 State of Emergency at Mercy Hospital
stomach turn, he was inspired by the selfless way in which the medical staff applied their seemingly
endless knowledge to treat patients.
Excited by the experience, Diliper enthusiastically pursued his premedical studies. While
spending long hours studying biology, chemistry, and physics, he also completed a research project
in cell biology. To further his knowledge of clinical medicine, he volunteered at the hospital, helping
out rehabilitating patients with their recovery.
Diliper applied to medical school during his senior year. In April, after being accepted at a
number of schools, he decided to attend the Yale School of Medicine. Diliper chose Yale because of
its emphasis on early clinical training and the flexibility of its curriculum. While studying basic
sciences during his first two years at Yale, he accompanied a physician tutor into the hospital once a
week to practice taking medical histories and conducting physical exams on patients. He treasured
having the opportunity to talk to patients and piece together diagnoses from their rich stories.
Simultaneously, the flexible curriculum allowed him to pursue a number of extracurricular volunteer
activities. In those first two years, he also founded a program that worked with a local middle school
to bring medical students in to teach low-income children about drugs and teenage pregnancy.
In contrast to the first two years, Diliper’s third year of medical school consisted of a series of four-
week clinical rotations in specialties ranging from surgery to psychiatry to emergency medicine. The
hierarchical structure of the medical teams he joined consisted of attending physicians at the top,
residents and interns (first-year residents) in the middle, and medical students at the bottom (Exhibit
2). During these rotations, he was paired with an intern and was responsible for following several
patients through their hospital course. Each morning, around 6:00 a.m., he would arrive at the
hospital to check on his patients in order to find out what happened to them overnight. At 7:00 a.m.,
he would join his team for patient rounds and they would visit each patient cared for by the team.
During rounds, Diliper would present the latest updates on his specific patients and then the team
would finalize the treatment plan for that day. After rounds, Diliper would spend the rest of the day
implementing the action plans and spending time with his patients.
Reality Hits
Diliper found the reality of hospital life to be somewhat disconnected from his vision of clinical
medicine when he entered medical school. Because the residents might be caring for as many as 20
people at any given time, they were often overworked and frequently rushed when examining new
patients. He knew that the hospital operated on small margins, but he often worried that the
exhausted residents would miss something important as a result of their time constraints in dealing
with individual patients. He did his best to help out by doing menial tasks such as recording lab
results in the team’s patient binder. He also conducted additional histories and physicals by himself
to make sure that nothing was missed with his patients.
Of all the clinical experiences, emergency medicine was, by far, his favorite. The Emergency
Department was a fast-paced environment that combined interacting with a variety of patients with
diagnosing illnesses and performing procedures. Residencies in emergency medicine required three
or four years of training after medical school. Residency training programs typically involved
rotating through a number of other services—surgery, internal medicine, pediatrics, and psychiatry,
for example—in addition to specific emergency medicine training. A career in emergency medicine
also offered higher average salaries and more work–life balance through a job shift structure as
opposed to the 36-hour call days of the other specialties.
State of Emergency at Mercy Hospital 409-048
Diliper finalized his decision to go into emergency medicine. To supplement the residency
application that he would submit at the beginning of his fourth year, Diliper sought out
recommendations from clinical supervisors from previous rotations. Because of his outstanding
performance in his emergency medicine and surgery rotations, he received excellent
recommendations from the chairpersons of each department. He consulted Gabu frequently
throughout this process. Seeing Diliper’s potential as a high performer, Gabu suggested that Diliper
apply to the residency program at Mercy Hospital.
The Residency
During the beginning of his fourth year, Diliper began preparing his residency application and
wrote a personal statement as to why he wanted to go into emergency medicine. He wrote about a
recent experience he had in which he helped to diagnose lung cancer in an elderly gentleman.
During one of those busy nights when his intern was occupied with another task, Diliper spent extra
time talking to the man. In doing so, he uncovered a history of asbestos exposure, leading to a
diagnosis that changed a small portion of the treatment strategy. He recalled beaming with pride
when his team congratulated him on his excellent history-taking skills. The experience had cemented
his desire to teach the importance of balancing the soft side of medicine with clinical acumen.
Of all the places he interviewed, he was most impressed with the program at Mercy Hospital.
Mercy Hospital had a prestigious reputation and would prepare Diliper for a career as a faculty
member at a top academic program. Mercy also appealed to Diliper because he liked the possibility
of having Gabu as a mentor while he trained as a resident. In March, the nationwide Match process
would occur, and through a complicated algorithm, he would be given a single residency spot based
on the fit between the programs’ student rankings and his choices. He put Mercy Hospital at the top
of his list.
As he opened the seal of the Match envelope, he reflected on the long process he had gone
through to get to this day. He recalled pulling all-nighters studying in order to write excellent exams
in the competitive premedical classes in college. He remembered his anxiety in waiting to hear
whether the top medical schools had accepted him. He looked down at his assignment, and saw that
he had indeed been assigned to Mercy Hospital.
A Growing Crisis
Diliper moved the day after graduating from Yale. He had about two weeks to settle into his new
apartment, and he wanted to spend some time revisiting some of the overcrowding and patient care
issues facing his specialty.
Specifically, he knew that while the number of patient visits to emergency rooms was rising
nationwide, the financial pressures on emergency rooms were immense, forcing many of them to
close down in the process. Third-party payers such as the government and managed care
organizations were not raising reimbursements as rapidly as the cost of care was rising. Lacking the
resources to expand their facilities, hospitals were forcing Emergency Departments to divide patient
rooms in half and put beds in hallways to accommodate more patients (Exhibit 3). During crowded
periods, the Emergency Department staff often had to work frantically to make sure that patients
received the examinations and treatments they needed. Coupled with the high cost of new,
expensive technologies, ordered primarily to protect against malpractice liability, Emergency
Departments, and the medical system as a whole, were being squeezed from all sides. (See Exhibit 4
and Exhibit 5 for recent trends in emergency medicine.)
As a result of overcrowding, patients were now, on average, waiting 4 or more hours just to see a
physician and up to 12 hours to be taken to a room in the hospital. Because of these long waits,
patients were becoming increasingly annoyed with the care they received. At times, physical
crowding also eliminated patient privacy, resulting in detailed histories being conducted with other
patients within hearing distance. (See Exhibit 6 for a representative work shift for an emergency
physician.)
Reputation for Excellence

In spite of these issues, Diliper approached his residency with rigor. Although it was challenging
to maintain a positive attitude when the Emergency Department became overcrowded, he recognized
the importance of professionalism when dealing with the vulnerability that a patient felt while in the
hospital. He often thought about how he would want his parents to be treated if they came through
the emergency room and tried to use that as a standard for the quality of care with which he
practiced medicine.
Throughout his first few years, he developed a strong reputation for being a team player and an
outstanding physician. On multiple occasions, the department had received letters from patients
highlighting his exceptional attitude and compassion in dealing with patients. He also received a
number of positive recommendations through Mercy Hospital’s “Star Performer” program, an
initiative in which employees anonymously reported outstanding acts of professionalism by fellow
employees. At the end of his second year of residency, he won the annual Peer Award, given to one
resident in each class who demonstrated the highest level of patient service for that year.
Diliper also impressed Gabu throughout his training. He was even better than Gabu had expected
and was an inspiration to both physicians and staff members. Diliper had mentioned his interest in
pursuing a career in academic medicine after residency several times, and Gabu tried to develop
Diliper’s teaching skills whenever they were working the same shift. During his third year, based on
Diliper’s professional ambitions and performance, Gabu nominated him for the important role of
chief resident for his final year of residency. Ultimately appointed by the residency director, a chief
resident nomination is a prestigious honor that combines the responsibility of instructing junior
residents with administrative responsibilities in the department. Diliper was formally nominated in
January of his third year and, touched by the vote of confidence his superiors had in him,
wholeheartedly accepted the position of chief resident for his fourth and final year of residency.
A Chief in Trouble
Gabu recalled the day in September that Nurse Marc Roy had come to him to discuss the first of a
series of negative incidents surrounding Diliper. Throughout his four-year employment in the
Emergency Department, Roy had earned Gabu’s trust as an effective, hard-working nurse. Three
days earlier, on a busy Friday night, Roy had seen Diliper enter a patient room to examine a
disoriented female patient. As Roy was assembling the medical chart, he looked into the room and
saw Diliper listening to the patient’s back as she sat up in her bed. Diliper had carelessly left the
curtains open, exposing a significant portion of the patient’s chest to him and several patients around
him. Fortunately, Roy was able to quickly close the curtains. Roy had struggled as to whether he
should report the incident to Gabu, especially given Diliper’s typical high-quality performance.
Diliper explained what happened when Gabu called him into his office to discuss the incident as
per the hospital’s protocol for disciplinary action (see Exhibit 7). Right before he had gone in to
examine the woman, he received a base station call from the paramedics informing him that several
trauma patients would be arriving in a few minutes. Diliper knew that he had to get the patient out
of the room quickly to free it up for one of the incoming patients. When Gabu specifically asked him
why he had left the curtains open, Diliper replied, “I wanted to close the curtains but, in the rush of
the moment, I just did not get around to it. It definitely will not happen again.” He also said that he
had not had much sleep the night before. He had been in the process of completing an application for
a fellowship program that would begin the following year. Given his reputation for compassionate
care, Gabu did not pursue disciplinary action but simply stressed the need for maintaining patient
privacy at all times.
In December, Gabu received a phone call from Dr. Lisa Davis, a neurologist. While consulting in
the emergency room on another patient, Davis witnessed Diliper behave unprofessionally with a
medical student. As part of the rotation experience at Mercy Hospital, medical students often
examined a nonurgent patient first and then presented the case to one of the physicians. Two days
earlier, Davis was standing outside a patient’s room writing in a medical chart and heard a medical
student talking to the patient. It was clear that the student was taking extra time to build rapport as
the patient sounded scared.
About a minute later, Davis said she saw Diliper hurriedly stomp toward the room. With one
swift move, he yanked the curtains open and, in front of the patient, scolded the medical student,
saying, “Why is this taking you so long? Move.” He stepped in front of the student and began to
examine the patient. Stunned, the medical student backed away. “It was painful to watch,” relayed
Davis.
Trying to get a better sense for what happened, Gabu went up to Diliper the next day and asked
how the medical students on the rotation were doing. Diliper dismissed any unusual incidents,
saying, “They are doing as expected.” Gabu also asked another attending physician to speak with
Diliper about the medical students, to which Diliper responded in a similar manner.
Diliper’s escalating lack of professionalism had come to a head with the most recent incident.
Yesterday, Gabu had received a letter from the daughter of Mr. Samson – an elderly man who
frequently came to the hospital from his local nursing home with shortness of breath episodes.
According to the letter, one week earlier, Mr. Samson had come in again with difficulty breathing.
His problems had been successfully resolved in the past with supplementary oxygen and nebulized
drug treatments.
From the letter and a conversation Gabu had with nurse Jessica Williams, he pieced together
what had happened. At around 1:20 p.m. on a busy Monday, Williams, a recent hire just out of
nursing school, wheeled Mr. Samson’s gurney into a spot in the hallway while he waited for an
empty patient room. At that time, she noted that he was breathing quite rapidly and appeared very
short of breath. His daughter, Tara, had come with him, but had stepped away to use the restroom.
As Williams interviewed Mr. Samson, Diliper walked out of a patient’s room nearby and announced
that he was starving and would return shortly after he got a bite to eat. Williams, worried about Mr.
Samson and anxious to have him seen immediately by a physician, beseeched Diliper to come help
her before he left. Clearly annoyed, he reluctantly agreed.
By this time, Tara had returned from the restroom and was trying to make her father more
comfortable. As Diliper walked over with Williams, he recognized Mr. Samson lying in the bed and
groaned. “Not again,” he muttered. Without examining the patient, he went over to the computer
and ordered the same medications he had ordered for Mr. Samson the previous week. He then said
he would be back in 10 minutes and walked out of the Emergency Department.
Williams started the treatment. Over the next five minutes, Mr. Samson struggled even harder to
breathe. Williams was dismayed when the first reading on his oxygen saturation was 72%. She knew
that it needed to be over 90% as quickly as possible. She turned up the oxygen. She waited another
minute and took his saturation again. It was at 75% and not improving.
Mr. Samson continued to struggle and appeared slightly blue. “Help him!” Tara said, alarmed.
Williams started to sweat. None of the other physicians in the department were anywhere to be seen.
Where was Diliper? Why wasn’t he back yet? She told one of the registration staff to page Diliper
immediately. She turned up the oxygen to the maximum setting and prayed that someone would
come and help her.
A minute later, Diliper walked in, as Williams waved at him frantically, he threw away the end of
a sandwich and hurried over. She quickly explained what had transpired with Mr. Samson since
Diliper had left the ER. He asked Tara to step back and then pulled out his stethoscope and listened
to Mr. Samson’s chest. After a few seconds, he told Williams to add a new medication and then
stepped over to the computer and put in the order. Williams administered the new medication and,
after a minute, checked Mr. Samson’s oxygen saturation. It was at 93%. Mr. Samson, exhausted, was
breathing a bit more easily. Before Diliper walked off, both Williams and Tara saw him take one last
annoyed look at Mr. Samson and say, “Serves him right.”
Diagnosis and Treatment

The incident with Mr. Samson found itself in the rumor mill. The story had spread rapidly
through the Emergency Department. Although Diliper still had a lot of credibility with the patients
and the staff, the most recent situation was very troubling. Not only was it a serious transgression of
patient responsibilities, but his unprofessional behavior was also threatening the very culture that
Gabu was trying to build in the Emergency Department. Gabu knew that Diliper was applying for a
fellowship position and continued to pursue an academic career and it did not seem like he was
losing interest in the specialty. Why was Diliper acting this way after so many years of outstanding
patient service? Was this the time to take disciplinary action against him to try and prevent legal
action, or did this situation warrant some other approach?
Exhibit 1 Letter from the Samson Family
The Samson Family

3624 Ionia Street
Worcester, MA 01602
January 22, 2002
Dr. Scott Gabu

Department of Emergency Medicine
Mercy Hospital
75 Jackson Street
Newtonville, MA 02115
Dr. Gabu:
I am writing to express my anger and disappointment with the care my father received from one
of your physicians, Dr. Jason Diliper, when we went to seek medical care for him in your Emergency
Room yesterday. My father came to the hospital because he was having trouble breathing. He was
placed in the hallway and was attended to by a nurse.
Dr. Diliper prescribed my father’s usual medication to take care of his breathing difficulty.
However, rather than waiting to see if my father improved, Dr. Diliper left the emergency room,
apparently to get something to eat. Neither the initial therapy nor the additional oxygen improved
my father’s breathing. It was not until Dr. Diliper returned from his lunch and gave my father
another medication that he improved. While we found Dr. Diliper’s behavior reckless, I was even
more appalled when I heard Dr. Diliper say that our father deserved what had happened and that he
should never come back.
Our family has been in consultation with our lawyers and is considering seeking legal action
against your physician. We did not want it to come to this, but as of now, we have no reassurance
that this type of problem will not happen again. While this is not our ideal way of solving this
problem, legal action may be the only way to get our point across.
Regards,
Tara Samson
Source: Created by casewriters.
Exhibit 2 Medical Team Structure
Consulting Attending
Physician Physician (MD)
Chief
Resident
Senior
Resident
Intern Intern
Medical Medical
Student Student
Exhibit 3 Patient Visits to Emergency Departments in the United States: 1992–19991
Exhibit 4 Number of Open Emergency Departments and Beds in a Representative State

(California), 1990–19992
Exhibit 5 Emergency Medicine Trends in the United States
• Number of emergency departments:
1994 1999 Change
4,547 4,177 –8.1%3
• 91% of hospital emergency department directors reported crowding as a problem.4
• 2001: Ambulance diversions due to overcrowding reported in 32 states. “Substantial problems

accessing emergency services occurred in at least 22 of these states.”5
• From 1992–2002, the number of critically ill people visiting emergency departments increased by
59 percent and urgent visits increased by 36 percent in California emergency departments.6
10
Exhibit 6 Representative Eight-Hour Emergency Medicine Attending Shift
7:00 a.m. Shift officially starts. Get updates from night shift attending on six overnight
patients currently awaiting inpatient rooms. Read patient charts.
7:50 a.m. Meet and examine remaining patients. Write notes in patient records.
9:00 a.m. Second-year resident lecture on acute myocardial infarction in ED conference room.
Chief resident continuing supervision in the department.
9:30 a.m. Construction worker presents with laceration. Resident handles stitches.
9:40 a.m. Paged by chief resident. Patient Desmond having acute shortness of breath
(suspected pneumonia patient). Leave conference to examine patient. Treatment
initiated.
10:20 a.m. Construction worker discharged. Multiple other patients placed into beds and
treatments initiated by residents. Unable to return to conference.
10:25 a.m. Two patients assigned to rooms on internal medicine service. Transported upstairs.
10:30 a.m. Mr. Desmond experiencing respiratory distress. Patient requires emergency
intubation, which is successfully performed by third-year resident. Patient
transported to available ICU bed.
11:35 a.m. Three patients assigned beds to surgery service. Transported upstairs.
12:05 p.m. Remaining overnight patient transported upstairs.
12:35 p.m. Receive call from paramedics. Auto versus pedestrian trauma patient with severely
depressed mental status will be arriving in 10 minutes. ED nurses prepare trauma
bays. Code Trauma paged.
12:45 p.m. Patient arrives and, after initial resuscitation, is emergently intubated by chief
resident. After x-rays, patient taken to CT scan by trauma surgery team.
12:56 p.m. CT complete. Patient transported to operating room for exploratory laparotomy.
1:04 p.m. Sit down to eat a banana.
1:10 p.m. Write medical note on trauma patient.
1:22 p.m. Listen to resident presentations on other patients in ED.
3:00 p.m. Shift officially ends. Begin briefing new attending on current patients.
3:40 p.m. Finish briefing new attending on existing patients. New patients already arriving.
Say goodbye to medical team and head home.
11
Exhibit 7 Resident Disciplinary Process at Mercy Hospital
I. Initial disciplinary investigations and actions against residents shall be initiated by the
department chairperson. Discipline for minor violations by the department chairperson
shall include reprimand and minor suspensions (two days or less).
II. For serious violations, the department chairperson shall convene the Administrative
Council. After performing an investigation, the council shall issue recommendations
regarding reprimand, suspension, or termination.
12
Endnotes
1 Richardson LD, Asplin BR, Lowe RA. Emergency department crowding as a health policy issue: past
development, future. Ann Emerg Med. 2002;40:388–393.
2Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency
departments, 1990–1999. Ann Emerg Med. 2002;39:389–396.
3American College of Emergency Physicians 1998–1999 Safety Net Task Force. Defending America's Safety Net.
Dallas, TX: American College of Emergency Physicians; 1999.
4 Derlet R, Richards J, Kravitz R. Frequent overcrowding in US emergency departments. Acad Emerg Med.
2001;8:151–155.
5 Waxman HA. National preparedness: ambulance diversions impede access to emergency rooms. US House
of Representatives Web page, October 16, 2001; http://www.house.gov/reform/min/pdfs/pdf_com/pdf_
terrorism_diversions_rep.pdf. Accessed April 2003.
6 Lambe et al. Trends in the use and capacity of California’s emergency departments.
13

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9-409-048

REV: JUNE 28, 2010

State of Emergency at Mercy Hospital

Reputation for Excellence

Diagnosis and Treatment

Exhibit 1 Letter from the Samson Family

The Samson Family

Dr. Scott Gabu

Source: Created by casewriters.

Exhibit 2 Medical Team Structure

Source: Created by casewriters.

Exhibit 3 Patient Visits to Emergency Departments in the United States: 1992–19991

Source: Created by casewriters.

Exhibit 4 Number of Open Emergency Departments and Beds in a Representative State

Source: Created by casewriters.

Exhibit 5 Emergency Medicine Trends in the United States

• Number of emergency departments:

1994 1999 Change

4,547 4,177 –8.1%3

• 91% of hospital emergency department directors reported crowding as a problem.4

• 2001: Ambulance diversions due to overcrowding reported in 32 states. “Substantial problems

Source: Created by casewriters.

Exhibit 6 Representative Eight-Hour Emergency Medicine Attending Shift

Source: Created by casewriters.

Exhibit 7 Resident Disciplinary Process at Mercy Hospital

Source: Created by casewriters.

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