For 3½ years an occupational therapist persevered in efforts to introduce an innovative outpatient service of multidisciplinary team case management within a general community hospital. The service was intended to meet the needs of discharged clients with severe mental illnesses who were attempting to live successfully and satisfactorily in the community. The reality of attempting to initiate change in medical bureaucracies involves ongoing negotiation and persuasion, issues of power and politics, differing cultural visions, and strongly committed leadership. This case study describes the developmental process of innovation and the contribution of occupational therapy philosophy and practice to the therapist’s emergent leadership in promoting cultural change. Some of the lessons to be learned from this case study by others who would attempt institutional innovation include articulating a clear vision that uses new language, building coalitions, and being flexible and persistent.