One of the great paradoxes of institutional change is that even when top managers in organizations provide support for change in response to new regulation, the employees whom new programs are designed to benefit often do not use them. This 15-month ethnographic study of two hospitals responding to new regulation demonstrates that using these programs may require subordinate employees to challenge middle managers with opposing interests. The article argues that relational spaces--areas of isolation, interaction, and inclusion that allow middle-manager reformers and subordinate employees to develop a cross-position collective for change--are critical to the change process. These findings have implications for research on institutional change and social movements.