Mathew, I loved your post! The two problems I see most often are both highlighted in your post, and well supported in the reading for this class. In hospital systems, where I work, there is a tremendous resistance to trade, which overlies much of the problems we see in modern healthcare. The aversion to improve a process is rooted in many causes, but is often bolstered by a culture of blame, especially for poor outcomes. In a recent report we prepared in my previous workplace at the Penn State College of Medicine, we called this "institutional inertia". The second problem is the inability to define clean and relevant metrics. I was constantly amazed by how difficult it was to measure what we actually wanted in a college of medicine. Seemingly great scoring systems could not stand up to scrutiny even for the first few minutes after they were floated