Justin still teaches us all, thanks to Dale's generous spirit

Dale Ann Micalizzi started Justin's Hope Project in memory of her 11-year-old son who died as a result of medical errors.  It took her nine years to learn why.

Dale now gives scholarships so that young people involved in pediatric care can attend the IHI Annual Forum and learn more about quality and safety and be among thousands of other people who likewise are committed to these ends.

Here's a video she recently produced that tells her story.  It begins, "The code blue was called," and then the story unfolds.  The video has already prompted some lovely comments on Facebook and is being shared on that platform, and now here (with Dale's permission).

Jim Conway noted: "So tragic, powerful and beautiful. An exceptional lever for change. Our gratitude only grows, Dale."

Indeed.

Mixed feelings

On the one hand, kudos to Lenox Hill Hospital’s Chair of Urology Dr. David Samadi, who highlighted the importance of early screening and prevention by performing prostate exams live on NBC Today Show anchors Matt Lauer and Al Roker. Helping people understand the ease of this screening test is a public service.

On the other hand, this is the same Dr. Samadi who permitted himself to appear in a testimonial video produced by Intuitive Surgery (posted on August 28, 2013) to support its marketing campaign for use of the daVinci robotic surgery machine, specifically by playing on men's fear of impotence and incontinence. His statement--"There's a huge benefit to patients when they go through the daVinci prostate surgery"--is not supported by scientific inquiry. This video was posted in the midst of numerous reports and concerns about the use of this technique.

Recall this report by Citron Research, on December 19, 2012:

Imagine a medical company with a single product — one which lacks any clinical data proving medical efficacy superior to other conventional treatments.

And another particularly damning report from Citron in October 2013:

In over 12 years of publishing probative stock research, Citron is most proud of the work we published on Intuitive Surgical (NASDAQ:ISRG) starting last December. Not because the stock suffered a decline of over 30% amidst a record- setting bull market, but rather because we helped raise to the forefront of public awareness the undisclosed dangers of robotic surgery and the subsequent dilemma: what happens when medical best practices collide with unbridled thirst for profits.

What you can't do directly . . .

. . . you do indirectly.

The country's labor unions tried hard to exempt themselves from the "Cadillac" tax on expensive (and generous) health insurance policies when the Accountable Care Act was being debated.  Whatever you might think about that tax, Congress wisely decided that labor unions were no different from companies on this matter.

But now Jay Hancock at Kaiser Health News reports that the unions may getting their way, through quiet, back-door administrative changes:

Buried in rules issued last week is the disclosure that the administration will propose exempting “certain self-insured, self-administered plans” from the law’s temporary reinsurance fee in 2015 and 2016.

That’s a description that applies to many Taft-Hartley union plans acting as their own insurance company and claims processor, said Edward Fensholt, a senior vice president at Lockton Cos., a large insurance broker.

Insurance companies and self-insured employers that hire outside claims administrators would still be liable for the fee, which starts at $63 per insurance plan member next year and is projected to raise $25 billion over three years.

Unions, a key Obama ally, have increasingly criticized the Affordable Care Act as threatening the generous medical plans held by many members.

Eliminating the reinsurance fee was one of several resolutions adopted at the AFL-CIO’s September convention.

Although it’s too early to tell whether the Department of Health and Human Services will give union plans all of what they want on the fee, last week’s language “is how HHS often breaks controversial regulatory news,” benefits lawyer R. Pepper Crutcher, Jr. wrote last week. It's not known when the administration will put out a new regulation on reinsurance. 

Another chance to vote

No, I'm not suggesting that you vote "early and often," but I am requesting you to vote on one more ballot.

My friends and colleagues Gilles Frydman and Roni Zeiger explain:

We are Smart Patients, a new online community of cancer patients and caregivers, for the era of molecular medicine. Our mission is simple; improve medicine, one story at a time.

We're here to help people get optimal care by sharing with other informed patients everything they need to know about any aspect of their disease.To do so, we have created a new platform, designed to tear down silos that have stopped people from sharing with others who know the answer to their particular question. 

This great duo is competing to get a grant from Chase Mission Main Street.  They need 250 votes to be considered for this grant, although more votes than that are even better. As I write this, they have 65, but I bet we can all get that number to go up pretty quickly.

That's where you come in. Please go to this site and vote. No muss. No fuss. Although you must first connect with you Facebook account, no one stores or shares your information. Then, just vote, and know that you have helped these great guys get one step closer to a better world.

Focus on ambulatory care on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Improving Safety and Satisfaction in Ambulatory Care — will take place on Thursday, November 7, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Gordon Schiff, MD, Associate Director, Brigham Center for Patient Safety Research and Practice, Brigham and Women's Hospital
• Nicholas Leydon, MPH, Director, PROMISES Project, Massachusetts Department of Public Health
• Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI)
• Damian Folch, MD, Family Practice and Lifestyle Medicine (Chelmsford, MA)

We don’t typically associate the ambulatory care setting with serious lapses in quality that threaten patient safety. Much of the improvement in recent years targeting outpatient care has focused on access, waiting times, communication, and coordination of care. But these areas ripe for change have often obscured others that, if not handled well, can have even more dire consequences: the ordering of tests, the timely handling and communication of results, and the overall process of making a diagnosis in response to a patient’s symptoms or complaints, including making referrals to specialists. 

With these issues in mind, we invite you to join the next WIHI on November 7, 2013: Improving Safety and Satisfaction in Ambulatory Care. On the program, we’re going to find out what’s been learned from a three-year initiative known as PROMISES, charged with reducing malpractice risk in the ambulatory setting by making care safer, more efficient, and more reliable. 

The WIHI panel will be headed up by the lead researcher for PROMISES, Dr. Gordon Schiff, who’s also the lead author of a recently published article in JAMA Internal Medicine ("Primary Care Closed Claims Experience of Massachusetts Malpractice Insurers") that found that the lion’s share of malpractice claims in Massachusetts primary care practices relate to allegations of misdiagnosis stemming, in part, from dropped balls with test results. This finding matches national trends, which is why the work of PROMISES, centered on making improvements at 16 sites, should resonate with many. Dr. Damian Folch worked on improvements at his practice in Chelmsford, MA, and he and other sites were coached by Improvement Advisors, including Nicholas Leydon. Because it’s rarely a matter of one thing that’s been missed or that can go wrong, IHI’s Frank Federico will help us understand why a systems approach is critical to managing the many things that transpire in the ambulatory setting, including careful tracking of prescribed medications.

This WIHI on PROMISES promises to be rich with results and real-world experience, and it will offer you ways to get involved to help shape and spread further change. Could your team use a PROMISES Patient Safety Curriculum? Would you like to explore becoming a Primary Care Patient Safety Innovator? Find out how and join the discussion on this next WIHI on Nov 7. Host Madge Kaplan and her guests are looking forward to your questions and hearing about your experiences.

I hope you'll join us! You can enroll for the broadcast here.

It's time for NHS Change Day 2014 to begin.

What happens when the third largest organization in the world decides to change? We'll see in a few months.

Today starts the countdown to NHS Change Day, set for March 3, 2014.

This is a grass roots approach to change, not something ordered from the top down.

How it works is remarkably simple and engaging.

First, you make a pledge and post it for all to see.

All you need is an idea of what you could do to make a positive difference. Then you make a pledge - a simple promise to yourself and others that you will act on that idea and become a 'changemaker'.

If a pledge inspires you, you hit "like."

The more likes you give, the more you'll inspire others.Tell other people you like it too by sharing it on your social networks.

Join someone else's pledge.

Find a pledge that inspires you and if you think you can do it too, hit Join!

This is the second year. Last year saw 189,000 pledges to make things better. This year the goal is for 500,000.The organizers summarize:

Anyone can make a pledge. We ask everyone to embrace the energy of Change Day and to PLEDGE, SHARE, DO and INSPIRE. To make the NHS the best is can be. Let's do something better and courageous together. It's time for NHS Change Day 2014 to begin.

Here's a picture of the kick-off with three of the organizers, Jeremy Tong, Helen Bevan, and Sebastian Yuen, where Helen noted, "We're doing this because it fits with our values."  Jeremy advised the assembled crowd: "Listen to what people say... they'll be able to tell you the problems... but also act on what you hear."

From this side of the pond, I say, "Bravo!"

Dammit, take credit for the good!

Many of us who support the primary goal of the Affordable Care Act--to provide access to insurance for many more Americans--get frustrated by the inability or unwillingness of the administration to create a powerful narrative for the law.  A story earlier this week in the New York Times provides an unfortunate example.

The headline is a winner: Under Health Care Act, Millions Eligible for Free Policies.

The lede is more qualified:

Millions of people could qualify for federal subsidies that will pay the entire monthly cost of some health care plans being offered in the online marketplaces set up under President Obama’s health care law, a surprising figure that has not garnered much attention, in part because the zero-premium plans come with serious trade-offs. 

We can't blame the administration for the reporters' choice of words, but in the second paragraph they start to dig themselves into a hole:

Three independent estimates by Wall Street analysts and a consulting firm say up to seven million people could qualify for the plans, but federal officials and insurers are reluctant to push them too hard because they are concerned about encouraging people to sign up for something that might ultimately not fit their needs.  

What is this paternalism? We are reluctant to tell people about plans that can help them because the plans may not help them as much as plans they can't afford?

In contrast, the advocates understand that something important is being made available:

Supporters of the Affordable Care Act say that the availability of free-premium plans — as well as inexpensive policies that cover more — shows that it is achieving its goal of making health insurance widely available.

But then we get this "no comment" from the administration:

Officials at the Department of Health and Human Services would not comment on the McKinsey analysis, saying in a statement that the goal of the health law was to provide a range of options for people with differing needs and budgets.

In a unattributed statement?   Luckily someone else is out there who is willing to be quoted:

The availability of zero-premium plans may make the deal especially enticing to the healthy young people the marketplace needs to succeed, said Mark V. Pauly, a professor of health care management at the University of Pennsylvania’s Wharton School. “This is such a good deal that you’d have to believe you were immortal not to really pick it up,” he said.

I wish the administration would likewise learn to claim victory on these matters.

A top ten list that indicts an industry

Cheryl Clark over at HealthLeaders Media summarizes the annual ECRI report on the top 10 health care technology hazards. It is tempting to think of this as a report on technologies, but let's remember it is actually a report on how people use technologies.

Here's the (drum-roll) list:

1. Alarm hazards
2. Infusion pump medication errors
3. CT radiation exposures in pediatric patients
4. Data integrity failures in EHRs and other health IT systems
5. Occupational radiation hazards in hybrid ORs
6. Inadequate reprocessing of endoscopes and surgical instruments
7. Neglecting change management for network devices and systems
8. Risks to pediatric patients from "adult" technologies
9. Robotic surgery complications due to insufficient training
10. Retained devices and unretrieved fragments

A few comments.  First, with regard to number 6, the only appropriate is "Eeew, that's disgusting!"

Number 9 relates to Intuitive Surgery and its daVinci robot. I wonder if this is the first time that one company accounts for an entire category in the ECRI report. What a milestone that would represent!

What is striking about the others is that there are work-flow remedies that could dramatically reduce these hazards. The fact that they remain on the list is an indictment of the clinical and administrative leaders in many American hospitals.

How to give positive reinforcement

It was a soccer practice session with my team of 12-year-old girls. I was explaining that we were going to work on a particular skill because they had not done very well with it in the game the day before.

"Well, that's not a very positive way to put it," noted one child, who knows well my penchant for positive reinforcement rather than criticism.

"Ok," I said.  "How about: You positively did not do this well during the game.  Is that better?"

"That will do," she replied.

In memoriam: Dr. Michael Palmer, healer

Photo by Gregory Rec in the Boston Globe

Strength from adversity might best describe Dr. Michael Palmer.  This obituary by Bryan Marquard begins:

A physician who nearly lost his career to drug and alcohol dependency, Dr. Michael Palmer found his way back to his calling partly by helping heal other doctors, and by replacing his daily pills with a page of writing every night.

“By the end of the 1970s, I was in solid recovery, and by 1981, I began to reach out to find doctors whom I could help,” he told the Globe in 2008. “It coincided with the beginning of writing. In retrospect, having a book to write was one of the things that kept me sane.”

My friend and colleague Rabbi Robert Goldstein adds:

Michael had an extraordinary career.  He was first and foremost a physician; but he was also a talented and highly successful writer, and perhaps most notably a recovering addict who courageously and generously used his experience to help others.  While still a young internist practicing in Falmouth he became addicted to drugs.  Michael eventually recovered and used much of his energy, aside from writing, to help other impaired physicians.  I sincerely believe that Michael, who was a skilled clinician, probably saved as many lives in his work with his colleagues who were in trouble as he did when he had a busy practice.  He was truly a healer of bodies and souls.

What's in a name? Not much, sometimes.

Over the years various sectors of the economy have gone through structural change, often from a regulated, price controlled environment to a more deregulated environment.  This has happened with electric utilities, natural gas companies, water and wastewater companies, telecommunications, and, now, hospitals.  The first step is to merge and/or acquire and/or be acquired.  Scale is viewed as way to achieve economies of scale and scope and to gain market power.  (As we now know, scale also brings its own set of problems, and such mergers often fail under their own weight.  So very few ever achieve the business economies that were envisioned at the outset.)

The second step is to change the corporate name to something perceived as more jazzy or powerful or something.  This is where branding companies make their money!  The telephone companies were really "good" at that. New York Telephone Company and New England Telephone and Telegraph Company merged and became NYNEX; then merged with Bell Atlantic (itself a combination of the Bell Telephone Company of Pennsylvania, New Jersey Bell Telephone Company, the Diamond State Telephone Company, and the Chesapeake and Potomac Telephone Company (including C&P of Maryland and C&P of Virginia) to become Verizon. Meanwhile, Illinois Bell Telephone, Indiana Bell Telephone, Michigan Bell Telephone, Ohio Bell Telephone, and Wisconsin Bell merged to create Ameritech. Ameritech later combined with Southwestern Bell, Pacific Bell, and Southern New England Telephone to become SBC Communications.

In my mind, it is unfortunate that each such renaming removes the company from its previous connection to a region or a community.  Wait till you see what some hospitals have done.

Ellie Rizzo over at Becker's Hospital Review recently posted a story about nine hospitals and health systems that recently changed their names or brands.  Most are understandable, but some may actually reduce consumer recognition.  I think this one sounds more like a restaurant or pasta company than a hospital:

Kennewick (Wash.) General Hospital is changing its name to Trios Health to better reflect its commitment to the Tri-Cities — the Washington cities of Kennewick, Pasco and Richland — and its growing range of services.

In July, Sabrina Rodack at Beckers reported on 23 name changes. Included in the group is this one that to me sounds like a body-building club:

University of Rochester (N.Y.) Medical Center acquired several assets of Lakeside Health System and will transfer all of the entities to its Strong Memorial Hospital's license. The health system will be renamed URMC Strong West.

And, back in January, Sabrina had reported this odd hagiographic shift.  Was this a directive from the Vatican?

Saint John's Health System in Anderson, Ind., changed its name to St. Vincent Anderson Regional Hospital. 

Here's another, reported by itself: 

Last year proved to be a year of many changes for Vidant Medical Center. First and foremost, we announced our name change from Pitt County Memorial Hospital (PCMH) to Vidant Medical Center.

Two commentors to a local news channel couldn't resist:

Is this a joke? LOL. What idiot came up with that name? Sounds like denture cream! Seriously, somebody didn't research in a dictionary the word vidant, which means to gut or empty out not "life." Hahaha.

This shows the intelligence of those who picked this name! Of course, the vidant French meaning of "to empty or gut" is an apt one when it comes to gutting the history behind this hospital.  

Another said:

Man, this is all just too confusing for me. I wish they would focus on providing good health care instead of doing fluffy work like coming up with a new name.

If you really want to dig in further, check out this site from Pennsylvania, listing several years' worth of all facility closings, mergers and/or significant name changes. My favorite is that Montrose General Hospital became Endless Mountains Health Systems. With an internet address of endlesscare.org, you have to wonder what they meant to portray to the public.

Some wars were different back then

Yesterday, Nov. 3, was the 110th anniversary of the Panamanian war of independence from Colombia, greatly aided and abetted by Theodore Roosevelt.  Here's a summary of the event from El Tiempo:

Eran las 9 de la noche cuando retumbaron los primeros cañonazos, parece que seis en total durante media hora: seis balas perdidas que fueron a estrellarse contra lo primero que se les atravesó, unas casas y unos gritos, dando de baja así a los dos únicos mártires que se conocen de la gloriosa gesta emancipadora de la República de Panamá: un chino y un burro. El primero se llamaba Wong Kong Yee, fumador de opio, el burro no lo sé.

It was 9 pm when the first cannon boomed, apparently six of them for half an hour, six stray bullets crashing into the first things that got in their way, some houses, and creating the only two known martyrs of the glorious struggle for independence of the Republic of Panama: a Chinese man and a donkey. The first was called Wong Kong Yee, opium smoker, about the donkey it is not known.

LUST in hospitals

My colleagues* David A. Lax and James K. Sebenius tell a story in their excellent book 3D Negotiation: Powerful Tools to Change the Game in Your Most Important Deals.

The EPA had promulgated new standards for gasoline underground storage tanks, requiring an owner of any such tank to repair or replace it if any leaks were detected (making it a LUST: a leaking underground storage tank.) A start-up company had developed a new detection system that was a hundred times more sensitive than anything on the market, and faster, and substantially cheaper than the competition. Lax and Sebenius relate what happened:

"When the new [EPA] standards were implemented, [the company] was sure it had a winner: not only faster, cheaper, and better, but now mandated. Its sales engineers began negotiating with potential buyers--and were astonished to receive a grand total of one order in the marketplace. One after another, potential customers walked away from the table."

Why? Well, the technology did not solve a problem that the consumers cared about. Indeed, it had only the potential to create a problem: If a gas station owner now was able to detect even tiny leaks in his tank, he would have to incur thousands of dollars in costs to dig up and replace or repair the tank. The authors present this as a classic case of failing to understand the interests of the other party in a negotiation.

I'm struck by how often I see this in the health care arena. There are a huge number of start-ups in this field, all trying to tap into the fact that health care represents over 1/6 of the US economy. They think that their device, technology, or information system will "sell itself" once the people in hospitals hear about it.

People offering to sell such products often do not understand that their new idea might work too well, creating extra work or obligations or liability for the hospital.

They also often fail for two other reasons:

First, hospitals have major capital constraints. CFOs are reluctant to allocate funds away from absolutely essential needs. They have been trained to be exceedingly skeptical about future savings that promise to generate an acceptable return on investment.

Second, the sales cycle in the health care world is interminable. No one is in charge of a hospital and can say "yes." But lots of people can say "no." A place in which "there are a 1000 points of veto" is a difficult sales environment.

It is possible to sell great new ideas to hospitals, but they need to satisfy the interests of several constituencies in those organizations.  They must improve the work flow of the staff on the floor and units, making day-to-day life easier and not harder. They must improve the safety and quality of care, but in a manner that does not expose the hospital to greater liability: Indeed they should help reduce liability. Finally, they should demonstrate cost savings and be priced in such a manner as to allow the hospital to show cash flow improvements rather than be a drain.

We all lust after technological improvements in the health care world, but let's recall the excellent advice of Lax and Sebenius. If an invention does not address the interests of those doing the work and paying for the work, it will rest comfortably on the shelf.

---
* Disclosure: I am Senior Advisor at Lax Sebenius, LLC.

It's about the money

I'm still on some hospital CEO mailing lists and received this postcard yesterday.

I once heard a Harvard business professor describe hospitals as “business cost structures in search of revenue streams.”  This advertisement seems to be geared along those lines. I'm not saying this firm is anything but reputable in offering qualified clinical staff.  Indeed, the case studies on its website include several with really thoughtful quality programs.  But the headline is clearly designed to catch the financially attuned hospital administrator.

Improving PTSD Treatment

Improving PTSD Treatment for US Military Personnel

via Enterprise Architecting

MIT SDM Systems Thinking Webinar Series

Elizabeth Cilley Southerlan, SDM '12
Strategic IT and Operations Manager, Health and Life Sciences, Oliver Wyman

Date: November 4, 2013
Time: Noon – 1 p.m. EDT
Free and open to all

Register

About the Presentation

This webinar centers on how SDM alumna Elizabeth Cilley Southerlan used enterprise architecting to investigate the current state of post-traumatic stress disorder treatment (PTSD) at Camp Lejeune's existing military psychological health enterprise (MPHE). 

Southerlan will discuss using enterprise architecting to:

• investigate the camp's current (as–is) state; and
• work in conjunction with multilevel analysis techniques to create a framework that could support the transformation of this complex, multilevel enterprise.

She will also describe takeaways—including dominant views of the organization, its processes, and the importance of stakeholder analysis—and review suggestions for the MPHE's transformation to better serve our soldiers.

We invite you to join us!

About the Series

The MIT System Design and Management Program Systems Thinking Webinar Series features research conducted by SDM faculty, alumni, students, and industry partners. The series is designed to disseminate information on how to employ systems thinking to address engineering, management, and socio-political components of complex challenges.

A haphazard reporting system that uses immature data

A bit more on robotic surgery to complement the post below.  Melissa Evans at Kaiser Health News notes:

The use of robotic surgical systems is expanding rapidly, but hospitals, patients and regulators may not be getting enough information to determine whether the high tech approach is worth its cost.

Problems resulting from surgery using robotic equipment—including deaths—have been reported late, inaccurately or not at all to the Food and Drug Administration, according to one study.

Dr. Martin A. Makary, an associate professor of surgery and health policy and management at John Hopkins University and one of the study’s authors,  said that, while the future for robotic surgery is promising, there is a gray area when it comes to assessing the difference between doctor and device error. And benefits from the use of the device may be inconsistent, he said.  

Makary and his co-authors noted an earlier finding that “among the 37 percent of U.S. hospitals that describe robotic surgery on their hospital website, none mentioned any potential risks or complications.

“We rely on a haphazard reporting system that uses immature data and only the best experiences make it into the data,” Makary said. “We introduce things but we don’t evaluate them very well. If we’re relying on the FDA about what (products) are superior, then we need a new process...you can’t make conclusions on the safety profile of a device based on a shoddy reporting system.”

Loss of trust

Is this how things unravel? Karen Gullo at Bloomberg Businessweek reports:

Intuitive Surgical Inc. (ISRG:US), the maker of robotic-surgery devices targeted by patient lawsuits, was sued by an insurer alleging the company hid the number of legal claims it might face when buying product-liability insurance.

Illinois Union Insurance Co. (UNION) seeks to rescind an Intuitive insurance policy, saying the maker of the $1.5 million da Vinci robot system concealed material facts about its legal risks.

The insurer said it was told Intuitive was confronting 25 claims during the policy application process earlier this year. Intuitive didn’t disclose that it had entered agreements with plaintiffs’ lawyers to suspend deadlines for additional legal claims over the da Vinci system, according to an Oct. 21 complaint filed in federal court in San Jose, California.

“Had plaintiff been informed of the tolling agreements and the increasing number of claimants during the application process, plaintiff would not have proceeded with the application process and would have withdrawn any quote for the policy,” Illinois Union said in the complaint. 

Not to generalize, but . . .

I have finally encountered the perfect analogy for the stereotypical relationship between a surgeon and an anesthesiologist. The video is of a sheep trying to teach a bull how to head butt.  Watch what happens when aggression meets passive aggression.

"Management" and "leadership" are not synonymous

My friend Boaz Tamir nails it again.  He has written a piece about the Israeli pharmaceutical company Teva, but it applies to so many others.  An excerpt:

Many people make the mistake of thinking that "management" and "leadership" are synonymous. But the practical implications of that mistake can lead to organizational pathology. The story of the rise and fall of Teva is about a Jerusalem pharmaceutical company that became an innovative global multi-national that developed original pharmaceuticals but is now facing a financial crisis that threatens its very existence. It is the story of a company that lost the balance between management and leadership: Teva is the flagship of Israeli industries, but, like most organizations, it suffers from over-managed and under-lead, and this root problem is casting a pall over the future of this giant company.

Managers deal with preservation. Assessment of the quality of management is based on its ability to preserve stability and continuity within the existing order, through organizational management and operational standards that serve as key resources in achieving product quality and profitability. Managers are concerned with creating and using power: designing processes, performing mergers and acquisitions and implementing organizational systems. And they do all this according to business plans and budget management, while defining jobs and manning positions, measuring performance.

Leaders are concerned with change and effectiveness. Leaders disrupt the existing organizational order. Leadership is neither a trait nor a job: it is a way of behaving. And that behavior of leaders for change has two unique qualities: a. Articulation of a vision, goal and purpose; and b. Enlistment of interested others (customers, workers, suppliers, stockholders and the community ) to fulfill that organizational vision.

Management and leadership are both necessary for the existence of an organization, yet they are by nature contradictory: Management deals with increased efficiency and gradual improvement in the current situation, while leadership for change is directed towards disrupting what currently exists. In a stable environment that allows for linear growth, the balance along the preservation-change axis tips towards the judgment of the managers. In a chaotic environment, external change demands flexibility and readiness for internal change; the tendency to preserve what exists becomes a hindrance that prevents adjustment to changing reality.

Engaging approach to safety

A great safety video from Virgin America. I especially like the line: "For the .001% of you who have never operated a seatbelt before: Really?!?"

Seriously, this shows how you can make safety training more compelling. You actually want to watch the whole thing, at least the first time.