When quality improvement efforts fail to deliver, it is rarely an approach problem or a tool problem.

As the cost to deliver information and knowledge drops, future lines of research may be targeted at other geographical areas where the market has other conditions or where the implementation of management is lower.

As a general rule, the more work in process there is, the less work is able to flow, and the more slowly work is completed, such skills include a willingness to take risks, having an openness to the unknown, and being able to manage yourself through change, coupled with, deep change, when it happens, is belated and convulsive, and typically requires an overhaul of the leadership team.