In a production environment, improvement must be continuous and relentless. To stay world class a company must examine every problem, every constraint, every imperfection and diagnose, measure, analyse, brainstorm, design, implement and control everything from tiny improvements to major breakthroughs, constantly. 

In a service environment, every customer is an individual who may have unique needs. A word here, a smile there, a moment of opportunity well managed can make the difference, the unique selling proposition, beyond the competition in order to prolong the partnership.  In the world of medicine, medical equipment and health services any changes can be lethal. Thus everything is thoroughly tested before implementation in order not to incur the risk of harm. But, habits get ingrained and die hard. 

A surgeon from one European country transferred to another European country. In the home country, when an experienced surgeon had finished with the main part of an operation, an apprentice would take over to finish the stitching whilst the expert took a break or moved on to the next operation.  Meanwhile, in the host country when the experts had finished the main operation, the experts had to do the stitching themselves, before taking a break. This took half as long again for an experienced and rare resource.  Providing less opportunity for breaks also increases risk, and furthermore reduces the opportunities for skills transfer to  apprentices. 

However, in the host country they were not ready to change. Such practices become ingrained and implicate a whole host of institutional factors.