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Sunday, July 26, 2015

5 pitfalls to avoid in managing the cultural aspect of health system integration

By Igor Belokrinitsky and Chase McCann, Strategy& | March 05, 2015

These days it seems every health system is in the middle of a transformation — be it buying, selling or trying to integrate the assets it has amassed over time. Being in the business of transformation, this means we find ourselves invariably and repeatedly answering the question, "What are the big stumbling blocks to avoid?"

Without fail, our answer will include some version of, "Don't underestimate the power of culture." It’s common wisdom, usually met with wizened nods and tales of past battles hard fought and lost. Then an awkward admission that, "We should have done more, but what?"

To quote Mark Twain, "Everyone talks about the weather, but nobody does anything about it."

Luckily, there's plenty to be done. Below we have listed five common traps we have observed — along with some suggestions on how to avoid them.

1. Blaming the culture. Why do transformations fail to achieve their objectives? One of the oldest tropes we hear is, "Our culture is one of our greatest strengths, and our greatest barrier to change." For example, "family-like" culture is blamed for not holding weak performers accountable or "mission-driven, community-oriented" culture is blamed for allowing sub-scale, low-quality service lines to persist. The real story is often quite different — and points to a lack of clear objectives, lines of accountability and the will to make tough choices.  

Where to start: Make the culture your ally. Use the deeply embedded, self-reinforcing behaviors, beliefs and mindsets that determine "how we do things around here" in order to change the conversation. No one cultural trait is ever all good or all bad, so emphasize the good. For example, a "family-like" culture is all about creating a supportive environment — but a strong family is also honest with its members and knows when to deploy a little "tough love."

2. Leaving the strategy on the shelf. Many health systems have thoughtful, aspirational, community-focused and mission-driven strategies. Unfortunately, some of these organizations have not taken the next step of translating that strategy into changes in how work actually gets done day in and day out. If we are now a "population health" system, how does this change the job description of a nurse? Until the implications are thought through, the strategy will stay on paper.

Where to start: Translate the strategic objectives into what actually needs to be done differently. A good first step is for senior executives to pick a few implications for themselves and how they lead to model the future in a visible way.

3. Being unclear in setting new behavioral expectations.Most organizations aspire to be more patient-centric, population-minded or quality-oriented. Defining processes and standards that get you there is straightforward. Where many fail is driving adoption of the behaviors that bring those processes, policies or standards to life. The common wisdom is to be very prescriptive about how you want individuals to behave every step of the way. In reality, when push comes to shove, no one will remember the memo — and everyone will revert to their tried and true pattern of behavior. The key to driving behavior change is to pick a few critical, shared behaviors that really matter. Well-chosen behaviors are easy to internalize, they're recognizable by others and they're easy to imitate.

Where to start: Identify a few key behaviors, three or four, that are emblematic of the larger change you're trying to drive. Focus on successfully adopting these, and then come back to add more.

4. Talking past one another. The healthcare industry is already prone to jargon, and recent developments have only made the situation worse. It is hard to find a healthcare executive who does not talk about "population health," "patient experience," and "value-based care" — and don't even get us started on "disruptive innovation." Yet, very few organizations have defined what these things mean — or found a way to measure them in ways that are meaningful and relevant to their customers, such as consumers and employers. Without clarity around key terms, it is hard to have meaningful conversations, articulate a compelling and concrete future staff vision, or create effective incentives.

Where to start: Pare down the jargon and pick a few key ideas that are a clear part of your strategy. Communicate them in plain language and explain what they actually mean. (By the way, the irony of consultants recommending that you use simple English is not lost on us).

5. Leaving the hard conversations until the end. Several conversations in healthcare are an equivalent of a third, electrified rail. Try asking physicians to improve their productivity and reduce the variability in their clinical practices. Try asking hospital leaders to give up a sub-scale service line to another facility in the system. Try asking everyone to get a flu shot.

The temptation is to put these conversations off for as long as possible. And yet, delaying these necessary conversations means trying to transform a health system with one hand tied behind your back. The most effective transformations are physician-led and nurse-led. Engaging them in the proverbial "sausage making" and starting a dialogue is crucial. Building physician and nurse alignment is a step that should be taken early — and often.

Where to start: Identify and start a conversation with the physicians, employed or aligned, as well as nurses, who are seen as authentic informal leaders. These individuals are unique in their willingness and ability to, with or without formal authority, motivate and influence others.  

Igor Belokrinitsky is a Strategy& partner based in San Francisco and Chase McCann is a Strategy& principal in New York.

http://www.beckershospitalreview.com




Thursday, July 16, 2015

2015 Most Wired Hospitals


 by 

Hospitals and health systems on the 2015 Most Wired list are pushing beyond meaningful use and optimizing their systems to improve performance and patient care.


The Most Wired List: http://m.healthcareitnews.com/news/see-which-hospitals-made-2015-most-wired-list


After more than a decade of building the foundational elements of a digitized health care environment, and billions of dollars in federal and private sector spending, hospitals and health systems are tapping into the power of the bits and bytes they’ve been collecting. This coincides not only with the requirement to meet federal standards for meaningful use of health information technology, but also the push toward value-based payments, population health management and cost-efficiency.

Optimize. It’s not a super sexy word. It sounds more like a command Tony Stark would bark at his computerized helper Jarvis to get the Mark 45 Iron Man suit ready for battle. With apologies to the genius/billionaire/playboy/philanthropist, optimization is actually the mantra for today’s real-life health information virtuoso.

As evidenced by data collected over the 17-year history of Health Care’s Most Wired Survey, hospitals and health systems have continually ratcheted up their use of cornerstone IT applications. For instance, 95 percent of the 2015 Most Wired hospitals have standing, evidence-based electronic order sets built into their CPOE systems. That’s up from 79 percent in 2010. Since 2008, the percentage of Most Wired organizations that have a compliance-driven alert system for Centers for Medicare & Medicaid Services key indicators leapt from 50 percent to 79 percent in 2015.

While work still needs to be done to bring implementation of these types of applications to 100 percent — and sustain their use over time — leaders at Most Wired hospitals are not merely resting on their laurels waiting to install the next gadget; they are using data to drive clinical improvement and shape strategy.

“Through implementation of our Epic system, we’ve been able to elevate the use of real-time information at the bedside,” says Paula Smith, senior vice president and chief information officer, Oakwood Healthcare, Dearborn, Mich. “We consolidated multiple, disparate systems into a single database that has provided more streamlined documentation of care delivery at every transition-of-care event.”

Records from emergency department visits, for instance, are instantly available to caregivers at the receiving inpatient unit. This, Smith says, accelerates quality care because the clinicians are prepared in advance of the patient’s arrival.

Organizations on the 2015 Most Wired list are extending the use of IT systems outside the hospital’s four walls, including connecting directly with patients. In fact, improvement in patient engagement — in its many forms — stands out in this year’s survey. More than two-thirds of the Most Wired extend the care environment to the patient and family via the Internet, providing education about his or her condition and allowing for e-visits with the care team, among other things. This dovetails nicely with efforts to improve population health.

At MetroHealth System, an automated screening and alert system led to a 15-fold increase in screening and 23 percent increase in diagnosis for depression between 2011 and 2014. There was a 25 percent increase in adolescent immunizations during the same period, largely a result of automated messaging to parents. And, importantly, between 2011 and 2012, a 15 percent increase in patients scheduling and completing referrals 30 days after discharge, reports David Kaelber, M.D., chief medical informatics officer for the Cleveland-based health system. All of these efforts are ongoing.

                            The engaged patient:

Part of the emphasis on patient engagement can certainly be traced to meaningful use regulations. In Stage 2 and the proposed rule for Stage 3, the Centers for Medicare & Medicaid Services places an emphasis on ensuring that patients can access their health records and become more connected with their providers. Stage 2 requires hospitals to show that 5 percent of all discharged patients have viewed, downloaded or transmitted their health information to a third party.

Of course, making records available is one thing, getting patients to participate online is something else entirely. At Citizens Memorial Hospital, Bolivar, Mo., staff called patients during the 90-day attestation period to get them to sign up for the patient portal and use secure messaging, says Chief Information Officer Denni McColm.

“We had to do some crazy things,” she explains. “If you signed up for the portal and sent a secure message, you were entered into a contest to win an iPad or a TV. We had one staff person in particular who would call up patients and say, ‘I saw you were at the doctor’s. I wanted to see how you were doing. Why don’t you get on the portal and let me walk you through it.’ And she would get them signed up.”

Most of those patients remain active users of the portal, McColm says.

To a certain degree, engaging patients online is a question of value, says Michael McCoy, M.D., chief health information officer, Office of the National Coordinator for Health IT. Is there enough information and meaningful interaction with providers to entice a patient to regularly visit a portal and become engaged?

“From my perspective, hospitals are missing the mark,” he says. “They complain about the number of [meaningful use] measures, rather than finding ways for doctors to be more proactive and responsive.”

While she contends that the regulations are too burdensome, Chantal Worzala, director of policy at the American Hospital Association, agrees that portal usage ultimately will increase as the sites become more user-friendly and useful. She says it’s encouraging to see in the Most Wired data that hospitals are going beyond meaningful use requirements to find ways of promoting patient engagement. For instance, 63 percent of Most Wired hospitals offer self-management for chronic conditions through the patient portal. And, 67 percent can incorporate patient-generated data through the portal, an important point since proposed Stage 3 regulations would require that hospital EHRs ingest patient-generated data from nonclinical settings for more than 15 percent of unique patients.

Worzala says there are still significant hurdles to marrying patient-generated data with an EHR, not the least of which is standards. McCoy adds that physicians are rightfully concerned about “being overloaded with noise.” It will be important going forward to figure out what information is truly useful to clinicians.

To that end, Worzala says the federal government needs to slow down on the regulator front.

“This is an opportune time to build on the tremendous investment in EHRs over the past few years,” she says. “We have so much interesting technology, let’s allow providers to figure out what the best uses are for providing care.”

Most wireless:

As with nearly everything in society, mobile technology is another part of the puzzle. The key is finding ways to connect with patients on their terms.

“I was surprised to see the high level of usage on mobile devices,” says Russ Branzell, president and CEO of the College of Healthcare Information Management Executives, H&HN’s partner in the Most Wired project. “We are seeing that mobility is an expectation in all parts of a consumer’s life. They’ll demand that from a patient engagement standpoint.”

Among Most Wired hospitals, 89 percent allow patients to access the portal via a mobile app, up from just 58 percent last year. Even among all respondents, there was a huge jump — 47 to 79 percent. Additionally, 63 percent of Most Wired organizations enable secure messaging, up from 40 percent in 2014. And 50 percent provide a mobile app for a personal health record, compared with 32 percent a year ago.

Looking more broadly, the field is challenged by the interoperability dilemma and the ability to exchange data across the continuum. As long as that challenge remains, it will be difficult for hospitals to fully move toward accountable care and value-based delivery.

“When you are at [financial] risk as a hospital, you want other providers who are caring for your patients to have the data,” says McCoy. “You want to ensure that patients are getting the right care at the right time.”

Part of the problem is that the payment system hasn’t caught up with the practice of more integrated care, says Branzell, who is quick to add that once incentives are aligned, hospitals need to be prepared to change lanes.

“Hospital leaders have to be ready because there’s a growing appetite to move away from fee for service,” he says.

2015 Most Wired Hospitals: Building a Foundation to Grow












More than a decade ago, leaders at Citizens Memorial Hospital took the bold step to invest mightily in information technology. Recall that those were the nascent days of health IT. The Office of the National Coordinator for Health IT didn't come into existence until 2004.

Still, across the industry, people were beginning to visualize how automated and digitized systems could streamline workflow and improve patient care. The board and executive team at the 89-bed rural hospital in Bolivar, Mo., were no different. In 2002–2003, they invested $6 million — roughly 12 percent of the organization's $50 million operating budget — on a health IT system.

“It was as much as we had spent on any building at that time,” says Denni McColm, CMH's chief information officer. “We had long discussions about the false sense of security that people had that their doctors knew everything about them. At that time, a patient's paper medical records could have been spread across 33 different locations so, of course, doctors had to redo tests.”

The significant capital investment coincided with a strategic plan to focus on the CMH brand. The hospital had been acquiring and affiliating with clinics and other providers. It was time to start acting like one organization, McColm says.

Flash forward to 2015: CMH is doing more than acting like one organization, it is using health IT as the underpinning to grow and drive care coordination across its market.

For instance, when CMH added a sixth long-term care facility to its portfolio in 2011, there was no hesitation in expanding the necessary infrastructure to ensure the flow of patient records.

“We administer a lot of medications to those 500 residents,” McColm says of the six long-term care facilities. “When we discharge a patient, we don't have to send the paper record. We just send the patient, because the record is all together” and available electronically.

CMH is also showing positive results in utilizing IT to improve population health. Through two years of a medical home program, IT is being used in 12 rural health clinics to help case managers improve care. They've seen significant improvement in care for people with diabetes, including a 7 percent climb in patients whose A1C is less than 8 percent; an 11 percent increase in females getting a mammogram; and a 10 percent increase in patients getting a colorectal cancer screening.

“IT is part of the foundation to grow and meet the needs of the community,” McColm says.

How Can YOU Become One of Health Care's Most Wired?

For the 17th year, H&HN has named the Most Wired Hospitals and Health Systems based on the Most Wired Survey. The 2015 survey results build on the analytic structure that was implemented in 2010 after two years of redesign. The methodology sets specific requirements in each of four focus areas. If any of these requirements are not met, the organization does not achieve the Most Wired designation. Thus, an organization may have many advanced capabilities, yet not achieve Most Wired status. The four focus areas are: (1) infrastructure; (2) business and administrative management; (3) clinical quality and safety (inpatient/outpatient hospital); and (4) clinical integration (ambulatory/physician/patient/community).

This year, there were additional requirements, many related to meaningful use Stage 2:

  • identity management and access controls 
  • CPOE for medication, lab and radiology orders 
  • use of assistive technology for five “rights” with point-of-care medication administration systems 
  • clinical decision support-enabled drug formulary check and high-priority hospital condition 
  • medication reconciliation 
  • electronic identification of patient-specific educational resources 
  • EHR-generated listing of patients for quality improvement 
  • patient portal functionality for access to health information 
  • summary care record for transitions of care

This year, 741 hospitals and health systems completed the survey, representing more than 2,213 hospitals — more than 39 percent of all U.S. hospitals. The number of hospitals and health systems designated as Most Wired is 338 organizations, down 
10 percent from last year due to additional requirements. H&HN uses the same criteria to name the Most Improved and the Most Wired–Small and Rural.

From a set of separately submitted essays, a panel of hospital and information technology leaders identifies noteworthy IT projects and names the Innovator Award winners and finalists. IT projects are evaluated on achievement of business objective, creativity and uniqueness of concept, scope of solution and impact on the organization.




A Flowchart for Choosing Your Religion

A Flowchart for Choosing Your Religion

Looking for a JOB - How to Be the Next Hire

Making You the Most Viable Next Hire
Being flexible, creative and adaptable in today’s economy is the cornerstone to survival. The job search is no different and, with unemployment rising, requires just as much vigilance. One way you can keep your options open and make yourself even more marketable is by considering Consulting in addition to your quest for full-time employment. Often perceived as an “either-or” scenario, Consulting offers you just as many benefits as it does your “would be” employer:

Track record of Fixing Problems?
Career wise, people typically fall into one of two categories: those who thrive on problem solving and the prospect of a new challenge –or- someone who is exceptionally good at steering the ship once it is on course. If the thought of fixing something that is broken appeals to you (versus has you thinking about reaching for the Tylenol), then Consulting might be an avenue to explore.

A More Flexible Interview
Quite often, what a company needs is someone to tackle a specific problem, not a new full-time employee. Identifying this in the interview and being able to present yourself as the solution to their problem (at a lower cost), can ultimately create a job tailor made for you and your skill set. No one can compete against that.

Dating Before Marriage
A consulting engagement can give you the opportunity to see if this company is a nice place to visit or a great place to live. The only thing worse than a prolonged job search, is ending up in a position that results in you being unemployed again in 6-12 months. Consulting lets you do more due diligence than you could ever accomplish in an interview.

“Consulting” on Your Resume
To many recruiters, seeing “consulting” as your current role without any clients/engagements is just a way to dress up being out of work. But, with a list of key accomplishments at those engagements, you show that you are in demand, have more control over your search and are broadening your experience. The latter is extremely important if you are looking to transition industries.

Change Agent
For companies looking to make some sort of change internally (and you should like this if you have a track record of fixing problems), consulting is a more preferred approach versus hiring a permanent employee. It is much easier to come in as a consultant, effect the course correction and then hand it off to the internal leadership.

Money
Besides the obvious benefit of having income during your search, it also gives you breathing room to be more objective in selecting your next job.

It’s Easier to Find a Job When You Already Have One
So much of what makes this true is that fact that when you are employed, you tend to be a bit more objective because you have a “bird in hand.” Consulting (in addition to easing that financial strain, which helps here) can provide the self-assurance that comes along with being employed, which can get whittled away while unemployed.

Presenting yourself as a viable consultant or full time employee isn’t mutually exclusive. Rather, they are simply two sides to the same coin. For the companies where you interview, this will only make you more viable and versatile in your eyes. For you, there is nothing to lose. The worst thing that happens here is you generate some income to inevitable financial strain of your job search. On the other hand, you might just find through this process that you discover your next career move.

Bağdat Caddesi

Gel de parmaklara hakim ol, yapma bir Caddebostan, Bağdat Caddesi nostaljisi şimdi!...diğer bir deyişle 'Karşı taraf' . Cok uzun seneler yazları gittiğim, son yıllarda ise her Türkiye'ye gittiğimde kaldığım Istanbul'un bir başka eşşiz köşesi.
1960'lı 70'li yıllarda köşkleriyle, bahçelerinden salkım salkım sarkan ortancalarıyla, billur gibi denizliyle, 'sayfiye' yeri olmasıyla meşhur Erenköy, Suadiye, Caddebostan.

Dükkanların az, ağaçların çok olduğu, bunca yıl geçmesine rağmen hala güzelliğini koruyan Bağdat Caddesi. On, onbir yaşımdan itibaren yazlarım geçti oralarda. Sokaklarda oynanırdı o zamanlar, öyle pek araba filan geçmezdi. Doyasıya bisiklete binilir, el birakarak gitmek büyük marifet sayılır Erenköy, Saskınbakkal, Göztepe bisikletle rahat rahat gidilir dönülürdü. Deniz için bazı sokakların denize vardıkları noktalarda bulunan kayıkhanelerden saatlik ücretle kayık kiralanır, kadın erkek kürek çekmeyi bilir, kayıktan denize girilirdi. Bazı gençler dalıp iskele ayaklarından midye toplar bazıları ise sığ kumda zıpkınla vatos avlarlardı. Sokaklardan dondurmacılar geçerdi o zamanlar. Simdiki gibi binbir çeşit ne gezer 'Dondurma, Kaymaaak' diye bağıran dondurmacının küçücük arabasında sadece kaymaklı ve limonlu dondurma olur, bazen ise çeşit olsun diye vişneli bulunurdu.

Caddebostan Plajı'nın yanı sıra bir de üyelikle girilebilen klüpler vardı. Marmara Yelken Klubü başta olmak üzere, Balıkadamlar, Caddebostan Yat Klübü ve İstanbul Yelken. Eğer bunlardan birine üyeyseniz veya üye bir arkadaşınız varsa bazı sporları yapma veya izleme olanağınız olur, voleybol, ping pong oynar, kıyıdan yelkenlilerin yarışlarını izlerdiniz. Denizin ortasında ise köfteciler vardı. Bunlardan aklımda kalanı ise mayomuzun kenarına sıkıştırdığımız parayla yüzdüğümüz, veya kayıkla yanaştığımız 'Fıştak'tı. Dönerken yüzülüyorsa demirlemiş kayıklara tutuna tutuna, dinlene dinlene yüzülürdü.

Akşamüstüne doğru herkesi bir 'piyasa' heyecanı alırdı. Saçlar yıkanır, bildiğımız ütüyle ütülenerek düzeltilir, ve (Bağdat) Cadde'ye binbir tur atmaya çıkılırdı. Bir aşağı, bir yukarı. Parkur ise genellikle Santral Durağı'ndan Saşkınbakkala kadardı. O zaman 'cafe' adeti bir elin parmaklarını geçmez, 'Borsa'da yer bulabilmek için hızlı davranmak gerekir, 'Divan' ise gençlere çok pahalı geldiğinden ancak hafif 'yaşı geçmiş'lerin duraklama mekanı olurdu. Hali varaba sahiakti oldukça yerinde olan birkaç genç ise bir aşağı bir yukarı arabayla giderek Mustang veya Corvette'leriyle gelene geçene hava atarlardı.

Geceleri ise açık hava sinemalarının keyfine doyulmazdı. Caddebostan'daki Ozan Sineması'nda genellikle Türk filmleri oynar, çıkınca biraz aşağıda, Caddebostan Maksim Gazino'sunun (MIGROS)yakınındaki büfe'de 'zümküfül' yenirdi (Bir çeşit sosisli sandoviç ) Yabancı filmlerin mekanı ise Budak Sineması'ydı (Şimdiki CKM). Yastıgını kapıp tahta iskemlelere yerleştirdikten sonra, çekirdeğini çıtlatarak izlenirdi filmler. Bazen bu sinemalarda Cem Karaca gibi o zamanın ünlü sesleri konserler verir, bazıları ağaç tepelerinden konser izlerdi.

Sonra sonra o köşkler birer birer yıkılmaya, yerlerin uzun uzun binalar dikilmeye, Cadde'deki evlerin yerlerini dükkanlar almaya, arabalar çoğalmaya, faytonlar yok olmaya, tekerlekli dondurmacıların yerini Algida'cılar almaya başladı. Ama ne mutlu ki tüm büyümeler, kalabalıklaşmalar rağmen 'Cadde'yi bozmayı başaramadı! O hala 'Cadde', İstanbul'un ,Türkiye'nin en güzide caddesi hala boydan boya yürümekten zevk aldığım, bir yerde oturup geleni geçeni izlemenin keyfini her yıl bir iki hafta yaşayabildiğim bir yer.

Galata' ya dogru...

Galata' ya dogru...

The best way to improve health care requires physicians and other stakeholders

My honest approach for how to improve the care is to support a methodology such as being self-serving. I would like to start a program to introduce a software-based point-of-care tool for obtaining patient feedback. This real time information can be used with clients to positively impact the patient experience, nurse engagement, physician (soft skills) competence and overall quality. In my perspective the criteria for fulfilling the demand for finding the best way to improve healthcare is that it need be simple to implement, impactful and cost effective. The most impact to healthcare improvement will come from process improvement and healthcare provider recruitment AND retention. The by-products will be reduced cost of care and improved patient satisfaction. This applies to hospitals and private practices. Based on current studies and the economy, supplying adequate healthcare to the community is already tough and is going to get more challenging. Recruiting sufficient healthcare coverage will boost revenue and provide some improvement to patient satisfaction (wait time and access). However, failure to retain the medical staff will significantly hurt the outcome. With high demand and low supply, it will be well worth the time and money to present "we have the greenest pastures here". The method mentioned above may be called such as point-of-care through successful implementations that may turn in to popular key parts of process improvement. You need to have some feedback from the patients and the physicians in order to measure the processes that should be or are currently being improved. In order to achieve this you have to create the acronym HOSPITAL to help those in Healthcare recall the numbers of different types of inefficiencies in any medical facility. Those who have been exposed to Six Sigma and Lean have an appreciation for improvement opportunities and generally view things through differently trained eyes that can see within all those facilities. Publishing the results of the similar programs online may offer a transparent access to the consumers to monitor these inefficiencies. Welcoming any feedback relative to this and encourage your staff to consider this method or similar training methods for their teams will be highly critical for the outcome. We have to understand that it is impossible to solve a problem that we are unaware of. By providing even the most basic tools at the lowest level possible, these problems have a way of surfacing. While everyone recognizes that healthcare systems and organizations need to improve, I think not enough time is spent on firstly identifying the key stakeholders, and secondly properly ENGAGING them. I strongly believe that not enough time is spent trying to engage physicians in this process. In my experience too many of these "improvement strategies" are top-down decisions by non-clinical managers who failed to conduct any research into what physicians might want or what stumbling blocks there are/were to get them to adopt the new technologies. EMR/EHR/CPOE are prime examples - all of these require a breakdown in the normal activity flow of providers, as it requires them to either find and log on to a terminal or carry a bulky instrument. Almost all clients and colleagues I have worked with resent and resist those methods. And look how few MDs are part of Healthcare consulting firm teams. IMHO, I believe more energy should be spent engaging rather than alienating MDs as a first step, then doing the same for patients in order to get buy in from the two key stakeholders as I see it. I've always found that engaging these stakeholders on projects from the beginning results in more buy-in and most importantly, better recommendations/outcomes (a better product).

ULTIMATE RESULTS

ULTIMATE RESULTS

Ilhan Arsel

Ilhan Arsel

BJK FOREVER

BJK FOREVER
Karga kartalların sırtına oturur ve boynunu ısırır. Kartal cevap vermez, kargayla savaşmaz; kargaya zaman veya enerji harcamaz, bunun yerine sadece kanatlarını açar ve göklerde yükselmeye başlar. Uçuş ne kadar yüksek olursa, karganın nefes alması o kadar zor olur ve sonunda karga oksijen eksikliği nedeniyle düşer. Kartaldan öğrenin ve kargalarla savaşmayın, sadece yükselmeye devam edin. Yolculuk için gelebilirler ama yakında düşecekler. Dikkat dağıtıcı şeylere yenik düşmenize izin vermeyin....yukarıdaki şeylere odaklanmaya devam edin ve yükselmeye devam edin!! Kartal ve Karga dersi