**MSU update fall 2019:** For the last two years I have hopefully challenged our thinking in my previous MSU update articles. My goals have been to move our conversation forward to open us up to a little more honesty about our culture. Some of the themes have been around accountability, behavior, engagement, and communication. And to what end do we pursue deepening the conversation? Because at this moment, like it or not, we are facing a choice. The choice is really one of our future, and what kind of organization we want to be a part of. All around us massive sweeping change is coming to the healthcare industry, largely in the form of consolidation. Consolidation in itself is neither a good nor an evil, but many of us initially chose and continue to choose Concord Hospital because It is different, and in my mind the choice up to us is what we fight to keep the difference? Or will we resign ourselves to a future as a small piece of a big puzzle, where our voice is quieter, and our way is homogenized. Consolidation in healthcare has not shown itself to be a force for empowering physicians, for improving quality, for improving access, and for reducing costs. In general it has not shown itself to be a force that promotes and advances the quadruple aim, that improves our lives and the lives of our patients. Instead it seems to be a force that takes money energy and resources directing them to financial gains but leveraging size to increase costs in the struggle between health systems and insurance companies, and nowhere in the calculation is the improvement of the patients lives nor the providers lives. I’ve spent countless hours with our administrator colleagues and I can say at the very top from the board, our CEO, and other top administrators that they want to fight for our survival as an independent organization, that they feel they share with us the responsibility for the charitable non-profit that exists only to serve the patients and families of the communities we serve. So the question for all of us is, are we prepared to link arms, to do what it takes to re-envision healthcare delivery? Are we prepared to get our patients the care at want with the service, access, and cost they seek? If so, if our community of practice is to continue, we have to link arms with our administration, and lean in to this work, re-engage with honest dialogue up and down the hierarchy, and form effective change alliances. The good news is, this is happened in areas. Specific examples include work on OR start time improvements, he delivers just pain, antibiotic stewardship and many others. The shared feature of these products has it has been a strong link between physician leaders and administrative support focused on delivery of care improvements, involving compromise between many departments and expanded thinking. The process is in a administrative support at a kaizen. And the outcomes are real and significant improvement in cost, access, safety, and standardization.