lack of self-awareness, market, and perspective among leadership that has been there a long time - too long, leadership self-interested and self-protective rather than helping their most promising direct reports to advance and better serve organization; lots of politics - important to stand up for yourself otherwise you'll just get ping-ponged around between large self-important personalities; tendency to reward rosy picture roles rather than those doing the most difficult work - should a highly regulated tax exempt safety net children's hospital really be paying so much for marketing and external affairs? don't just reward the obnoxious people or you'll lose the best people - who's doing the actual work navigating hurdles and preventing reputation damage