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Creating an environment that supports innovation.

Entrepreneurship and innovation in transplantation originally stemmed from the fact that no other viable alternatives to end-stage organ failure existed. The first successful kidney transplant was performed at a time when dialysis was so primitive as to be considered ineffective. The first liver, heart, and lung transplants were also performed at a time when no alternatives existed. As transplantation has evolved, the entrepreneurial spirit that marked its birth and growth have been tempered by the fact that transplantation is now well accepted as definitive therapy, so the threshold for taking risk has decreased. In parallel with this development, the administrative structures of academic institutions and the regulatory environment have also evolved. Academic institutions have become increasingly risk averse, adopting a more corporate culture engrained in manuals of operations and procedures designed to implement reliability and compliance. Moreover, funding agencies and study sections currently assimilate and amalgamate transplantation research with other disciplines, whether systems based or anchored to particular organs, resulting in funding thresholds that have become increasingly difficult to cross, especially for high-risk/high-reward research. As a result, although in the early phase of transplantation investigative teams enjoyed strong support from academic leadership and from peerreviewed funding agencies and were typically viewed and considered with vibrant enthusiasm and passion, this has now given way to indifference or, at best, benevolent curiosity. Therefore, the challenge for investigators now consists of galvanizing and maintaining the innovative energy that fuels discovery while accepting and dealing with the realities of becoming part of a corporate structure. The successful transplant research enterprise will adapt to the requirements of this corporate culture while remaining at the margins of discovery. This means that transplant leaders must leverage the benefits of a highly reliable organization (HRO) while fueling the engine that drives innovation in order to provide an environment that supports innovation.