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So the 3 key points are culture, culture and culture. It seems frothy but it ain't. What's important to us, what do we stand for, where will we not compromise? To quote from commentary above: "NHS also has blaming, naming, shaming and gaming culture. There is no proper accountability for the Board level leaders for their values and behaviours."

For me the key takeaway from the VM approach is the Patient Safety Alert System and the benefits that has brought. Lean is a side issue well commentated on by others here. Let's not try and compare the whole of the US health economy as being representative of the best - take the best and be open to ideas wherever from.