In today's H&HN Daily mailbag, our readers respond to recent pieces on Lean management strategies, results from the CMS Physician Group Practice Demonstration and the importance of reducing process variation in hospitals. First off, Mark Graban's recent piece on how Lean techniques can be used to significantly reduce hospital costs sparked a flurry of debate. Reader JT Smith weighed in with his thoughts on the root causes of unexpected costs:

"The fundamental issue is not unique to hospitals, it is people. People making mistakes costs organizations money. Those mistakes manifest themselves in people not doing what they are supposed to do when they are supposed to do it. As the work of Phil Crosby demonstrated, true quality and savings happen when people do things correctly the first time. That result only happens when expectations are clear, validation is done in real time and consequences are enforced. It has less to do with respect than it has to do with professional discipline."

Meanwhile, reader Lena Kauffman explored the role of the patient in reducing health care costs:

"Part of the change must involve selling patients on a more efficient health care system. Particularly in primary care, seeing a doctor for checkups, common colds or well-child visits is simply inefficient. Modern dental practices provide a good example of having the right person doing the right job at the right time. You spend 90 percent of your time with the hygienist and 10 percent with the dentist."

Next up, Jon Pearce responded to my blog on a report from the Centers for Medicare & Medicaid Services trumpeting positive results from its Physician Group Practice Demonstration, a shared savings initiative that is considered a model for CMS's upcoming Accountable Care Organization pilot. Pearce took a critical look at the new data, noting that the program's financial rewards have not been distributed uniformly:

"The details in the report are important to understanding the results. Of the 10 groups, 52 percent of shared savings payments went to one group. Three groups received no payments. Two groups achieved sizeable shared savings payments in all five years, suggesting that some factor in the demonstration's design may have favored their particular patient mix (This was partially corroborated by the 2009 CMS report on the demonstration.).  The other eight groups' payments were highly variable, with none receiving payments in more than three years. Trends in quality scores were inconsistent, with only 6 of the 10 groups having higher average scores in years 4 and 5 than they achieved in years 1 and 2; the other four groups had lower average quality scores in the later years. There was no apparent correlation between quality scores and shared savings payments. These results seem to be driven by randomness, and possibility a bias in the demonstration methodology, more than by actions of the participating groups."

And finally, reader Mike Parish responded to H&HN Contributing Editor Bob Kehoe's podcast interview with James Benneyan, co-director of the Center for Health Organization Transformation, on how hospitals can dramatically improve their overall quality and patient safety performance by focusing on process variation and building better, standardized models of care

"Jim Benneyan understands things correctly — deep, lasting change and quality improvement is difficult and requires persistent dedication. Simple approaches to QI will solve some simple problems, but to achieve the dramatic changes we need going forward, it will take greater emphasis on a much deeper focus, using more complex skill sets that are the bread and butter of industrial engineers, management engineers and operations research analysts."