Tuesday, July 27, 2010

The Red Bead Game Applied to Medical Errors — Lean Blog

The Red Bead Game Applied to Medical Errors — Lean Blog

by MARK GRABAN on JULY 26, 2010

A blog reader sent me a link to this UK news article — really, it’s a lesson in statistical literacy, so thanks to the BBC for that. In the web piece, “Can chance make you a killer?“, Dr. Deming’s famous lessons from the “Red Bead Game” are illustrated in the context of deciding, based on data, which hospitals or doctors have patient death rates so high that negligence would be implied.

Are you fluent in the terminology and concepts of “common cause” and “special cause” variation? The BBC provides a great primer.

I have facilitated the Red Bead Game a number of times, after having read about it Dr. W. Edwards Deming’s classic Out of the Crisis. I own a copy of the kit, as pictured above, which I used at a healthcare conference a few years back.

Some of the lessons learned from running this game:

Arbitrary quality targets are useless if the system is not capable of delivering that level of quality
People are often punished or rewarded for situations that are just “dumb luck” instead of anything reflecting their skill or ability



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