Bayberry General Hospital - Never Event Case Study The healthcare insurance industry has recently decided to get tough. Many have started a policy that, for things they feel shouldn't occur at all during a hospital stay (which they call "never events"), the hospital will not get reimbursement for the additional expenses incurred to treat them. The theory is that, if people were truly accountable and just did their jobs, these things should not occur! Bayberry General Hospital's performance is shown below in a typical bar graph/trend line display. Their executive feels that the overall trend looks good, especially given the six quarters of zero. But she is concerned by the excessive number of quarters with three events, especially since the last two occurred after a quarter of zero. She insisted on going back to all the root cause analyses for the past two years. The board is really applying pressure by insisting on no more than one incident per quarter and a special report to them with a proposed action plan if two or more occur.

Is there statistical evidence that the root cause analyses have helped?

Is the trend line in the above bar graph insightful?

From this data, construct a run chart. Based on your chart, is there any statistical evidence of either a downward trend or a beneficial process shift? Is it OK to take the average of all the data?