The Red Bead Experiment
The Red Bead Experiment, presented by Dr. Don Berwick and originally designed by W. Edwards Deming, powerfully illustrates how system-level flaws, not individual performance, are often the root of poor outcomes. In the experiment, Dr. Berwick employs several traditional management techniques—goal setting, performance quotas, incentives, public praise or reprimands—to motivate workers to reduce the number of red beads (Institute for Healthcare Improvement [IHI], 2017). Despite these efforts, outcomes do not improve, because the system (the bead selection process) is inherently flawed.
These management techniques are ineffective in this context because they ignore a key principle of Deming’s System of Profound Knowledge: most performance variation stems from the system, not from workers themselves (Deming, 1986; TMI Education, 2019). Holding individuals accountable for outcomes beyond their control, as seen in the experiment, creates fear, reduces morale, and diverts attention from needed process improvements.
If I were in charge of the Red Bead Company, I would apply the Model for Improvement, which includes setting clear aims, testing small changes through Plan-Do-Study-Act (PDSA) cycles, and measuring results (IHI, n.d.-b). A critical first step would be to define the problem clearly (Setting Aims) and use root cause analysis, like the “5 Whys” technique, to uncover systemic causes of defects (iSixSigma, n.d.; Zaske, 2021).
Engaging frontline workers in identifying solutions would also be key. Don Goldmann’s (2015) “7 Rules for Engaging Clinicians” emphasizes the importance of respecting clinical insight, minimizing disruption, and starting small—principles that are just as applicable in any system, including the Red Bead Company.
This experiment mirrors issues in healthcare today. Clinicians are often evaluated based on readmission rates, patient satisfaction, or throughput, even though many of these metrics are affected by factors outside their control—like staffing shortages or flawed discharge processes. For example, a nurse might be penalized for delayed discharges caused by delays from the pharmacy, not their own inefficiency.
The takeaway is clear: sustainable quality improvement starts with changing systems, not blaming people. By applying systems thinking and improvement models, leaders in healthcare—and beyond—can create environments where quality thrives.
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