The Red Bead Experiment Debrief

Don Berwick, MD, MPH, President Emeritus and Senior Fellow at IHI Rebecca Steinfield, MA, Improvement Advisor

Rebecca Steinfield: What does the Red Bead game teach us about quality in healthcare?

Donald Berwick: Well, it's a purified model of what is known in industry as reliance on inspection to improve. You make the thing, you look at whether you like it or not, if you don't like you throw it out. And a whole lot of belief and process has been organized in our lives, not just in healthcare, in fact, in our entire lives around that idea, make it, study it, if you don't like it, throw it out. When there are people involved, like the workers in the Red Bead game, it's a terrible environment. I mean, you're out of control, you can't make things, you can't change it, but you're being held accountable for improvements you can't accomplish. And it produces this whole vicious cycle of misunderstanding, anger, frustration, demoralization. And by the way, most importantly, some ways, no improvement. So it's a purified example of the wrong way to think about how to make things better.

Rebecca Steinfield: And why do you think, so many people have seen the Red Bead game in healthcare, what makes it so hard to learn those lessons?

Donald Berwick: If you see the bead game you say, "That's not going to work, what else could I do?" You have to have a place to have that conversation. It has to be a place where people can actually sit together and say, "What do we want to do? What is the process? How will we make it better? Could we learn together? Maybe we need to come up with a new way to understand each other." Well, that takes time. It takes energy. And you notice in the bead game, when I'm doing the bead box, it goes faster and faster and faster. Why? Because the productivity pressures on the defects are making you go faster exactly at the time when you need to take a breath in awake or slower, and stop and reflect healthcare, that's really hard right now. Ask a stress doctor or nurse about whether they'd like to sit down and talk about the process, I think at the moment, that sounds really hard.

Rebecca Steinfield: So when people talk about the lessons from the Red Bead game in their organization, what advice might you give people relative to where they are in the organization at different levels,

Donald Berwick: It kind of depends on where they are in the organization. For a frontline worker, look, if there's a pay for performance system and you're being treated like a bead worker, you may feel very helpless. You can't work in that system and feeling effective to change the system. It's hard to say what's best there. Talk to each other, understand that at least in the workforce, and by the way, if you change the way you act, even if in a hostile environment, it's more fun to improve. It's more fun to learn. It's harder, but it's more fun. And so I'd say, do that.

Donald Berwick: In middle management levels, understand how crucial you are. If there are eight or 10 people that report to you, you run that department. You are determining the game in a way you. You're either going to see yourself as a coach and supporter to the growth and development of capabilities and knowledge for yourself and others or you're going to see yourself as a regulator, enforcer, controller, you decide, but you just watch the bead game and what do you think is going to happen.

Donald Berwick: At the senior executive level, it's sort of the same. You're setting the tone, you're setting the pace. At that level, I think you need to ask some very hard questions about corporate systems. Does the compensation system act like the bead box? Are you using data and information correctly? Are you misinterpreting variation? Are you able to spend the time and energy to get different components of the system together so they actually can understand what's going on? Can you celebrate defects in a way? Can you sit in an environment in which you treat failure as a good thing because it teaches you if you're wise enough to look at it? There are big stakes here for boards and government and senior senior executives.

Donald Berwick: I think if I had to maybe give one piece of advice, it's to ask how you're doing. That is ask, if you're a director, ask the workforce is, how am I treating you? What does this feel like to you? Does this feel right to you or not? And be willing to set up the circumstance for a real dialogue. As an executive, same question, which is, am I helping you improve the work that I know you want to do better? Or am I doing things that keep you from inventing and trying and being a team? You may hear some things that you could put to use.

Rebecca Steinfield: What are some of the gaps in what the Red Bead game can do for us as a teaching tool?

Donald Berwick: Yeah, I mean, it's a great demonstration for what it does. There are some fuzzy edges to it or gaps. A couple, for example are the bead box is visible. That is right from the start, you can see the course and that's one of the things that makes the workers feel so helpless is that they actually know the answer, get the reds out of the mix. I can't produce, blues if the red's there. So, it's a supplier problem. In the work we do, we're in healthcare. We don't know that. The causes of the complications and problems in waste and miscommunication, we see the causes are very networked and difficult to visualize. [inaudible 00:05:29] again, my teacher says, "Healthcare doesn't have a catwalk." You can't walk up and watch it like you can on a manufacturing floor.

Donald Berwick: So one of the points I try to make after the bead game is, the game you're in, it isn't visible. You don't know the causes. And actually that leads us to a whole agenda of leadership, because if the causes aren't immediately evident, then you, leader, workforce, manager, you need to find the skills and tools and science that'll help you understand the causes. And that's an agenda that is easy. We gloss over it a little in the bead game.

Donald Berwick: A second, that is really crucial, which is in the world of improvement, your PDSA, plan, do, study, act, the cycles of testing are really crucial. We work in complex systems, and unless you test changes like in small cycles, it's really hard to learn your way to what ought to be done. The bead game doesn't have any testing in it, and it would be hard to even do imagine a test of change because it's such a simple system, but just remember the bead game doesn't include a key piece of improvement, which is running small tests of change all the time to probe the world and understand it better and increase your confidence in what changes work.

Donald Berwick: The third is the role of the customer. You don't see the customer in the bead game, but they're out there, and in the world of improvement, we really need to change that relationship and our relationship with the people we serve so we understand essentially what's blue and what's red is crucial. And it's the whole maturation of the improvement movement, thanks largely to [inaudible 00:07:05], I think has been an international spokesperson for this is to understand what matters to you, not just, what's the matter with you. That's not in the bead game.

Donald Berwick: I think the last piece is creativity and reinvention. I mean, there is a big question outside of the bead game, which is, should we make beads at all? Maybe something other than beads is better. And in the world of improvement, we try to remember control, quality control, kind of keep things, stable, quality improvement, which is really the bead game issue about learning. But we also have to have innovation. And the full set suite of skills in the management improvement to me is fostering control, when it's needed, to fix the flat tire if your car tire's flat, improvement and learning all the time everywhere, and then how are we going to make airplanes instead of trying to make cars better? How do you invent something totally new? So bead game's the beginning, but it's not the end.