One Saturday in 2000, some unsuspecting moviegoers showed up at a suburban theater in Chicago to catch a 1:05 p.m. matinee of Mel Gibson’s action ﬂick Payback. They were handed a soft drink and a free bucket of popcorn and were asked to stick around after the movie to answer a few questions about the concession stand. These movie fans were unwitting participants in a study of irrational eating behavior.
There was something unusual about the popcorn they received. It was wretched. In fact, it had been carefully engineered to be wretched. It had been popped ﬁve days earlier and was so stale that it squeaked when you ate it. One moviegoer later compared it to Styrofoam packing peanuts, and two others, forgetting that they’d received the popcorn for free, demanded their money back.
Some of them got their free popcorn in a medium-size bucket, and others got a large bucket—the sort of huge tub that looks like it might once have been an above-ground swimming pool. Every person got a bucket so there’d be no need to share. The researchers responsible for the study were interested in a simple question: Would the people with bigger buckets eat more?
Both buckets were so big that none of the moviegoers could ﬁnish their individual portions. So the actual research question was a bit more speciﬁc: Would somebody with a larger inexhaustible supply of popcorn eat more than someone with a smaller inexhaustible supply?
The sneaky researchers weighed the buckets before and after the movie, so they were able to measure precisely how much popcorn each person ate. The results were stunning: People with the large buckets ate 53 percent more popcorn than people with the medium size. That’s the equivalent of 173 more calories and approximately 21 extra hand-dips into the bucket.
Brian Wansink, the author of the study, runs the Food and Brand Lab at Cornell University, and he described the results in his book Mindless Eating: “We’ve run other popcorn studies, and the results were always the same, however we tweaked the details. It didn’t matter if our moviegoers were in Pennsylvania, Illinois, or Iowa, and it didn’t matter what kind of movie was showing; all of our popcorn studies led to the same conclusion. People eat more when you give them a bigger container. Period.”
No other theory explains the behavior. These people weren’t eating for pleasure. (The popcorn was so stale it squeaked!) They weren’t driven by a desire to ﬁnish their portion. (Both buckets were too big to ﬁnish.) It didn’t matter whether they were hungry or full. The equation is unyielding: Bigger container = more eating.
Best of all, people refused to believe the results. After the movie, the researchers told the moviegoers about the two bucket sizes and the ﬁndings of their past research. The researchers asked, Do you think you ate more because of the larger size? The majority scoffed at the idea, saying, “Things like that don’t trick me,” or, “I’m pretty good at knowing when I’m full.”
Imagine that someone showed you the data from the popcorn-eating study but didn’t mention the bucket sizes. On your data summary, you could quickly scan the results and see how much popcorn different people ate—some people ate a little, some ate a lot, and some seemed to be testing the physical limits of the human stomach. Armed with a data set like that, you would ﬁnd it easy to jump to conclusions. Some people are Reasonable Snackers, and others are Big Gluttons.
A public-health expert, studying that data alongside you, would likely get very worried about the Gluttons. We need to motivate these people to adopt healthier snacking behaviors! Let’s ﬁnd ways to show them the health hazards of eating so much!
But wait a second. If you want people to eat less popcorn, the solution is pretty simple: Give them smaller buckets. You don’t have to worry about their knowledge or their attitudes.
You can see how easy it would be to turn an easy change problem (shrinking people’s buckets) into a hard change problem (convincing people to think differently). And that’s the ﬁrst surprise about change: What looks like a people problem is often a situation problem.
This is a book to help you change things. We consider change at every level—individual, organizational, and societal. Maybe you want to help your brother beat his gambling addiction. Maybe you need your team at work to act more frugally because of market conditions. Maybe you wish more of your neighbors would bike to work.
Usually these topics are treated separately—there is “change management” advice for executives and “self-help” advice for individuals and “change the world” advice for activists. That’s a shame, because all change efforts have something in common: For anything to change, someone has to start acting differently. Your brother has got to stay out of the casino; your employees have got to start booking coach fares. Ultimately, all change efforts boil down to the same mission: Can you get people to start behaving in a new way?
We know what you’re thinking—people resist change. But it’s not quite that easy. Babies are born every day to parents who, inexplicably, welcome the change. Think about the sheer magnitude of that change! Would anyone agree to work for a boss who’d wake you up twice a night, screaming, for trivial administrative duties? (And what if, every time you wore a new piece of clothing, the boss spit up on it?) Yet people don’t resist this massive change—they volunteer for it.
In our lives, we embrace lots of big changes—not only babies, but marriages and new homes and new technologies and new job duties. Meanwhile, other behaviors are maddeningly intractable. Smokers keep smoking and kids grow fatter and your husband can’t ever seem to get his dirty shirts into a hamper.
So there are hard changes and easy changes. What distinguishes one from the other? In this book, we argue that successful changes share a common pattern. They require the leader of the change to do three things at once. We’ve already mentioned one of those three things: To change someone’s behavior, you’ve got to change that person’s situation.
The situation isn’t the whole game, of course. You can send an alcoholic to rehab, where the new environment will help him go dry. But what happens when he leaves and loses that inﬂuence? You might see a boost in productivity from your sales reps when the sales manager shadows them, but what happens afterward when the situation returns to normal? For individuals’ behavior to change, you’ve got to inﬂuence not only their environment but their hearts and minds.
The problem is this: Often the heart and mind disagree. Fervently.
Consider the Clocky, an alarm clock invented by an MIT student, Gauri Nanda. It’s no ordinary alarm clock—it has wheels. You set it at night, and in the morning when the alarm goes off, it rolls off your nightstand and scurries around the room, forcing you to chase it down. Picture the scene: You’re crawling around the bedroom in your underwear, stalking and cursing a runaway clock.
Clocky ensures that you won’t snooze-button your way to disaster. And apparently that’s a common fear, since about 35,000 units were purchased, at $50 each, in Clocky’s ﬁrst two years on the market (despite minimal marketing). The success of this invention reveals a lot about human psychology. What it shows, fundamentally, is that we are schizophrenic. Part of us—our rational side—wants to get up at 5:45 a.m., allowing ourselves plenty of time for a quick jog before we leave for the ofﬁce. The other part of us—the emotional side— wakes up in the darkness of the early morning, snoozing inside a warm cocoon of sheets and blankets, and wants nothing in the world so much as a few more minutes of sleep. If, like us, your emotional side tends to win these internal debates, then you might be a potential Clocky customer. The beauty of the device is that it allows your rational side to outsmart your emotional side. It’s simply impossible to stay cuddled up under the covers when a rogue alarm clock is rolling around your room.
Let’s be blunt here: Clocky is not a product for a sane species. If Spock wants to get up at 5:45 a.m., he’ll just get up. No drama required.
Our built-in schizophrenia is a deeply weird thing, but we don’t think much about it because we’re so used to it. When we kick off a new diet, we toss the Cheetos and Oreos out of the pantry, because our rational side knows that when our emotional side gets a craving, there’s no hope of self-control. The only option is to remove the temptation altogether. (For the record, some MIT student will make a fortune designing Cheetos that scurry away from people when they’re on a diet.)
The unavoidable conclusion is this: Your brain isn’t of one mind.
The conventional wisdom in psychology, in fact, is that the brain has two independent systems at work at all times. First, there’s what we called the emotional side. It’s the part of you that is instinctive, that feels pain and pleasure. Second, there’s the rational side, also known as the reﬂective or conscious system. It’s the part of you that deliberates and analyzes and looks into the future.
In the past few decades, psychologists have learned a lot about these two systems, but of course mankind has always been aware of the tension. Plato said that in our heads we have a rational charioteer who has to rein in an unruly horse that “barely yields to horsewhip and goad combined.” Freud wrote about the selﬁsh id and the conscientious superego (and also about the ego, which mediates between them). More recently, behavioral economists dubbed the two systems the Planner and the Doer.
But, to us, the duo’s tension is captured best by an analogy used by University of Virginia psychologist Jonathan Haidt in his wonderful book The Happiness Hypothesis. Haidt says that our emotional side is an Elephant and our rational side is its Rider. Perched atop the Elephant, the Rider holds the reins and seems to be the leader. But the Rider’s control is precarious because the Rider is so small relative to the Elephant. Anytime the six-ton Elephant and the Rider disagree about which direction to go, the Rider is going to lose. He’s completely overmatched.
Most of us are all too familiar with situations in which our Elephant overpowers our Rider. You’ve experienced this if you’ve ever slept in, overeaten, dialed up your ex at midnight, procrastinated, tried to quit smoking and failed, skipped the gym, gotten angry and said something you regretted, abandoned your Spanish or piano lessons, refused to speak up in a meeting because you were scared, and so on. Good thing no one is keeping score. The weakness of the Elephant, our emotional and instinctive side, is clear: It’s lazy and skittish, often looking for the quick payoff (ice cream cone) over the long-term payoff (being thin). When change efforts fail, it’s usually the Elephant’s fault, since the kinds of change we want typically involve short-term sacriﬁces for long-term payoffs. (We cut back on expenses today to yield a better balance sheet next year. We avoid ice cream today for a better body next year.) Changes often fail because the Rider simply can’t keep the Elephant on the road long enough to reach the destination.
The Elephant’s hunger for instant gratiﬁcation is the opposite of the Rider’s strength, which is the ability to think long-term, to plan, to think beyond the moment (all those things that your pet can’t do). But what may surprise you is that the Elephant also has enormous strengths and that the Rider has crippling weaknesses. The Elephant isn’t always the bad guy. Emotion is the Elephant’s turf—love and compassion and sympathy and loyalty. That ﬁerce instinct you have to protect your kids against harm—that’s the Elephant. That spine-stiffening you feel when you need to stand up for yourself—that’s the Elephant.
And even more important if you’re contemplating a change, the Elephant is the one who gets things done. To make progress toward a goal, whether it’s noble or crass, requires the energy and drive of the Elephant. And this strength is the mirror image of the Rider’s great weakness: spinning his wheels. The Rider tends to overanalyze and overthink things. Chances are, you know people with Rider problems: your friend who can agonize for twenty minutes about what to eat for dinner; your colleague who can brainstorm about new ideas for hours but can’t ever seem to make a decision.
If you want to change things, you’ve got to appeal to both. The Rider provides the planning and direction, and the Elephant provides the energy. So if you reach the Riders of your team but not the Elephants, team members will have understanding without motivation. If you reach their Elephants but not their Riders, they’ll have passion without direction. In both cases, the ﬂaws can be paralyzing. A reluctant Elephant and a wheel-spinning Rider can both ensure that nothing changes. But when Elephants and Riders move together, change can come easily.
When Rider and Elephant disagree about which way to move, you’ve got a problem. The Rider can get his way temporarily—he can tug on the reins hard enough to get the Elephant to submit. (Anytime you use willpower you’re doing exactly that.) But the Rider can’t win a tug-of-war with a huge animal for long. He simply gets exhausted.
To see this point more clearly, consider the behavior of some college students who participated in a study about “food perception” (or so they were told). They reported to the lab a bit hungry; they’d been asked not to eat for at least three hours beforehand. They were led to a room that smelled amazing— the researchers had just baked chocolate-chip cookies. On a table in the center of the room were two bowls. One held a sampling of chocolates, along with the warm, fresh-baked chocolate-chip cookies they’d smelled. The other bowl held a bunch of radishes.
The researchers had prepped a cover story: We’ve selected chocolates and radishes because they have highly distinctive tastes. Tomorrow, we’ll contact you and ask about your memory of the taste sensations you experienced while eating them.
Half the participants were asked to eat two or three cookies and some chocolate candies, but no radishes. The other half were asked to eat at least two or three radishes, but no cookies. While they ate, the researchers left the room, intending, rather sadistically, to induce temptation: They wanted those poor radish-eaters to sit there, alone, nibbling on rabbit food, glancing enviously at the fresh-baked cookies. (It probably goes without saying that the cookie-eaters experienced no great struggle in resisting the radishes.) Despite the temptation, all participants ate what they were asked to eat, and none of the radish-eaters snuck a cookie. That’s willpower at work. At that point, the “taste study” was officially over, and another group of researchers entered with a second, supposedly unrelated study: We’re trying to ﬁnd who’s better at solving problems, college students or high school students. This framing was intended to get the college students to puff out their chests and take the forthcoming task seriously.
The college students were presented with a series of puzzles that required them to trace a complicated geometric shape without retracing any lines and without lifting their pencils from the paper. They were given multiple sheets of paper so they could try over and over. In reality, the puzzles were designed to be unsolvable. The researchers wanted to see how long the college students would persist in a difﬁcult, frustrating task before they ﬁnally gave up.
The “untempted” students, who had not had to resist eating the chocolate-chip cookies, spent 19 minutes on the task, making 34 well-intentioned attempts to solve the problem.
The radish-eaters were less persistent. They gave up after only 8 minutes—less than half the time spent by the cookie-eaters—and they managed only 19 solution attempts. Why did they quit so easily?
The answer may surprise you: They ran out of self-control. In studies like this one, psychologists have discovered that self-control is an exhaustible resource. It’s like doing bench presses at the gym. The ﬁrst one is easy, when your muscles are fresh. But with each additional repetition, your muscles get more exhausted, until you can’t lift the bar again. The radish-eaters had drained their self-control by resisting the cookies. So when their Elephants, inevitably, started complaining about the puzzle task—it’s too hard, it’s no fun, we’re no good at this—their Riders didn’t have enough strength to yank on the reins for more than 8 minutes. Meanwhile, the cookie-eaters had a fresh, untaxed Rider, who fought off the Elephant for 19 minutes.
Self-control is an exhaustible resource. This is a crucial realization, because when we talk about “self-control,” we don’t mean the narrow sense of the word, as in the willpower needed to ﬁght vice (smokes, cookies, alcohol). We’re talking about a broader kind of self-supervision. Think of the way your mind works when you’re giving negative feedback to an employee, or assembling a new bookshelf, or learning a new dance. You are careful and deliberate with your words or movements. It feels like there’s a supervisor on duty. That’s self-control, too.
Contrast that with all the situations in which your behavior doesn’t feel “supervised”—for instance, the sensation while you’re driving that you can’t remember the last few miles of road, or the easy, unthinking way you take a shower or make your morning coffee. Much of our daily behavior, in fact, is more automatic than supervised, and that’s a good thing because the supervised behavior is the hard stuff. It’s draining.
Dozens of studies have demonstrated the exhausting nature of self-supervision. For instance, people who were asked to make tricky choices and trade-offs—such as setting up a wedding registry or ordering a new computer—were worse at focusing and solving problems than others who hadn’t made the tough choices. In one study, some people were asked to restrain their emotions while watching a sad movie about sick animals. Afterward, they exhibited less physical endurance than others who’d let the tears ﬂow freely. The research shows that we burn up self-control in a wide variety of situations: managing the impression we’re making on others; coping with fears; controlling our spending; trying to focus on simple instructions such as “Don’t think of a white bear”; and many, many others.
Here’s why this matters for change: When people try to change things, they’re usually tinkering with behaviors that have become automatic, and changing those behaviors requires careful supervision by the Rider. The bigger the change you’re suggesting, the more it will sap people’s self-control.
And when people exhaust their self-control, what they’re exhausting are the mental muscles needed to think creatively, to focus, to inhibit their impulses, and to persist in the face of frustration or failure. In other words, they’re exhausting precisely the mental muscles needed to make a big change.
So when you hear people say that change is hard because people are lazy or resistant, that’s just ﬂat wrong. In fact, the opposite is true: Change is hard because people wear themselves out. And that’s the second surprise about change: What looks like laziness is often exhaustion.
Jon Stegner believed the company he worked for, a large manufacturer, was wasting vast sums of money. “I thought we had an opportunity to drive down purchasing costs not by 2 percent but by something on the order of $1 billion over the next ﬁve years,” said Stegner, who is quoted in John Kotter and Dan Cohen’s essential book The Heart of Change.
To reap these savings, a big process shift would be required, and for that shift to occur, Stegner knew that he’d have to convince his bosses. He also knew that they’d never embrace such a big shift unless they believed in the opportunity, and for the most part, they didn’t.
Seeking a compelling example of the company’s poor purchasing habits, Stegner assigned a summer student intern to investigate a single item—work gloves, which workers in most of the company’s factories wore. The student embarked on a mission to identify all the types of gloves used in all the company’s factories and then trace back what the company was paying for them.
The intrepid intern soon reported that the factories were purchasing 424 different kinds of gloves! Furthermore, they were using different glove suppliers, and they were all negotiating their own prices. The same pair of gloves that cost $5 at one factory might cost $17 at another.
At Stegner’s request, the student collected a specimen of every one of the 424 different types of gloves and tagged each with the price paid. Then all the gloves were gathered up, brought to the boardroom, and piled up on the conference table. Stegner invited all the division presidents to come visit the Glove Shrine. He recalled the scene:
What they saw was a large expensive table, normally clean or with a few papers, now stacked high with gloves. Each of our executives stared at this display for a minute. Then each said something like, “We really buy all these different kinds of gloves?” Well, as a matter of fact, yes we do. “Really?” Yes, really. Then they walked around the table…. They could see the prices. They looked at two gloves that seemed exactly alike, yet one was marked $3.22 and the other $10.55. It’s a rare event when these people don’t have anything to say. But that day, they just stood with their mouths gaping.
The gloves exhibit soon became a traveling road show, visiting dozens of plants. The reaction was visceral: This is crazy. We’re crazy. And we’ve got to make sure this stops happening. Soon Stegner had exactly the mandate for change that he’d sought. The company changed its purchasing process and saved a great deal of money. This was exactly the happy ending everyone wanted (except, of course, for the glove salesmen who’d managed to sell the $5 gloves for $17).
Let’s be honest: Most of us would not have tried what Stegner did. It would have been so easy, so natural, to make a presentation that spoke only to the Rider. Think of the possibilities: the spreadsheets, the savings data, the cost-cutting protocols, the recommendations for supplier consolidation, the exquisite logic for central purchasing. You could have created a 12-tabbed Microsoft Excel spreadsheet that would have made a tax accountant weep with joy. But instead of doing any of that, Stegner dumped a bunch of gloves on a table and invited his bosses to see them.
If there is such a thing as white-collar courage, surely this was an instance.
Stegner knew that if things were going to change, he had to get his colleagues’ Elephants on his side. If he had made an analytical appeal, he probably would have gotten some supportive nods, and the execs might have requested a follow-up meeting six weeks later (and then rescheduled it). The analytical case was compelling—by itself, it might have convinced Stegner’s colleagues that overhauling the purchasing system would be an important thing to do . . . next year.
Remember that if you reach your colleagues’ Riders but not their Elephants, they will have direction without motivation. Maybe their Riders will drag the Elephant down the road for a while, but as we’ve seen, that effort can’t last long.
Once you break through to feeling, though, things change. Stegner delivered a jolt to his colleagues. First, they thought to themselves, We’re crazy! Then they thought, We can ﬁx this. Everyone could think of a few things to try to ﬁx the glove problem— and by extension the ordering process as a whole. That got their Elephants ﬁred up to move.
We don’t expect potential billion-dollar change stories to come dressed up like this. The change effort was led by a single employee, with the able help of a summer intern. It focused on a single product. The scope of the presentation didn’t correspond in any way to the scope of the proposal. Yet Stegner’s strategy worked.
That’s the power of speaking to both the Rider and the Elephant.
It’s true that an unmotivated Elephant can doom a change effort, but let’s not forget that the Rider has his own issues. He’s a navel-gazer, an analyzer, a wheel-spinner. If the Rider isn’t sure exactly what direction to go, he tends to lead the Elephant in circles. And as we’ll see, that tendency explains the third and ﬁnal surprise about change: What looks like resistance is often a lack of clarity.
Two health researchers, Steve Booth-Butterﬁeld and Bill Reger, professors at West Virginia University, were contemplating ways to persuade people to eat a healthier diet. From past research, they knew that people were more likely to change when the new behavior expected of them was crystal clear, but unfortunately, “eating a healthier diet” was anything but.
Where to begin? Which foods should people stop (or start) eating? Should they change their eating behavior at breakfast, lunch, or dinner? At home or in restaurants? The number of ways to “eat healthier” is limitless, especially given the starting place of the average American diet. This is exactly the kind of situation in which the Rider will spin his wheels, analyzing and agonizing and never moving forward.
As the two researchers brainstormed, their thoughts kept coming back to milk. Most Americans drink milk, and we all know that milk is a great source of calcium. But milk is also the single largest source of saturated fat in the typical American’s diet. In fact, calculations showed something remarkable: If Americans switched from whole milk to skim or 1% milk, the average diet would immediately attain the USDA recommended levels of saturated fat. How do you get Americans to start drinking low-fat milk? You make sure it shows up in their refrigerators. And that isn’t an entirely facetious answer. People will drink whatever is around the house—a family will plow through low-fat milk as fast as whole milk. So, in essence, the problem was even easier than anticipated: You don’t need to change drinking behavior. You need to change purchasing behavior.
Suddenly the intervention became razor-sharp. What behavior do we want to change? We want consumers to buy skim or 1% milk. When? When they’re shopping for groceries. Where? Duh. What else needs to change? Nothing (for now). Reger and Booth-Butterﬁeld launched a campaign in two communities in West Virginia, running spots on the local media outlets (TV, newspaper, radio) for two weeks. In contrast to the bland messages of most public-health campaigns, the 1% milk campaign was punchy and speciﬁc. One ad trumpeted the fact that one glass of whole milk has the same amount of saturated fat as ﬁve strips of bacon! At a press conference, the researchers showed local reporters a tube full of fat—the equivalent of the amount found in a half-gallon of whole milk. (Notice the Elephant appeals: They’re going for an “Oh, gross!” reaction.)
Reger and Booth-Butterﬁeld monitored milk sales data at all eight stores in the intervention area. Before the campaign, the market share of low-fat milk was 18 percent. After the campaign, it was 41 percent. Six months later, it held at 35 percent.
This brings us to the ﬁnal part of the pattern that characterizes successful changes: If you want people to change, you must provide crystal-clear direction.
By now, you can understand the reason this is so important: It’s so the Rider doesn’t spin his wheels. If you tell people to “act healthier,” think of how many ways they can interpret that— imagine their Riders contemplating the options endlessly. (Do I eat more grains and less meat? Or vice versa? Do I start taking vitamins? Would it be a good trade-off if I exercise more and bribe myself with ice cream? Should I switch to Diet Coke, or is the artiﬁcial sweetener worse than the calories?)
What looks like resistance is often a lack of clarity. Before this study, we might have looked at these West Virginians and concluded they were the kind of people who don’t care about their health. But if they were indeed “that kind” of people, why was it so easy to shift their behavior?
If you want people to change, you don’t ask them to “act healthier.” You say, “Next time you’re in the dairy aisle of the grocery store, reach for a jug of 1% milk instead of whole milk.”
Now you’ve had a glimpse of the basic three-part framework we will unpack in this book, one that can guide you in any situation where you need to change behavior:
We created this framework to be useful for people who don’t have scads of authority or resources. Some people can get their way by ﬁat. CEOs, for instance, can sell off divisions, hire people, ﬁre people, change incentive systems, merge teams, and so on. Politicians can pass laws or impose punishments to change behavior. The rest of us don’t have these tools (though, admittedly, they would make life easier: “Son, if you don’t take out the trash tonight, you’re ﬁred”). In this book, we don’t talk a lot about these structural methods.
As helpful as we hope this framework will be to you, we’re well aware, and you should be, too, that this framework is no panacea. For one thing, it’s incomplete. We’ve deliberately left out lots of great thinking on change in the interests of creating a framework that’s simple enough to be practical. For another, there’s a good reason why change can be difﬁcult: The world doesn’t always want what you want. You want to change how others are acting, but they get a vote. You can cajole, inﬂuence, inspire, and motivate— but sometimes an employee would rather lose his job than move out of his comfortable routines. Sometimes the alcoholic will want another drink no matter what the consequences.
So we don’t promise that we’re going to make change easy, but at least we can make it easier. Our goal is to teach you a framework, based on decades of scientiﬁc research, that is simple enough to remember and ﬂexible enough to use in many different situations—family, work, community, and otherwise.
To change behavior, you’ve got to direct the Rider, motivate the Elephant, and shape the Path. If you can do all three at once, dramatic change can happen even if you don’t have lots of power or resources behind you. For proof of that, we don’t need to look beyond Donald Berwick, a man who changed the face of health care.
In 2004, Donald Berwick, a doctor and the CEO of the Institute for Healthcare Improvement (IHI), had some ideas about how to save lives—massive numbers of lives. Researchers at the IHI had analyzed patient care with the kinds of analytical tools used to assess the quality of cars coming off a production line. They discovered that the “defect” rate in health care was as high as 1 in 10—meaning, for example, that 10 percent of patients did not receive their antibiotics in the speciﬁed time. This was a shockingly high defect rate—many other industries had managed to achieve performance at levels of 1 error in 1,000 cases (and often far better). Berwick knew that the high medical defect rate meant that tens of thousands of patients were dying every year, unnecessarily.
Berwick’s insight was that hospitals could beneﬁt from the same kinds of rigorous process improvements that had worked in other industries. Couldn’t a transplant operation be “produced” as consistently and ﬂawlessly as a Toyota Camry?
Berwick’s ideas were so well supported by research that they were essentially indisputable, yet little was happening. He certainly had no ability to force any changes on the industry. IHI had only seventy-ﬁve employees. But Berwick wasn’t deterred.
On December 14, 2004, he gave a speech to a room full of hospital administrators at a large industry convention. He said, “Here is what I think we should do. I think we should save 100,000 lives. And I think we should do that by June 14, 2006—18 months from today. Some is not a number; soon is not a time. Here’s the number: 100,000. Here’s the time: June 14, 2006—9 a.m.”
The crowd was astonished. The goal was daunting. But Berwick was quite serious about his intentions. He and his tiny team set out to do the impossible.
IHI proposed six very speciﬁc interventions to save lives. For instance, one asked hospitals to adopt a set of proven procedures for managing patients on ventilators, to prevent them from getting pneumonia, a common cause of unnecessary death. (One of the procedures called for a patient’s head to be elevated between 30 and 45 degrees, so that oral secretions couldn’t get into the windpipe.)
Of course, all hospital administrators agreed with the goal to save lives, but the road to that goal was ﬁlled with obstacles. For one thing, for a hospital to reduce its “defect rate,” it had to acknowledge having a defect rate. In other words, it had to admit that some patients were dying needless deaths. Hospital lawyers were not keen to put this admission on record.
Berwick knew he had to address the hospitals’ squeamishness about admitting error. At his December 14 speech, he was joined by the mother of a girl who’d been killed by a medical error. She said, “I’m a little speechless, and I’m a little sad, because I know that if this campaign had been in place four or ﬁve years ago, that Josie would be ﬁne…. But, I’m happy, I’m thrilled to be part of this, because I know you can do it, because you have to do it.” Another guest on stage, the chair of the North Carolina State Hospital Association, said: “An awful lot of people for a long time have had their heads in the sand on this issue, and it’s time to do the right thing. It’s as simple as that.”
IHI made joining the campaign easy: It required only a one-page form signed by a hospital CEO. By two months after Berwick’s speech, over a thousand hospitals had enrolled. Once a hospital enrolled, the IHI team helped the hospital embrace the new interventions. Team members provided research, step-by-step instruction guides, and training. They arranged conference calls for hospital leaders to share their victories and struggles with one another. They encouraged hospitals with early successes to become “mentors” to hospitals just joining the campaign.
The friction in the system was substantial. Adopting the IHI interventions required hospitals to overcome decades’ worth of habits and routines. Many doctors were irritated by the new procedures, which they perceived as constricting. But the adopting hospitals were seeing dramatic results, and their visible successes attracted more hospitals to join the campaign.
Eighteen months later, at the exact moment he’d promised to return—June 14, 2006, at 9 a.m.—Berwick took the stage again to announce the results: “Hospitals enrolled in the 100,000 Lives Campaign have collectively prevented an estimated 122,300 avoidable deaths and, as importantly, have begun to institutionalize new standards of care that will continue to save lives and improve health outcomes into the future.”
The crowd was euphoric. Don Berwick, with his 75-person team at IHI, had convinced thousands of hospitals to change their behavior, and collectively, they’d saved 122,300 lives—the equivalent of throwing a life preserver to every man, woman, and child in Ann Arbor, Michigan.
This outcome was the fulfillment of the vision Berwick had articulated as he closed his speech eighteen months earlier, about how the world would look when hospitals achieved the 100,000 lives goal:
“And, we will celebrate. Starting with pizza, and ending with champagne. We will celebrate the importance of what we have undertaken to do, the courage of honesty, the joy of companionship, the cleverness of a field operation, and the results we will achieve. We will celebrate ourselves, because the patients whose lives we save cannot join us, because their names can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would have been only beds of weeds.”
Big changes can happen.
Don Berwick and his team catalyzed a change that saved 100,000 lives, yet Berwick himself wielded no power. He couldn’t change the law. He couldn’t ﬁre hospital leaders who didn’t agree with him. He couldn’t pay bonuses to hospitals that accepted his proposals.
Berwick had the same tools the rest of us have. First, he directed his audience’s Riders. The destination was crystal clear:
Some is not a number; soon is not a time. Here’s the number: 100,000. Here’s the time: June 14, 2006—9 a.m. But that wasn’t enough. He had to help hospitals ﬁgure out how to get there, and he couldn’t simply say, “Try harder.” (Remember “act healthier” versus “buy 1% milk.”) So he proposed six speciﬁc interventions, such as elevating the heads of patients on ventilators, that were known to save lives. By staying laser-focused on these six interventions, Berwick made sure not to exhaust the Riders of his audience with endless behavioral changes.
Second, he motivated his audience’s Elephants. He made them feel the need for change. Many of the people in the audience already knew the facts, but knowing was not enough. (Remember, knowing wasn’t enough for executives at Jon Stegner’s company. It took a stack of gloves to get their Elephants engaged.) Berwick had to get beyond knowing, so he brought his audience face-to-face with the mother of the girl who’d been killed by a medical error: “I know that if this campaign had been in place four or ﬁve years ago, that Josie would be ﬁne.” Berwick was also careful to motivate the people who hadn’t been in the room for his presentation. He didn’t challenge people to “overhaul medicine” or “bring TQM to health care.” He challenged them to save 100,000 lives. That speaks to anyone’s Elephant.
Third, he shaped the Path. He made it easier for the hospitals to embrace the change. Think of the one-page enrollment form, the step-by-step instructions, the training, the support groups, the mentors. He was designing an environment that made it more likely for hospital administrators to reform. Berwick also knew that behavior was contagious. He used peer pressure to persuade hospitals to join the campaign. (Your rival hospital across town just signed on to help save 100,000 lives. Do you really want them to have the moral high ground?) He also connected people—he matched up people who were struggling to implement the changes with people who had mastered them, almost like the “mentors” found in Alcoholics Anonymous. Berwick was creating a support group for health care reform.
In this book, you’ll learn about people like Berwick who’ve created sweeping change despite having few resources and little structural authority. You’ll learn about an entrepreneur who saved his small company by turning his skeptical employees into customer-service zealots; a student fresh out of college who saved an endangered species from extinction; a manager who plotted a way to get his colleague to stop acting like a jerk; and a therapist who reformed a group of child abusers.
Whether the switch you seek is in your family, in your charity, in your organization, or in society at large, you’ll get there by making three things happen. You’ll direct the Rider, motivate the Elephant, and shape the Path.