Switch: How to change things when change is hard

Switch: How to change things when change is hard is an incredibly useful book. The authors, brothers, and co-authors of Made to stick: Why some ideas survive and others die,  Chip and Dan Heath,  begin  by explaining why making changes can be so difficult and using real life case studies, colourful anecdotes and backed up by theoretical research explain how implementing changes can be made easier. I’ve managed to use a number of the techniques illustrated in this book in a tricky (but very timely) work change scenario and found them to be really effective at opening up new possibilities.

In brief, the framework they recommend to change things when change is hard is as follows; they borrow from an analogy created by Jonathan Haidt in his book The Happiness Hypothesis and describe our emotional side as an elephant and our rational side as the rider sitting atop the elephant and holding the reins. Although the rider seems to be steering the elephant, the reality is it’s a precarious control. Anytime the elephant and the rider disagree about the direction to go in, the elephant by dint of it’s sheer size, wins.  Similarly, most of us are familiar with situations where our elephant overpowers our rider; e.g. you make that resolution to go the gym/get fit/lose weight and after the initial flurry of activity you fall off the bandwagon.

The weakness of the elephant, our emotional side, is obvious; we want the quick win over the long term pay off. And oftentimes, change efforts (such as the gym example above) fail for the very reason that typically short term sacrifices are needed for long term payoffs. The rider, our rational/logical side, who has the ability to plan and think long term often can’t keep the elephant on the road long enough to achieve the goal.

On the flip side the elephant’s strengths are its energy, drive and taking action that comes from having an emotional attachment to achieving a particular goal;  the reader’s weakness can be a tendency to over analyze and over think.

In summary, therefore, effective change interventions must appeal to our emotional and logical/rational side. Or, in the authors’ words they must:

1. Direct the rider
2. Motivate the elephant
3. Shape the path

There were a number of very compelling case studies in this book; one I think is particularly relevant and perfectly illustrates the change framework is that of Donal Berwick, a doctor and CEO of the Institute for Healthcare Improvement (IHI), and his astonishing feat in mobilising hospitals to achieve the goal of saving 100,000 lives. In 2004, the IHI had conducted research on patient care using analytical tools normally reserved to assess the quality of cars coming off a production line. They uncovered a shocking statistic - the ‘defect’ rate in health care was as high as 1 in 10—in other words, 10 percent of patients did not receive their antibiotics within the required timeframe. Berwick realised that this excessively high medical defect rate meant that tens of thousands of patients died every year, unnecessarily.

Berwick believed that hospitals could use the same kinds of rigorous process improvements that worked in other industries e.g. why couldn’t a transplant operation process as consistently and flawlessly as an automobile production line?
Although Berwick's ideas were very well supported by research he had no power to force any changes on the industry. IHI was a small organisation with only 75 employees. How did Berwick achieve his goal?

On December 14, 2004, Berwick gave a speech to a room full of hospital administrators at a large industry convention. He stated: ‘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.’

Berwick and his team set out to achieve this daunting goal. IHI began by proposing six very specific interventions to save lives. This involved asking hospitals to adopt proven procedures to manage patients with particular illnesses.

In addition, a major obstacle to achieving the goal was to engage the hospitals in reducing their defect rate (which in effect meant admitting that patients were dying needless deaths). IHI made joining the campaign easy: it required only a one-page form signed by a hospital CEO. 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. They 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. And, crucially, they encouraged hospitals with early successes to become ‘mentors’ to hospitals just joining the campaign. 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.’

Berwick managed to achieve what had seemed impossible at the outset.  Breaking down the process he used we see the following steps: first, he directed his audience's Riders. Their destination was crystal clear: 100,000 lives saved by June 14, 2006. He also made it as easy as possible for hospitals to get there. He introduced very specific interventions that were known to save lives.

Secondly he motivated his audience's Elephants. He made them feel the need for change. At his initial speech he brought them face to face with the mother of a girl who died due to medical error. And he made the change very specific-it was to save 100,000 lives.

Finally, he shaped the Path. He made it easier for the hospitals to manage the change. There was a simple one-page enrolment form, step-by-step instructions, training, support groups, and mentors. He designed an environment that made it more likely for hospital administrators to change their behaviour. He matched up people who were struggling to implement the changes with people who had mastered them.

Perhaps the change or switch you’re looking for is in your work, your family, your organisation. You'll achieve it by making three things happen: Directing the Rider, motivating the Elephant and shaping the Path.