Feature

Overcoming Resistance to Change

How one can marry the emotional and the rational to be an effective change agent, according to the co-authors of Switch: How to Change Things When Change Is Hard by CHIP HEATH AND DAN HEATH

In 2004, Donald Berwick, a doctor and the CEO of the Institute for Healthcare Improvement, had some ideas about how to save lives — massive numbers of lives. The institute he led had analyzed patient care applying the analytical tools used to assess the quality of cars coming off a production line.

Berwick and colleagues discovered the “defect” rate in health care was as high as 1 in 10, meaning that, say, only 90 percent of patients received their antibiotics in the right dose at the right time. This was a shockingly high defect rate. Other industries had managed to achieve performance at levels of one error in 1,000 (and often far better). Berwick knew the high medical defect rate meant that tens of thousands of patients were dying every year, unnecessarily.

Chip HeathStanford business professor Chip Heath is co-author of Switch: How to Change Things When Change is Hard. Photo by Linda A. Cicero/Stanford News Service


Berwick’s insight was that hospitals could benefit from the same rigorous operational 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 nothing was happening. And he certainly had no ability to force any changes on the industry. The Institute for Healthcare Improvement had just 75 employees. The medical field accounts for one out of every six dollars that we spend in the whole U.S. economy. How do you start to change medical practice when you don’t control a single hospital, and when you can’t hire or fire a single doctor or nurse?

Not of One Mind
Often, big changes like those Berwick was contemplating seem paralyzingly distant. In public education, the behavior patterns of teachers, administration, parents and students are sufficiently entrenched that any change proposal quickly encounters resistance.

What follows is a game plan we have outlined for overcoming resistance to change in a school district. But to understand the game plan, we first need to understand how resistance to change arises from a conflict that wages within our own minds whenever we think about a change.

Consider what happens when we decide to go on an exercise program. Part of us, our rational side, wants to get up at 5:45 a.m., allowing 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. When we kick off a new diet, we toss the Cheetohs 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.

The unavoidable conclusion is this: Your brain isn’t of one mind.

The conventional wisdom in psychology, in fact, is that our brains have two independent systems at work at all times. First, there’s what we call 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, analyzes and looks into the future.

The human race always has been aware of the tension. Plato said that in our heads we’ve got a rational charioteer who has to rein in an unruly horse who “barely yields to horsewhip and goad combined.” Freud wrote of the selfish id and the conscientious superego (and the ego that mediates between them). More recently, behavioral economists have dubbed the two systems the Planner and the Doer.

But the duo’s tension was captured best by an analogy used by the University of Virginia psychologist Jonathan Haidt in his wonderful book The Happiness Hypothesis. Haidt said our emotional side is an Elephant, and our rational side is its Rider. The Rider, perched atop the Elephant, holds the reins and seems to be the leader. The Rider’s control is precarious, though, because he’s so tiny relative to the Elephant. Anytime the 6-ton Elephant disagrees with the direction, the Rider is going to lose. He’s completely overmatched.

Most of us are all too familiar with situations where the Elephant overpowers our Rider. You’ve experienced this if you’ve ever: slept in, overeaten, dialed up your ex at midnight, procrastinated on a report, tried to quit smoking and failed, skipped the gym, gotten angry and said something you regretted, abandoned your Spanish or jitterbug or piano lessons, refused to speak up in a meeting because you were scared, etc. Good thing no one is keeping score.

So the weakness of the Elephant, our emotional and instinctive side, is clear: It is 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 changes we want typically involve short-term sacrifices for long-term payoffs.

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. 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.

The Elephant’s strength is the mirror image of the Rider’s great weakness: spinning his wheels. The Rider tends to over-analyze and overthink things. If you’ve ever met someone who can agonize for 20 minutes about what to eat for dinner, or if you’ve had a colleague who could brainstorm about new ideas for hours but never seemed to get around to doing anything, you’ve met the Rider.

The challenge of a change agent is to appeal to both. If you reach the Riders of your team but not the Elephants, they’ll have understanding without motivation. If you reach their Elephants but not their Riders, they’ll have passion without direction. In both cases, their flaws can be paralyzing — a reluctant Elephant and a wheel-spinning Rider can both ensure that nothing changes. But when they are moving together, change can come easily.

A Daunting Goal
On Dec. 14, 2004, Donald Berwick 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.
The Institute for Healthcare Improvement proposed six highly specific interventions to save lives. One intervention 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. (For example, patients’ heads should be elevated between 30 and 45 degrees so that oral secretions can’t get into the windpipe.)

All hospital administrators agreed with the goal to save lives, of course, but the road to that goal was filled with obstacles. For one thing, for hospitals to reduce their “defect rates,” they had to acknowledge having a defect rate. In other words, they had to admit some of their patients were dying needless deaths. Hospital lawyers were not keen to put this on record.

Berwick knew he had to address the hospitals’ squeamishness about admitting error. At his speech, Berwick 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 my daughter Josie would be fine. … But, I’m happy, I’m thrilled to be part of this, because I know you can do it.”

The institute made joining the campaign easy. It required only a one-page form signed by the hospital CEO. By two months after Berwick’s speech, more than 1,000 hospitals had enrolled. Once a hospital joined, the Institute for Healthcare Improvement team helped the hospitals embrace the new interventions. The team provided research, step-by-step instruction guides and training. They arranged conference calls for hospital leaders to share with other leaders their victories and struggles. They encouraged hospitals with early successes to become mentors to hospitals just joining the campaign.

A Vision Fulfilled
The friction in the system was substantial. Adopting the institute’s interventions required hospitals to overcome decades’ worth of habits and routines. Many doctors, too, 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 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, 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, Mich.

It was the fulfillment of the vision Berwick articulated as he closed his speech, 18 months earlier, about how the world would look when they achieved their 100,000 lives goal:

“And, we will celebrate. Starting with pizza and ending with champagne. 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.”

A Plan for Change
Big changes can happen.

Don Berwick and his team catalyzed a change that saved 100,000 lives, and he had 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.

He 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 just say, “Try harder.” So he proposed six specific interventions, such as elevating the heads of patients on ventilators, that were proven to save lives. By staying laser-focused on these six interventions, Berwick made sure not to evoke the endless wheel spinning that might otherwise have crippled Riders who were given a big goal but weren’t told how to achieve it.

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. Berwick had to get beyond knowing, so he brought them face to face with the mother of the girl who’d been killed by a medical error, who said: “I know that if this campaign had been in place four or five years ago, that Josie (my daughter) would be fine.”

Berwick also was careful to motivate the people who hadn’t been in the room for his presentation. He didn’t pose this challenge in the jargon that was typically used by medical change efforts, exhorting people to “use evidence-based medicine” or “bring TQM to health care.” Instead, he challenged them to save 100,000 lives. That speaks to anyone’s Elephant.

Third, he shaped the Path, the environment that supported the individuals who were trying to change. Think of the one-page enrollment form, the step-by-step instructions, the training, the support groups, the mentors. Berwick also knew behavior was contagious. He used peer pressure to persuade other 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 those who were struggling to implement the changes with people who had mastered them, almost like the mentors you find in Alcoholics Anonymous. Berwick was creating a support group for health care reform.

In sum, Berwick used a game plan that is used by every successful change leader: He directed the Rider, he motivated the Elephant, and he shaped the Path.

Culture of Failure
The Rider-Elephant-Path game plan has been successful not only in health care, but also business, nonprofits and education. It works even in the hands of change leaders who have little previous experience leading organizational change.

In 1995, Molly Howard, a longtime special education teacher in Louisville, Ga., watched as the new Jefferson County High School building was being constructed.
“Every day I’d drive by the building, and I’d wonder, ‘Who’s gonna run that school?’ And it kept tugging at me, ‘Why don’t you apply?’” Howard said.

She applied and got the job, but with the promotion came a tough challenge. Eighty percent of the school’s students lived in poverty. Only 15 percent of students in the previous high school had continued on to postsecondary school. “The kids you’d expect to be successful were successful,” said Howard. “But what about the other 85 percent?”

Many teachers had a near-defeatist attitude. “There was this belief that some children can and some children can’t. That we’re here for the ones that can get it, and we’ve got to accept that we’re going to lose some. I knew I’d have to challenge that,” said Howard.

Howard acted quickly. Believing every student could aspire to go to college, she abolished the school’s two-track system that had separated “college-bound” students from “vocational” students. She matched students with teachers who’d be their “on-campus advisers” through all four years. She beefed up assessments and tutorial programs.

Perhaps her most distinctive change, though, was to the grading system. She eliminated the option of failure. The new grading system at Jefferson was A, B, C, and NY. The last stood for “Not Yet.”

In Howard’s view, the 3,000 students attending Jefferson, located in a rural area south of Augusta, had accepted a culture of failure — they wouldn’t do their homework, or they’d do a bad job. It was an easy way out for them, a D or an F may mean you have failed, but you’re done. In the new system, the students couldn’t stop until they’d cleared the bar.

“We define up front to the kids what’s an A, B and C,” said Howard. “If they do substandard work, the teacher will say, ‘Not yet.’ That gives them the mindset: My teacher thinks I can do better. It changes their expectations.”

The school was reborn. Students and teachers became more engaged, the school’s graduation rate increased dramatically, and student test scores went up to the point that remedial courses were eliminated. In 2008, Howard was chosen as the nationwide Principal of the Year, out of 48,000 principals, by the National Association of Secondary School Principals.

A Jolt of Energy
Notice that Molly Howard, who now serves as superintendent of the Jefferson County Schools in Georgia, was running the same game plan as Donald Berwick in tackling the weaknesses of Rider and Elephant. She entered a situation where the Elephants were demoralized (there was a “culture of failure”) and the Riders, if they thought about change at all, would have been quickly confused about where to begin.

Howard shaped the Path by eliminating the two-track system of classes and by changing the grading scale. Combined, these two moves directed the Riders — both teachers and students — to focus on the task at hand: We’ve got everyone in regular math now, how do we get everybody up to at least a C-level performance on fractions? The task is not easy, but at least it’s clear.

And for the Elephants, Howard provided a necessary jolt of energy and hope. Before Howard, the perception was that some students can do the work and some can’t — they’re just that way. After Howard, the assumption was that every student was capable of doing acceptable work. There’s no “never” at Jefferson anymore, only a “Not Yet.”

The changes you face may feel daunting, but there is tremendous hope in change stories like those of Donald Berwick and Molly Howard. Both walked into situations where bad behaviors were so entrenched that no one was trying to change. Yet both of them systematically addressed the weaknesses of Rider and Elephant. And they both succeeded where no one thought success was possible.

Whether the switch you seek is in your family, your school system or society at large, you’ll get there by making three things happen. You’ll direct the Rider, motivate the Elephant and shape the Path.

Chip Heath is a professor at the Graduate School of Business at Stanford University in Palo Alto, Calif. E-mail: chip.heath@stanford.edu. Dan Heath is a fellow of the social enterprise program at Duke University’s Fuqua School of Business. They are co-authors of Switch: How to Change Things When Change Is Hard, from which this article is based.