The Rider and the Elephant: Switch Book Details How to Create Change

A remarkable book provides leaders with a practical, simple framework, based on the latest brain research, for turning an organization to a new direction.

If you’d like to read a book on making organizational change happen that’s very practical, organized around an easy-to-understand framework and filled with great examples, I recommend you put “Switch: How to Change Things When Change Is Hard” at the top of your summer reading list. The authors, Chip and Dan Heath, successfully integrate the latest brain research into a simple (not simplistic) model for leading change, and they delight the reader with amazing examples told in a smart, colorful manner.

The model has three parts, all of which are demonstrated in this extraordinary story.

On Dec. 14, 2004, Don Berwick, who was then CEO of the Institute for Healthcare Improvement (IHI), delivered a talk at a hospital administrators’ convention. Berwick had ideas for saving large numbers of lives by significantly reducing the “defect rate” of certain procedures using process-improvement procedures that had been very successful in other industries. His research convinced him that these procedures would make a huge difference, but he couldn’t require physicians to change their practices. So he challenged the hospital administrators in the room to step up.

“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. ‘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.”

No doubt the administrators’ jaws dropped. But Berwick was just getting started. He then spelled out six specific interventions that had been shown to save lives (such as keeping a pneumonia patient’s head elevated at a certain angle so that oral secretions wouldn’t go into the windpipe). But the administrators needed more than information; they had to be motivated to take on the many barriers to change in their institutions.

Berwick then introduced a mother he’d invited to the convention. The woman’s daughter had died because of a hospital’s medical error. Then a second person spoke, the chair of the North Carolina State Hospital Association, who said that “an awful lot of people for a long time have had their heads in the sand on this issue [of injuries and death caused by hospital errors], and it’s time to do the right thing. It’s as simple as that.”

The campaign save 100,000 lives began. IHI provided participating hospitals with step-by-step instructions on how to implement the new medical procedures, the research base for these procedures and training. IHI also helped the hospitals’ leaders communicate with each other through a weekly conference call (as many as 800 people participated), and arranged for the most-successful hospitals to mentor those that joined the campaign later. Many physicians resented the new procedures, but those procedures soon produced impressive successes, and in the months after Berwick issued his challenge more than 3,000 hospitals joined the campaign.

And on June 14, 2006, precisely at 9 a.m., Berwick announced that the participating hospitals had exceeded their goals: The campaign had prevented approximately 122,300 avoidable deaths. Moreover, hospitals were institutionalizing the new procedures, ensuring that uncounted lives would be saved in the future.

At first glance, this may seem to be an exciting story about an inspiring, risk-taking leader. But there’s far more to it than that. The authors of “Switch” use this and other examples to illustrate their framework for leading difficult changes, one built around current understanding of the human brain. As the Heaths explain, our brains have two key parts that affect our decisions and actions:

• The logical, rational side, which analyzes our options and thinks long-term. It is very good at self-control. The authors call this “the rider.”

• The emotional side (a much larger part of the brain), which feels pleasure, pain, love, empathy, and so on. It’s more short-term-oriented and demands instant gratification. The authors call this “the elephant.”

Our rider tells us we need to change our diet and use the gym regularly if we really want to shed 30 pounds; our elephant won’t let us walk past the Ben and Jerry’s without trying the latest flavor. If you visualize a rider sitting atop an elephant, you understand the dilemma: The elephant is far larger and stronger than that lonely rider.

On the other hand, the wise and rational rider doesn’t provide energy for change; indeed, the rider is often at risk of “paralysis by analysis,” getting lost in the facts and options. That’s why our elephant is so critical: We don’t make difficult changes without feeling highly motivated. So we need both rider and elephant pulling in the same direction to successfully change.

Let’s take another look at the campaign to save 100,000 lives through the lens of the “Switch” framework. Berwick appealed to the hospital administrators’ rider through his documentation of the problem. He gave the rider a clear destination (save 100,000 lives by June 14, 2006) and explicit directions (six interventions that were known to save lives). Berwick also hooked his audience’s emotions — their elephants — through the two people he introduced at the conference.

There’s a third part of the “Switch” framework, called “shaping the path” by making the change easier. In Berwick’s campaign, the path to change was simplified through the use of step-by-step instructions and support groups. The weekly conference call enabled real-time communications among hospital leaders. And the campaign helped those hospitals that weren’t making progress by connecting their leaders to colleagues who had started earlier and were experiencing success.

The Heath brothers have given us a path to leading change that will appeal to your rider as well as your elephant. It’s a delightful read, and a very important book.


4 comments on “The Rider and the Elephant: Switch Book Details How to Create Change

  1. Mary says:

    This book was very good; I had read it a couple of years ago. However, he has a newer book out, “Decisive”, that I am looking forward to reading.

  2. Adams, Robert E. (CMS/OC) says:

    Russ, I really appreciate receiving these. Hope you are doing well. Bob

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