The only person who likes change is a wet baby!

The high-reliability expert, former founding partner of Healthcare Performance Improvement (HPI), and current partner at Press Ganey Associates, Craig Clapper recently wrote in his book  Zero Harm, "Improvement by the yard is hard; improvement by the inch is a cinch." In other words, any improvement initiative - really, any major organizational change initiative - should start with small tests of change, focusing on small, pilot groups before spreading to the broader organization.  "Big Bang" types of change initiatives that touch virtually every part of the organization at the same time are rarely, if ever successful.  Data analyzed by the consulting firm, McKinsey, suggests, in fact, that only 30% of change initiatives succeed.  

One of the most important aspects of leadership is change management, and change management is something that leaders continue to struggle with in every industry, including health care.  All health care organizations need to change in order to survive in this rapidly evolving environment in which we all currently live and work.  Given the need for change, why is it so difficult for organizations to do so?

As the old saying goes (reportedly first stated by Mark Twain), "The only person who likes change is a wet baby."  The question is why?  Why are we so resistant to change?  The best-selling authors, Chip and Dan Heath provide two possible answers in their book, Decisive: How to Make Better Choices in Life and Work.  The first answer is something called the mere exposure effect.  Basically, this well-known psychological effect states that individuals develop a preference for things that are familiar to them (the effect is also called the familiarity principle).  

Here's a great study ("Field Extension of the Frequency-Affect Findings") that explains the mere exposure effect, which was originally described by the psychologist, Robert Zajonc in the early 1960's.  College students would enter their classroom every day to find strange words written on the blackboard (the study was performed by Rick Crandall in the 1970's, long before the use of smartboards of course) - words like, SARICIK, RAJECKI, KADIRGA, NANSOMA, and ZAJONC.  Different words would appear every day without any explanation from the professor teaching the class.  On certain days, the same words in different combinations would appear.  After about 9 weeks of this very peculiar exercise (at least for the college students), the students completed a survey with a list of 14 foreign words on it - five of these 14 words had appeared on the blackboard.  The survey asked the students to rate how they liked each word.  Crandall found that the most-liked words were the ones that had appeared most frequently on the blackboard.  In other words, as the Heath brothers write, "Familiarity doesn't breed contempt, then, but more like contentment."  Similar studies have been performed with a variety of objects, words, symbols, etc - they consistently show that mere exposure to these objects, words, and symbols created strong preferences for them.  We like things that are familiar to us!

The second answer to the question "Why is change so hard?' provided by the Heath brothers is something known as loss aversion, which was best described by Amos Tversky and Daniel Kahneman.  This well-known principle states that individuals prefer to avoid loss, even at the expense acquiring equivalent gains.  Some studies would even suggest that losses are twice as powerful as gains in this regard.  In other words, we hate to lose!  As an example, imagine playing a game based upon a flip of a quarter.  If the coin flip turns up "heads", you will win $100.  If the coin flip turns up "tails", you will have to pay me $50.  Would you play?  It's a standard quarter, so no tricks are involved here.  You have a 50/50 shot at winning $100 or losing $50.  Most studies suggest that we would prefer not to risk losing $50 and just not play.

In another frequently cited study ("Experimental tests of the Endowment effect and the Coase Theorem") on loss aversion (it's actually a related concept, known as the Endowment effect), half of the students in a college class are awarded a free coffee mug with the university's logo emblazoned on the side.  The students who didn't receive a coffee mug were asked how much they would be willing to pay to buy one.  The average amount they were willing to pay turned out to be $2.87.  Okay, fair enough - that seems like a pretty good deal (actually, it's a great deal, just walk into your friendly neighborhood college bookstore and see how much these things really cost!).  Conversely, the students who had the coffee mugs were asked what price they would be willing to sell the mug (remember - the mugs were a free gift).  The average selling price turned out to be $7.12!  When it comes to coffee mugs, the selling price is nearly two and half times as high as the price that most of the students were willing to pay.  Call it whatever you want, we are just not willing to part with something that we possess.  

Resistance to change - also known as the status quo bias - is not easy to overcome.  We are dead-set in our ways, because we like familiarity (mere exposure effect) and we hate to lose (loss aversion) things that we are comfortable with (i.e. the way we've always done things).  I would like to finish, as I frequently do (my apologies) with two final quotes:

"Sometimes the most difficult act of leadership is not fighting the enemy; it's telling yourself and your friends that it is time to change." --- Bill Gates

"When you improve a little each day, eventually big things occur...Don't look for the quick, big improvement.  Seek the small improvement one day at a time.  That's the only way it happens - and when it happens, it lasts." --- John Wooden

Leadership is about managing change.  And the best way to manage change is to start with small improvements.  "Improving by an inch is a cinch."