Switch - Chip Heath [101]
Fortunately, at both Alpha and Beta, there was substantial support for signout change among the interns’ superiors, such as senior residents and chief residents. At Alpha, 13 out of 31 superiors were “reformers” who supported the change; at Beta, 12 out of 18 were reformers. Because of this support, circumstances looked ripe for real change. All signs were “Go.” At long last, the 120-hour workweek would be abolished.
There was just one problem: The interns wouldn’t sign out. As one intern said, “Being considered a good intern has nothing to do with what you know or how well you manage your patients. It is totally based on working hard and not handing stuff off. It’s your attitude, not your ability…. This is where I live. I only go home to sleep. It sounds sick, but these people are like my family. The worst thing would be not to be respected by these guys.”
For the interns, social status was at stake. The interns felt they wouldn’t be respected if they embraced the signout. Change was coming into conflict with culture, and let’s face it, a new rule is no match for a culture.
Could the hospitals change their culture? Here’s where their paths diverge: Fifteen months into Katherine Kellogg’s research, Alpha had managed to win the culture battle, and Beta had lost it. Anyone who wants to create organizational change needs to understand why.
7.
Kellogg discovered that the change hinged on the smallest work teams at the hospital, which met each day for “afternoon rounds.” Each team was composed of three or four residents (both interns and more senior people), and during afternoon rounds, they discussed the patients under their care and other important issues. The afternoon rounds at the two hospitals differed a great deal:
At Alpha, the rounds were lengthy (around an hour) and had a high attendance rate. The teams tended to meet in quiet corners, moving from patient to patient around the hospital floor.
At Beta, the rounds were more casual. They were shorter (twenty or thirty minutes), and team members often called in or sent a message instead of showing up in person. The teams at Beta didn’t meet at patients’ bedsides; they met in the computer lounge, where all the residents hung out between shifts. (Take a moment to contemplate the different behaviors that might be encouraged by the differing formats of these rounds.)
Teams were shuffled about once a month, and every so often, by the luck of the draw, all the people on a team would be reformers who supported the shorter workweeks. At Alpha, the reform-minded teams found great strength in their rounds. They were spending an hour in private discussions with a group of their fellow believers. But at Beta, the format of the afternoon rounds blocked any momentum for reform. The teams met for only a short time, and members often were missing. Worse, teams were meeting in the computer lounge, where lots of people who opposed reform could overhear their conversation, which led reform-minded members to self-censor.
Bottom line: At Beta, the afternoon rounds were irrelevant to the change. At Alpha, they became the spark, and the rounds became, in essence, underground resistance meetings.
8.
Researchers who study social movements call situations like these “free spaces”—small-scale meetings where reformers can gather and ready themselves for collective action without being observed by members of the dominant group. Free spaces often play a critical role in facilitating social change. Civil rights leaders, for instance, were able to use southern black churches as free spaces to prepare themselves for action.
Kellogg was present, every day, at Alpha and Beta as one reform movement blossomed and the other wilted. She attended thirty-one free-space meetings at Alpha and twenty-two meetings at Beta. The meetings at Beta had a comparable number of reformers but weren’t conducted in a free space.
At Alpha, 77 percent of the meetings included discussion about the legitimacy of the signout process, and 81 percent