HealthPOWER! Prevention News (Fall 2011) - From the Chief Consultant

Making Change Happen

Linda Kinsinger, MD, MPH
Chief Consultant for Preventive Medicine 

In their recent New York Times best-seller, Switch: How to Change Things When Change is Hard, authors Chip and Dan Heath tell the story of one man's amazing success in decreasing malnutrition among children in Vietnam. The man went to Vietnam without any idea of how to solve the problem of child hunger in this impoverished country but, by talking with the mothers of the few children who seemed to be thriving despite the poor conditions, he learned how they were able to feed their children in ways that kept them healthy. He encouraged these mothers to share their successful strategies with other mothers in villages all across the country and, over time, rates of childhood hunger decreased and the health of Vietnamese children improved. It's a moving story of "changing things when change is hard."

What does this story have to do with the VHA's commitment to improving the health and well-being of Veterans? I think there are important lessons that we can learn from the stories and ideas in Switch. At the VHA Senior Leadership Conference in Chicago in August, Dan Heath spoke energetically about the challenges of making changes in our personal and organizational behavior. He pointed out that there are three essential elements needed for successful change: direction for our rational side, motivation for our emotional side, and a clear path forward. All these areas need to be addressed for things to change.

To direct the rational aspect of change, Heath talked about "following the bright spots"—the unusually positive performers who have found a way to achieve the desired goal when most haven't. He noted the need to understand what it is that they're doing and then find a way to reproduce their practices. The mothers in Vietnam who had found a way to keep their children healthy were certainly "bright spots." Heath suggested "scripting the critical moves,"—being clear about how people should act, getting rid of abstractions, and picking one place to start. He also described how to "point to the destination," that is, to paint a detailed picture of what the target outcome looks like, so that people will know when they've arrived at the goal and when to pop the champagne cork to celebrate.

Heath explained how to motivate the emotional aspect of change. The first is to "find the feeling," meaning to engage people in the need for change by making it visual or graphic. He told a story about a man whose company bought hundreds of different kinds of gloves for their workers. He couldn't get the leaders to see this as a problem until he made a huge pile all of the various types of gloves on the table at a board meeting. Only then were they able to realize how inefficient it was to buy so many kinds. Heath also described the need to "shrink the change," that is, to make the first step small enough that everyone can do it and feel good about it and, if possible, to give people a head start toward the goal. He talked about an experiment in which people were given a loyalty card for a car wash. Some people got a card with eight spaces to be punched to get a free wash; others got a card with 10 spaces but the first two were already punched. Guess which group got to the free car wash faster?

Finally, in regard to making the path forward as clear as possible, Heath talked about the need to "tweak the environment" so that people are more likely to make the change that you'd like them to make, to shift things so that the "right" behaviors happen more easily. He also suggested finding ways to develop habits that support the desired goals—for example, by connecting new behaviors with things that we're already doing routinely. And he urged "rallying the herd," that is, using social pressure in a positive way to showcase those who have made successful changes and reached the targets. When the people who are resisting changing see that others have embraced it, they may be more likely to come along themselves.

How could we apply some of these ideas to our work in changing the way we provide health promotion and disease prevention (HPDP) services and programs? Thinking about the rational side of things, we should "follow the bright spots" in our organization: staff and facilities that have found ways to achieve high levels of success in HPDP, despite the common barriers and challenges that we all face. One of the articles in this issue of HealthPOWER! highlights Health Behavior Coordinators (HBCs) who have already made significant accomplishments. They are models for what can be achieved, despite competing priorities and needs in VA medical centers. As a way to "script the critical moves," the nine Healthy Living Messages include general directions that will lead to better health outcomes and also provide specific action steps to take. The new online tobacco cessation resources discussed in the newsletter are examples of tools that will "point to the destination" and help smokers quit.

How can we motivate ourselves and others in the emotional aspect of change, to "find the feeling?" One project NCP is working on that may help to make a desired change more visual is the creation of short videos for staff, showing an easy yet effective way to engage patients in conversations about making health behavior changes, such as increasing physical activity. It's a lot easier to understand how to do this when you see it being done in a way that is consistent with how things work in your clinic. The video will emphasize the small steps that staff can take to get started having these conversations. Attending TEACH and motivational interviewing (MI) training is a great first step that many staff members have already taken.

Other articles in this issue illustrate the advice about "tweaking the environment" to make behavior change as easy as possible. The story about Jennifer Gonzalez's efforts to take HPDP to the National Veterans TEE Tournament is a great example of making the path forward clear for Veterans, as is Bay Pines Health Care System's use of a novel partnership and health care program. Since many people look to the Internet as a main source of health information, the Veterans Health Library is an example of a way to connect the desired outcomes (in this case, helping Veterans to be involved in their health care) to things that people are already doing.

And if the story about Veteran Donald Morrison doesn't help to "rally the herd" by showcasing successful health behavior change, I'm not sure what will. His account of working hard to achieve his goals is very "MOVE!^®-ing!"

The take-home message from this book for me isn't that change is hard (we all know that), but that there are lots of ways to support making that change happen—ways that, by themselves, aren't so hard and are certainly things we can do. We just need to look around for inspiring stories of success!

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