Here is a chapter summary I wrote of The Power of Habit, by Charles Duhigg. If you are interested in the psychological aspects of QI, then you may find the book a good read. If you’ve read the book then I’d love to know your thoughts, and if you’ve done a summary why not share it here?
I’m using the ideas in the book in three ways at present:

1. To think about how to generate more cohesion and connection in my organisation around QI
2. To develop my own QI practice, with a specific mind to the content on willpower, and
3. To think about what of this we connect onto training we currently deliver locally around The Habits of an Improver (Lucas & Nacer)

Anyway I hope you find the summary of interest.
Cheers, Paul

The Power of Habit: Why we do what we do and how to change – by Charles Duhigg (Amazon UK link)

PART 1: THE HABITS OF INDIVIDUALS

Chapter 1: The Habit Loop – How Habits Work
Cites various famous cases of patients with brain injuries, and experiments in MIT with rats highlights the importance of specific regions of the brain for habit formation. Possible to see brain activity change as habits are formed. Habits are framed as an evolutionary way of saving effort. If something is a habit, it saves brain power as don’t need to think about it. Sets out the habit loop;
Proposes that habit forming always follows same pattern:

1. Cue – a signal to trigger the habit
2. Routine – a specific action or set of actions
3. Reward – the desired outcome

By understanding habits in this way, we can begin to understand the components of what needs to be in place for habits to form. The absence of any one part of the loop will prevent the habit from forming. Observes that although easy to describe, it can often be really hard work to correctly identify each component.

Chapter 2: The Craving Brain – How to Create New Habits
Uses several examples from advertising and experiments to develop an argument that the habit loop above in itself is not enough for new habits to form. Cue, routine and reward are the components that need to be present. However, a new habit is only formed if there is fuel to power it; craving. Craving for the reward. Example is toothpaste (Pepsodent). A successful campaign used “film on teeth” as cue, routine of brushing teeth with product, and feeling beautiful as the reward. All other pastes at time used similar approaches. What set pepsodent apart was they added chemicals to create a tingly sensation in mouth after use which consumers craved. No other paste at time had done this. “I want to feel beautiful” was not enough to form the habit – it had to be accompanied by a physical sensation that the consumer craved. There is also a long case study about Febreze – no one would buy amazing product when its reward was positioned as “masks bad smells”. When rebranded as “freshens room/ clean air feeling” sales rocketed because, so the theory goes, they created craving for a feeling of fresh clean air that could be sensed.

Chapter 3: The Golden Rule of Habit Change – Why Transformation Occurs
This chapter draws heavily on the career of an NFL American Football coach, Tony Dungy. Dungy transformed the fortunes of several NFL teams by using the golden rule of habit change. The Golden Rule is that “bad” habits are very difficult to eradicate. Instead, seek to change them/ reprogramme them/ overwrite them with a new routine. Cue stays the same, reward stays the same, craving stays the same, but the routine linking the cue to the reward is changed.

Cites (world renowned) Alcoholics Anonymous 12 step programme as one of the most long-standing habit change programmes. AA has had v mixed empirical evaluations, with particular criticism for the spiritual aspects of the 12 steps. But many have benefitted and suggests the 12 steps mimic what we now know about how the brain forms habits.

Re the spiritual aspect, proposes that it’s not belief in God which is the key. It’s belief in something that matters. And if that belief is strong enough, it eventually spills over into belief that change in oneself is possible. Cites longitudinal research into people using AA that found that without belief, habit change was possible, but prone to relapse when life got difficult eg bereavement, job loss etc. However add belief in something into the mix and habit change appears more resilient to life events. Lastly, suggests that beliefs are fostered in community/ group setting far more commonly than in isolation. Therefore, bringing people together to create belief is vital to successful creation of beliefs and associated change in habits.

PART 2: THE HABITS OF SUCCESSFUL ORGANISATIONS

Chapter 4: Keystone Habits, or the Ballad of Paul O’Neill – Which Habits Matter Most
Case study of Alcoa, a huge US aluminium producer appointing Paul O’Neill as its CEO. Against tradition, O’Neill set out worker safety as the number 1 priority. Stakeholders and shareholders initially wobbled and didn’t like this approach, but one year on revenue, profits and staff engagement had rocketed.
“You can’t order people to change, that’s not how the brain works” said O’Neill. “But I knew Alcoa had to transform. So I decided to start by focusing on just one thing. If I could disrupt habits around one thing, it would spread through the entire company.”

And so it did. Keystone habits say that success doesn’t depend on getting every single thing right, but instead relies on picking one or two priorities, delivering them and using them as powerful levers, or “small wins” that set scene for other small wins to happen. Need to think about where the keystone habits are – the ones that will shift, dislodge or remake other patterns. O’Neill spent a lot of time in federal govt. He observed the best depts to be the ones who understood the importance of routines. The worst never thought about what they were doing. Understanding these principles and using them are two different things, the latter requires ingenuity.
Another example given of swimmer Michael Phelps. He used visualisation and calming as his cornerstone habits and believes that’s what set him apart from everyone else.

Chapter 5: Starbucks and the Habit of Success – When willpower becomes automatic
The cornerstone habit in Starbucks approach to training is willpower. Many studies apparently identify willpower/ self control/ self-discipline as the single most important keystone habit for individual success. Longitudinal studies observing childrens’ willpower, then tracking their lives consistently find a high correlation between those who resisted and those who attained selection for sought after schools and obtained higher SATs. Self-discipline has a bigger effect on academic performance than IQ. So push to make willpower a habit. Starbucks now train self-discipline to achieve better service quality. Willpower is learnable.

Researcher Mark Muraven not satisfied with explanation of willpower as a skill. A skill is something usually attained and not forgotten, so why does it seem to ebb and flow? He demonstrated that willpower is finite. Like a muscle, if used a lot it gets depleted. Hence if undertaking something that requires willpower, bring it earlier in the day and if that’s not possible, conserve your willpower til you need it. Not easy to put in place training for self-discipline though – many companies tried and failed. If you have low self-discipline, prob not likely to attend or do the work that’s needed.

Study in 1992 in an orthopaedic unit in Scotland demonstrated that patients will improve recovery rates following surgery if they plan and anticipate how they are going to manage the pain involved in recovering from joint ops. And if they plan themselves (not following someone else’s plan), and if the plan is specific. So, not “if/ when pain occurs I will…” but “when I go to the bus stop my knee will ache. When this happens I will rest on a seat for 5 minutes before pushing on”. Knowing their plan also meant planning ahead and thinking about what to do when their temptation to stop would be at its greatest, hence connection with willpower.

Starbucks gives employees routines to habitualise around difficult situations, but the training manuals also have lots of blank pages. Each employee is asked to think ahead and figure out for themselves what they will do when the cue occurs. And populate their own training manual.

Muraven wondered why in some situations willpower was easy to build and in others it was not. He found that when people were given a task that required willpower and they felt they had a choice or were asked in a friendly way, it was easy. It took less willpower. If people felt coerced or forced to participate, it took more willpower and was harder to foster. Hence, giving employees a sense of agency can radically increase the amount of energy and focus they bring to their jobs. And vice versa; lack of autonomy needs more willpower and likely more mistakes will occur when/ if it runs out.

Chapter 6: The Power of a Crisis – How Leaders Create Habits Through Accident and Design
Rhode Island Hospital had a lot of unhealthy habits. This was evident in a number of wrong site surgeries and incidents as well as staff climate. Uses this example to highlight that there are no organisations without habits. There are only those with ones that have been deliberately designed, and ones where habits have been created without forethought. But sometimes in the heat of a crisis, leaders can transform undesirable ones into virtuous ones.

Seminal economic study by Nelson and Winter of many organisations found that, though it might seem like organisations make rational choices based on deliberate decision making, particularly larger orgs are guided by long-held org habits formed from the thousands of interactions and independent decisions of its employees. These are what gets the work done. Or not. The habits of an org are the unspoken truces that dampen the civil war of rivalry, power-grabbing and success seeking that takes place within companies. They can prevent the outbreak of out and out conflict. However as with Rhode Island, they can create an unstable peace which can be as corrosive as any civil war. The truce here was inequitable, the nurses found workarounds to tyrannical medical behaviour.

A more equitable truce may have saved things, but a truce in keeping everyone level also has to paradoxically make it clear who is in charge. Lengthy case study into the KX fire in 1987 illustrates this point.

Rhode Island and KX both suggested that things had to deteriorate so low before enough people were motivated to change their daily routines. Never waste a good crisis.

Chapter 7: How Target knows what you want before you do – When Companies Predict (and Manipulate) Habits
When there is enough data, statisticians can analyse and identify patterns. Target is a large retailer with v broad product range in USA. They used data from loyalty schemes to stratify their customer groups based on buying patterns to then target specific product offers and coupons at them. Were even able to do this to identify pregnant mothers who didn’t want to be identified. So had also to figure out how to target them without them knowing they were being targeted.

To do this, use the research around habits. Habits (including buying habits) change most effectively a little at a time. One well known strategy in music industry is to “sandwich” a new song in between two existing well known ones. Did this with “Hey Ya!” 🙂 . Gradually the new song becomes habitual, as do buyer habits, so place new product offers in between existing product line choices and the change happens.

PART 3: THE HABITS OF SOCIETIES
Chapter 8: Saddleback Church and the Montgomery Bus Boycott – How Movements Happen
Rosa Parks. Movement was created by three elements coming together:

1. Starts because of the social habits of friendship and strong ties between close acquaintances
2. Grows because of the habits of a community and the weak ties that hold neighbourhoods and clans together
3. Endures because the movement’s leaders give participants new habits that create a fresh sense of identity and feeling of ownership.

Parks was by no means the first black person to be arrested for breaching segregation rules. The climate was shifting however at the time of Parks’ arrest. And the three ingredients were there to turn it into a movement. Parks had a close church community but also had many, weaker, links to other communities, so word got out. Then Martin Luther King Jr quickly was thrust into the epicentre of the movement, kind of by chance. And he brought the third element. A new set of habits that overwrote the hatred that existed in the black community and created something new.

Case Study of the growth of Saddleback church which used social habits to grow and spread its faith community. Using social methods and approaches, the congregation grew tilk it was too big and had become a bureaucratic nightmare of having to find larger and larger venues. Then changed tack – begin groups in own homes. Social vision of a faith rather than a cathedral congregation. But problem arose about what then was being discussed in homes – was it Christian doctrine or just another social gathering? So created a set of materials that taught new habits that could be used in these groups and participants could practice in their daily routines. Now the church had a way of creating a shared belief, not bound by walls, where habits could grow in communities that would eventually become self-propelling.

Movements don’t happen because everyone suddenly aligns. They begin through friendship, they grow through communities and they are sustained by new habits that change participants’ sense of self.

Chapter 9: The Neurology of Free Will – Are we responsible for our habits?
Two case studies form this chapter. One of the growing problems surrounding someone who became a compulsive gambler, the other noting the case of a man who murdered his wife, seemingly in his sleep during a bout of sleep terror.

The gambler’s habit grew slowly and manageably at first over a period of years. When life got tough she began to lose perspective and the habit loop had well and truly formed. Got into considerable debt until everything was gone. The casinos, who profile each customer and determine for the most frequent ones a “lifetime value” in revenue, used the techniques above (chapter 7) to keep enticing in. more and more offers, lines of credit etc. They allegedly train their managers to be good listeners and compassionate (see chapter 5). Research into the neurology of compulsive gambling has shown that, to a compulsive gambler, a near miss (eg 2 out of 3 hits in a slot machine, or presenting a win as an opportunity to take another gamble) neurologically has the same pattern as a win. Whereas to a normal punter, a near miss looks neurologically like a loss does. Hence, casinos/ bookmakers have complicated the landscape exponentially alongside the growth of information about their customers. Gambling is more profitable than ever before as the industry knows how to exploit habit loops for profit.

The sleep terror case where the man murdered his wife while apparently asleep resulted in the charges being dropped. Even though it was undisputed that he had killed her (he himself did not contest this), the court decided that he was not in control of his actions.

Book compares these two cases and notes the similarities in both in terms of automating the brain. However, one key distinction between the two is made; the gambler could reasonably have predicted the outcome of her habit. The sleep terror case he could not, because despite having suffered from sleep terror all his life, he had never had a sleep terror previously where he had endangered his own, hers or anyone else’s life. Therefore not reasonable to suggest it could have been predicted, nor reasonable to suggest he be held responsible for the crime.

However, the book concludes by suggesting that aside from a sleep-walking murderer’s actions, our lives are filled with habits that we do know exist. And once we understand that habits can change, then we have the freedom – and the responsibility – to change them.

Appendix: A Reader’s Guide to Using These Ideas
Changing habits is not as easy as reading about them. People want to know the magic formula. That’s why there are thousands of books on the subject, including this one. Habits are different, people are different. This appendix attempts to distill all the research in the book into a framework for readers to try out. It goes thus:
• Identify the routine
• Experiment with the rewards
• Isolate the cue
• Have a plan

Step 1 is to figure out the constituent parts of the habit loop you want to modify. What’s the cue, what’s the routine, what’s the reward and what’s the craving. Routines are usually easy to identify as they’re observable behaviours, by and large.
Step 2, experiment with the rewards – when the routine is activated, try out different rewards. What you choose isn’t important. You’re just trying to isolate what you’re following the routine for. So do this each time tweaking the reward. As soon as you get the reward, write down three things that you feel or think. Then set watch for 15 mins and if after those 15 mins you still have the craving, you know the reward you tested is not satisfying the craving.
Step 3 is to isolate the cue. Experiments have shown that almost all habitual cues fall into one of 5 categories; location, time, emotional state, other people, immediately preceding action. So write those categories down and answer them whenever the urge hits, and each time it hits. The one (or more) that remain consistent are likely to point to the cue.
Step 4 is to have a plan. The plan is simply to then think ahead and figure out what your choices are when the cue occurs, what routine you might follow to still achieve the reward you seek. The point here is to come up with a plan that gives you a chance of rewiring the automatic cue – routine – reward cycle.