I have just read ‘Atomic Habits’ by James Clear, a book that had been on my night stand for a while. I enjoyed reading it; it resonated for lots of reasons. In particular it has made me reflect on the habits of improvers and the habits of organisations striving for operation excellence and perpetual improvement and the relentless reduction of unwarranted variation in practice to benefit patients. And it made me think, why is sustaining improvement so hard, when these habits sound so easy? Some ideas to answer that ‘Why?’ are posed in this book. Here are my reflections.
First, the book re-emphases the neuroscience research that I was introduced to whilst learning to practice Toyota Kata. That is, a habit is to learn something and practice it so well, that it will become second nature, routinised, and then you can let your brain focus on new problems to solve. I still like this idea of reducing cognitive load, as I can remember occasions when I haven’t noticed what I was doing whilst thinking hard about something else. I also like this because it reminds me of first and second loop learning.
Second, Clear then connects this idea of automatic and unconscious behaviour with the ability to then use the freed up brain to focus intentionally on marginal gains. The conscious perfection of the practice (an idea I have written about before). My daughter is currently learning to drive so this makes me think of perfecting the parallel park; after learning how to drive. What I really like here is that Clear connects operational excellence not with breakthrough innovation and step changes in performance; but instead with that of mastery and incremental perfectionism. The gradual – yet persistent focus – on obstacle removal and intentional honing of practice, over and over and over.
Third, Clear then connects habits with identity, which is a new idea on me. He suggests that if I write every day as a habit and change my language to ‘I’m a writer’ rather than ‘I’m a manager who sometimes writes a blog’ then my ‘writing habit’ really reframes how I am thinking of myself and opens me up to new perspectives of myself. This idea is keeping me thinking.. what does that mean for me? What does this mean for transformation and improvement work, and ‘improvers’? What could this mean for new work habits and standard work to reduce unwarranted variation and striving for operational excellence. I’m also curious what could it mean for exnovation and the reduction and removal of old ways of doing things? How does the identity loss kick in then, how can we smooth that ride for individuals and teams? We all know the maxim that ‘habits are hard to break’.. smoking is just one example from the public health space that helps us to learn and observe more about bad habits.
Fourth, Clear breaks down habit formation into several steps, called his ‘Laws of Habit Formation’. Again similarly to a Toyota Kata routine. I like this practicality. These are:
1. Make it obvious
2. Make it attractive
3. Make it easy
4. Make it satisfying
Lots to think about here. If I think of new standard work (eg a protocol, new guidance, new SOP, a cheat-sheet, a checklist, etc) that can be introduced in work settings usually to reduce variation, resolve some safety issues and make things somewhat more productive, then how might these 4 laws work? Standard work (one of the 5 elements of a work cell) can be one of the hardest to ‘sustain’ , and often the superficial analysis as to why it doesn’t sustain is ‘leadership and culture’. But what if we thought about the application of these Laws here, what might we learn about achieving operational excellence if we thought about standard work as a type of everyday habit as a foundation of leadership? What practical leadership actions could we take to improve here, and help sustain these new habits?
How could we make it obvious? Examples I can think of: We could design it into the process, we could put a label into notes (btw does this ever work?); colour coding; we could put a passive-aggressive note on the cutlery drawer asking people to put the teaspoons back; we could use jigs, shapes and so on to ensure a task could only be done a particular way – clinical equipment that can only click together in one specific location etc. We could make it culturally normal and acceptable and very visible when completed perhaps with an alarmed sensor if not completed – eg seatbelts in cars. What environmental solutions could help here? What could we learn from mask wearing (or non-compliance with mask wearing) here?
Make it attractive? How could we make it fashionable? How can we make the new method ‘the thing’ to do. Examples might be recognition, awards, media profiles, videos about how to do it, stressing its ease and simplicity. Creating a buzz, the ‘social movement’ element of improvement I guess. There are lots of other incentives I suppose, for me, making it something that really speaks to my values of helping people to make things better through learning would probably be what made it attractive. I would be too curious and nosy to not be interested enough to find out more and probably too conscientious to not keep wanting to try it. Again could visual management help here? And internal accreditation and team recognition schemes? Could visual management as a form of peer accountability help here? Clear stresses accountability is a key element of new habit formation. Could we put visual management in here as leaders to help here, how would we and the team know at a glance if this new obvious habit is being practiced?
Make it easy: use process mapping to simplify and reduce steps comes into its own here. How can obstacles of the new approach is too complicated be overcome? Digital and mechanical forcing functions might help here, ready set up trolleys of equipment for the habit and new standard work might also help here, how can it be easier and who does what when? The ‘7 How’s’ improvement tool might too help here. How could we get the new habit to take 2 mins or less or at least in a 3 step protocol each step to only take 2 mins or less? That’s a Challenge to dwell on.
Make it satisfying. Ummm so this is the bit I’m reflecting and thinking on. Perhaps a step I’ve missed out a lot in my improvement practice. The ‘how to make the new habit stick’ part. How can we make new standard work, new ways of doing things, new habits stick and be satisfying?
This section of the book is like a prediction of what might have been helpful during the first wave of the pandemic. How do you get new habits like hand washing to stick? In the book, Clear talks about the feeling and the smell of soap lather being significant in making the habit satisfying. That immediate feedback and reinforcement of the habit through a luxurious feeling and reward as a subconscious suggestion to that habit brain to keep doing this habit. If we want to achieve operational excellence in healthcare with routinised methods (where appropriate, I’m not talking about clinical decision making and autonomy and making clinicians robots here btw; more like processes such as raising a requisition, completing a handover, conducting an audit etc) to help us to reduce unwarranted variation in practice then perhaps we need to think about the ‘satisfying’ piece. Else, why keep doing it this ‘new’ habit way? It is easier the way I already know how to do it, (and I don’t like doing what other people telling me what to do anyway?)
In my ‘I don’t have to think about it’ way it’s in my automatic habit brain thinking, so to keep a new process going we have to move over the new habit formation piece and make it satisfying, even when it’s got a bit boring to keep practicing this new way. I’m still reflecting on this, and also acknowledge the role improvement teams can play here, in terms of ‘just being around’ to help remind people to do it the new way, and encouraging and celebrating when new processes are being tested and implemented. Often a role missing when things are ‘rolled out’ ‘at pace’. Perhaps improvement teams do put some short term satisfaction in place for new work habit formation. Leaders perhaps have the harder ask in BAU of how to prevent short cuts (or use them to improve further) and to keep the new habit/standard work satisfying, when improvers are asked to move on to the next thing to be improved.
At the end of Atomic Habits, James Clear describes achieving operational excellence as the endless fascination with doing the same things over and over. He says:
“You have to fall in love with boredom“
James Clear, Atomic Habits, page 236
I really like this idea of relentless perfectionism, and focus on the atomic achievement of basic must-do’s, a lot. In my research, I have described improvement capability as a bundle of routines. This book for me reinforced that it can be satisfying to achieve operational excellence through the simple pursuit and achievement of habitual atomic routines; which in healthcare have the potential to transform our daily work for patients and help us all to achieve excellence.
Healthcare Quality Improvement 