Dan and Chip Heath Say Nix Ambiguity and Focus for Lasting Change

To succeed on the path to change, say Dan Heath and Chip Heath, you have to eliminate ambiguity.

Dan and Chip Heath Say Nix Ambiguity and Focus for Lasting Change
A NEW BALL GAME: Economists discovered our aversion to ambiguity through experiments using different colored balls. | Photograph by Mikyl Roventine/Flickr A NEW BALL GAME: Economists discovered our aversion to ambiguity through experiments using different colored balls. | Photograph by Mikyl Roventine/Flickr

Allina Hospitals and Clinics, an innovative health-care network that serves Minnesota and western Wisconsin, had a drug-abuse problem. And it fell to Bruce McCarthy, Allina’s chief medical officer, to fight it.


Many patients at Allina needed narcotics to manage chronic pain due to back problems or arthritis. Unfortunately, some patients were misusing or reselling the drugs. “In our group, we’d had malpractice suits related to narcotics prescriptions,” says McCarthy, who recently became the president of the physician division at Columbia St. Mary’s health system. “Worse, in a seven-year period, two people died, despite having well-meaning, caring, and smart doctors.”

Everyone agreed on the goal: eliminate narcotics misuse. But good intentions hadn’t been enough. How could McCarthy make real change happen?

He realized that Allina needed an infusion of clarity, change’s best ally. Just as mountains seem closer on a clear day, our work, too, can seem more within our reach, more actionable, when what’s expected of us is crystal clear.

Imagine that you have two items on your to-do list. One is “pick up AAA batteries.” The other is “deal with tax issues.” Guess which one is still unchecked four weeks later? (Or, if you are Willie Nelson, six years later.) Clarity begets action.

Economists tell us that we dislike ambiguity. Consider the Ellsberg paradox (named after Daniel Ellsberg, who later became famous for releasing the Pentagon Papers). Suppose you have a box — box A — that’s filled with 50 red balls and 50 white balls. If we draw a ball at random, would you rather bet that its color will be red or white? You’re probably indifferent. And if you’re not, Harrah’s would like to invite you to join its Total Rewards frequent-gambler program.

Now consider a second box, box B. It’s also filled with red and white balls, but you don’t know the color breakdown. Same drill: If we draw a ball at random, would you rather bet on white or red? You’re still indifferent. Understandably. How could you have a preference?


But here’s the kicker: Would you rather bet on drawing a red ball from box A or B? Most people say box A. That doesn’t make strict logical sense. You know that box A is 50-50 and you’ve assumed box B is 50-50 (otherwise you would have had a color preference). So you shouldn’t care which one you choose, but the murkiness of box B spooks you. Ellsberg called this phenomenon “ambiguity aversion.”

And that’s why clarity is essential for change. “Deal with tax issues” feels daunting. But, in reality, there’s nothing mysterious about dealing with your taxes. It’s a sequence of concrete steps — the first of which might be to ask your friend Chuck for the phone number of his CPA, whom he seems to like. Then you’d schedule an appointment. Then you’d ask the CPA whether you could write off your trip to Fiji as a business expense (“The boogie board served as a temporary home office!”). Notice that every step in this chain is just as simple and actionable as picking up AAA batteries. You’ve turned box B into box A.

Good leaders excel at converting something ambiguous into something behavioral. Take Terry Leahy, one of the leaders responsible for reversing the fortunes of Tesco, now the U.K.’s No. 1 grocer. One of Tesco’s ambiguous goals was to do a better job “listening to customers.” Leahy broke down that goal into a set of specific actions. For instance, cashiers were trained to call for help anytime more than one person was waiting in the checkout line. In addition, Tesco received 100,000 queries per week from customers. Leahy’s team made sure that all Tesco managers had access to customer concerns. (If you want to listen to customers, you had better make sure your managers can hear what they’re saying.) As a result, they learned counterintuitive lessons, such as that customers dislike stainless-steel refrigerators, which remind people of a hospital — not an ideal association for a grocer.

This brings us back to McCarthy at Allina, whose goal was to reduce narcotics abuse. McCarthy knew that his team needed to, as he said, “break down the play,” that is, to decompose the problem into specific actions. He points out that the 11 members of a foot-ball team on the field — every lineman and receiver and running back — know their roles on any given play. McCarthy and his team resolved to map out the play that would prevent narcotics misuse.

Their play started with the patients receiving narcotics prescriptions; they were asked to sign a controlled substance agreement acknowledging that they were receiving a drug that required special precautions. The patients made pledges: They would fill prescriptions only at a single pharmacy. They wouldn’t request a refill before it was due. And they would consent to random drug testing by their doctor.

The nurses defined their part in the play too. They were asked to scan the agreements into the patients’ medical records and also to note the narcotics prescription in the patient’s “problem list.” This ensured that any doctors who saw the patient would be well aware of his or her prescription and could factor that information into the treatment advice.


Through these steps, the Allina team has been able to identify numerous cases of narcotic misuse that might have otherwise been missed. And Allina isn’t done. It’s developing a conversion chart that displays equal potencies of different narcotics: For instance, 30 milligrams of Vicodin has about the same potency as 20 milligrams of OxyContin. This way, if one narcotic isn’t working for a patient and a doctor needs to make a switch, there would be no chance of making a mistake with the conversion.

Note that breaking down the play is not the same thing as being a micromanager. McCarthy never could have made up a set of specific instructions for his nurses and doctors, in the vein of a McDonald’s franchisee who tells a teenager exactly how to fry the beef patties. The process was inherently collaborative and creative: His team had to figure out a way to transform an admirable goal into a set of individual responsibilities.

Every mission, no matter how ambitious, proceeds via a series of specific steps. Even John F. Kennedy’s call to put a man on the moon within the decade probably began with a conference call between NASA and the White House. (“Mr. President, we are hoping you were using the word decade in a metaphorical sense.”)

If you’re leading a change, know that ambiguity is your enemy. Focus on breaking down the play. If you can kill the fog, you’ll bring those distant mountains closer.

Dan Heath and Chip Heath are the authors of the No. 1 New York Times best seller Switch: How to Change Things When Change Is Hard, as well as Made to Stick: Why Some Ideas Survive and Others Die.