Do you know a “positive deviant”?

Do you know any “outliers in a community who, despite having no special advantages, are doing exceptionally well.” They could be the key to promoting social change by reshaping social norms. Hat tip: Freakonomics.

What choice architects can learn from a new medical checklist

A new study on another medical checklist is out, this one conducted on noncardiac surgery in eight hospitals in eight cities around the world to ensure a diverse range of clients. As with the now-famous previous checklist – call it Checklist I – this one produced decreases in death and infection rates. What is most interesting about this checklist – call it Checklist II – is that is undercuts one of the supposed insights of Checklist I, namely that shorter was better.

Checklist II is long. Very long. Totaling 19 items. (Recall that Checklist I uses only six.) Does this mean checklist designers need not worry about keeping the number of items to remember to a minimum? Though it would tempting to draw this conclusion, it would be as foolhardy as pronouncing the absolute virtues of brevity based solely on the findings from Checklist I. What is more likely is that checklist length matters less than the overall environment in which each step is taken; the mechanisms in place for enforcing each step are what matter most. This enforcement is all the more necessary since human memory is not reliable enough to count on recalling every step. Indeed, the authors of the Checklist II study point out that, in spite of the medical improvements, “omission of individual steps was still frequent.”

Designers of Checklist II broke the 19 steps into three subcategories, administering the steps at different points in the surgical process. The number of steps and points of administration make the identification of key steps difficult. But the authors explain the overall choice architecture this way:

Use of the checklist involved both changes in systems and changes in the behavior of individual surgical teams. To implement the checklist, all sites had to introduce a formal pause in care during surgery for preoperative team introductions and briefings and postoperative debriefings, team practices that have previously been shown to be associated with improved safety processes and attitudes and with a rate of complications and death reduced by as much as 80%. The philosophy of ensuring the correct identity of the patient and site through preoperative site marking, oral confirmation in the operating room, and other measures proved to be new to most of the study hospitals.

After devising the steps, determining the appropriate points in the surgical process to implement them was the key challenge. For example, the designers encouraged administering antibiotics in operating rooms instead of preoperative wards, “where delays are frequent.”

The paper’s authors are unsettled about the potential of a Hawthorne effect – in which an improvement in performance is the result of doctors’ knowledge of being observed – in the overall results. At the risk of carelessness, for now, this concern is perhaps best left to the academics. Building in an observant whose presence leads to changes in behavior is a perfectly acceptable option for someone who is not so worried about the exact contribution of each casual mechanism. As social scientists know, even trying to isolate the effect of observation can be futile, for in some cases observation is one way to enforce particular social norms, making the combination of the two what influences behavioral change. So while the Hawthorne effect has confounded social scientists for years, everyday choice architects may need not worry so much. After all, the Hawthorne effect itself is just another nudge.

Social norms in Louisville, Kentucky

From the News and Tribune:

Perhaps you have seen the billboards on Interstate 64 saying things like, “78 percent of Portland youth have never tried alcohol!” They come from the Portland Now Prevention Partnership’s (PNPP) social norms campaign. This campaign is designed to contradict the notion that all young people are using alcohol, tobacco, or drugs. Since young people are greatly influenced by what they think their peers are doing, the PNPP wanted to be sure that they are getting accurate information.

Nudge ratios on Capitol Hill

This spring, Blue Cross Blue Shield invited Congressional members and their staffs to take part in the Capitol Hill Challenge, described as a “healthy competition to see who on Capitol Hill can walk the greatest distance over six weeks while promoting physical activity and benefiting a charity along the way.” Sixty members signed up and kept track of their steps for six weeks. Winning the category of most miles walked was the office of Sen. Ted Stevens (Alaska) with 6,590 miles. The highest average per walker came from the office of Rep. John M. Jr. Spratt (South Carolina) with almost 299 miles walked per person.

To count every step, Blue Cross Blue Shield gave Congressional members and staffers a pedometer, a tool – a visual display that gives immediate feedback – that we at the Nudge blog have always liked.
But the Capitol Hill Challenge also tapped in another theme that interests us: Persuasion. Congressional members were able to sign up staffers in their offices, plus staffers on committees they served on, which meant the surest way to be a top walker was to nudge your aides to walk with you. Through social norms, direct appeals, incentives, or good old fashioned coercive paternalism, members had a variety of different ways to sign up staffers. So which member’s reach extended the furthest?

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Duty is what one expects from others*

* Oscar Wilde quote

Cass Sunstein digs up a nice paper that draws on the social norms literature to explain common empirical results that people contribute more to public goods like charity or public radio when they see others contributing. Economists Kjell Arne Brekke, Gorm Kipperberg, and Karine Nyborg invoke the specific norm of responsibility – not a staple of standard economic theory – which they say is activated when someone recognizes that her individual actions have an impact on the public good and accept their role in contributing to it.

A duty-oriented individual prefers to keep a self-image as a decent or responsible kind of person, someone who can be trusted to do what “a person such as I do in a situation such as this.” Further, if he does not live up to his perceived responsibilities, this will impair his self-image.

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Nudges needed to make cell phone driving bans work

Some laws are self-enforcing. Others are not. Cell phone driving bans are apparently in the others category. From MSN:

Increasingly, states are banning drivers from using handheld cell phones, but that doesn’t mean people are listening. With little knowledge or enforcement of the bans in some states and no insurance penalties for many drivers, it’s not clear whether the laws are much of a deterrent.

Cell phone bans are becoming more popular as the evidence mounts that driving while holding a cell phone and talking increases increases driver distractions, which leads to more wrecks.

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Stop scaring teenagers. Start talking to them.

Why do teachers think scaring teenagers is the best way to get their attention? Scare tactics are common for sex, crime, parenthood, and alcohol and drug abuse. For years, schools have tried to warn students about the dangers of drunk driving by hauling in smashed cars (or smashing them on school property), using fake blood and stage make-up to recreate the effects of accident injuries, or having a teacher dress in costume as the Grim Reaper and pull students out of class who have “died” in an auto accident. This week, El Camino High School in San Diego, California, is defending a routine that involved local cops delivering some tragic news.

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Japan fights obesity with a mandate and nudges

Worried about the economic and social costs of obesity, Japan has instituted a national law forbidding waist lines larger than 33.5 inches for men and 34.5 inches for women.

Under a national law that came into effect two months ago, companies and local governments must now measure the waistlines of Japanese people between the ages of 40 and 74 as part of their annual checkups. That represents more than 56 million waistlines, or about 44 percent of the entire population.

Violators are given nutritional guidance and “further education” if they are still overweight after six months of dieting. The law has prompted companies to adopt nudges.

With the new law, Matsushita has to measure the waistlines of not only its employees but also of their families and retirees. As part of its intensifying efforts, the company has started giving its employees “metabo check” towels that double as tape measures.

“Nobody will want to be singled out as metabo,” Kimiko Shigeno, a company nurse, said of the campaign. “It’ll have the same effect as non-smoking campaigns where smokers are now looked at disapprovingly.”

What the Transportation Security Administration might have known if someone there had read Nudge

The U.S. government keeps trying to fix the airport mess. In an effort to speed up congested terminals, the Transportation Safety Administration recently unveiled its plan for 21 airports to split the standard single security line into three “self-select” lines that people can choose between. The lines, modeled after ski slope categories, are for “families and special assistance” (marked in green), the “casual traveler” (in Aspen ice blue), and the “expert traveler” (black like the diamond). According to the New York Times, TSA officials have now learned what Thaler’s business school students know all too well: As humans, most air travelers are overconfident.

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