Let me see,” said the health center manager, reading from a sheet of paper. “Last month we had 353 and the month before that 309. They usually average around 300 a month I suppose. It can be a real problem.”
She was talking about patient “no-shows”—or DNAs (Did Not Attends) as they are more commonly known in healthcare industry parlance—people who schedule an appointment and then fail to show up. It turns out that the problem of people failing to attend appointments isn’t just limited to inner city health centers or, more broadly, the healthcare industry. As noted in this book’s introduction millions of business meetings, hairdresser appointments, restaurant reservations, sales presentations, and student tutorials are missed every year. On a micro level one missed restaurant booking doesn’t seem like that big a deal—small potatoes even! But the theme of this book is how small things can make for big differences, and when it comes to missed appointments the costs can add up to staggering sums of money. Recall in our introduction how health economists in the UK have estimated that the overall cost of people failing to show for health appointments is £800 million (that’s over a billion US dollars) every year. That’s money being poured down the drain simply because individuals fail to live up to their commitments.
Also in the introduction we suggested that there are ways of persuading people to keep their appointments, and more generally to live up to their commitments, simply by making a couple of small, costless changes in approach that can lead to some pretty dramatic improvements.
One of the fundamental principles of social influence involves the relationship between commitment and consistency. This principle describes a deeply held motivation that most of us have to behave consistently with the previous commitments we have made, especially those commitments that are active, require effort on our part, and that are made public to others.
To give an example, researchers posing as visitors to a beach would place a beach towel and a radio on the sand in close view of a sunbather before heading down to the shore to take a dip in the sea. In one condition, one of the researchers would ask the sunbather (who was really the subject of the study) to watch the radio. Most agreed and verbally signaled their commitment with a friendly, “Of course I will.” In a second condition the researcher simply went for a swim without making any kind of request of the sunbather. Then the real experiment began. Another researcher, posing as an opportunistic thief, would run past, snatching up the radio and making off with it. The small act of asking for a verbal commitment made a big difference as to whether sunbathers who witnessed the fake theft gave chase. Only 4 out of 20 of those who weren’t asked to make a verbal commitment made any attempt to right the wrong. Contrast that with the 19 out of 20 sunbathers who were asked to watch the radio and who, consequently, leapt into action. Why? Because they had verbally agreed to a commitment, and giving chase was entirely consistent with that previous verbal commitment.
If a small change such as asking for a verbal commitment could be employed to such impressive effect to reduce theft at the beach, one wonders whether a similar strategy could be used to reduce appointment no-shows at the medical center.
In an attempt to answer this question, we conducted a series of experiments in three busy doctors’ offices where patients, immediately after being provided with a date and time in a standard appointment-making call, were asked to read back out loud those appointment details before hanging up the phone. This small change proved to have a modest effect when we measured the impact on subsequent no-show rates, reducing them by just over 3 percent. At first glance this doesn’t appear to be that big a difference until one considers two important factors. First, the strategy was costless to implement, adding at most a second or two to the interaction. Second, even though the 3 percent reduction appears to be relatively small, in terms of scale it is actually quite large. A 3 percent reduction such as this applied to a $1 billion problem would save $30 million.
The implication is clear. It is all too easy in our busy lives to cut short one interaction or conversation so that we can then focus our attention on the next. To do so without seeking some sort of verbal commitment of what has been agreed is an opportunity wasted, even if that opportunity is likely to spawn seemingly modest results. For example, a manager might garner greater commitment to solid actions from a team meeting if the individual members vocalized them at the end of the meeting. A parent might reduce those stressful bedtime negotiations by seeking a verbal agreement before agreeing to just one more game or story or TV program.
It turns out that sometimes these verbal commitments don’t have to be fully explicit either. For example a business development manager hoping to persuade a prospect to attend a meeting to hear an industry speaker could increase the chances that he or she will attend by asking them to submit a question for the Q&A session. Eliciting a question in advance from a prospect can act as a small commitment that potentially increases the likelihood that they will subsequently attend the event.
These are all examples of how requesting a simple verbal commitment could be a costless SMALL BIG that improves your chances for effective influence. But might there be an even better way to secure future commitments from others? It turns out that there is, and to understand what it is we need to return to the doctor’s office.
One common strategy that we noticed all the health centers in our study utilizing was to provide patients with an appointment card with the time and date of their next appointment. Usually, the appointment details were written out by a healthcare receptionist. We wondered whether this approach was unwise, given that the principle of consistency states that people are most motivated to be consistent with those commitments that they actively make themselves.
Accordingly, we tested the impact of another small change—one that served to actively, rather than passively, involve the patient in the appointment-making process. What was this small change? It was for the receptionist to simply ask the patient to write down the time and date of the next appointment on the card themselves. When we tested this approach over a four-month period, we measured a significant, 18 percent reduction in no-shows in that group. A SMALL BIG that, if scaled up properly, could now result in savings not of $30 million, but of $180 million. All done at a cost of, well, zero.
This additional insight from our doctors’ studies shines a spotlight on another important but undernoticed trap that we often fall into in the course of modern-day interactions and meetings: How easy it is to default to doing things ourselves in the knowledge that at least they will get done. As a result, a salesperson leaving a meeting might find that she has many subsequent actions to undertake, yet her customer has relatively few or even none at all. In such a context it is likely that the salesperson will be much more committed than the customer to the sales process itself. A personal trainer might believe that writing up his client’s tailored exercise program demonstrates how attentive, focused, and service-oriented he is, but maybe misses the point that the client is potentially less committed to the program.
But what about instances when it is unrealistic to expect a potential client or customer to make active and written commitments? Or how about those meetings where multiple people attend, and it would be unwise to share actions across the group, or unfair to nominate one person to take total responsibility? In situations like these it is probably better to write up all the actions and then circulate them yourself, ensuring that you make a small but crucial addition to the top of your email. Asking recipients to signal by way of a simple “yes” response that the notes you have sent are an accurate reflection of their understanding of next steps is a good start.
But sometimes, no matter how hard we try, our persuasion attempts can fall short. In such situations, what other small changes, linked to the commitment and consistency principle, might we employ?