Duhigg begins Chapter 6 examining the Rhode Island Hospital, which was notorious among its staff for human resource issues, angry doctors, and unhappy nurses. Up and down the organization, employees felt unable to speak up without serious repercussions. Lacking strong guidance and established routines, the hospital’s employees created their own bad habits, which often pitted nurses against doctors and led to serious mistakes in the operating room. By the early 2000s, the organization had reached a moment of crisis. This moment, Duhigg argues, presented an opportunity for broad institutional change.

In 1982, researchers Richard Nelson and Sidney Winter published An Evolutionary Theory of Economic Change. The book focused on the routines that organizations practice. When companies have clear, structured routines, it facilitates camaraderie among individuals and departments that might otherwise compete: “For an organization to work, leaders must cultivate habits that both create a real and balanced peace and, paradoxically, make it absolutely clear who’s in charge” (166). When organizational leaders do not establish strong routines, employees will begin to establish habits on their own. In the case of most institutions, those habits are damaging for employees, consumers, and profits.

Duhigg jumps to his next case study, a deadly fire that occurred within the London Underground’s King’s Cross station.