The Invisible Glue of Excellence: How ECU Health Embodies Charles Duhigg's "Truces" Principle

Faramarz Hidaji
Nov 5
3 min read

Updated: Nov 6

In The Power of Habit (2012), Charles Duhigg introduces the concept of organizational “truces”—the unspoken, often unconscious agreements that employees at every level make to avoid conflict and maintain short-term harmony. These truces, Duhigg argues, are the true drivers of performance, more powerful than even the most charismatic CEO. To illustrate, he recounts the transformation of Alcoa under Paul O’Neill, who became CEO in 1987 when the aluminum giant was hemorrhaging money and morale. Instead of focusing on profits or innovation, O’Neill zeroed in on worker safety. He demanded that every injury be reported to his office within 24 hours and tied executive compensation to safety metrics. This move threatened the fragile truces that had long governed Alcoa: union workers ignored minor safety violations to meet quotas; supervisors looked the other way to avoid confrontation. These compromises kept the peace but fostered complacency, breakdowns, and injuries. By forcing transparency and accountability, O’Neill shattered the toxic truces and replaced them with a new keystone habit—rigorous safety reporting. The result? Within a year, Alcoa’s injury rate fell 90%, productivity soared, and profits followed. As Duhigg writes, “You can hire the best people in the world, but if the truces between them are toxic, nothing will work” (p. 84). The real power, O’Neill proved, lies not in the C-suite but in the daily habits forged between people on the ground.

This same principle illuminates what makes ECU Health, a major academic medical center in eastern North Carolina, exceptionally effective—and rare among hospitals. Early in my tenure as an Ophthalmic Hospitalist at ECU, I noticed something deceptively simple: the handwashing stations were always stocked with soap and paper towels. In prior my roles at other hospitals, dispensers were often empty or half-filled, a silent symptom of broken truces—housekeeping staff felt undervalued and disengaged, supply chains were neglected, and frontline workers adapted by skipping washes or improvising. At ECU, the consistency of full dispensers signaled something deeper: the people responsible for refilling thousands of stations across multiple buildings took their jobs seriously. They felt seen, supported, and accountable. This wasn’t a top-down mandate from infection control; it was a bottom-up habit, a healthy truce where every role—from environmental services to nursing—was treated as mission-critical.

The contrast is stark when considering infection prevention strategies. A hospital could spend $100,000 on a provider education campaign promoting hand hygiene compliance—complete with lectures, posters, and audits. But if there’s no soap, the campaign is theater. At ECU, the presence of supplies is the intervention. It removes friction, reinforces routine, and communicates trust: “We value your contribution, so we equip you to do your job well” is the implied message to employees. This aligns directly with Duhigg’s framework: keystone habits (like Alcoa’s injury reporting) trigger widespread behavioral shifts. Stocked stations don’t just enable handwashing—they cultivate pride, ownership, and mutual respect across silos.

This culture was reinforced during new employee orientation I experienced as part of my onboarding at ECU. I had sat through countless orientations during my 30 year career, most of them boring and painful. This one was different, complete with funny skits and an appearance by the hospital president, which must have spoken volumes to new hires about their value to ECU. At one point, a presenter posed a provocative question: “Who is the most important person at ECU?” Expectations leaned toward the CEO, a star surgeon, or even the patient. The next slide revealed the answer: a large arrow pointing to the audience with the word “You!” This wasn’t motivational fluff; it was a deliberate cue in a habit loop. New hires—whether nurses, techs, or administrative staff—were told from day one that their contribution defined the institution. This message dismantles hierarchical truces that marginalize “support” roles and instead builds a shared identity: I am ECU. The reward? Engagement, accountability, and a willingness to speak up—whether reporting a near-miss, restocking a dispenser, or challenging a protocol.

ECU Health demonstrates what Duhigg observed at Alcoa: organizational excellence emerges not from grand strategies but from rewriting the daily truces that govern how people treat each other and their work. Full soap dispensers and an orientation slide declaring “You!” are not peripheral details—they are diagnostic signals of a high-reliability culture. They reveal an institution that understands a profound truth: when people at every level feel valued enough to do their best in the smallest tasks, the largest outcomes—patient safety, staff retention, clinical quality—follow naturally. As Paul O’Neill transformed aluminum through safety, ECU transforms healthcare through respect. And in both cases, the CEO matters far less than the habits we agree to live by, together.