The Brown M&Ms in Healthcare

Back in high school, when I was just as passionate about music and much more of a proselytist than I am now, I had some strong and rather strident opinions about bands and musical styles.  It was at this time when I heard about the rock band Van Halen’s concert riders.  I would let that band name stand alone, but I realize, now, that it has been thirteen years since their last album and thirty years since their last mainstream Top-40 hit song.  If you remember Van Halen, well, then I am sorry for making you feel very, very old.  If you are under the age of 40, we will all wait while you go Google them, and then come back… 

For those who don’t know what a concert rider is, it is an agreement between a band and a venue about what resources will be available for that band at that venue.  It can be a couple of pages long, or much longer, and can cover things like promotion for the concert, stage layout, green room amenities, and can go deeper into security, backstage passes, and when a band can load in their gear and when they can load out their gear.  Anything at all that would ensure a profitable and enjoyable night for everyone.

Van Halen was an arena-rock band who dominated the airwaves and who were known for putting on large shows with moving stage elements, complex lights and pyrotechnics.  In other words, they symbolized everything that was wrong with popular music at the time to this teenage punk-rock kid.  (My feelings for Van Halen have mellowed a bit since then, but that is another story for another time.)  And a specific rider tidbit cemented my antipathy.

One element in their rider was that, among the other things in the green room, they wanted a bowl of M&Ms, but that the bowl could not contain any brown M&Ms.  This was interpreted by me (and others) as being one of those prima donna requests, the kind of busy-work you make some poor intern spend an afternoon doing simply because you are big enough to push people around.  The story went on to say that if there were brown M&Ms in the bowl, they might not perform or they may trash the green room.  I wasn’t even sure if the story was true (this being the days before the internet, when a conscientious person could easily validate facts), but since it conformed to my previously held beliefs about the band being bloated and over-blown, it was good enough for me and was just another brick in the wall.  [Please forgive the insertion of a Pink Floyd metaphor.  Don’t get me started on them.]

It was only much later that I learned two things about this story.  The first is that it is true—Van Halen did have an element of their rider that specified no brown M&Ms.  The second, though, was that this was not an example of rock and roll excess, but a very important element to ensure a safe and successful show.  As mentioned, the Van Halen concert was a spectacle.  While it was another in a long line of big arena rock shows, they pushed the envelope of what they would do on stage.  This meant making sure that the stage could bear the load of all the equipment, that the electrical supply was sufficient to drive the demand of the lights and amps and, that loading docks and doors would accommodate their equipment needs.  This is all very technical and complex stuff, which was not necessarily immediately obvious to the band members or anyone simply walking through the facility. 

So how do they verify that the technical specifications in the rider were followed perfectly?  By inserting an element in the rider that was immediately obvious.  So here is where the brown M&Ms come in.  If they saw no brown M&Ms in the bowl, they could be confident that the rider was very carefully followed and all the ‘invisible’ stuff was accounted for.  If they DID find brown M&Ms in the bowl, it likely meant that there was less care to the other more important elements of the rider and the band would likely have problems with the show. 

Afterall, if the venue could not get that simple thing right, how can the band be confident that the venue was attentive to wiring schematics or having the stage set up appropriately to bear the load of the equipment?  This was an intelligent short-cut.  For me, this revelation reframed both my opinion of Van Halen and the way I see the work we do in patient experience. 

When I talk with folks who work in a hospital, especially clinical people, I often bump up against two related pushbacks:

• We gave them quality care, what else do they want?
  • This is sometimes more colorfully expressed as “We are here to save their ass, not kiss their ass!”
• Patients don’t even know what quality care looks like!

These are often said by individuals who want to negate their responsibility for providing any sense of service, but what they don’t realize is that, believing these things actually REQUIRES them to have a sense of service.  I will tackle the first one another day in another blog post.  Today, let us look at the second one…

Patients don’t even know what quality care looks like!

I actually agree with this sentiment, but it isn’t really the argument-winner that they think it is.  A majority of care, and in some cases a vast majority of care, exists outside of the patient’s knowledge base and field of view.  They see the blood draw, but they don’t see the orders.  They don’t see the person who wrote the orders or what their thought process was in writing the orders.  They don’t see the available pre-set orders in the electronic health record (EHR) or how easy it is to amend them.  They don’t see the lab where the work is being done.  They don’t even see the dozens of vials sitting next to theirs on the lab counter.  They don’t see the qualifications or experience of the lab team.  They don’t see the age of the machines being used or whether they are top-of-the-line or hand-me-downs.  They don’t know the margin of error for testing or if test are rerun to verify results. 

Even with something non-clinical, such as patient transport, the patient doesn’t see the order, doesn’t know if they are being taken to the right place, if they are being taken the long-way or the most direct route, if they are on-time or running late.  If they are on a gurney, they just see ceiling tiles and fluorescent lights.  If they are in a wheelchair, they see the chair rail, the tops of workstations, and everyone’s belts.  So, they rarely see the care itself, let alone if the care was “quality care.”

Even if something was done wrong—insufficient blood was drawn for the tests requested or the order to draw that blood was incomplete, or the lab made a mistake—the patient won’t notice this, either.  They are not going to question why a second blood draw was performed an hour after the first one.  Even if something significant occurs, like a surgical site infection or an adverse drug interaction, this might not be seen as an absence of quality care by a patient unfamiliar with what post-surgery care or pharmacy procedure is; they may simply think that these things sometimes just happen.  So, not only do they not see quality, they also don’t see gaps in quality. 

So, you are right.  Patients don’t know what quality care looks like and even if they did, they are not in a position to see the work being done properly.  Of course, this ALSO applies to other areas of life.  You don’t know what quality automotive service looks like.  You don’t know what quality banking looks like.  You don’t know what quality restaurant operation looks like.  The reality is that a vast majority of everything we engage with on a daily basis happens outside of our knowledge base and outside of our field of vision. 

Consider this—you enter a restaurant you have never been to before.  What cues are you looking for to derive assumptions about the experience?  For example,

As you arrive, do you consider:

• Is there a staff dress code?
• Do the staff look friendly or stressed?
• Does the floor look swept?
• Is the place where you wait for your table comfortable? 

Once seated, do you notice:

• Is the table linen clean (or the table sticky)?
• Are the bathrooms clean?
• Is the staff attentive?
• Are there delays in the ordering and food-deivery process?

Now it is true that your expectations may be different depending on the nature of the experience (24-hour diner vs 4-star restaurant) and your own standards (whether you would be caught dead in either of those places.)  It is also true that you may focus on things that other people don’t notice.*  The point is, we all have different things we focus on, and we have different levels of importance we put on those things, from pet peeves to deal-breakers.  But we are all making evaluations based upon what we experience.

Not only that, but, just like health care consumers, we often don’t even have the knowledge base to know what acceptable or appropriate behavior is.  If you discovered that there were 20 insect parts in that candy bar sitting on your desk, you might be disgusted, but that would be under the acceptable level of insect parts allowable in chocolate, which is 74 per 4.4 ounces, or about 26 or 27 per 1.55-ounce candy bar.  So, while this may put you off candy bars forever (you are welcome), it indicates that you are not even a good judge about what “quality” even is.

The point here is that health care is like every other business.  Consumers know very little about what TRUE quality looks like.  Even if that standard were explained to them, it may not be sufficient for them.  Consumers in health care are like consumers everywhere.  They base opinions not on reality, but on the cues they receive.  If you entered a hotel room and found a dirty towel in the bathroom, you would likely be suspicious of everything in that room and in that hotel.  After all, if they cannot get that simple and straightforward thing right, how can they be expected to deliver on the more important (if perhaps invisible) things? 

So, in healthcare, if a patient cannot evaluate the quality, what are they evaluating?  They are evaluating the cleanliness of the space, the friendliness of the phlebotomist, the calmness of the emergency department staff, the fact that their primary care doctor remembers the new medicine they put them on last time they were there.  None of these things matter in terms of quality, but they absolutely matter in terms of patient confidence, which in turn impacts patient anxiety, which in turn impacts patient ability to listen to, trust and follow directions. 

I love my primary care doctor.  I mentioned a while back that my father was having some health issues and he asks after him whenever I have an appointment.  He asks about my dogs as well because everyone knows I love talking about them.  Now, I know that this is all in my chart, but it tells me that even if he doesn’t remember me, he is trying to build a connection with me.  It also tells me that he remembers that my father’s health is causing stress for me, so finding out about him is also finding out about my anxiety.  He knows that the most consistent exercise I get is walking my dogs, so, again, finding out about them, is evaluating my exercise regimen.  If he were to simply say, “I am prescribing a mood-stabilizer to address the stress your father’s illness is putting on you,” or, “I need you to get more exercise,” these are not as likely to foster a connection or start a conversation because these statements are not designed to foster a connection or start a conversation.  If I feel like I am being diagnosed or lectured, I am less likely to listen. 

So, you say that patients don’t know what quality of care looks like.  This does not excuse you then from delivering on service, it DEMANDS that you deliver on service.  Since we are not experts in what quality is, we rely on whether there is attention to the simple stuff, the obvious stuff, the understandable stuff.  We are checking to see if there are brown M&Ms in the bowl.  If there are none, we have more confidence in the complex and invisible stuff. 

I am sure you all already know what it looks like when a patient peers into the bowl and sees a brown M&M.

*Personally, when I go into a bar, I focus on dust.  I don’t really care about stray napkins or swizzle sticks on the floor or even a slightly sticky table or bar, but if the tchotchkes on the wall or, even worse, the bottles behind the bar, are visibly dusty, I may leave.  If I am there with friends and can’t leave, I will only have bottled beer, since it is the only thing that I can trust is clean.