by Kate Daly

11 Nov 2015

Sentinel Events

Sometimes I wonder what I should be when I grow up. I didn’t end up where I am because I wanted to. That was never the plan.

But to be honest, there never was a plan.

...

I am, by all accounts, a grown-ass adult. I’m 40. I have three cats, two kids, and one ex-husband. I’ve worked in the tech industry for over 13 years. I settled into my career as a software project manager pretty early on, a job that didn’t fit perfectly, but was good enough.

At times I flourished. At other times, it was as uncomfortable as a borrowed pair of shoes.

No matter what you call the job, people in project, product, or engagement management roles fall into one of two camps.

There are the ones who enjoy the analysis. These are the guys with the amazingly detailed, multi-tabbed spreadsheets. These are whom I call “The Beancounters.”

The world needs Beancounters. The beans must be counted, for you need to know how many beans you have left. It’s helpful, too, to predict how many beans you’ll use on a weekly basis until the bean bucket’s kicked.

Some of my best friends are Beancounters.

I, however, am not.

I’m the other kind. In my mind, The Other Kind doesn’t have a name beyond that. In reality, the term “proxy product owner” is far too formal, but “experience manager” has the right level of raw emotion. 

Experience managers use every ounce of energy and inspiration, drawn from books they read as a kid and stuff they saw on Twitter and the silent nods they observed in the last meeting and that conversation they just had in the hallway.

They bring this to every client interaction, email, idea, and strategic roadmap. We draw connections. We own problems. We care, and we care deeply. For the most part, we are ourselves.

Spreadsheets are good when needed. I believe in MVS, or Minimum Viable Spreadsheeting. I believe in owning things. Policies and procedures should never trump people and practicality. It’s just common sense, and it’s my mantra.

Put simply, I’m me. WYSIWYG. And removing the “me” from my job, the part that brings excitement and passion and ideas and zeal, is completely impossible.

So when someone demands I do this, I lose my shit.

...

I don’t lose my shit in the classic way. I don’t throw tantrums; I don’t withdraw. I do, though, internalize it. I question what I’m doing. I question my skills. I assume I’ll never find a job in the tech industry ever again, not that I could update my resume anyway, as who would want someone who doesn’t have any tangible skills? I’m just an English major after all. I don’t have a CS degree; I don’t give a fuck about having a PMP. I can count beans, sure. Anyone can.

I can, but I’ll hate every minute of it.

When this happens, I start making other plans. It happened earlier this year, and I had intense fantasies about leaving technology completely. I needed a job where I could show my passion, feel the adrenaline of good ideas put into practice, and help people. Two possible paths emerged.

Both my mom and sister are educators. For a long time, I was convinced I’d missed my calling. I didn’t pursue it in college for several reasons. I didn’t really click with the Education majors around me. I also was very content with my Art minor, and got to spend hours in the darkroom swishing chemicals and even more hours at the kick wheel, throwing pots. I loved my dirty art student hands, stained for weeks. I also loved my intimate English classes.

I looked into going back for a teaching degree. The prospects were grim, and the courses looked costly. I knew I’d kick ass, but couldn’t make the jump.

The other option made more sense. I’d worked with oncology nurses for 12 years. I was a curious scientist in high school; I’d been inspired by amazing midwives during my pregnancies. I’d worked at the local community college back in the day, and I knew that their nursing program would get me a jump start on being an RN on the cheap. There’s been a nursing shortage for years. Pittsburgh has hospitals aplenty. I could enroll in the spring.

And then my tech job got good again.

I realize that those reading this may chalk me up as yet another swinger. Our industry is full of them. We love it, WE FUCKING HATE IT. We’re gonna change the world, WE’RE GONNA BURN THIS SHIT DOWN. Swingers are the “I’m moving to Canada!” of tech workers. Yeah, none of us want Trump to be president. But if he gets the gig, four years later, he’ll lose it, and things will change.

No job is awesome all of the time. But no job should suck all of the time, either.

My pressure to be a Beancounter had been miraculously lifted. It was a combination of staff changes, methodology changes, and overall common sense being applied. 

The sense of relief was nothing short of physical.

...

A few weeks ago I was in Colorado. Go ahead, make the weed jokes.

I was there to celebrate my best friend’s 40th birthday. She’s an event planner in a small mountain town, located literally at the end of the road. Mt. Crested Butte is the peak opposite Aspen, and it’s opposite in every way, from the townies to the snow birds. Yeah, there’s weed everywhere. It’s fucking Colorado. There’s been weed everywhere for years.

(I did have to laugh, though: Crested Butte has no pharmacies. I was sick as hell with a head cold during my stay, and the only place you could get Aleve Cold and Sinus was 30 miles away, in Gunnison. They do have at least three dispensaries, though.)

We flew in for the party, joined by another dear childhood friend, who is a nurse in South Carolina. The birthday party was off the chain (events in Crested Butte are not cheap, and my friend has some sweet-ass connections).

We partied like no one was documenting the whole thing on Facebook.

My nurse friend, Sheri, is amazing. We weren’t that close as kids — we had the same best friend, but were rarely together just the two of us — but as adults, we’ve grown closer. I call her my “Sheri-lama,” for her advice and measured confidence have a calming, peaceful effect on me.

The night before the party, we got to talking about jobs. Fresh off my I SHALL NOW BE A NURSE plan, I asked her how things were going. She works in a pediatric intensive care unit, or PICU, at a large hospital in the Charleston area.

“It’s good,” she said. “I’m making a difference. And I have to tell you about this tool I developed.”

My ears pricked up. After years at ONS, I knew that nurses don’t use the term “tool” lightly. Tools, in the nursing world, are processes or procedures used to place some semblance of formality on the chaotic, often tragic world they live in. They’re used as a way to support evidence-based practice, or EBP.

EBP, in non-medical terms (I was a “layperson” while I worked in healthcare) is a methodology that supports reinforcing practices that work because the evidence, or collected data, supports it. Instead of doing something because “that’s they way they’ve always done it,” good institutions seek to employ EBP.

(A good example is recommending exercise to patients undergoing chemo. The evidence says that people on chemo who exercise have a better outlook, increased quality of life, and better chance of survival. Twenty years ago, this was rarely recommended — why would they tell someone to take a daily walk when they can barely stand up without puking? Thanks to EBP, nurses and other primary caregivers now recommend exercise as part of a patient’s care plan. It’s saving lives.)

“Well,” she said, “I was involved in a sentinel event. It was in no way my fault, but I didn’t know how to deal with it. I was called to testify. I wanted to talk about it, but was told I couldn’t. They offered to ‘arrange a conversation’ [read: instituted psychiatry], but that wouldn’t be enough.”

At this point, I was curious to the point of shaking. October in CO is pretty chilly, though.

...

A sentinel event, I learned, is an unexpected, and preventable, death or serious injury (either physical or psychological) that is unrelated to a patient’s primary condition. For many reasons, the medical community discourages making “sentinel events” synonymous with “mistakes,” but patients’ families obviously feel otherwise. Every year, thousands of nurses and doctors are called to testify in wrongful death lawsuits because, well, it just shouldn’t have happened.

“Every time I go to work, I don’t know what’s going to happen. I send one child to the morgue, then wait for the next one to come in. One time, the patient I got was dead before they got to me. I knew it, but someone else didn’t. It was horrible. So I developed a tool to help us through situations like this.”

My friend developed a process. She developed a tool for anyone on her unit to use. When a traumatic event occurs, be it an unexpected death after a bloody gunshot wound, or the decision to withdraw life support from a 6-year-old child with leukemia who has been on their floor for months, anyone, no matter their rank or title, can ask for a debrief meeting.

During this meeting, they discuss what they did well. They next discuss what went wrong. They talk about how they can improve. They document all of this, and a report is sent out so that others can learn.

They talk about roles; what works, and what doesn’t.

“It happens so fast — someone has to be the leader, calling out meds. We also need a recorder, who tells us how many minutes pass between doses and takes notes for the chart. The rest are the ones who do the work.”

The roles are self-assigned, with staff naturally falling into one or the other. “They’re usually the same, but I’m better at giving compressions to an infant than an 18-year-old, so I don’t always give compressions. It depends on the situation.”

Her tool has changed the way this nursing staff operates. Examples of improvements including pre-assembling goggles (they come from the supplier with the lenses detached; putting a pair together while a patient is bleeding out in front of you is difficult) and ensuring that their “code cart” is unlocked (before it had a special code; putting in this code slowed things down, as remembering the code, and punching in numbers with a gloved hand while a mother screams in pain for her dying child, is also quite difficult).

The conversations about these events occur as soon as possible afterwards, while it’s fresh in everyone’s minds.

...

I listened in amazement. My mind spun with parallels.

“I need to ask you something,” I’d said. “Have you ever heard the words agile, or sprint retrospective? You know, in the context of software or product development? Because what you just described is exactly that.”

She hadn’t. Of course she hadn’t. And I felt like a giant nerd for asking. What she was doing was just the right thing to do. It was applying common sense. It was introducing a formalized process for reflection in an otherwise fast-paced, very chaotic, ever-changing environment.

...

We had a kick-ass weekend.

When I spoke with her afterwards in anticipation of writing this, we talked about agile a little more. She laughed. “That’s awesome. But how did you see the connection?”

“That’s just what I do,” I said. “I draw connections. It’s my job.”

And you know what? I love it.

 

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