Sentinel Events – Recognize, Respond, Revisit

Every day, we face numerous challenges. Urgent demands from others, unexpected events, system breakdowns, equipment malfunctions, and failed communications are “all in a day’s work,” for most of us. Occasionally, a singular event arrives that has the potential to alter the circumstances of our life or work. Such an event is called a sentinel event.

Recognizing A Sentinel Event
Sentinel events can be positive or negative, but regardless, they are sentinel because they are a warning that from now on things are going to be different. A positive sentinel event can be the adoption of a new shop information system that will change the way jobs are quoted and reported. A positive sentinel event could also be a new machine tool that promises to expand the type of
work that your shop will be capable of producing.

A negative sentinel event could be the delivery of the wrong medicine in a health care setting or a death resulting from some aspect of the provided care. Losing identity on barstock used to produce precision parts, or a crippling accident at work are examples of negative sentinel events in our shops.

Recognizing negative sentinel events is easier than recognizing positive ones because of the urgency to get resolution of the negative event. However, positive and negative sentinel events must be recognized, and a plan for a response should be developed if the organization is to effectively deal with this new challenge. The greatest threat to a successful resolution is for the organization and its people to be in denial over the sentinel nature of the occurrence.

Responding To Sentinel Events
An organization’s response to the sentinel event is key in determining whether or not it will survive and maintain its customers’ confidence in the business. While urgency is an important component of your company’s response, it is even more important for your company’s disciplined re-commitment to use your existing systems, processes and procedures to deal with the sentinel event. Improvised responses make for drama but seldom contribute to the solution of the problem at hand, let alone restore or maintain customer confidence.

Instead, a grounded, systematic response centered around your existing systems and featuring clear and timely communications is key to resolving the problem. Keeping a schedule of communications as they become available provides your customer and others involved with the assurance that your company has a plan, is following the plan, and is therefore likely to succeed.

Using a structured, team-oriented approach to resolving the problem is the next critical step on the road to dealing with a sentinel event. This kind of approach assures that you will find a root cause rather than just react and treat the immediate symptoms. You do not need to reinvent your company’s problem solving just because the problem is “larger” or “more urgent” or the “stakes are higher.” What is important is that you have people on the team that have both the authority to get the resources and facts needed, as well as the process knowledge to use that information for successful problem description and ultimate resolution.

Revisit Your Response
Revisiting your organization’s response is the unexpected, but crucial step in dealing with a sentinel event. Without recognition, denial thwarts the ability of your organization to respond. Without a response based on your existing systems, key information may be overlooked, resulting in an inadequate containment and an incomplete or unsatisfactory response. Without revisiting your organizational response to the occurrence of the sentinel event, no organizational learning will take place. The lessons learned in your handling of the sentinel event need to be communicated throughout your organization. Other processes should be analyzed to see if those lessons learned are applicable to them as well.

Remember that you are not alone when facing a sentinel event. Networking by phone, face-to-face at meetings, e-mail or by PMPA listserves can help you harvest the wisdom of industry colleagues and avoid deadends or pitfalls on your journey to a resolution. Your retained business counsel can supplement your team’s efforts and help you establish safeguards to prevent reoccurrence.

But most of all, revisiting the issue with your customer allows you both to share in the satisfaction of a problem eliminated, and a business relationship stronger and still intact.