The sentinal event

One of the key requirements for learning in any complex endeavor is time for focused reflection following action. Looking back on goals, choices, actions, and perceptions, and comparing them to actual outcomes is the one best way to become more effective over time, and to adjust action or strategy that doesn’t deliver.

This is what’s supposed to happen in staff meetings — in addition to equally essential forward-looking discussion. It’s supposed to happen in board meetings. And it would seem a useful element within any community of practice — cultural managers in a particular city, discipline, job function, or who share a common mission.

In the medical professions, such reflection is a requirement, not a choice — especially when something goes terribly wrong. A sentinal event — defined as ”any unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a person or persons, not
related to the natural course of the patient’s illness” — triggers an evaluation and reflective process to determine what happened, and what choices or processes might have influenced the outcome. Says the Wikipedia description:

Participation is necessary by the leadership of the organization and by
the persons closely involved in the systems under review. Causal
factors are analyzed, focusing on systems and processes, not individual
performance. Potential improvements, called an “action plan,” are
identified and implemented to decrease the likelihood of such events in
the future.

The drastic turn in the economy has initiated or revealed lots and lots of sentinal events in the arts and culture industry — from the endowment-draining of Los Angeles MoCA to the insolvency of symphonies, theater companies, and museums across the country (our own Madison Repertory Theater sent up a red flare just this week).

Beyond the media reports on these events, there is really no mechanism, incentive, or opportunity to dig into these cases — to explore if or where assumptions were wrong, processes were ineffective or destructive, or structures were misaligned. The organization’s board may have these conversations (although they tend to focus on who should be blamed), but little insight is gained in the larger ecology from internal review.

I’m not suggesting we air dirty laundry, nor that we all descend on troubled institutions like medical examiners. But there must be a safe, reflective, and collective space for those who steward cultural organizations to dig deep, suspend blame and attribution, and adjust their work in response.