It’s hard to fix what you can’t picture.
I started in 2011 as a dialysis technician, running the machine that cleans a patient’s blood when their kidneys no longer can. Then nurse, charge nurse and nurse manager. Then clinical sales and sales management. Now quality and safety for a hospital program. I never left a seat behind when I took the next one. Each one added a view the others couldn’t see.
For most of that time a missed detail could cost someone their life. Leave one cap loose on the tubing and blood leaks when you walk away. That’s where my attention to detail comes from. The business side added the other half: knowing where a shortcut is affordable, and where it never is.
Tools give people access. They don’t give them mastery. My talent may not be dialysis-specific at all. What I do is take tangled things and make them legible.
How I think
Sit in every seat.
A problem looks different from each place it touches. I’ve worked seven of those places in healthcare, so I read a problem from all of them before I touch it.
Borrow what already works.
Nothing is new under the sun. Most fixes already exist somewhere else. The skill is noticing they apply, then building the version that fits.
Borrowed, then built
From a gym check-in
The arrivals sheet
Nurses on a busy dialysis floor couldn’t see which patients had arrived. The idea was a wristband patients tap at the door, like scanning a gym badge. It was my first business idea. The closest I could build: a tablet at the front desk and one shared sheet. Check the box when someone walks in, and every nurse’s screen shows who’s waiting and since when.
From a Sudoku grid
The standing schedule
Every patient has set days, a treatment length that changes when a doctor’s orders do, and a chair they’re used to. Fitting a 37-chair clinic into one standing schedule works like Sudoku: every placement limits the next. Fewer complaints, per the clinic’s own records.
From a restaurant QR menu
Help in one scan
During COVID, every menu became a code you scan with your phone. A nurse running a one-on-one treatment in a hospital can’t leave the bedside to find help, but everyone has a phone in their pocket. So I made a code for the machine that calls the service line directly, and another that opens the manual and short clips of the hands-on steps.
From a hospital intranet
The clinic’s own intranet
Big workplaces have one home page that links to everything. The clinic had links scattered across bookmarks and inboxes. I built it one from tools it already had: schedules, documents and equipment maintenance, all from one landing page.
Also built
The shared prep list
A care team got ready for its weekly patient review from scattered notes. Shared lists of patients and what’s due for each, so everyone prepares from the same screen.
The team board
A remote sales team, each person keeping their customers in their head. One shared internal site put every customer in front of all of us.
Experience
Dialysis does the work of failing kidneys: a machine cleans the blood, usually for hours at a time, several times a week. I’ve worked in that world since 2011, in seven seats, each one added to the last. Open any one for what it let me see, what it hid, and what carried forward.
2011–2015The chairDialysis technician · 4 clinics · Queens, the Bronx, Manhattan
What I could seeThe one treatment in front of me: placing the needles, setting the machine, and keeping each patient on for their full prescribed time, so their bloodwork tells the truth.
What I couldn’tAnything above the clinic. I didn’t know the federal rules every dialysis clinic runs on even existed.
Carried forwardMy nursing license came through while I was a technician in one of those clinics. I was promoted in the same building.
2015–2022The bedsideNurse · 9 sites, clinics and hospitals · Long Island, Queens, Manhattan
What I could seeMy group of patients and everything they needed: medications, guiding the technicians, keeping their lines clean, watching for infection. In the hospital, whatever the patient came in with, alone with no second nurse on the way.
What I couldn’tContinuity. In the hospital you treat someone once and never see them again.
Carried forwardI worked in one of these clinics early on, and later came back to run it.
2019–2021The floorCharge nurse, running the shift · a 37-chair clinic · Manhattan
What I could seeEvery patient on the shift, every staff member, and a manager counting on me. The whole floor was my problem, not just my own patients.
What I couldn’tWhere the structure came from: who above the floor decides how a clinic runs, and why.
Carried forwardYears later, four of this organization’s clinics would become my sales customers.
2017, 2021The unitNurse manager · 2 clinics, two short stints
The turnThe first time, I was pushed in early and learned that being good at the work is very different from managing people. I stepped back to the floor, and went deep on leadership after.
What I could seeWhy they call it middle management: squeezed between the staff you have to understand and the leaders you answer to.
What I couldn’tHow far the chain runs above you.
Carried forwardThe second time, I came back to run a clinic I once worked in.
2021–2023The accountClinical sales rep · 9 customers · New York, Pennsylvania
What I could seeThe clinic from the outside, across nine of them. Even the best product asks people to trade problems they’ve mastered for new ones. No sale skips that.
What I couldn’tThe whole picture. I was paid for getting a product adopted, not for what the clinic carried after I left.
Carried forwardAll nine came with me when I was promoted to manager.
2023–2024The territoryClinical sales manager · about 100 customers · 11 states and DC
What I could seeThe region: how dialysis programs differ from one hospital to the next, the hardest room I’ve sold into. It took a clinician’s credibility and a salesperson’s fluency in the same person. I was carrying both.
What I couldn’tThe inside of each customer. A region that wide is held through your reps. You see the coverage, not the patient.
Carried forwardMy nine original customers, still mine. And four clinics of the organization where I once ran the floor, seen from the outside this time.
2024–nowThe systemQuality and safety · 1 program · Boston
What I could seeNo orders to follow: the first seat where problems arrive with no instructions attached. I look for the constraints first, then build inside them.
What I couldn’tThe chair. I’m further from patients than I’ve ever been. The seat that finally sees the whole system is the one that stopped touching it.
Carried forwardThe federal rules I didn’t know existed in 2011 are what I work inside every day.
Registered nurse, New York and Massachusetts. BSN.
What working with me looks like
Calm when it’s hectic.
A dialysis floor runs against the clock, with patients who would rather be anywhere else. I learned to keep my own head, and to help everyone else keep theirs.
Constraints first.
Before I build anything, I find what can’t change. Then I build inside it.
Built from what’s there.
A shared sheet, a tablet, a site builder the team already has. The fix should fit the place, not the other way around.
Every side of the table.
I’ve done the jobs on the floor, in the office and on the sales side, so I can explain each one to the others.
Three places it goes
The same habits, pointed at three different tangles.
Write to John
If you’re weighing whether to work with me, or you just want to think out loud about how a system works, write. I read everything and answer what I can.
If you came for the practice rather than the person, it’s at cruzframeworks.com.
Received.
Thanks. I’ll write back.