Why do we need to LEARN lessons?
Learning lessons leads to improved operational effectiveness, reduced operational risk and increased efficiency. Consistent approaches to Lessons Management will encourage adaptability and flexibility and may highlight opportunities for improvement. Sharing of knowledge and experience will assist with ongoing continuous improvement of people and the organisation.
The term ‘lessons learned‘ is sometimes used to describe raw observations or opinions without any validation or analysis, and therefore is not well understood and is often misused. This results in significant perception and expectation management problems. Not all issues that emerge during and after operations and exercises are ‘lessons’ that can be ‘learned.’
Some issues are ‘wicked problems’ that on a bad day will never be perfect. This does not mean they can be ignored but sometimes mitigating the risk is the best that can be achieved. Statements such as ‘we will learn all the lessons from this event’ can create unrealistic expectations that during catastrophic events it is possible for every aspect of operations to run smoothly.
Regardless of how the lessons come to be viewed, it is important for organisations to reflect on an event to share experiences and learnings. It is also important to consider a Near Miss as well in relation to Lessons Management learnings.
A Near Miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. A faulty process or management system invariably is the root cause for the increased risk that leads to the near miss and should be the focus of improvement.
The importance of fostering a learning CULTURE
It is imperative to establish and maintain a culture that embraces learning and change to support continuous improvement and lesson sharing within an organisation. The values that contribute to a learning culture potentially increase the effectiveness as workplaces move from a ‘compliance culture’ to a ‘no-blame’ or ‘just’ culture.
Individuals should feel confident to take”informed risks”to share their knowledge and speak the truth which are critical elements of the Lesson’s Management cycle.
Transparency is an aspect of a learning culture. Transparent communication should occur throughout the whole lessons process and can assist with managing expectations. By specifying exactly what people should expect to occur throughout the Lessons Management process, particularly with regards to their contribution, people will not be left wondering or having unreasonable expectations.
A focus on transparent processes which demonstrate consistency and fairness will support acceptance and increase the value people place on a just culture and the procedures that support it.
What is a learning organisation?
At the organisational level, adopting a Lessons Management approach builds an organisation’s ability to achieve their goals and increase effectiveness and efficiency. While learning lessons often begins in one organisation, frequently organisations operate in multi-agency environments and the learnings are often highly transferable across multiple organisations.
Garvin, Harvard Business Review, (2008 ) suggests that there are three broad factors that are essential for organizational learning and adaptability: a supportive learning environment, concrete learning processes and practices, and leadership behaviour that provides reinforcement. There are multiple definitions of what constitutes a learning organisation. The one adopted for use by the AIDR is:
An organisation skilled at creating, acquiring, interpreting, transferring and retaining knowledge, and at purposefully modifying its behaviour to reflect new knowledge and insights.
— (Garvin 2000)
- Encouraging people to modify their behaviour/s to reflect new knowledge and insights
- Encourage new and expansive patterns of thinking which are nurtured
- Result/s of learning encouraged at a whole organisation level
- Collaboration and accountability towards change which are directed towards shared values or principles.
Knowledge Management has an organisational focus: at its core is the continuous improvement of the organisation. Lessons Management is just one element of Knowledge Management and an essential component of improvement. Knowledge is more than just data or information.
Knowledge Management delivers a new way of working, where knowledge is generated and shared, continuously improved and routinely reapplied, and where knowledge is treated as a valuable common asset which drives performance. Lesson Management is a core part of this new way of working, one vital work-stream among the several activities that thrive within the knowledge enabled enterprise.
There are three types of knowledge (US Centre for Army Lessons Learned 2011). Click below to reveal:
Tacit: Personal knowledge that resides within an individual based on experiences, ideas, insights, values and judgements.
Explicit: Personal knowledge that is conveyed easily – for example, by using documents, emails and multimedia. This knowledge is easily codified.
Organisational: The combination of data, information and collective knowledge of individuals in the organisation that enables an organisation to learn from experiences, innovate, make decisions, create solutions, perform tasks or change positions.
Real time lessons
Real time lessons are a systematic and objective function that monitors performance of systems and processes to identify opportunities for learning/improvement. It needs to be performed by trained personnel to ensure it is both effective and in a form that can be embraced and used by the people involved.
Learn before-learn during-learn after
Lessons have traditionally been identified after the event, which is too late. Lessons identified after an event may be useful in informing future events ONLY IF there is a process to enable that learning.
The Learn before, Learn during, Learn after model (Nick Milton. Knoco)
- Learn Before-Learning from past events. Learn from the failures of others rather than your own failures.
- Learn During-(See Real Time Lessons above). Trained lessons personnel can support learning and improvement during an event.
- Learn After-Learn after is standard practice with debriefs and reviews to capture observations and lessons to enables continuous improvement.
Adapted from Australian Maritime Safety Authority (AMSA) Lessons Management document.
An integral part of Lessons Management is Change Management. An organisation’s ability to demonstrate changed behaviour by implementing a lesson is limited unless a change can be observed, and it can be determined that the lesson was learned. Therefore, the actions taken have improved the organisation’s performance. A learning culture needs to exist at all levels of the organisation for the cycle to be effective.
What type of Culture is necessary to facilitate Lessons Management Processes?
The effectiveness of lessons relies on the culture within an organisation to support continuous improvement and lesson sharing. The values that contribute to a learning culture potentially increase in effectiveness as workplaces move from a ‘compliance culture’, (The conventional workplace environment was more commonly founded on a compliance culture, based on sanctions that get the non-compliant into ‘trouble’ Dekker, 2007 ), to a ‘no-blame’ or ‘just’ culture‘.
Collecting enough information requires an environment of trust where workers feel safe enough to openly report or disclose ‘honest mistakes’ or unintentional slips or lapses without fear of retribution.
There are TWO types of CULTURE identified in the Lessons Management process:
- A learning culture involves people being actively involved in continuous improvement to ensure that the Lessons Management process is effectively implemented at each stage of the cycle.
- A learning organisation embraces experiences, including failure, as an opportunity to improve.
- The tendency to blame individuals after a major event breeds a culture that is resistant to creativity, innovative thinking and adaptability, and reduces the capacity of leaders, managers and practitioners to take informed risks when required.
- A learning culture is supported and sustained by a just culture.
- A just culture is about balancing the demand for accountability with an ability to collect enough information to make sense of the situation, to contribute to learning and safety improvement.
- A non-judgemental just culture encourages learning and maximises the potential for ongoing improvement.
- If personnel do not feel safe to speak up without fear of ridicule or blame, or if others declaring a contrary view challenge them, they can be discouraged from sharing their experiences.
- The best performing teams work in an atmosphere where they are encouraged to speak up if they see anything ‘dumb, dangerous or different’.