In a large organisation, lesson-learning can happen at multiple levels.
In global oil and gas companies for example, there are often three levels
- Firstly team learning uses After Action Review to learn within project teams. Discussions take place within the team, and any changes are to team processes. Lessons are documented in simple form, perhaps in Excel spreadsheets.
- A more complex form of learning is learning from one project to another, using facilitated lessons-identification meetings. Lessons are collected, actions are assigned, and changes made to organizational process. Lessons are documented in lesson management systems.
- Finally in analyses of major incidents, an investigation team is tasked with collecting observations, the insights, the learnings, and even the recommendations for action. Lessons are documented in evaluation reports.
In each case, and at each scale, the learning cycle is similar.
However the scale varies - from one project team, to multiple project teams, to the whole organisation, and as the scale changes, so does the rigour of, and the investment in, the learning process.
The table below shows how the learning stages and steps are applied at each of the three levels.
Lessons are identified through discussion and investigation, and pass through a series of stages, from context to observation to insight to lesson. If the lesson is to be truly learned (in other words, embedded into new ways of working), then there are further stages.
The lesson must be documented and validated, it must lead to assigned actions, those actions must be disseminated to the correct people through a lessons management system, the appropriate actions must be taken, and the lessons closed.
However the scale varies - from one project team, to multiple project teams, to the whole organisation, and as the scale changes, so does the rigour of, and the investment in, the learning process.
The table below shows how the learning stages and steps are applied at each of the three levels.
Step/Stage
|
Within
a team
|
Between
projects
|
Major
Investigation
|
1. Context
|
Discussed within the team After Action
Review
|
Discussed within the retrospect, led by
the facilitator
|
Investigated by the incident
investigation team
|
2. Observation
|
Discussed within the team After Action
Review
|
Discussed within the retrospect led by
the facilitator
|
Collected by the incident investigation
team
|
3. Insight
|
Discussed within the team After Action
Review
|
Discussed within the retrospect led by
the facilitator
|
Analyzed by the incident investigation
team
|
4. Lesson
|
Discussed within the team After Action
Review
|
Discussed within the retrospect led by
the facilitator
|
Recommendations made by the incident
investigation team
|
5. Documented lesson
|
Either not documented, or documented
within a lessons log
|
Documented within a lesson management
system by the facilitator
|
Documented as the incident investigation
report
|
6. Assigned action
|
Discussed within the team After Action
Review
|
Either discussed within the retrospect
led by the facilitator, or discussed after the facilitator by senior staff
|
Discussed and agreed by senior management
|
7. Validated lesson/action
|
Validated within the team and by the team
leader at the After Action Review
|
Validated a) within the lessons
management system, or b) by senior staff
|
Discussed and agreed by senior management
|
8. Distributed/notified
lesson/action
|
Action assigned using existing team
processes such as action log
|
Use of a lessons management system
|
Use of a system such as the ‘strategic
implementation planning’ tool
|
9. Taken action/change
|
Action taken by team member
|
Action taken a) by other teams, or b) by
company authorities such as Subject Matter Experts
|
Action taken by company authorities
|
10. Completed lesson
|
Action closed in action log
|
Actions tracked and lessons closed in
lesson management system
|
Actions tracked and lessons closed by
central team.
|
Monitor, review, report
|
Monitor through routine team action
monitoring
|
Statistics created and reported from the
lessons management system
|
Lesson closure reported by central team.
|
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