Learning from the Past to Prevent Future Occurrences
Learning from the experiences of the past is just what lessons learned are about. Lessons of the past can include lessons that resulted from the actions or activities that produced favorable or unfavorable conditions and results. Using the knowledge gained from performing activities to avoid the same or similar results is at the core of the purpose for utilizing lessons learned. Effective use of the concept involves having a credible process to identify, evaluate, document, validate and communicate what has been learned and its applicability to the business in which it is being applied. Most organizations have a lessons learned program that includes internal lessons learned as well as those learned from other industries or companies that have applicable business practices. In many cases, this program has assisted companies in averting unpleasant to catastrophic situations and improving processes and the quality of services and products provided to their customers. Figure 11.1 demonstrates the path that should be taken to utilize the lessons learned process effectively. Each element represented along the path is discussed below in A-E.
A. Identify: Identify the process or practices that can be exported and learned by employees, which can have positive or negative impacts on the business. The process or procedure should be the best in the industry or must help improve quality and increase productivity.
B. Evaluate: Evaluate carefully and completely the lessons learned and ensure that it is compatible with the intent of use. Ensure that the lessons learned are transportable to your business and can be repeated in a manner to gain optimal results as well as provide positive overall business impact.
C. Document: Annotate in detail the lessons learned and the process or procedure that is applicable for implementation. A detailed mapping of the process, program, procedure or project will be helpful especially for complex processes.
D. Validate: Ensure that the proposed lessons learned is in fact useful to the business or project and can be integrated into the business practices and processes for achieving the desired results.
E. Communicate: Communication of lessons learned should be timely and comprehensive and in writing, although verbal communication is also acceptable as long as it is followed by written means so that it can be retrieved as needed.
FIGURE 11.1 Lessons learned validation process.
Lessons learned can be positive and propelling or it can be negative and costly in various ways. However, the lessons learned that are frequently published and studied are those having negative impact, alerting others to beware so as to prevent the same event from happening in their organizations. Consider how much can be gained from publishing positive lessons learned in the same manner in which we see negative lessons learned documented and shared within companies and across industries. Figure 11.2 provides a pictorial view' of the positive and negative lessons learned and the expected results.
Positive Lessons Learned: The impact of documenting and publishing positive lessons learned can help a company to replicate the activity, process or actions that can lead to a positive outcome in other areas of the company. This can help in improving product quality and customer relations, reduce injuries to people and the environment, reduce cost, facilitate process improvement and increase productivity. The knowledge gained through positive lessons learned when shared externally can help the industry improve across the globe.
Negative Lessons Learned: This type of lessons learned is typically what is published and shared to assist organizations in not repeating a process or practice that has had negative impact on process, equipment, people or the environment. Negative lessons learned often impact the process capability, people and the environment and are often costly to the organization in terms of downtime for workers and equipment to impacting a company’s reputation. When identifying lessons learned, consider exploring answers to the following questions:
- • What went well?
- • What didn’t work well?
- • What could have been done differently?
- • What were the impacts?
- • Who or w'hat was impacted?
- • What events were not anticipated?
Lessons learned provide an opportunity to learn from the mistakes and woes of previous events or from the past events encountered by others. A comprehensive lessons learned program is instrumental to the continuous improvement process. Lessons learned can yield best practices for an organization or an industry when modeled and communicated properly.
FIGURE 11.2 Lessons learned web chart.
Capturing and Documenting Lessons Learned
Organizations document procedure, policies and work practices to ensure that workers know what is expected of them and how to perform work correctly and safely and determine when process improvement is necessary. Proper documentation can provide management the ability to protect themselves when it comes to legal matters, audits, employee disputes and demonstrating compliance witli rules and regulatory requirements. Documentation sets the stage on what is expected of everyone and how an organization operates and interacts with workers. Without documentation, organizations lack the record of how business is conducted and expectations for organizational members.
Reapplying lessons to prevent future mistakes is at the center of why it is necessary to capture lessons learned. A good method to use in capturing complex lessons learned is to provide a pictorial view of the process or activity. Process mapping is a great tool to use in providing this pictorial view. An example of how process mapping can be used is depicted in Figure 11.3. A process map is a planning tool that visually describes the flow of work and is sometimes referred to as a flowchart or process flow diagram. It outlines who and what is involved in a process and can divulge areas in the process that should be improved or discarded.
Documenting lessons learned can be complex especially when the practices or procedure that is being imported from another organization has an extensive number of steps that are critically needed to be captured to provide the full context of the process. If not documented accurately, lessons learned will not have the same impact as it may have had for the organization from which it is being imported. In
FIGURE 11.3 Lessons learned process maps soil management.
fact, it can have unintended impact and cause damage to the business, workers or products.
Figure 11.3 is a partial map of a process to gain regulatory approval for handling soil resulting from several large- and small-scale projects that took place on a Comprehensive Environmental Response Compensation and Liability Act (CERCLA) site, also known as a Superfund site. To ensure health and safety of the workers and the environment, regulatory compliance and project execution remain as scheduled, a soil management plan was developed with consultation with all of the applicable regulatory agencies’ input in advance of project start. The plan was approved and signed off by all agencies providing approval to perform work and dispose of soil excavated based on the approved strategy. As long as work was performed in accordance with the strategy, there was no longer a need to gain regulatory approval for each project. This best practice resulted from the lessons learned from other CERCLA sites and the past experiences of having projects on hold while regulatory approval is sought and gained. This practice can cost a company their reputation in terms of following through with project commitment, loss of resources while waiting to move forward with work and the cost associated with paying workers that are not productive, equipment rentals, etc.