Hold that thought whilst we look at root causes…
A vital element of any lessons learned process (including After Action Reviews, lessons capture meetings and interviews) is Root Cause Analysis (RCA). There are numerous RCA techniques but one of the most common is the ‘5 Whys’ method (see diagram). In practice, this simply involves asking the question ‘Why?’ until you get to the key element(s) requiring change in order to improve performance. In my experience, this can be uncomfortable for some people but such discomfort is itself often proof that such enquiry is getting somewhere!
Note: insufficient time, people or money are not root causes but are symptoms or reflections of priority. If something is deemed important, it will be resourced generously. If a function is considered less important (in relative terms), it will have to make do – I simplify to make the point. Learning from experience enables organisations to assess whether such resourcing decisions were, with the benefit of hindsight, correct.Since the experiences from which lessons are identified are merely symptoms of root causes, it is common for one root cause to have many symptoms (and many lessons identified as a result).
Addressing the root cause effectively will therefore ensure a significant number of lessons are ‘learned’ and, from a management perspective, closed and archived within an organisation’s lessons library/database/management system.
Now let’s come back to the analysis bit…With a large number of lessons, grouping together the root causes themselves may tell us something. Combining keywords, a taxonomy and its clustered root causes gives an organisation an even deeper understanding of some of its challenges and, crucially, the effect these challenges are having on its performance. This new knowledge, to use an engineering analogy, gives an organisation greater leverage, with any intervention having a far greater effect, as shown in the diagram below.
For example, a company finding that >25% of its lessons have ‘poor discipline’ as a root cause might consider a cultural audit, revisions to its leadership programme and a review of its performance incentive scheme as ways of addressing this issue that is producing so many lessons.
So what are these big issues that come up time and again?
I have helped clients identify, analyse and manage thousands of lessons from sectors as disparate as finance, engineering, design, media, cosmetics, pharmaceuticals, security, defence, energy, local government, construction and the voluntary sector. Client confidentiality prevents the sharing of any details but, in general, the following areas come up time and again:
· QualityOver the coming weeks, these will each be examined in greater depth, with a look at some of the potential recommendations that might be made to address them. Click here for more information on Knoco’s lessons analysis service.