Introduction

The high cost of repeating mistakes

Repeatedly making the same errors is a tragic waste of time, money, and other valuable resources. Fortunately, many errors can be avoided. At the very least, their impact can be minimized.

Medical errors are a prime example. According to the U.S. Department of Health and Human Services, up to forty percent of patients with chronic conditions receive the wrong treatment protocol. Of the 36 million people who check into a U.S. hospital each year, more than 10 million acquire an infection or some other adverse effect unrelated to the condition for which they were originally admitted.

Even worse, the Institute of Medicine estimates that as many as 100,000 patients die in U.S. hospitals each year from preventable medical errors. That’s roughly equivalent to one 737 jetliner crashing every day, and that’s just in the U.S.

Given the high cost of repeating mistakes, there are two things we can do about it:
  1. Learn from past mistakes
  2. Reduce the occurrence of new mistakes.

Common barriers to capturing, sharing and applying lessons learned

Lessons learned is a relatively simple idea. It’s a way to continually ask: “What’s working, what’s not working, and how can we do better next time?”

Many leaders agree that their organizations waste too much time, money and effort repeating mistakes and re-inventing the wheel. Yet if you ask them what they’re doing about it, they’ll usually just shrug their shoulders.

In our work with organizations of all types and sizes, we’ve found two common barriers to capturing, sharing and applying lessons learned:
  1. The lessons learned process is overly complicated
  2. The culture punishes rather than rewards learning from mistakes.

Barrier #1: Avoiding overly complicated approaches

People are torn between succinctness and completeness. The more succinct you are, the more detail you have to leave out. Add more detail, and the lesson you’re sharing becomes too long for a world with a sound bite mentality.

Over-complication also comes from applying old database mindsets to capturing and sharing something fluid and nebulous like knowledge. Too often a lessons learned system becomes a nightmare of pre-formatted fields, layers of pick-lists, and annoying instructions.

The solution is to think of lessons learned as bite-sized nuggets, a conversation around the water cooler like: "Did you hear what happened over the weekend? We got a panic call from the field. They needed item X immediately, but the lead time was three weeks. Then somebody said, ‘Let’s try Y instead,’ and guess what, it worked."

Unfortunately, knowledge like that often gets lost in the walls around the employee lounge, never making it to the rest of the organization. Aside from planting hidden microphones, which would raise too many other issues, consider using a simple online storytelling system for capturing and sharing those nuggets of wisdom. Move away from rigid, mind-numbing data structures. Think campfire ghost stories instead.

At Lessons Learned World, we do this by breaking each story down into a few key parts. Setting describes the context of the problem/opportunity, who was involved, and the circumstances, including time and place. Problem/goal describes the obstacles encountered and, preferably, the root causes behind them. Solution covers the steps that were or were not taken, followed by the outcome. And like every good story, it ends with a moral or some kind of memory jogger to help people avoid making the same mistake in the future.

By the way, we’re not opposed to developing case studies along with supporting data. Rather, we see using nuggets as front-end summaries that give supporting data and case studies greater context, meaning and value.

Another major contributor to making things too complicated is management’s insistence on a lengthy validation process. Such behavior discourages sustained, meaningful contribution, as people grow frustrated with the formal system and go back to the simpler water-cooler method of knowledge sharing.

Many knowledge nuggets are informal, innovative ideas that save time and money. Why ruin them by making people jump through endless hoops? Of course you need to guard against dangerous shortcuts, especially where safety and other important concerns are involved. But by moving stories out of the shadows and into the open, potential hazards can be brought to everyone’s attention more quickly.

Barrier #2: Overcoming cultural barriers

Capturing lessons learned may mean having to admit you’ve made a mistake. You’re probably thinking: "Yeah, right. Does that mean adding a list of ‘greatest misses’ to my performance review?” Our answer is, “Why not?” When a snafu occurs, instead of hanging somebody out to dry, put the same effort into finding out what went wrong and how to prevent it from happening again.

Finally, creating a “safe proving ground" environment encourages identifying and correcting errors when they are small—long before they can grow into larger, and possibly catastrophic, failures. This not only prevents repeated errors but promotes habitual learning and innovation, putting you on an upward trajectory of sustained improvement.

Competing in a complex, fast-changing world means quickly learning from mistakes and building upon successes. A simplified lessons learned system is an important step toward achieving that high level of performance.


The original document is available at http://lessonslearnedworld.com/tikiwiki1/tiki-index.php?page=Introduction