As we move through of careers we all have endless incidents that can either be denied and suppressed or acknowledged and framed as “falls,” “failures,” or “mistakes.” These so-called falls all enhance our professional growth. By focusing on the process of falling, and then rising back up, we are able to have a greater understanding of the choices we have made, and the consequences of our choices.
Sharing and bearing witness to stories of failure from our professional and personal lives provide opportunities for us to explore and get closer to the underlying meaning of our work, our questions of what is it that we are trying to accomplish in our work as quality professionals. Our missteps allow us to identify paths we needed to take or create new stories and new pathways to emerge within the context of our work. As we share stories of tensions, struggles, and falling down, we realized how important these experiences are in the process of learning, of crafting one’s presence as a human being among human beings, of becoming a quality professional.
We may not have asked for a journey of struggle when we decided to become quality professionals, but the process of becoming tacitly involves struggle and difficulty. There is a clear pattern among individuals who demonstrate the ability to rise strong pain and adversity in that they are able to describe their experiences, and lay meaning to it.
It is important to recognize that simply recognizing and affirming struggle, or that something is not going as it should, does not necessarily lead to productive change. To make a change and to work towards a culture of excellence we must recognize that emotions and feelings are in the game. Learning to lead is an emotionally-laden process. And early-stage professionals feel exceptionally vulnerable within this process. This field requires early-stage professionals to hone their interpersonal, technical, and organizational skills, all while turning their gaze inward to understanding how their positioning in the organization impacts can be utilized for change. Novice professionals often struggle in terms of communicating ideas orally or in writing, being able to manage multiple tasks at once, staying on top of their technical content, or even thinking critically about who they are in the broader world. Early-stage professionals are always on the brink of vulnerability.
My six years at Sanofi were really the transition from manager to leader. It wasn’t always easy, but this is where I started to truly apply self-awareness to my tasks and expanded my perspectives to move beyond the day-to-day and focus on the strategic needs of building a quality organization.
I came into the organization really focused on the immediate needs of building a serious change management and change control. This was a site under a consent decree and I felt pressured to have results fast.
Over time, as the consent decree moved to later stages I shifted focus to being less day-to-day and more about implementing continuous improvements and driving a vision of what quality and excellence really could be.
I made mistakes. I had successes. I’m leaving quite proud of what I’ve done and the relationships I’ve built. Relationships I am confident will continue.
I often joke with folks that I started this blog as a public form of journaling. That remains true, and will continue in the future. As I move into my next position, here are my key things to remember:
Focus on outcomes not deliverables with the long term goal of building a quality culture through innovative digital solutions and thus helping shape not only my organization but others beyond it.
Don’t just instruct but inspire. Strive toinspire, to motivate, and to communicate the overall quality philosophy at every opportunity. If my coworkers are truly inspired by and proud of the ideals and values that I help communicate, then they will drive even more improvements.
CommunicateBig Quality Ideas. In addition to setting a digital agenda, utilize the platform to create wider strategies for quality, and defining the tone for quality culture by crafting effective, clear, transparent, and consistent messaging that inspires the best.
Slow down. Be humble. Understand that I do not need to prove myself as the smartest person in every room. Encourage people to speak up, respect differences of opinion and champion the best ideas. Breathe.
One of the hallmarks of a quality culture is learning from our past experiences, to eliminate repeat mistakes and to reproduce success. The more times you do an activity, the more you learn, and the better you get (within limits for simple activities). Knowledge management is an enabler of quality systems, in part, to focus on learning and thus accelerate learning across the organization as a whole, and not just one person or a team.
This is where the” lessons learned” process comes in. There are a lot of definitions of lessons learned out there, but the definition I keep returning to is that a lessons learned is a change in personal or organizational behavior as a result from learning from experience. Ideally, this is a permanent, institutionalized change, and this is often where our quality systems can really drive continuous improvement.
Lessons identified is generate, assess, and share.
Updated processes (and documents) is contextualize, apply and update.
Identify Lessons Learned
Identifying lessons needs to be done regularly, the closer to actual change management and control activities the better. The formality of this exercise depends on the scale of the change. There are basically a few major forms:
After action reviews: held daily (or other regular cycle) for high intensity learning. Tends to be very focused on questions of the day.
Retrospective: Held at specific periods (for example project gates or change control status changes. Tends to have a specific focus on a single project.
Consistency discussions: Held periodically among a community of practice, such as quality reviewers or multiple site process owners. This form looks holistically at all changes over a period of time (weekly, monthly, quarterly). Very effective when linked to a set of leading and lagging indicators.
Incident and events: Deviations happen. Make sure you learn the lessons and implement solutions.
The chosen formality should be based on the level of change. A healthy organization will be utilizing all of these.
Level of Change
Form of Lesson Learned
Consistency discussion After action (when things go wrong)
Retrospective After action (weekly, daily as needed)
Retrospective After action (daily)
Successful lessons learned:
Are based on solid performance data: Based on facts and the analysis of facts.
Separate experience from opinion as much as possible. A lesson arises from actual experience and is an objective reflection on the results.
Generate distinct lessons from which others can learn and take action. A good action avoids generalities.
In practice there are a lot of similarities between the techniques to facilitate a good lessons learned and a root cause analysis. Start with a good core of questions, starting with the what:
What were some of the key issues?
What were the success factors?
What worked well?
What did not work well?
What were the challenges and pitfalls?
What would you approach differently if you ever did this again?
From these what questions, we can continue to narrow in on the learnings by asking why and how questions. Ask open questions, and utilize all the techniques of root cause analysis here.
Then once you are at (or close) to a defined issue for the learning (a root cause), ask a future-tense question to make it actionable, such as:
What would your advice be for someone doing this in the future?
What would you do next time?
Press for specifics. if it is not actionable it is not really a learning.
Update the Process
Learning implies memory, and an organization’s memories usually require procedures, job aids and other tools to be updated and created. In short, lessons should evolve your process. This is often the responsibility of the change management process owner. You need to make sure the lesson actually takes hold.
Differences between effectiveness reviews and lesson’s learned
What can we learn from this change for the next change?
Effectiveness reviews are 1 and 2 (based on a risk based approach) while lessons learned is 3. Lessons learned contributes to the health of the system and drives continuous improvements in the how we make changes.
Lesson learned management model for solving incidents. (2017). 2017 12th Iberian Conference on Information Systems and Technologies (CISTI), Information Systems and Technologies (CISTI), 2017 12th Iberian Conference On, 1.
Fowlin, J. j & Cennamo, K. (2017). Approaching Knowledge Management Through the Lens of the Knowledge Life Cycle: a Case Study Investigation. TechTrends: Linking Research & Practice to Improve Learning, 61(1), 55–64.
Michell, V., & McKenzie, J. (2017). Lessons learned: Structuring knowledge codification and abstraction to provide meaningful information for learning. VINE: The Journal of Information & Knowledge Management Systems, 47(3), 411–428.
Milton, N. J. (2010). The Lessons Learned Handbook : Practical Approaches to Learning From Experience. Burlington: Chandos Publishing.
Paul R. Carlile. (2004). Transferring, Translating, and Transforming: An Integrative Framework for Managing Knowledge across Boundaries. Organization Science, (5), 555.
Secchi, P. (Ed.) (1999). Proceedings of Alerts and Lessons Learned: An Effective way to prevent failures and problems. Technical Report WPP-167. Noordwijk, The Netherlands: ESTEC