Eli Schragenheim, originally presented his method “Learning from Experience” in an expert workshop1 as part of the 12th annual meeting of German-speaking TOC experts, users and interested parties in 2011. At that time, he advised companies to learn from their experience by analyzing the cause of a surprising event meticulously. A couple of years later, Eli presented new aspects of his method in his webinar2 (11th May 2013). This three-part blog series presents the main insights from both events.
Companies that “hold their employees accountable“ for their actions are trying to find a culprit rather than the cause after a mistake has been made. Out of fear, employees “cover up” or ignore their errors.
As a result the company does NOT learn from its experiences!
Furthermore, according to Eli, the process of identifying the cause of a mistake is, in many companies, unfocused and lengthy. Often, vast amounts of data are aimlessly collected. Although the employees involved in the incident are consulted, they are often not actively involved in the search of the cause of the mistake. This approach delays a swift correction of the mistake, because the employees who have the most knowledge of the incident itself and on the processes in the departments are excluded from the search for the cause. Rather than investigating the exact cause, often the first available explanation is accepted or simply the opposite is done in the future.
This approach damages the company considerably, because the same mistakes are repeated over and over again!
Eli explains in his webinar and workshop that companies need a structured analysis process to quickly and effectively eliminate errors and to learn from their experiences. According to Eli, a mistake is always due to an operational cause, which is caused by an underlying flawed paradigm.
I recently advised a company whose employees frequently made mistakes in their daily duties. The company had, without analyzing the cause of the high error rate, carried out training in order to avoid mistakes in the future. However, the error rate remained high.
I discovered that the employees practiced multitasking and therefore could not fully concentrate on one task at the time. The operational cause of the high error rate was “to allow multitasking” but the causative flawed paradigm was “everyone must always be busy”. It was not enough to simply prohibit multitasking. The flawed paradigm had to be adjusted to eliminate the errors once and for all. Together with the management and employees, we developed the new paradigm “tasks and projects must flow freely within the company”. This resulted in a new approach to task processing: “tasks must be processed without interruption and as soon as possible with optimal use of resources”. Once the new paradigm had been internalized by the employees and the management, there was automatically no longer any multitasking. The employees were able to concentrate on one task at the time and made few or no errors at all.
There are flawed paradigms in every company! Even in yours!
(Nasty) surprises give us the opportunity to identify them and to adapt or develop a new paradigm and thereby permanently eliminate mistakes.
Eli recommends following procedure:
Step 1: Choose an appropriate incident and analysis team
1.1 Identify the unexpected incidentWe can only learn from (nasty) surprises, if we identify them. Therefore the company should encourage its employees to admit their mistakes and managers should check regularly whether their expectations have been met. Often we focus on things that go wrong, but we can also learn something if we are pleasantly surprised.
Eli presented following example in the expert workshop:
A food manufacturer hired a top chef to create a new gourmet soup. The new soup only achieved mediocre, average grades in the taste test. Usually, such products are not placed on the market, but in this case the management made an exception and the soup became a huge success.
Can the company learn something from this positive surprise?
Therefore, we will analyze the example later in more detail.
1.2 What do you expect to learn from the structured analysis process?It`s important to maintain focus in the analysis of unexpected events! If you try to learn from everything, you learn nothing. Only (nasty) surprises with serious consequences are worth analyzing in detail!
1.3 Assemble the team that will carry out the analysis
The analysis should be carried out by a team and not by individuals. This minimizes the risk that the first available explanation will be accepted. Experience has shown that different team members have different “plump explanations” – this forms the basis for discussion and a profound analysis. In addition, team members have to convince each other through logical “cause-and-effect” arguments.
A team of 5 employees has been proven to work best, with at least one person who was directly involved in the unexpected incident. This is because the affected employees generally have the key information and intuition required to analyze the incident accurately. By involving the affected employees, management shows that it does not intend to blame anyone. However at the same time the organization insists that mistakes are identified and corrected.
The main focus has to be on the search for the cause of the mistakes and not for a culprit! Even if a guilty employee should be identified, the employee must not be punished, but should be supported, so that he or she will not commit this error again.
The aim of this method is to learn the right lesson from a mistake and not to “point the finger”. If the employees, who were involved in the unexpected incident, are part of the team which identifies and corrects the mistake, then this also significantly reduces their guilt and strengthens their self-esteem. Hence, in the future they can continue their work unencumbered.
In addition to the affected employees, people that had nothing to do with the incident should be part of the team. One reason for this is that the “outside perspective” can identify the flawed paradigms faster than the “insider perspective” of the affected employees. In addition, it forces the team members of a particular field to explain technical processes in simple, easy to understand terms. Thereby errors in complicated processes are more easily found.
In the next article of this three-part blog series you will learn how to identify the flawed paradigm quickly by means of a structured analysis of the causes and how to update or develop a new paradigm to permanently eliminate mistakes.
1: Eli Schragenheim, expert workshop “Learning from Experience – Wir lernen aus Erfahrung“, 04. Dec. 2011
2: Eli Schragenheim, webinar „Learning from ONE event – A `learning from experience` methodology”, 11. May 2013