In the first part of this blog series, you learned why one has to adapt the causative flawed paradigm to eliminate mistakes permanently. In the second part I have described the process of the identification of the flawed paradigm in detail. In the last part of this blog series I will now explain which two mistakes you must avoid, so that your company can learn the right lesson.
Mistake #1: Accept the new paradigm without considering any ramifications
It may have fatal consequences for your company if you do not check the ramifications of the new or updated paradigm. Therefore, in the 5th step of his learning process, Eli recommends considering all the implications of the new or updated paradigm and eventually developing new procedures..
Eli’s learning process:
Step 5: Consider the impact of the new or updated paradigm
If you verbalize the paradigm, you need to consider all practical ramifications – positive but in particular negative ones – of the change of the paradigm. The future reality tree (FRT) is ideally suited for testing the impact of the new paradigm. For this purpose, a future reality tree is created based on the paradigm shift. As in all future reality trees the potential negative branches of any process changes should be verbalized and eliminated. Often the density of the details is so great that it makes sense to designate other teams, to determine all detailed consequences.
Step 6: Develop new procedures, which result from the adjusted or new paradigm
Eventually many existing procedures have to be adjusted accordingly. Sometimes new opportunities arise through the new understanding of the paradigm.
If you follow both steps, you will successfully avoid mistake #1. Many companies finish the learning process at this point and thus do not achieve the full learning potential and commit mistake #2.
Mistake #2: Team does not share the lessons learned with others.
In order to develop a positive error management culture within the company, the lessons learned should be shared with all employees. Therefore, in the last step of his learning process, Eli recommends documenting the lessons learned.
Step 7: Document the lessons learned from the specific event
After the team has learned the lesson from the unexpected event, the lessons learned should be shared with other employees. In some cases it makes sense to even share the findings with other organizations.The aim is that not only the employees, who were involved in the event itself or its analysis and who have derived the lesson, understand this lesson, but that the findings will be made available to a large group of people. It should be noted that by merely changing the guidelines or processes, the underlying lesson is not shared.
Furthermore, we should be careful not to overwhelm the members of the organization with too many lessons! Therefore, we need to focus only on the most essential lessons. It is advisable to present only the summary of the unexpected event and the most important logical arguments that identified the old (flawed) paradigm and showed the direction to the new (updated) paradigm.
In practice, a focused database has been proven to work best. It contains brief descriptions of the most important lessons and is openly accessible by all employees, thus ensuring that all members of the organization, now and in the future, are aware of the lessons learned. The purpose of the database is to spread the new understanding of cause-and-effect in the organization and to create a culture of “pain-free” learning.
Congratulations! Now that you know all the steps of the learning process, you can start searching for flawed paradigms in your company and thus learn from your experiences. Establish a positive error management culture in your company and create a competitive advantage!
Finally, a summary of the most important points.
Summary of Eli’s “Learning from ONE event” method:
- Mistakes are opportunities to update our paradigms
- An unexpected event is a signal from which we can perhaps learn something.
- The gap between prior expectations and the actual outcomes is the focus of the learning.
- A team consisting of affected employees, intuitive people and outsiders forms a good foundation to find the hidden lesson.
- The search for information should be based on hypotheses and the need to validate or invalidate them.
- The “operational cause”, that is, the facts which causes the “gap”, is not the end of the analysis, because the “operational cause” is always caused by a hidden paradigm.
- The identification of the flawed paradigm should be the mission for the first part of the learning process.
- Re-verbalizing the paradigm requires special care not to simply adopt the opposite.
- A formidable challenge is to generalize the new (updated) paradigm as much as possible, to represent the wider aspects of the new understanding.
- The change in policies and procedures is not enough to teach the lesson to all members of the organization now and in the future.