Learning and improving

Learning our lessons

Learning from incidents is a critical activity in the world of disaster management, but do we do it effectively?

The Pollock Report (2013), a commission of the Cabinet Office, reviewed the lessons identified from 32 high impact incidents between 1986 and 2010. Although focused specifically on interoperability between agencies, thematic commonality in lessons identified features throughout the report.

What the Pollock Report leads us towards is the hypothesis that we do not learn as effectively as we can from incidents. A hypothesis that as a professional in the field I certainly would not challenge. There is no doubt that we do identify lessons, and we do implement changes in order to resolve some of these – but it would not be surprising to read a series of debrief reports and see broadly similar content. Furthermore, to this day the term ‘lessons learned’ is still widely used to indicate the process of debriefing, but lessons are not learned by being identified. Lessons are learned by action being taken and the alternative desired outcome evidenced.

As we progress through COVID-19 the potential and the need for learning is remarkable and must not be missed. Yet it presents many challenges. 

  • Where and when should we start? 
  • How should we structure and what format should we use? 
  • Should we debrief thematically or chronologically? 
  • What do we need to learn the most before we move into the next peak or incident? 
  • How do we capture learning from such a vast amount of actors?
  • How do we capture learning in a socially-distant and virtual world?
  • How do we join up organisational learning?

The list goes on. One thing we must be sure of, however, is that we are not only identifying our lessons, but are proactively learning them. 

The Joint Emergency Services Interoperability Principles (JESIP) model of debriefing guides us to consider the following:

  • What went well?
  • What didn’t work well?
  • What could have been done differently.

Focused on interoperability it also suggests we use these questions thematically against the JESIP principles, but this will not serve to capture all the lessons for organisations from COVID, and nor is it designed to.

My own view is that we should approach the lesson identification process both chronologically and thematically. For example, each area of business whether that be ICCs, critical care, medicines, out of hospital services, estates or transport, should now be debriefing against the activity from phase 1, or the onset of the incident up until the post-first-peak lockdown relaxation.

The learning from this phase will be distinctly useful in application to any onset of a second peak. Furthermore, when we approach the end of this first phase of restoration and enter into a second peak, the learning from that phase will be directly applicable to any subsequent restoration and recovery work.

Beginning the process of formal lesson identification as expediently and efficiently as possible should be high on all priority lists.

As we approach this challenge it is important to consider how organisational learning takes place more broadly, and the taxonomy of relevant theories. 

Identifying lessons is not sufficient to learn from them. Equally, taking action to alter policy or process is not always sufficient either. Often the success of learning from incidents is dependant upon organisational culture and engagement.

The JESIP Joint Organisational Learning (JOL) secretariat utilise the single and double loop learning methodology in their guidance document to analyse lessons and transform them into recommendations. Double loop learning is a theory originally developed by Chris Argyris (1976) which pertains to challenging underlying assumptions, values, and beliefs in order to advance learning, rather than simple addressing the problem itself through traditional solutions (single loop).

Figure 1: Single and double loop learning.

Some critical thinkers have taken this further in applying a third loop. This approach involves learning ‘how to learn’, through reflecting on how we learn in the first place.

Figure 2: Triple loop learning.

This process allows individuals, or in this case organisations, to determine how they must induce change, often in organisational culture, to create transformation and promote optimal self-awareness and learning.

Improving our processes

A key work stream in organisations, certainly those with large-scale operations, is often that of improvement. Improvement as a concept is not only focused on cost-saving, thought that is clearly an important factor. Within the healthcare arena improvement methodology can be used to ensure that a consistent, accessible, and appropriate service is offered to each patient based on individual needs.

There are two primary schools of thought within the improvement world. Lean, and Six Sigma. Often these are blended into ‘Lean Six Sigma’.  

The philosophy of Lean is to reduce waste. In short, this is achieved through reviewing the processes involved with a particular service, and identifying non-value adding steps that could potentially be removed. The philosophy of Six Sigma is to challenge variation and make processes predictable and reliable. This is achieved through a 5 phase process: define, measure, analyse, improve, and control.

Blended learning and improvement

What peaks my interest is how within the world of disaster management we can utilise improvement methodology to support our debriefing and learning processes, providing a blended and holistic approach to learning and improvement.

COVID-19 provides an interesting and complex case study within which to explore this. Whilst some recommendations will be easy to identify, others will require more effort to uncover.

References

Argyris, C., & Schön, D. (1976). Theory in practice. San Francisco, Calif.: Jossey-Bass.

JOL Guidance. (2017). Retrieved 14 May 2020, from https://www.jesip.org.uk/jol-guidance

Pollock, K. (2013). Review of Persistent Lessons Identified Relating to Interoperability from Emergencies and Major Incidents since 1986. Emergency Planning College. Retrieved from https://www.jesip.org.uk/uploads/media/pdf/Pollock_Review_Oct_2013.pdf

4 comments On Learning and improving

  • Excellent article Alex, thank you

  • Philip Trendall

    Very interesting stuff. None of the suggested frameworks have really been successful in determining why organisations don’t learn even though most shout about the importance of learning. Long before Pollock authors, particularly in the safety world, were questioning why previous lessons had not be heeded. I would suggest that there is considerable potential for a examination of blended approaches to blame/no blame methods of lesson identification. It may be that accountability is the key to a systems based approach. Please post further as things develop on this important subject area.

  • Hi Alex,
    Excellent and thank you for sharing. Lying at the heart of many risk and resilience issues is the understanding of ‘value’. When trying to eliminate waste a one-eyed focus on cost cutting tends to underestimate the positive value of resilience to the organisation and instead narrows value to a short term $ value. An example of this would be someone saying ‘by reducing our stocks we can save £££/month on warehouses, staff costs, insurance etc’. This might be true, but having stock in the first place has advantages, but these are often softer in value or more difficult to assess over the short term.
    Your point about highlighting THINKING gives us pause to more fully consider situations. We use a simple question to help folks focus on Borge the positive and negative aspects … ‘if this, what else?’. It is a way of looking at conditions and challenging bias and assumptions. It can connect processes with both risk identification and mitigation, but it’s real value is in stimulating more creative thinking that identifies opportunities and threats. In the current climate an example would be the associations between COVID-19, distance working and Cyber (with Cyber being both a threat and an opportunity). This approach helps consider the bigger picture and make better value based judgements.

  • Very interesting read. Maybe our approach to problem solving needs to change? We’ve advanced the application of analytical thinking in recent years through a move to ‘data analytics’, but what about a completely different and complementary approach to problem solving? Systems Thinking. Anyone?

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