KM and Hansei, where "no problem" becomes a problem

Effective learning within an organisation requires consistent and rigorous self-analysis, in order to pick up learning points and points of improvement. In Japan, this process is known as Hansei.

Hansei, by Jim O’Neil, on Flickr

Although alien to many in the west, Hansei is an important part of the Japanese culture. Han means “change” and Sei means “to review”, so the whole thing means “introspection” or “reflection for the purposes of change”.  This translates into a behaviour , instilled from childhood, of looking for mistakes, admitting responsibility, and implementing change.(When Japanese children do something wrong, for example, they are scolded and are told: hansei shinasai – Do hansei!).

Hansei can become very public, as the footage of the crying Toyota CEO shows. As a response to poor safety performance, the CEO admitted responsibility, apologised, promised change, and wept – behaviour lauded in Japan but deemed strange in the West. In the West we would probably avoid responsibility, deny the mistake as “fake news”, and insult our detractors.

Hansei is at the heart of Kaizen – the “learning from experience” approach seen in Japanese industry. It may part of the reason why Japanese companies succeed so well at Kaizen as a core component of Knowledge Management, while other cultures struggle. Where a European company might see lesson-learning as a witch-hunt, for example, a Japanese company would see it as a way to put right the embarrassment of self-acknowledged failure. Where a US company might fear a blame culture, Hansei means that individuals already accept any blame and if they fear anything, they fear the lack of ability to make restitution.

How do we develop Hansei?

In non-Japanese cultures we have not been brought up with Hansei. Seeing our leaders accepting full responsibility for mistakes and sincerely, with emotion, promising change is something exceedingly rare (name me one example!).  However this is a behaviour we would dearly love to promote at work, so that mistakes are not hidden, but lead to learning and change.

So here are six things we can do to begin to develop Hansei behaviours.

1. We can understand the current culture, and recognise the barriers. One of the 10 cultural barriers is defensiveness – an unwillingness to take responsibility and examine your mistakes. Our cultural assessment service allows you to see whether this is a major barrier in your own organisation.

2. We can build reflection into the work process. After Action Review, for example, is a Kaizen activity that can be embedded into the working pattern, to trigger reflection and change on a regular basis.

3. We can adopt no-blame learning processes. The Retrospect is widely recognised as a no-blame lesson-learning process for use at the end of projects or project stages. The open questioning within the Retrospect gives people the opportunity to examine what went wrong, and to suggest how this might be improved.

4. We can ask the team leader to set the tone. If we are concerned about lack of openness in a Retrospect, we can work with the team leader before hand to identify an area where they can openly admit to making a mistake, and explore how to avoid this happening again. When the leader sets the tone, the rest of the team may follow.

5. We can ensure all learnings lead to action. We must make sure that everyone present in a Retrospect or After Action review can see that their admissions, introspections and lessons will lead to action. Lessons will not just rot away in overstuffed databases, but become embedded in changes to process. Knowing that your mistakes can be turned into successes for others can make Retrospects into something like group therapy. This is the positive outcome of Hansei.

6. We can become intolerant of complacency. Another of the 10 cultural elements, complacency is the feeling that “we did alright, there was no problem, we don’t need to change anything”.  Here is what the Toyota website says about “no problem”:

“Even if a task is completed successfully, Toyota recognises the need for a hansei-kai, or reflection meeting; a process that helps to identify failures experienced along the way and create clear plans for future efforts. An inability to identify issues is usually seen as an indication that you did not stretch to meet or exceed expectations, that you were not sufficiently critical or objective in your analysis, or that you lack modesty and humility. Within the Hansei process, no problem is itself a problem“.

This type of thinking – where “no problem” is seen as symptom of a lack of introspection and a lack of analysis, and something to challenge rather than to feel smug about – may be what separates the  true learning cultures from the also-rans.

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Why a no-blame culture needs no-blame processes

We hear a lot about the importance of a “no-blame culture” in Lesson-learning, but a no-blame culture won’t work unless you have no-blame processes as well. 

Image from wikimedia commons

Learning lessons in an organisation requires a culture of openness, so that people are willing to explore honestly and openly what happened, and what might be learned.  This is particularly important when learning from projects or incidents where things have gone wrong and where mistakes have been made.  If people feel they are likely to blamed for the mistakes, and that their career or reputation might suffer as a result, they are unlikely to discuss the issue openly.

When we discuss the topic of lesson-learning with clients, we often hear the concern that lesson-learning meetings could be seen as “witch-hunts” – in other words, a search for someone to blame. To reassure them, we talk them through the lesson-learning process we use; the Retrospect.

The Retrospect is an externally-facilitated team meeting, held after the end of a project or project stage, where the team identifies and analyses learning points through discussion and dialogue, in order to derive lessons and actions for the future. The facilitator leads an inclusive discussion to identify

  • What went well and what did not go to plan in the project
  • Why the successful elements succeeded, and why the failures and mistakes happened (looking for root cause)
  • How future projects can repeat the success and avoid the failure. 

The key questions are therefore What, Why and How; very open questions which allow full exploration of the lessons learned.

Note that there is no Who question. 

We do not really care who was the hero or who was the villain. This is a no-blame process, as well as a no-praise process. We are searching neither for Witches or for Knights; only for the truth.

An open, no-blame culture requires open no-blame processes such as the Retrospect.

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Why "Knowledge for action" is better than "knowledge for storage"

Knowledge has to lead to action in order to add value. 

call to action by Sean MacEntee on Flickr

As the blogger Bill Wilson says (in the context of root cause analysis) “Learning without action is mere mental trickery, while action without learning is simply useless physical exercise”.  If knowledge management is to deliver more than mere mental trickery and to live up to its promise of adding value, then it must lead to action.

A few years ago we worked with a client who was developing a lesson learning system from projects. The collection of lessons has been going well, but the client had the firm view that lessons should be stored in a library that future projects could review if they wanted. For them, the knowledge would be stored “for future reference”.

Of course, few people have time to read through the lessons, and there are now so many lessons that reading through them is becoming more and more daunting. 
We are now helping the client to move to a different philosophy, where lessons are forwarded to the owners of the organisational processes, so they can continue to update the processes, procedures and guidance in the light of the new learning. This is “knowledge for action”, and if we assume that people follow the updated guidance, it should result is less “useless physical exercise” and to more efficient ways of working.

This philosophy is that wherever possible, every piece of new knowledge should lead to an action. The action might be;

  • Fix a problem,
  • Investigate further (especially if the learning is not yet clear),
  • Document a new procedure, process or guidance document,
  • Update an existing documented procedure, process or guidance document,
  • Update a training course or other training or e-learning material,
  • Circulate the lesson for others to decide on an action.
Communities of practice, as well, should focus on creating and managing actionable knowledge. Actionable knowledge can be stored on the community wiki, and includes

  • Advice and guidance
  • Good practices
  • Improved practices
  • Solutions to problems
  • Answers to questions
  • New approaches
  • Recommendations
  • Tips and Tricks
Non-actionable knowledge is
  • Interesting articles
  • Links to interesting articles
  • Musings
  • Quotes and aphorisms
  • Descriptions of what you are doing (unless you analyse this to bring out actionable learning)
  • Descriptions of what you have done (unless you analyse this to bring out actionable learning)
  • Large document stores
Communities that circulate non-actionable knowledge, or “knowledge for interest” are classified as Communities of Interest rather than communities of practice, the clue being in the title. 

CoPs deliver more value when they focus on solving the problems of the members than when they circulate “interesting links and ideas”. CoPs that operate through a Pull process – where members with problems or issues ask questions and receive recommendations and support from other members – know they are adding value.  Each answered question represents a solved problem; knowledge which the person who asked the question can immediately put into action.

So when you are sharing knowledge in a CoP, ask yourself whether you are sharing “something that others will find interesting” or “something that will help people do their job better” – something actionable.

And when you are designing lesson learning systems, make sure each lesson leads to action, rather than being retained “for interest”.

We recommend “knowledge for action” rather than “knowledge for storage” as being a far more effective system.

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How to calculate the transmission efficiency of lessons learned

The lesson learning system should be a supply chain for new knowledge. But how do you calculate its effectiveness?

We can look at lesson learning as a supply chain; identifying new pieces of knowledge and supplying them to other knowledge workers so they can improve their work. If it works well, knowledge is gathered, accumulated, synthesised into guidance, and used to inform future operations.
But how well does this supply chain work, and how can you calculate its efficiency?
This is something I tried to measure recently with a client, using a survey.
I divided the lesson supply chain into three steps, shown below
  1. Capture and documentation of lessons from project experience;
  2. Update of guidance documents based on new lessons;
  3. Review of guidance documentation in future projects.
Now this particular client  did not have a clear supply chain for lessons, so many people accessed lessons through search.
I therefore asked survey respondents to estimate in what percentage of cases the following happened, giving them the options to selecting 0%, 20%, 40%, 60%, 80% and 100%. The average estimate from the survey responders is shown below.

  • Any given project documents lessons (46%)
  • Any given lesson is used to update guidance documents (32%)
  • Any given project makes use of guidance documents (43%)
  • Any given project seeks for documented lessons (44%)
  • Any given search finds useful lessons (36%)
We can then use these figures to estimate the effectiveness of lesson transmission, as shown in the diagram above, and described below.
The effectiveness of transmitting lesson through guidance is 46% (capture) x 32% (update) x 43% (review) = 6%.

The effectiveness of transmitting lesson through search is 46% (capture) x 44% (search) x 36% (find) = 7%.

These are pretty low figures! Even if both routes were independent and there was an overall success rate of 13%, that still means that 87% of project knowledge was never transmitted other than via human memory.

Let’s compare that with an organisation that treats lessons seriously. The diagram and numbers below are not from a survey, but from published statistics in another organisation. This organisation does not require users to search for lessons, but has a well-resourced supply chain to embed lessons into procedures and guidance.

  • Any given project documents lessons (100% – lesson capture is mandatory part of every project, and supported by dedicated resources)
  • Any given lesson is used to update guidance documents (93% – this figure was tracked on a quarterly basis and the “closure rate” for lessons varied between 88% and 95%)
  • Any given project makes use of guidance documents (100% – all activity was directed by operational procedures which were reviewed and use to make the action plans)
The overall transmission efficiency is 93%

Please note that these figures only reflect the documentation of lessons and their transmission to future knowledge workers; they don’t include the loss of knowledge in the documentation process, or the issues of transmission of understanding from writtenprocedires into the human braid – they only look at the effectiveness of the supply chain of written lessons.

This effectiveness can be measured, through surveys or through lesson tracking, and we can see that is can vary between very ineffective (as low as 6%) or extremely effective (as high as 93%).  If you are applying lessons learned, then aim for high effectiveness!

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Why you should never leave your lessons in the project report

Probably the worst place to store project lessons is to leave them in the End of Project Report.

Tombstone created using

I know this is still the default approach for many project organisations, and 19% organisations who run KM programs still use this approach (according to our KM survey). However this approach was linked to the second-lowest satisfaction score for lesson learning, second only to “we don’t store our lessons anywhere”. So leaving lessons in project files is only slightly better than not storing them anywhere.

But why is this the case?

It makes sense for the project team to leave the lessons in the report, because lessons are a project output, and surely all project outputs are documented in the report? Once the report is written, the job of the project team is done.

However although the job of the lesson writer may be over, the job of the lesson-seeker is only just starting.

People searching for lessons (whether they are people in future project teams, or subject matter experts maintaining process documentation) will be searching for lessons to help with a specific issue, risk, process or task. They would like to find all the lessons associated with that issue, risk or task in the same place. They almost certainly will not know which projects learned lessons on which topic. They don’t want to have to go back through 20 or 30 project reports, looking through the lessons learned section of each one, just in case there is something of relevance.

Therefore they don’t bother.

The lessons remain unread; the project report becomes a tomb in the lessons graveyard. Learned once, and destined to be relearned in future.

Two of the basic principles for effective lesson learning are that you need to 1) capture lessons individually, and 2) store them centrally. As I pointed out in yesterday’s blog post, lessons are a knowledge output from a project, and should be stored with the rest of the knowledge, not the rest of the project files. In order to make it easy for the lessons to be found, you need to store the individual lessons under themes or topics in a lessons management system until they make their way into updated practice and procedure, guidance and training.

 If lessons are being learned from many projects, for example from Retrospects and After Action reviews, then these lessons need to be stored somewhere where they can be compared, reconciled, and actions assigned, notified, tracked and managed. They need to be captured in a consistent format, and stored in a central system.

 This is often done in some sort of Lessons Management System, set up either for a major business stream such as Sales or Engineering or for the entire organisation, to store and track lessons from many projects.

An effective lessons management system should be structured according to the needs of the “knowledge user”. People who come to access lessons from the database should be able to find what they are looking for very easily. If they don’t find relevant and useful knowledge within a few minutes, they will leave and never come back.

Think about the needs and interests of the knowledge user, think about how the knowledge will be re-used, and think about how you should structure the database to most easily give them access to what they need.  The knowledge seeker is  looking for lessons about procuring steel pipe for example, or for all the lessons to do with safety while working at height, or for all the lessons to do with partnering with a particular national authority; in other words, lessons to do with the particular issue that they face. The lessons therefore need to be grouped into a structure,  index or taxonomy, based on work activity or work process. Think about how supermarkets gather and present produce, and use ideas such as this to stock your knowledge supermarket.

In addition, the lessons management system should be able proactively to route lessons and associated actions to the relevant process owner, in order that the lessons can be embedded in improved process, and can be declared properly “learned” and the learning loop can be closed.

Leaving them in the project report graveyard destroys the learning loop at the first step.

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Lesson learning at NASA – video

From the AFAC lesson management forum last week, this video below from David Oberhettinger, NASA’s Jet Propulsion Lab, talking about lesson learning in their human and robotic space exploration program

David makes some interesting points, such as

  • the need to dedicate individuals for lessons capture (although NASA allows engineers to submit lessons themselves, he says he has never seen this happen in 25 years)
  • lessons need verification and quality control – particularly verifying the facts of what happened
  • lessons recommendations need to be “infused” into procedures and training to ensure closed-loop learning. The key documents are the JPL design principles and the JPL flight project practices, which are built up over time from the combined and synthesised lessons
  • weekly meetings of the lessons learned committee, for the past 35 years

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Every lesson is a story

Capture your lessons as stories, that way they will be remembered more easily.

Native American Storytelling. Photo By: Johnny Saldivar

One of the way humans learn is through stories. Stories can Inform, Educate, and/or Entertain (transmit information, knowledge, and entertainment) and some of the best stories do all three.

A post from the Farnham Street blog entitled “The structure of a Story” tells us that a great story has structure, and includes Context, Action and Result; where Context includes Where, Who, What do they Want, and What’s getting in the way. As the blog says

“It all hangs on the central Context, Action, Result (CAR) structure. It starts with the Subject, Treasure, and Obstacle, and concludes with the Right lesson and link back to why it’s being told”.

When we transfer Knowledge, story is one of the best formats. That is equally true of lesson-learning as it is of the other elements of KM. Yet all too often, lessons fail to meet the test of a good story.

As the Farnham Street blog says, aspirant storytellers usually start with the Action, because that is the exciting part, and omit the context, and as a result the reader of the story or lesson cannot easily identify with nor internalise the learnings.

When we teach lesson-learning to organisations, we say that Every Lesson is a Story, and we recommend that the lesson has at least 6 components

1) Context. Here we explain what was expected to happen, but didn’t. This is the “What did we want” step of the story. It is amazing how many project teams or facilitators skip this step. Because “what was expected to happen” is so obvious to them, they expect it to be obvious to the reader, but of course it seldom is. 

2) Outcome. Here we explain what actually happened – the Action step of the story. What went wrong? What actually happened? 

3) Root cause. Here we explain WHY it happened – what the Obstacles were, what was missing that should have been there, or (in a success story) what was done to achieve the result. 

4) Impact. Here we explain or try to quantify the result, either negative or positive. 

5) Lesson. Based on the root cause, what is the learning for future projects? This is the “Right Lesson” part of the story.

6) Action to Embed.What action do we take to embed that lesson into business process, so mistakes are never repeated, and successes always copied.

A lesson with a story-based structure such as this takes about a page to write down or a couple of minutes to tell, compared to typical bullet-point one-liner lessons – told in seconds, forgotten almost as quickly.

However if we treat every lesson as a story, then we realise that it must be presented as a Narrative, with Context, Action and Result, concluding with the Right Lesson.

This is the simple structure that conveys the message.

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The four most costly words in KM – "this time it’s different"

“This time it’s different” can be the four most costly words in project knowledge management, if they are used as a reason not to learn from the past.

Albert Einstein’s definition of insanity was “doing the same thing over and over again and expecting different results”.

And yet, any analysis of a collection of corporate lessons will show the same mistakes being made time after time. So organisations obviously DO “do the same thing over and over again and expect different results”.

Are organisations insane?  Or is there another factor at work?

The factor may well be what the Farnam Street blog calls the “This time it’s different” fallacy. I quote from the blog –

“This time is different” could be the 4 most costly words ever spoken. 

It’s not the words that are costly so much as the conclusions they encourage us to draw. We incorrectly think that differences are more valuable than similarities. After all, anyone can see what’s the same but it takes true insight to see what’s different, right? We’re all so busy trying to find differences that we forget to pay attention to what is the same.

Different is exciting and new, same is old hat. People focus on the differences and neglect the similarities. In projects, this becomes the “my project is different” fallacy that I described here. People look at their projects, see the unique situations, find the differences, overlook the similarities to all similar projects on the past, and assume that “this time it will be different”.

It never is.

The same old mistakes will creep up on you and bite you in the bottom, as they always do.

Instead of assuming “this project is different”, perhaps we should start with the assumption that “this project is just like any project. It involves building and understanding client requirements, choosing and forming the team, selecting and managing sub contractors, balancing the innovation against the risk, communicating within the team and with the client, keeping the client requirements always in mind, managing quality, managing cost, managing time, managing expectations, managing risk, and so on”.

Then look for the lessons that will help you with all those tasks, and will help you avoid all the old pitfalls. As the Farnam Street blog says,

If you catch yourself reasoning based on “this time is different” remember that you are probably speculating. While you may be right, odds are, this time is not different. You just haven’t looked for the similarities.

A great antidote to the “This time it’s different” fallacy is that good old, tried and tested mainstay of Knowledge Management, the Peer Assist. Once a project team gets into a room with a bunch of people with experience, the conversation automatically focuses on the similarities. “Yes, we’ve seen that, we’ve been there, here’s what we learned” and it becomes increasingly difficult to maintain that “This time it will be different”.

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Operationalising Lessons Learned in a small organisation

Here’s a really great video on a small organisation operationalising a lessons learned process

The organisation is Boulder Associates, an Architect and Design firm with a couple of hundred staff working out of a handful of US locations. The video was recorded at the KA-connect conference in San Francisco in 2018; an annual knowledge-focused conference for the AEC community organised by Knowledge Architecture.

The video is of a 27 minute presentation given by Todd Henderson and James Lenhart of Boulder Associates, and thanks Todd for the namechecks!

They make the point that collecting lesson is not the purpose of lesson learning, and they drive lesson learning through just in time delivery, using checklists as the final destination for the learning. Their combination of spreadsheet, tracking dashboard and checklists is a very simple, very appropriate system for an organisation of this scale.

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Why admitting mistakes is so hard, and what we can do to counter this

It is part of the human condition to deny our mistakes, but that makes it hard for us, and for our organisations, to learn.

make no mistake by Meshl
make no mistake, a photo by Meshl on Flickr.

I can recommend a really interesting book called “Mistakes were made – but not by me – (why we justify foolish beliefs, bad decisions and hurtful acts)”.

The book is about cognitive dissonance – how people square their self-image of being a good, competent and smart person, with the realisation that they can make mistakes – sometimes pretty big mistakes.

The way most people deal with this problem is to maintain the self-image and explain away the mistake.

“It wasn’t really a mistake” – “Of course I didn’t see the stop sign, it was in such a stupid place” – “The sun was in my eyes” – “Nobody told me it was wrong” – “He pushed me” – “I don’t see why I should say sorry, he started it” – “I’m not wrong, aliens really DO exist; the government is covering it all up” and so on.

They didn’t REALLY make a mistake; they were smart people all along. It wasn’t their fault.

This cognitive dissonance works particularly strongly in cultures that are intolerant of mistakes, and to be honest, that’s most cultures. As the playwright Lillian Hellman says about US culture, for example

“We are a people who do not want to keep much of the past in our heads. It is considered unhealthy in America to remember mistakes, neurotic to think about them, psychotic to dwell on them”.

Knowledge Management, however, requires that organisations, and the people within them, learn from experience, and 50% of experience comes from Mistakes. KM, if it is balanced, must allow learning equally from failures and from successes. Somehow this very powerful driving force of cognitive dissonance, present in every culture and every human, must be allowed for, sidestepped and redressed.

How do we do this?

Firstly, there much be a very conscious top-down drive for a culture that allows learning from mistakes. Call it a no-blame culture, call it an organisational learning culture, call it openness – it needs to be a clear and conscious expectation. This sets up a counter-dissonance. “I am a smart person. But I made a mistake. But the company expects me, if I am smart, to admit mistakes. Hmmmm!”

We all know the story told about Tom Watson Sr, the first president of IBM.

A young worker had made a mistake that lost IBM $1 million in business. She was called in to the President’s office and as she walked in said, “Well, I guess you have called me here to fire me.” “Fire you?” Mr. Watson replied, “I just spent $1 million on your education!”

That is a very powerful story that sets up a counter-dissonance.

Or look at the NASA approach, of getting senior leaders to publish stories entitled “my best mistake”.  I suggested this to an organisation recently, and the head of KM actually said “you will NEVER get leaders to publish their mistakes”. And yet that’s just what they did at NASA.

Or look at the Japanese attitude of Hansei. Although alien to many in the west, Hansei is an important part of the Japanese culture. Han means “change” and Sei means “to review”, so the whole thing means “introspection” or “reflection for the purposes of change”.  This translates into a behaviour , instilled from childhood, of looking for mistakes, admitting responsibility, and implementing change.(When Japanese children do something wrong, for example, they are told: “Hansei shinasai – Do hansei”!). Hansie also contains the thought that “to say there were no mistakes, it itself a mistake”

Secondly, we use objective facilitation.

Take lessons-identification meetings, for example. The temptation, when scheduling a meeting for a project team to identify lessons from experience, is for the project leader to lead the meeting. However the outcome, most of the time, is that the project team made No Mistakes. Sure, mistakes were made, but not by the project team!

You see this, for example, when the lessons coming from the team are like this ….

We ordered a set of number 6 widgets, and when they arrived, they were very poor quality. We had to send them all back, which delayed construction by a week.  The lesson is not to use that supplier again”.

So the fault was with the supplier.

However a good objective facilitator would dig deeper. They would ask – what were your quality control procedures? What was your ordering philosophy? Did you wait for the widgets to arrive before doing quality control? If so, why did you leave it until the last minute, so that re-ordering caused delay? Did you just assume that everything would be top quality?” The lesson would be more about quality control procedures and mental assumptions, that it would be about suppliers and vendors.

Any good system of lessons identification and lesson-learning has to use objective external facilitation, if you are to overcome the tendency to say “mistakes were made, but not by my team.” That’s why an increasing number of companies are calling us in, for example, to provide that skilled external evaluation as part of their lesson learning system.

This is even more the case with high level review and learning. As the authors of the book say,

“Few organisations welcome outside supervision and correction. If those in power prefer to maintain their blind spots at all costs, then impartial review must improve their vision ……. If we as human beings are inevitably afflicted with tunnel vision, at least our errors are more likely to be reduced or corrected if the tunnel is made of glass”.

This goes for teams and individuals as well as organisations – impartial assistance is vital.

So, set the high level expectation for openness, and use external facilitation to probe the blind spots.

We all make mistakes – mistakes have been made, often by us, and those mistakes are an opportunity to learn and improve, despite our best efforts to pretend that they never happened.

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