Thursday, 9 July 2015

Post Mortems - A Learning Experience

I was recently reminded about learning from mistakes when I was watching my son draw a picture of a turtle. As he was making the turtles body he stopped abruptly and had a distinctly irritated scowl on his face. I recognized this as the beginnings of the paper being crumbled and chucked into the bin. I asked him what was wrong and he said that the body was too big. I told that it was ok and he drew a smaller version after turning the original into a flower.

The same can be said when we are reviewing incidents, problems or changes.

The reason we have these most mortems is to identify what effectively caused us to be there in the first place. Whether it is to review the latest major incident or a component of a failed change we need to know what happened and how to prevent it again.

In my opinion, to get the most out of these meetings you need to set a tone that this is a place to learn and make improvements rather than pointing fingers. Having been to a few of these at various organizations and also getting some feedback from others, this is not always the case. The trouble with the latter is that you might not get an honest assessment of what really happened as some details are left to the imagination or are assumed. When this happens, the ability to improve is reduced.

In meeting which have a high level of transparency you are able to gather factual details from several stakeholders on what really happened. The climate for these meetings should be such that the person or people who made a mistake are not only able to learn from it but also educate the rest of the team on what happened.

Aside from transparency, make sure that there is an understanding that these reviews are scheduled soon after the issue has occurred. Everyone is busy, but when we start pushing out the meeting time or have those who can’t make it, you will find that details may get lost in the shuffle. Make this review a high priority activity. Think of it in these terms, if the issue happened again at the same time would you push it out or attend – if you don’t review and make improvements it is likely to repeat.

Keep the meeting simple. You should review the timeline of the issue, including details such as:
  • What happened and at what times,
  • What decisions were made and why
  • Any assumptions that were made
  • Things that were tried and did not work
  • Fixes which were discussed but not tried


In the end, as you wrap the meeting up, quickly review what was discussed including the impact to users, preventative activities, and lessons learned. If there action items ensure that they have a deadline and that this is followed through with the same priority as the meeting itself.

Remember that the issue has happened we just need to identify what to correct, learn from it and turn it into a flower.


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