In Latin, mortem means "death," and
post means "after," in other words something that happens after death.
This morose definition
lends itself to a less than proactive viewpoint on a critical improvement activity.
However, how this is managed will make the difference to improve service
through transparency rather than people holding back as a result of fear.
Recently, and part of the
reason I am sharing this post, I ran into a friend who was in the middle of his
holiday. After exchanging the usual questions and answers he ended up on the
topic of work, as people tend to do. He was thrilled that he was off work this
week as they were going over a post mortem for a recent outage his company had
with one of its key applications.
He continued to tell me that
there are very few things dreaded as much as the post mortem. People hate them
so much that even during the outage they are already thinking about what
actions will get them into hot water during the review. Imagine that?
He said that the post
mortem at his company is lovingly referred to as “the blame game”. To add
insult to injury he said that the team he is on, infrastructure, typically gets
the lion share of the blame sine they aren’t as “inventive” with their
explanations for issues and as such are not able to conclusively rule out that
they aren’t responsible for the issue to some degree.
This should clearly not be the intention for a post mortem
By its very nature these
post mortems should be an exercise in understanding, sharing and learning.
These principals should be
applied early on. Involving all parties who were a part of the restoration of
the service(s) as well as anyone who have a vested interest in the service(s)
should be invited to the meeting to review as well as getting the document that
outlines all the findings and outcomes. We need to foster transparency, and as
such our culture should allow us to be open enough to be able to see where we
can make improvements without worrying about who to blame.
After all the issue
happened, and was fixed. That is the hard part, now we need to ensure that we
can learn enough from this exercise to ensure we don’t repeat the same mistakes
if we can avoid them.
Digging deep into the
timeline will allow us to clearly see what actions we took, and why, at
intervals throughout the issue. After all we may have experienced many
different symptoms which led us to make particular assessments, which at the
time seemed appropriate, but afterwards might not have.
Personally I avoid the use
of the phrase ‘post mortem’ whenever I can and replace it with incident review.
While you are making a step in the right direction to hold these reviews, if
you are not fostering a culture of collaboration and transparency, you risk
some details being supressed in fear of some form of punitive action.
Key components of a blame
free incident review:
People involved during the issue
- What contributing factors came into play during the issue
- What was the impact of the issue
- What did we learn as a result of this issue
Keep these activities in
mind, take small actions as a result of the discussion you have after the
incident and you will be setting yourself up for your team to make improvements
on these issues rather than pointing fingers.
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Labels: Continual Service Improvement, Incident Management, ITIL, ITSM, postmortem, Problem Management