Learning from incidents

How to improve by learning from incidents?
We give you the tips and tools.

What is learning

Our behavior is a pattern of actions. Depending on a happening arouind us, we react a certain way. If someone gets sick, we call the doctor. 

Learning is the process of changing our behavior. It’s the process of creating new patterns of reactions – to do something differently.

Learning is the key proess in continous improvement incident-, and risk management.

There are two key aspects of learning to address here:

  1. Single loop learning
  2. Double loop learning
Single loop learning

Single loop learning only focus on the symptoms of the issue. If a production line if overflooded once a month, we stop the production, clean up and update our maintenance plan to reset before this happens. But we don’t dive into the root cause and fix the problem.

Double loop learning

Double loop learning is all about the deeper understanding. It challenges your assumptions make you rethink the chain of events leading up to incidents.

How to become a learning organization

In order to become a learning organization and use incidents as opportunities for improvement, there are some key elements to be aware of. DigiLEAN is also a key element providing the tools to support you.

Documenting incidents

It’s impossible to learn from incidents that are not identified. Establishing a culture where all incidents are reported without fear of reprisals is key to success. As a manager you must have data to build upon.

DigiLEAN enables all employees to report incidents wherever they go. The user interface is simple to use and adding photos and video from your phone gives a much better understanding of the incident.

Process incidents

A good understanding of the situation is key to investigate and understand the underlaying causes. Some may be more apparent than others, and can be documented directly in the incident report in our kanban.

In other cases, performing a root cause analysis is necessary, and we provide the tools necessary. DigiLEAN let you combine different tools in a way that makes sense.

From an incident, you can create and perform a root cause analysis using our A3 template. This template gives you:

Learning from incidents

Performing root cause analyses or using 5x why methodology are good tools to achieve double loop learning. The identified actions will represent a change, and change cannot be implemented alone.

The key is to share the learning with your team or organization. The root cause analyses are stored automatically and allows re-use and reviews according to the PDCA cycle. 

The output follows the A3 standard format. Add it to your team boards and include it in your meeting agenda. Put it up on information screens in common areas for everyone to see.

The learning center is also an area where you can share learning with your organization. New procedures, one point lectures or revised standards can be documented here, and is easily available for all users.

We’d love to tell you more. Book a meeting, chat with us and learn something new today!