Updated: Mar 12
What is Knowledge Governance for Change and Knowledge Management initiatives, and how does it help to create meaningful value as part of the user experience?
Change Management inevitably leads to emergent challenges and opportunities, which invariably leads to Lessons Learned. If you are capturing stories or lessons learned on the likes of a Sharepoint site, then this article is for you! You will find an outline governance template at the end of this article, but, please, read the rationale first.
Meaningful and valuable lessons learned rely on visibility and velocity to create impact (see the article above for information on the 6Vs of data-to-knowledge hygiene). When working with Change or KM teams, I test the user experience to benchmark Lessons Learned Portals, from content creation to access and action, leading to impact and results.
One of the biggest mistakes I find is the lack of consideration for knowledge hygiene, particularly visibility. I have lost count of the number of organisations where, in sitting with users to conduct 'findability tests', experiments designed to measure the value of a given portal, the knowledge-seeker gives up because what they are searching for exists but is buried so deep in the system that to them it is lost. The findability challenge is one that I spoke of fifteen years ago, and, sadly, it remains a significant challenge to those seeking to create meaningful value from lessons learned.
I know from our Collider Cafes (see the sidebar for upcoming free events) that many have not considered the knowledge hygiene challenge. Either that or they need help with tools or experience to do something about it. If this is you, I want to give you an insight into how some organisations are tackling this challenge. The following will provide you with the rationale for Lessons Learned Governance, as well as a sample of a Lessons Learned Governance template (headings and excerpts).
Imagine jumping into your car today and driving to work in a world where commonly agreed road safety practices did not exist. Imagine that world where drivers could do whatever they wanted without consideration for the common good.
Would you want to drive in that world because that is more-often-than-not the world of lessons learned?
What is Knowledge Management Governance, and why do you need it?
Lessons Learned exists to provide meaning and value to its users;
Meaning and value means that lessons learned managers must anticipate, respond and hold themselves accountable for the user experience and the move from access-to-action; and
Therefore, to achieve meaning and value, KM needs to consider knowledge hygiene factors, including governance.
The biggest determinant in our lives is culture, where we are born, what the environment looks like. But the second biggest determinant is probably governance, good governance or a certain kind of governance makes a huge difference in our lives - Nicolas Berggruen
To produce a meaningful and valuable service, you need to understand the user and what they find meaningful and valuable. Without such understanding, you will only move knowledge to action by luck, not design.
If lesson Learned exists to serve the common good within your organisation, what do your lessons learned do to create meaning and value for its users? In other words, how do lessons learned contribute to impact and results by providing a meaningful and valuable experience to the user? [See the video above for clarification on meaningful and valuable user experiences]
Meaningful and valuable lessons learned means the provision of service that finds solidarity with your organisation's internal and external stakeholders. From such thinking, three things immediately emerge:
Lessons learned cannot provide a meaningful and valuable service without first engaging with all relevant stakeholders to establish meaning and value from the user perspective. In doing so, lessons learned managers identify the boundaries within which they will function.
Lessons learned cannot provide meaning and value over time without constantly monitoring and managing its boundaries.
Lessons learned influence change, and change leadership or management requires influence.
Lessons learned governance promotes commonly good structures, systems, processes, values and behaviours to promote meaningful value - measured through results and impact - over time.
Lessons Learned initiatives fail when they fail to provide meaningful value
I worked on a project where a healthcare system in Canada was implementing a new Sharepoint intranet project. System users didn't use existing tools because they didn't find search results useful, where information was incomplete, lacking in depth, out of date and, therefore, insecure.
Imagine if a high-reliability system failed to operate a high-reliability Intranet, where critical knowledge was not readily available to its users. Quite simply, the cost to life could be catastrophic.
The system reacted by investing in Microsoft SharePoint. However, the Intranet team failed to consider the user experience or the creation of meaningful value. In failing to engage and involve users in the design of the new intranet, they missed the need for a framework for using, monitoring or evaluating the new intranet and, due to time constraints and several missed deadlines, had ported over all the old data from the intranet to the new one.
I came in 30-days before rollout to benchmark the lessons learned initiative and its potential for creating meaningful value across the system. Unfortunately, it was like shutting the stable door after the horse had bolted.
A findability test, where we sit down with a variety of users to identify questions they had and the intranet's ability to provide rapid and secure (reliable) answers, provided a 26% response rate.
A discussion with the Intranet team demonstrated that there had been zero consideration for the intranet search algorithm. Of concern, users were creating sites without a framework for commonly good practice – users often rage against SharePoint, but is it the technology or a lack of governance that contributes to negative user experiences? After all, rubbish in = rubbish out! Finally, the intranet team had not considered a means to monitor, evaluate, and report the impact and results of knowledge to action.
In other words, a high-reliability system was reliant on a low-reliability Intranet, where there was a significant risk to patient care and the patient experience.
Part of what needed was governance, but back to the big question: what does governance mean? It is challenging to find examples of governance approaches because companies pay large sums of money for assistance in this area. I want to help.
The following is an excerpt from a basic version of a governance document co-created by users for a Lessons Learned initiative in a Canadian hospital system. I hope you find it useful because good governance could be the difference between a rich, meaningful and valuable, lessons learned initiative and failure.
Lessons Learned Governance - Sample Template: document headings and excerpts
1. >>your organisation << Lessons Learned Governance Guidelines: Introduction
Lessons Learned is a tool provided to facilitate changes to values, behaviours, systems, structures and processes, where failures or challenges have been identified in these areas by colleagues across the whole of the >>your organisation << system in carrying out day-to-day business activities (see Section 11).
The key function of the >>your organisation << Lessons Learned is to provide the means to publish and rapidly access information about, or relating to, the system and its work, including that information relating to the work of business units, committees or workgroups. The [Your organisation] Lessons Learned programme provides the best means available for organising, storing, accessing, sharing, developing and actioning this type of material. It is also secure in that only people within the organisation can access it.
There are three elements to >>your organisation << Lessons Learned strategy, these are:
Information, Learning and Knowledge Management.
While recognising the importance of the last two points in creating an overall Lessons Learned strategy, the purpose of this document is to focus on the first and overall controlling point by presenting actionable governance for the Lessons Learned programme.
e.g. 1.1 Why >>your organisation << needs Lessons Learned Governance >>Example – Insert your story<<
1. A >><< Superior Court jury returned a $>>< million verdict against a doctor in favour of a minor plaintiff who suffered a devastating brain injury at birth. On the evening >><< the plaintiff's mother presented to >><< Medical Center at 00 weeks pregnant with complaints of decreased fetal movement. She was placed on electronic fetal monitoring and admitted for continued observation.
Although the monitor strips were initially non-reassuring, the baby's heart improved and remained stable for the next 18 hours. However, there were significant changes to the baby's condition starting shortly before 0:00 pm on x-day. The baby's heart rate began to drop into the 00's and 00's for several minutes each time. The residents on duty recognised the problems and placed calls to the on-call attending physician.
The Doctor's plan over the phone was to continue monitoring and watch the baby closely. He never came to the hospital, nor did he contact any attending physicians in the hospital to have them evaluate the mother. This type of concerning pattern continued for the next 0.0 hours.
2. The above incident was known to us, yet it has happened again. $>><<,000,000 verdict on behalf of >><< Family for permanent brain injuries sustained to their child as a result of a failure to timely perform a c-section. >><< X >><< Hospital. Jury awards $>><<.00 million in damages; >><< Medical Center found liable in case.
A jury awarded $>><<.00 million in damages to the parents of a child who suffered severe brain damage at birth under the care of Dr.>><< and >><< Ob-Gyn and Associates and >><<. According to records, the infant was not breathing at the time of birth and was later diagnosed with cerebral palsy and developmental delays. The suit claimed both the hospital, nursing staff and Dr. >><< failed to read fetal monitoring tapes, contraction patterns accurately, mismanaged the induction of labor, and failed to report to the physician an accurate status of the labor of the patient.
The suit states as a direct and proximate result of >> hospital <<, the doctor and staff's negligence, the baby suffered a permanent, irreversible brain injury and will continue to suffer from injuries throughout his lifetime.
Implications for >>Your Organisation<<
Without a Lessons Learned process >> your organisation << will struggle to collect and analyse system-wide data and information to anticipate and overcome issues related to safety, time, innovation, quality, cost and patient care/experience. An efficient and effective Lessons Learned programme would accelerate learning across the system by overcoming barriers to learning, whether the obstacles be values, behaviours, processes, systems or structures.
The >>your organisation << Lessons learned process will not be a repository of past events. To create high-impact, the >>your organisation << Lessons Learned process will be obsessed with changing values, behaviours, processes, systems, and structures to anticipate and avoid failure. Furthermore, when failure happens, the >>your organisation << Lessons Learned process will assess the potential for the incident to be repeated and its impact, and respond accordingly. For this to happen, the >>your organisation << Lessons Learned process would use past events to anticipate and overcome future challenges efficiently and effectively.
While success will be celebrated, the >>your organisation << Lessons Learned process would be obsessed with avoiding failure, which is an essential requirement for a High-Reliability Learning Organisation such as ours.
>>Your organisation << will create the best Lessons Learned process possible. Success will be measured by benchmarking and lowering existing safety, time, innovation, quality, cost, and patient care/experience indicators reliant on people. As such, it is essential that all employees and contractors within the >>your organisation << system feel compelled to act when gaps in required behaviours, process and structures are first identified.
Simply put, if >>your organisation << is to achieve the objective of High-Reliability, people must be motivated to engage in the lessons learned process. Such an effort will require broader support within the system.
In summary, a >>your organisation << Lessons Learned process will contribute to the attainment of High-Reliability by achieving the following objectives:
Enabling all staff to clearly demonstrate their contribution to the development of >>your organisation << as a High-Reliability System by using employee feedback.
Ensuring all staff have the support tools to efficiently and effectively achieve their objectives (Safety, Time, Innovation, Quality, Cost and Experience).
Allowing more precisely targeted and relevant changes to processes, structures and behaviours across the system in the prevention, early identification and mitigation of failure, and redesign of processes based on identifiable failures.
Allowing all staff to understand and identify their contribution to the success and ongoing performance of >>your organisation << as a High-Reliability System.
Demonstrating impact and results of staff contribution against key high-reliability indicators of safety, time, innovation, quality, cost and experience (quality of patient care and quality of patient experience) across the >><< system.
Providing structure, process and behaviors that have a demonstrable impact on safety, time, innovation, quality, cost and experience (quality of patient care and quality of patient experience) across the >>your organisation << System (e.g. by ensuring that Lessons Learned content across the system can be found, understood and actioned on demand).
1.2 What Success Looks Like for Lessons Learned Users
e.g. 1. A >>your organisation << is injured in a fall and the nurse needs to fill out an incident report. The >><< logs into Inside >><< and searches Incident Reporting and they can clearly see which version applies to a >><< as opposed to the >><< Network. They click through and are able to create the report and get back to >>customer<< care with minimal interruption.
2. Lessons Learned Scope
>>your organisation << Lessons Learned Governance Guidelines sets out to develop more than 'management' structure and processes. As such, the Lessons Learned guidelines include:
The objectives of the >>your organisation << Lessons Learned programme, ensuring these objectives remain in line with >>your organisation << requirements over time, as set out against criteria for a High-Reliability System.
Setting out roles and responsibilities for Lessons Learned-related tasks [e.g. Intranet Site Owners (ISO) and Authors (ISA)].
The establishment, monitoring and reporting of Lessons Learned content standards, processes and practice, against impact and results, while not defining parameters for these controls [information on these parameters, while not in this document can be found where <transparency>?].
Outlining implications for non-conformance to Lessons Learned standards.
Rapidly improving the use and usability of the Lessons Learned on a continuous basis (e.g. working with the Intranet team to improve the time required to locate documents – getting the right information, to the person who needs it, at the time they need it most).
3. Lessons Learned Objectives
Lessons Learned is a key tool in enabling >>your organisation << to achieve the aspiration of becoming a High-Reliability System (see Section 11).
Lessons Learned also assists the system in achieving the following objectives:
Ensuring all staff have the support tools to achieve their objectives (Safety, Time, Innovation, Quality, Cost and Experience (quality of patient care and quality of patient experience) efficiently and effectively.
Allowing more precisely targeted and relevant changes to processes, structures and behaviours across the system.
Enabling all staff to clearly demonstrate their contribution to the development of >>your organisation << as a High-Reliability System.
Allowing all staff to understand and identify their contribution to the success and ongoing performance of >>your organisation << as a High-Reliability System.
Demonstrating impact and results of staff contribution against key high-reliability indicators of safety, time, innovation, quality, cost and experience (quality of patient care and quality of patient experience) across the >>your organisation << System.
Providing structure, process and behaviours that have a demonstrable impact on safety, time, innovation, quality, cost and experience (quality of patient care and quality of patient experience) across the >>your organisation << System (e.g. by ensuring that Lessons Learned content across the system can be found, understood and actioned on demand).
4. The Governance Model
5. Ownership and Management
6. [Your organisation] Lessons Learned Management
7. [Your organisation]: Roles and Responsibilities
e.g. 7.5 Lessons Learned Auditor
Intranet Auditors are responsible for:
Communicating performance (capability/audit) data and reports, including lessons learned and actions taken, directly to Lessons Learned Manager(s).
Auditing Site Author content against a published schedule, ensuring content meets Lessons Learned standards and good practice guidelines (e.g. see Section 8).
Proactively soliciting feedback from site users, Content Authors and Site Owners to inform improvements to good practice guidelines and the technical performance of Lessons Learned.
Ensuring all available style and content guidelines have been published and applied to the Lessons Learned content (see Section 8).
Publishing and communicating feedback on performance to Site Owners and Content Authors, once it has been analysed and approved by the Lessons Learned Manager(s).
Providing rapid feedback to Lessons Learned Operations (copying the Site Owner), relating to any negative author or user experience (e.g. technical issues or a need to modify good practice guidelines).
Providing on-time responses to requests for data and feedback from Lessons Learned Manager(s) and Lessons Learned Operations.
Attending training, as requested by Lessons Learned Operations or Lessons Learned Manager(s).
8. Authoring and Auditing Lessons Learned Content
e.g. 8.11 Good Practice Compliance Alerts
Compliance with the commonly agreed Lessons Learned Governance Guidelines directly informs >>your organisation << ability to act as a High-Reliability System. The following sets out the process for compliance alerts, where a failure to act can critically impact Safety, Time, Innovation, Quality, Cost and Experience (quality of patient care and quality of patient experience within the >>your organisation << System.
Example of Knowledge Management Governance Alerts table
9. Lessons LearnedRoles and Responsibilities Matrix
R = Responsible for the activity.
A = Accountable for the activity.
C = Consulted as part of the activity.
I = Informed that the activity is taking place or informed of the results of the activity.
e.g. Table x: Lessons Learned RACI Matrix lists each of the major intranet related activities and, for each activity, whether a specified role is:
Example of a Knowledge Management Governance RACI Table
LS = Lessons Learned Sponsor KM=KM Committee
LM = Lessons Learned Manager(s) IT = IT Operations
AU = Auditor SO = Lessons Learned Site Owner
CA = Lessons Learned Author
10. Help and Assistance (Contact Details)
11. High-Reliability System Characteristics
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