Learning and Morbidity & Mortality

I have been watching a hospital type show.  That show demonstrated something called a Morbidity and Mortality (M&M) Conference and it occurred to me that some adaptation of this approach would help organizations to bring the learning from the work to the entire company.

Learning and Conventional Projects

We have written considerable on the learning organization and how to distribute what is learned throughout the organization.  Writing down lessons learned in books, as conventional project management describes, is only so successful.  Recovery of those lesson gems can be difficult requiring somebody to read a multitude of lessons that do not apply before stumbling on that piece of jade or diamond that may help.  We can make this easier if we have digitized our lessons learned book.  However, we really still have the same problem even if we make use of metadata and tags to help the search.

Learning and Agile

The agile approach to lessons learned is a bit more intimate.  Rather than documenting our learning into a book, we opt to work through the learning together in the retrospective.  This allows all team members to contribute, discover and learn from the variety of perspectives and bits of information and knowledge within the individual team members.  Part of the problem is the amount of time spent using this approach, as in rather little, and some lessons are not so quickly learned.  Sometimes we have to determine what to measure, how to measure then analyze the results.  This can take more time than that allocated during retrospectives.  Additionally, what is learned really goes no farther than the team, scrum master, and perhaps the product owner. This does not distribute the lessons learned throughout the organization.

What we can learn from M&M

Now we come back to the medical approach of Morbidity and Mortality Conference.  In this event, as described in the link, includes more than just the immediate team, but also is not focused entirely on researching the problem and propagation via written work.  We have the entire team, and it is often presented not by the most senior personnel.  This gives the newer members of the team to present the material and field questions.  Doesn’t this quote from the article demonstrate what we really want from our organization?[1]

The idea is that the discussion informs the whole department, and everyone does not have to make the same mistake. In theory, the complication might be averted the next time.

Summary

We think perhaps the best solution is not to short cut the time with people by relying entirely on the written word that is cumbersome to search.  We also submit, improving one agile team is interesting, but the entire organization learning from these events, now that represents a larger scale of improvement.  We also believe that more time really understanding the failure is often required than what is often allocated in agile