Incident Reviews for a Learning Organisation
We all aspire to have a culture of learning and continuous improvement in our teams and organisations but learning and improving when things go wrong is far from easy.
When dealing with the fallout from failure - Incident reviews, Incident reports, investigations etc. - the way in which we respond to is a crucial to improving safety and the performance of our organisations.
Andy will talk about how Major Incident Reviews are run in IT Operations at Auto Trader. He’ll discuss what works well for them and will bring together practical advice from industry experts for creating a culture of safety and learning. Andy will also cover what mistakes they’ve made, what to avoid and the factors that can prevent learning.
Pre-mortems are a process that help you proactively visualise, identify and mitigate project risk.
This deck sets out how and when to conduct a pre-mortem, and provide an example.
XD 2020: Jonathan Lovatt-Young, Love ExperienceUX STRAT
Ssssshhhh. Mental Health. Say it quietly. We all have mental health, and it continually fluctuates. The great digital transformation supertanker seemed to have sailed past healthcare, causing a real disconnect from our needs to a range of available services. Over the course of a year, Jonathan led a consortium incorporating MIND and the NHS in Bradford to discover what was needed. If you’re interested in the next great age – the age of responsibility, and wanted to know how designers actually create the strategy for a Machine Learning Engine, come get stuck in the weeds of doing, not talking.
So software development has been broken for a long time due to the need to create a formal approach, however the approach that has generally been adopted didn't work and has never worked, but at least the people at the top had a modicum of control which created the illusion that everything was working fine.
So in conclusion, software development has been around for a relatively long time and due to that there are a hundred and one ways of doing apparently the same thing, creating software. However compared to the sciences, software development isn't yet out of its teens and as such there really isn't an empirical evidenced based approach to software testing.
So we just have to fumble along with the knowledge that we currently have and continue to improve.
The document discusses the "Henyo Model", which promotes open sharing of knowledge and solutions to problems. It argues that restricting access to information in the past slowed innovation in the Philippines. But now with greater online access to concepts and learning, people called "millennials" have benefited from a mix of new knowledge and technologies that make learning easier and faster. The model proposes a six step process for "self optimization" involving awareness, learning acceleration tools, applying them, sharing solutions, improving solutions, and creating revolution. It provides an example of using this process to address issues at a call center like long call handling times and low customer satisfaction scores. The model aims to draw on diversity and sharing of ideas to find solutions and make the
This webinar session discusses new approaches to volunteer recruitment. It covers fundamental principles of volunteer recruitment, such as ensuring volunteers have meaningful work and tailoring recruitment to specific roles. It outlines a seven step process for successful recruitment, including identifying reasons people do and do not volunteer, considering trends, designing attractive assignments, brainstorming candidate sources, and matching techniques to audiences. The presentation emphasizes adapting recruitment approaches and eliminating vocabulary that may repel volunteers.
Organizations, regardless of size or maturity, will always run into IT related incidents. The trick, however, is to ensure that these incidents cause the least amount of downtime as possible for the customer while avoiding turning into a bigger, company-wide problem.
Join Adam O’Brien, Product Marketing Manager for SunView Software, as he examines the basics of ITSM incidents and problems and covers 3 critical strategies that your organization can implement to help minimize the impact that incidents and problems can have on your customers and company
kamyabology presentations are rich with practical, real life examples and lessons which provide insights and learning’s in an interesting manner by making use of scriptures ,movies, famous personalities etc.
ILO Achievement Communicator How you are demonstrating you.docxwilcockiris
ILO Achievement: Communicator
How you are demonstrating your growth as a Communicator?
There are six aspects of the reflection: Description; Feelings; Evaluation; Analysis; Conclusion; Action Plan.
Description - What happened?
Describe in detail the event you are reflecting on. Include e.g. where were you; who else was there; why
were you there; what were you doing; what were other people doing; what was the context of the event;
what happened; what was your part in this; what parts did the other people play; what was the result?
Feelings - What were you thinking and feeling?
At this stage, try to recall and explore those things that were going on inside your head. Include:
How you were feeling when the event started?
What you were thinking about at the time?
How did it make you feel?
How did other people make you feel?
How did you feel about the outcome of the event?
What do you think about it now?
Evaluation - What was good and bad about the experience?
Try to evaluate or make a judgement about what has happened. Consider what was good about the
experience and what was bad about the experience or what did or didn’t go so well?
Analysis - What sense can you make of the situation?
Break the event down into its component parts so they can be explored separately. You may need to ask
more detailed questions about the answers to the last stage. Include:
What went well?
What did you do well?
What did others do well?
What went wrong or did not turn out how it should have done?
In what way did you or others contribute to this?
Conclusion - What else could you have done?
This differs from the evaluation stage in that now you have explored the issue from different angles and
have a lot of information to base your judgement. It is here that you are likely to develop insight into you
own and other people’s behaviour in terms of how they contributed to the outcome of the event. Remember
the purpose of reflection is to learn from an experience. Without detailed analysis and honest exploration
that occurs during all the previous stages, it is unlikely that all aspects of the event will be taken into
account and therefore valuable opportunities for learning can be missed. During this stage you should ask
yourself what you could have done differently.
Action Plan - If it arose again what would you do?
During this stage you should think yourself forward into encountering the event again and to plan what you
would do - would you act differently or would you be likely to do the same? Here the cycle is tentatively
completed and suggests that should the event occur again it will be the focus of another reflective cycle.
Reflection Mechanics
Your reflection must:
be between 200 and 400 words;
follow spelling and grammar conventions.
ILO Achievement: Communicator
If you need a refresher, here is Mohawk College's definition of Communicator:
"A communicator will communicate effectiv.
Pre-mortems are a process that help you proactively visualise, identify and mitigate project risk.
This deck sets out how and when to conduct a pre-mortem, and provide an example.
XD 2020: Jonathan Lovatt-Young, Love ExperienceUX STRAT
Ssssshhhh. Mental Health. Say it quietly. We all have mental health, and it continually fluctuates. The great digital transformation supertanker seemed to have sailed past healthcare, causing a real disconnect from our needs to a range of available services. Over the course of a year, Jonathan led a consortium incorporating MIND and the NHS in Bradford to discover what was needed. If you’re interested in the next great age – the age of responsibility, and wanted to know how designers actually create the strategy for a Machine Learning Engine, come get stuck in the weeds of doing, not talking.
So software development has been broken for a long time due to the need to create a formal approach, however the approach that has generally been adopted didn't work and has never worked, but at least the people at the top had a modicum of control which created the illusion that everything was working fine.
So in conclusion, software development has been around for a relatively long time and due to that there are a hundred and one ways of doing apparently the same thing, creating software. However compared to the sciences, software development isn't yet out of its teens and as such there really isn't an empirical evidenced based approach to software testing.
So we just have to fumble along with the knowledge that we currently have and continue to improve.
The document discusses the "Henyo Model", which promotes open sharing of knowledge and solutions to problems. It argues that restricting access to information in the past slowed innovation in the Philippines. But now with greater online access to concepts and learning, people called "millennials" have benefited from a mix of new knowledge and technologies that make learning easier and faster. The model proposes a six step process for "self optimization" involving awareness, learning acceleration tools, applying them, sharing solutions, improving solutions, and creating revolution. It provides an example of using this process to address issues at a call center like long call handling times and low customer satisfaction scores. The model aims to draw on diversity and sharing of ideas to find solutions and make the
This webinar session discusses new approaches to volunteer recruitment. It covers fundamental principles of volunteer recruitment, such as ensuring volunteers have meaningful work and tailoring recruitment to specific roles. It outlines a seven step process for successful recruitment, including identifying reasons people do and do not volunteer, considering trends, designing attractive assignments, brainstorming candidate sources, and matching techniques to audiences. The presentation emphasizes adapting recruitment approaches and eliminating vocabulary that may repel volunteers.
Organizations, regardless of size or maturity, will always run into IT related incidents. The trick, however, is to ensure that these incidents cause the least amount of downtime as possible for the customer while avoiding turning into a bigger, company-wide problem.
Join Adam O’Brien, Product Marketing Manager for SunView Software, as he examines the basics of ITSM incidents and problems and covers 3 critical strategies that your organization can implement to help minimize the impact that incidents and problems can have on your customers and company
kamyabology presentations are rich with practical, real life examples and lessons which provide insights and learning’s in an interesting manner by making use of scriptures ,movies, famous personalities etc.
ILO Achievement Communicator How you are demonstrating you.docxwilcockiris
ILO Achievement: Communicator
How you are demonstrating your growth as a Communicator?
There are six aspects of the reflection: Description; Feelings; Evaluation; Analysis; Conclusion; Action Plan.
Description - What happened?
Describe in detail the event you are reflecting on. Include e.g. where were you; who else was there; why
were you there; what were you doing; what were other people doing; what was the context of the event;
what happened; what was your part in this; what parts did the other people play; what was the result?
Feelings - What were you thinking and feeling?
At this stage, try to recall and explore those things that were going on inside your head. Include:
How you were feeling when the event started?
What you were thinking about at the time?
How did it make you feel?
How did other people make you feel?
How did you feel about the outcome of the event?
What do you think about it now?
Evaluation - What was good and bad about the experience?
Try to evaluate or make a judgement about what has happened. Consider what was good about the
experience and what was bad about the experience or what did or didn’t go so well?
Analysis - What sense can you make of the situation?
Break the event down into its component parts so they can be explored separately. You may need to ask
more detailed questions about the answers to the last stage. Include:
What went well?
What did you do well?
What did others do well?
What went wrong or did not turn out how it should have done?
In what way did you or others contribute to this?
Conclusion - What else could you have done?
This differs from the evaluation stage in that now you have explored the issue from different angles and
have a lot of information to base your judgement. It is here that you are likely to develop insight into you
own and other people’s behaviour in terms of how they contributed to the outcome of the event. Remember
the purpose of reflection is to learn from an experience. Without detailed analysis and honest exploration
that occurs during all the previous stages, it is unlikely that all aspects of the event will be taken into
account and therefore valuable opportunities for learning can be missed. During this stage you should ask
yourself what you could have done differently.
Action Plan - If it arose again what would you do?
During this stage you should think yourself forward into encountering the event again and to plan what you
would do - would you act differently or would you be likely to do the same? Here the cycle is tentatively
completed and suggests that should the event occur again it will be the focus of another reflective cycle.
Reflection Mechanics
Your reflection must:
be between 200 and 400 words;
follow spelling and grammar conventions.
ILO Achievement: Communicator
If you need a refresher, here is Mohawk College's definition of Communicator:
"A communicator will communicate effectiv.
Musst masterclass instantly increased influence hand outPower2Improve
The document provides tips and strategies for influencing people effectively. It discusses determining what you want from an interaction and what the other person wants to give them what they really want while achieving your own goals. It also addresses dealing with resistance, focusing on understanding motivations and asking the right questions. The document emphasizes using an appreciative approach, building relationships, and focusing on positivity to influence outcomes.
Collaborative Research The Conference by Media Evolution MalmöErika Hall
The document discusses collaborative research and user research methods. It provides an overview of stakeholder interviews, competitive analysis, usability testing, analyzing research findings, and creating models and reports. The key goals are to form good research questions, gather and analyze qualitative data, and create a shared understanding to inform decisions.
The calm before the storm: Action steps in SoMe crisis managementKomfo
Do you want to improve the way you engage with your customers on social and prevent shitstorms from setting off? Join this webinar with Nana Dall (Conflict Resolution Advisor) and Katrine Thielke (Digital Advisor) to discover an innovative method for handling criticism and conflicts in the social media ecosystem better. Find out how The Danish Railway manages a social media crisis before going viral through actionable steps.
Key takeaways:
- Strategic advice on crisis management in the social media ecosystem
- Insights on crisis communication practices in the digital space: learn how to improve communication with customers and handle customer complaints better
- Key action steps in crisis management and conflict resolution based on key brand cases
"From Insights to Action" by Andrew Vincent, a Revelation Great Research Thin...Revelation Next
The document summarizes a webinar on maximizing the impact of research insights. It discusses establishing credibility with clients, understanding their needs and communication styles, and focusing insights by understanding the client's culture and priorities. Effective communication requires both "push" skills like assertiveness and feedback, as well as "pull" skills like active listening, rapport building, and questioning assumptions.
Crisis Communications Webinar - June 10Ted Skinner
Staying Ahead of the Game: The Steps to Effective Crisis Communications Planning
Don't wait for a crisis to hit before considering your communications strategy. Getting caught off guard can mean the difference between success and failure, especially if your competitors are quick to respond. Take action today to ensure tomorrow's stability.
> Planning for crisis incidents and overcoming resistance
> Engaging in rapid response
> Putting crisis plans into action
> The role of social media in a crisis
Moderator: Ted Skinner, Vice President, Public Relations Products, PR Newswire
Panelists:
Anne Sceia Klein, APR, Fellow PRSA, President, Anne Klein Communications Group, LLC
Irv Lipp, Principal, LippService LLC
David Weiner, Senior Account Manager, PR Newswire
This document provides guidance for a team to establish roles, responsibilities, and ground rules for working together on a project. It prompts the team to reflect on their strengths and weaknesses, pick an idea to pursue, define roles and responsibilities, establish structural and behavioral ground rules, determine how much loss they are willing to accept, and articulate shared visions for their company culture and goals. The overall purpose is to help the team have productive discussions to organize their work and set expectations for collaborating effectively.
The document discusses various organizational diagnosis and change models including McKinsey 7S model, Weisbord 6-box model, and systems theory. It also discusses the reflective learning model and how it is used in organizational diagnosis and change processes. Traditional problem-solving approaches are contrasted with solution-focused approaches like appreciative inquiry.
User Experience Doesn’t Happen on a Screen - It Happens in the Mind. Introduc...UXPA International
User experience happens in the mind, not on a screen. The document discusses an approach to understanding user experience called the "Six Minds" which are the vision/attention, wayfinding, memory, language, emotion, and decision making aspects of how users think. It describes methods like eye tracking, interviews, and observation to understand each of these areas and gain insights into the user's experience. The real-world application section then shows how these insights can be used throughout an emergent design process to develop validated prototypes that meet user needs.
This document summarizes a workshop delivered by Dr. Pratik P. Surana, founder and chief mentor of Quantum, India. It provides details about Dr. Surana's qualifications and experience in training and coaching. It also gives an overview of Quantum, including its clients, services offered, and geographic presence. The workshop discusses concepts of accountability and taking ownership of one's work or "job." It emphasizes developing a mindset of owning rather than renting one's job to increase motivation and responsibility.
20100811 jwv dommel valley group workshopDommelValley
This document discusses facilitating informal learning in the workplace. It begins by asking why informal learning is needed given trends like newer, more complex equipment and a decreasing experienced workforce. It then discusses assessing reality through questions about equipment, technologies, information access, and learner expectations. The rest of the document focuses on adapting a teaching approach to incorporate both formal and informal learning methods like case studies, discussions and learner participation. It emphasizes the facilitator role in creating an engaging environment, managing group dynamics, and ensuring the group feels ownership over the learning process.
This presentation provides an introduction to planning a small-scale project evaluation. It's aimed at small organisations, charities, purposeful businesses.
Every decision we make is one made on behalf of your user. How do we know the decisions we make are the right ones? It is time we initiate a conversation: About where we are and where we want to go, about how we define and measure goodness and rightness in the digital realm, about responsibility, about decisions and consequences, about building something bigger than our own apps. It is time we talk about the ethics of web design. This talk introduces a method for ethical decision making in web design and tech. Rather than a wet moralistic blanket covering the fires of creativity, ethics can be the hearth that makes our creative fires burn brighter without burning down the house.
Presented at WordCamp Europe 2018: https://2018.europe.wordcamp.org/session/the-ethics-of-web-design/
Marketing vs. IT - Let the Battle BeginConnect2AMC
Marketing and IT teams at associations often have tensions that arise from differing priorities, languages, and work processes. However, both groups are charged with being creative problem-solvers who are driving revenue and operations. To reconcile tensions:
1) Facilitate dialogue by bringing both groups in early, using visuals to brainstorm, and speaking in each other's languages.
2) Communicate strategy by prioritizing projects based on strategic goals and reviewing priorities together.
3) Solve problems collaboratively by learning each other's roles, challenging each other respectfully, and brainstorming solutions together.
Toolkit for Human Centered Design by Radboudumc REshapeRobin Hooijer
When using Human Centred Design there are many tools available to support the design process. This toolkit contains some of our favourite ones. Not all of these were made by us, check the license for each template at the bottom left corner for more information about the original creator.
For the latest downloadable version check toolkit.reshapecenter.com.
Ces 2013 towards a cdn definition of evaluationCesToronto
The document outlines the process undertaken by a panel to develop a Canadian definition of evaluation. It describes conducting a literature review, using social media to gather perspectives, and attempting a survey, each of which provided insights but also challenges. The panel encountered unclear and varied definitions, difficulty accessing intended users, and unanticipated issues with surveys. They invite audience input on next steps. The goal is an inclusive definition that represents diverse views while building consensus around Canadian evaluation.
This document outlines the agenda and topics that will be covered in a business seminar on developing a company mission and purpose, and expanding business operations globally. The seminar will first address determining the purpose of the organization and communicating it to stakeholders. Participants will then evaluate strategic choices for expanding the company internationally, considering factors such as country selection, challenges, and overcoming barriers. Key learning outcomes include describing the company's mission and vision, developing a plan to communicate it, evaluating decisions for global expansion, and identifying challenges of going global.
The Role of Storytelling in Community and Economic Development
Jolene Schalper, Senior Vice President Business Development, Great Falls Development Authority, Great Falls, MT
This document discusses measuring and maintaining employee engagement. It begins by examining the challenges in defining and measuring engagement, noting that some see it more as a feeling than something strictly quantifiable. It then reviews different engagement surveys and their focuses, such as levels of engagement or key drivers. The document warns that surveys only provide part of the picture and notes other approaches like those from positive psychology. Finally, it discusses measuring the impact of engagement initiatives and using engagement levels over time as a metric to assess success.
Dandelion Hashtable: beyond billion requests per second on a commodity serverAntonios Katsarakis
This slide deck presents DLHT, a concurrent in-memory hashtable. Despite efforts to optimize hashtables, that go as far as sacrificing core functionality, state-of-the-art designs still incur multiple memory accesses per request and block request processing in three cases. First, most hashtables block while waiting for data to be retrieved from memory. Second, open-addressing designs, which represent the current state-of-the-art, either cannot free index slots on deletes or must block all requests to do so. Third, index resizes block every request until all objects are copied to the new index. Defying folklore wisdom, DLHT forgoes open-addressing and adopts a fully-featured and memory-aware closed-addressing design based on bounded cache-line-chaining. This design offers lock-free index operations and deletes that free slots instantly, (2) completes most requests with a single memory access, (3) utilizes software prefetching to hide memory latencies, and (4) employs a novel non-blocking and parallel resizing. In a commodity server and a memory-resident workload, DLHT surpasses 1.6B requests per second and provides 3.5x (12x) the throughput of the state-of-the-art closed-addressing (open-addressing) resizable hashtable on Gets (Deletes).
Musst masterclass instantly increased influence hand outPower2Improve
The document provides tips and strategies for influencing people effectively. It discusses determining what you want from an interaction and what the other person wants to give them what they really want while achieving your own goals. It also addresses dealing with resistance, focusing on understanding motivations and asking the right questions. The document emphasizes using an appreciative approach, building relationships, and focusing on positivity to influence outcomes.
Collaborative Research The Conference by Media Evolution MalmöErika Hall
The document discusses collaborative research and user research methods. It provides an overview of stakeholder interviews, competitive analysis, usability testing, analyzing research findings, and creating models and reports. The key goals are to form good research questions, gather and analyze qualitative data, and create a shared understanding to inform decisions.
The calm before the storm: Action steps in SoMe crisis managementKomfo
Do you want to improve the way you engage with your customers on social and prevent shitstorms from setting off? Join this webinar with Nana Dall (Conflict Resolution Advisor) and Katrine Thielke (Digital Advisor) to discover an innovative method for handling criticism and conflicts in the social media ecosystem better. Find out how The Danish Railway manages a social media crisis before going viral through actionable steps.
Key takeaways:
- Strategic advice on crisis management in the social media ecosystem
- Insights on crisis communication practices in the digital space: learn how to improve communication with customers and handle customer complaints better
- Key action steps in crisis management and conflict resolution based on key brand cases
"From Insights to Action" by Andrew Vincent, a Revelation Great Research Thin...Revelation Next
The document summarizes a webinar on maximizing the impact of research insights. It discusses establishing credibility with clients, understanding their needs and communication styles, and focusing insights by understanding the client's culture and priorities. Effective communication requires both "push" skills like assertiveness and feedback, as well as "pull" skills like active listening, rapport building, and questioning assumptions.
Crisis Communications Webinar - June 10Ted Skinner
Staying Ahead of the Game: The Steps to Effective Crisis Communications Planning
Don't wait for a crisis to hit before considering your communications strategy. Getting caught off guard can mean the difference between success and failure, especially if your competitors are quick to respond. Take action today to ensure tomorrow's stability.
> Planning for crisis incidents and overcoming resistance
> Engaging in rapid response
> Putting crisis plans into action
> The role of social media in a crisis
Moderator: Ted Skinner, Vice President, Public Relations Products, PR Newswire
Panelists:
Anne Sceia Klein, APR, Fellow PRSA, President, Anne Klein Communications Group, LLC
Irv Lipp, Principal, LippService LLC
David Weiner, Senior Account Manager, PR Newswire
This document provides guidance for a team to establish roles, responsibilities, and ground rules for working together on a project. It prompts the team to reflect on their strengths and weaknesses, pick an idea to pursue, define roles and responsibilities, establish structural and behavioral ground rules, determine how much loss they are willing to accept, and articulate shared visions for their company culture and goals. The overall purpose is to help the team have productive discussions to organize their work and set expectations for collaborating effectively.
The document discusses various organizational diagnosis and change models including McKinsey 7S model, Weisbord 6-box model, and systems theory. It also discusses the reflective learning model and how it is used in organizational diagnosis and change processes. Traditional problem-solving approaches are contrasted with solution-focused approaches like appreciative inquiry.
User Experience Doesn’t Happen on a Screen - It Happens in the Mind. Introduc...UXPA International
User experience happens in the mind, not on a screen. The document discusses an approach to understanding user experience called the "Six Minds" which are the vision/attention, wayfinding, memory, language, emotion, and decision making aspects of how users think. It describes methods like eye tracking, interviews, and observation to understand each of these areas and gain insights into the user's experience. The real-world application section then shows how these insights can be used throughout an emergent design process to develop validated prototypes that meet user needs.
This document summarizes a workshop delivered by Dr. Pratik P. Surana, founder and chief mentor of Quantum, India. It provides details about Dr. Surana's qualifications and experience in training and coaching. It also gives an overview of Quantum, including its clients, services offered, and geographic presence. The workshop discusses concepts of accountability and taking ownership of one's work or "job." It emphasizes developing a mindset of owning rather than renting one's job to increase motivation and responsibility.
20100811 jwv dommel valley group workshopDommelValley
This document discusses facilitating informal learning in the workplace. It begins by asking why informal learning is needed given trends like newer, more complex equipment and a decreasing experienced workforce. It then discusses assessing reality through questions about equipment, technologies, information access, and learner expectations. The rest of the document focuses on adapting a teaching approach to incorporate both formal and informal learning methods like case studies, discussions and learner participation. It emphasizes the facilitator role in creating an engaging environment, managing group dynamics, and ensuring the group feels ownership over the learning process.
This presentation provides an introduction to planning a small-scale project evaluation. It's aimed at small organisations, charities, purposeful businesses.
Every decision we make is one made on behalf of your user. How do we know the decisions we make are the right ones? It is time we initiate a conversation: About where we are and where we want to go, about how we define and measure goodness and rightness in the digital realm, about responsibility, about decisions and consequences, about building something bigger than our own apps. It is time we talk about the ethics of web design. This talk introduces a method for ethical decision making in web design and tech. Rather than a wet moralistic blanket covering the fires of creativity, ethics can be the hearth that makes our creative fires burn brighter without burning down the house.
Presented at WordCamp Europe 2018: https://2018.europe.wordcamp.org/session/the-ethics-of-web-design/
Marketing vs. IT - Let the Battle BeginConnect2AMC
Marketing and IT teams at associations often have tensions that arise from differing priorities, languages, and work processes. However, both groups are charged with being creative problem-solvers who are driving revenue and operations. To reconcile tensions:
1) Facilitate dialogue by bringing both groups in early, using visuals to brainstorm, and speaking in each other's languages.
2) Communicate strategy by prioritizing projects based on strategic goals and reviewing priorities together.
3) Solve problems collaboratively by learning each other's roles, challenging each other respectfully, and brainstorming solutions together.
Toolkit for Human Centered Design by Radboudumc REshapeRobin Hooijer
When using Human Centred Design there are many tools available to support the design process. This toolkit contains some of our favourite ones. Not all of these were made by us, check the license for each template at the bottom left corner for more information about the original creator.
For the latest downloadable version check toolkit.reshapecenter.com.
Ces 2013 towards a cdn definition of evaluationCesToronto
The document outlines the process undertaken by a panel to develop a Canadian definition of evaluation. It describes conducting a literature review, using social media to gather perspectives, and attempting a survey, each of which provided insights but also challenges. The panel encountered unclear and varied definitions, difficulty accessing intended users, and unanticipated issues with surveys. They invite audience input on next steps. The goal is an inclusive definition that represents diverse views while building consensus around Canadian evaluation.
This document outlines the agenda and topics that will be covered in a business seminar on developing a company mission and purpose, and expanding business operations globally. The seminar will first address determining the purpose of the organization and communicating it to stakeholders. Participants will then evaluate strategic choices for expanding the company internationally, considering factors such as country selection, challenges, and overcoming barriers. Key learning outcomes include describing the company's mission and vision, developing a plan to communicate it, evaluating decisions for global expansion, and identifying challenges of going global.
The Role of Storytelling in Community and Economic Development
Jolene Schalper, Senior Vice President Business Development, Great Falls Development Authority, Great Falls, MT
This document discusses measuring and maintaining employee engagement. It begins by examining the challenges in defining and measuring engagement, noting that some see it more as a feeling than something strictly quantifiable. It then reviews different engagement surveys and their focuses, such as levels of engagement or key drivers. The document warns that surveys only provide part of the picture and notes other approaches like those from positive psychology. Finally, it discusses measuring the impact of engagement initiatives and using engagement levels over time as a metric to assess success.
Similar to Learning From Incidents at Autotrader (20)
Dandelion Hashtable: beyond billion requests per second on a commodity serverAntonios Katsarakis
This slide deck presents DLHT, a concurrent in-memory hashtable. Despite efforts to optimize hashtables, that go as far as sacrificing core functionality, state-of-the-art designs still incur multiple memory accesses per request and block request processing in three cases. First, most hashtables block while waiting for data to be retrieved from memory. Second, open-addressing designs, which represent the current state-of-the-art, either cannot free index slots on deletes or must block all requests to do so. Third, index resizes block every request until all objects are copied to the new index. Defying folklore wisdom, DLHT forgoes open-addressing and adopts a fully-featured and memory-aware closed-addressing design based on bounded cache-line-chaining. This design offers lock-free index operations and deletes that free slots instantly, (2) completes most requests with a single memory access, (3) utilizes software prefetching to hide memory latencies, and (4) employs a novel non-blocking and parallel resizing. In a commodity server and a memory-resident workload, DLHT surpasses 1.6B requests per second and provides 3.5x (12x) the throughput of the state-of-the-art closed-addressing (open-addressing) resizable hashtable on Gets (Deletes).
Have you ever been confused by the myriad of choices offered by AWS for hosting a website or an API?
Lambda, Elastic Beanstalk, Lightsail, Amplify, S3 (and more!) can each host websites + APIs. But which one should we choose?
Which one is cheapest? Which one is fastest? Which one will scale to meet our needs?
Join me in this session as we dive into each AWS hosting service to determine which one is best for your scenario and explain why!
Northern Engraving | Modern Metal Trim, Nameplates and Appliance PanelsNorthern Engraving
What began over 115 years ago as a supplier of precision gauges to the automotive industry has evolved into being an industry leader in the manufacture of product branding, automotive cockpit trim and decorative appliance trim. Value-added services include in-house Design, Engineering, Program Management, Test Lab and Tool Shops.
zkStudyClub - LatticeFold: A Lattice-based Folding Scheme and its Application...Alex Pruden
Folding is a recent technique for building efficient recursive SNARKs. Several elegant folding protocols have been proposed, such as Nova, Supernova, Hypernova, Protostar, and others. However, all of them rely on an additively homomorphic commitment scheme based on discrete log, and are therefore not post-quantum secure. In this work we present LatticeFold, the first lattice-based folding protocol based on the Module SIS problem. This folding protocol naturally leads to an efficient recursive lattice-based SNARK and an efficient PCD scheme. LatticeFold supports folding low-degree relations, such as R1CS, as well as high-degree relations, such as CCS. The key challenge is to construct a secure folding protocol that works with the Ajtai commitment scheme. The difficulty, is ensuring that extracted witnesses are low norm through many rounds of folding. We present a novel technique using the sumcheck protocol to ensure that extracted witnesses are always low norm no matter how many rounds of folding are used. Our evaluation of the final proof system suggests that it is as performant as Hypernova, while providing post-quantum security.
Paper Link: https://eprint.iacr.org/2024/257
This talk will cover ScyllaDB Architecture from the cluster-level view and zoom in on data distribution and internal node architecture. In the process, we will learn the secret sauce used to get ScyllaDB's high availability and superior performance. We will also touch on the upcoming changes to ScyllaDB architecture, moving to strongly consistent metadata and tablets.
Skybuffer SAM4U tool for SAP license adoptionTatiana Kojar
Manage and optimize your license adoption and consumption with SAM4U, an SAP free customer software asset management tool.
SAM4U, an SAP complimentary software asset management tool for customers, delivers a detailed and well-structured overview of license inventory and usage with a user-friendly interface. We offer a hosted, cost-effective, and performance-optimized SAM4U setup in the Skybuffer Cloud environment. You retain ownership of the system and data, while we manage the ABAP 7.58 infrastructure, ensuring fixed Total Cost of Ownership (TCO) and exceptional services through the SAP Fiori interface.
Must Know Postgres Extension for DBA and Developer during MigrationMydbops
Mydbops Opensource Database Meetup 16
Topic: Must-Know PostgreSQL Extensions for Developers and DBAs During Migration
Speaker: Deepak Mahto, Founder of DataCloudGaze Consulting
Date & Time: 8th June | 10 AM - 1 PM IST
Venue: Bangalore International Centre, Bangalore
Abstract: Discover how PostgreSQL extensions can be your secret weapon! This talk explores how key extensions enhance database capabilities and streamline the migration process for users moving from other relational databases like Oracle.
Key Takeaways:
* Learn about crucial extensions like oracle_fdw, pgtt, and pg_audit that ease migration complexities.
* Gain valuable strategies for implementing these extensions in PostgreSQL to achieve license freedom.
* Discover how these key extensions can empower both developers and DBAs during the migration process.
* Don't miss this chance to gain practical knowledge from an industry expert and stay updated on the latest open-source database trends.
Mydbops Managed Services specializes in taking the pain out of database management while optimizing performance. Since 2015, we have been providing top-notch support and assistance for the top three open-source databases: MySQL, MongoDB, and PostgreSQL.
Our team offers a wide range of services, including assistance, support, consulting, 24/7 operations, and expertise in all relevant technologies. We help organizations improve their database's performance, scalability, efficiency, and availability.
Contact us: info@mydbops.com
Visit: https://www.mydbops.com/
Follow us on LinkedIn: https://in.linkedin.com/company/mydbops
For more details and updates, please follow up the below links.
Meetup Page : https://www.meetup.com/mydbops-databa...
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Blogs: https://www.mydbops.com/blog/
Facebook(Meta): https://www.facebook.com/mydbops/
Introduction of Cybersecurity with OSS at Code Europe 2024Hiroshi SHIBATA
I develop the Ruby programming language, RubyGems, and Bundler, which are package managers for Ruby. Today, I will introduce how to enhance the security of your application using open-source software (OSS) examples from Ruby and RubyGems.
The first topic is CVE (Common Vulnerabilities and Exposures). I have published CVEs many times. But what exactly is a CVE? I'll provide a basic understanding of CVEs and explain how to detect and handle vulnerabilities in OSS.
Next, let's discuss package managers. Package managers play a critical role in the OSS ecosystem. I'll explain how to manage library dependencies in your application.
I'll share insights into how the Ruby and RubyGems core team works to keep our ecosystem safe. By the end of this talk, you'll have a better understanding of how to safeguard your code.
For the full video of this presentation, please visit: https://www.edge-ai-vision.com/2024/06/temporal-event-neural-networks-a-more-efficient-alternative-to-the-transformer-a-presentation-from-brainchip/
Chris Jones, Director of Product Management at BrainChip , presents the “Temporal Event Neural Networks: A More Efficient Alternative to the Transformer” tutorial at the May 2024 Embedded Vision Summit.
The expansion of AI services necessitates enhanced computational capabilities on edge devices. Temporal Event Neural Networks (TENNs), developed by BrainChip, represent a novel and highly efficient state-space network. TENNs demonstrate exceptional proficiency in handling multi-dimensional streaming data, facilitating advancements in object detection, action recognition, speech enhancement and language model/sequence generation. Through the utilization of polynomial-based continuous convolutions, TENNs streamline models, expedite training processes and significantly diminish memory requirements, achieving notable reductions of up to 50x in parameters and 5,000x in energy consumption compared to prevailing methodologies like transformers.
Integration with BrainChip’s Akida neuromorphic hardware IP further enhances TENNs’ capabilities, enabling the realization of highly capable, portable and passively cooled edge devices. This presentation delves into the technical innovations underlying TENNs, presents real-world benchmarks, and elucidates how this cutting-edge approach is positioned to revolutionize edge AI across diverse applications.
inQuba Webinar Mastering Customer Journey Management with Dr Graham HillLizaNolte
HERE IS YOUR WEBINAR CONTENT! 'Mastering Customer Journey Management with Dr. Graham Hill'. We hope you find the webinar recording both insightful and enjoyable.
In this webinar, we explored essential aspects of Customer Journey Management and personalization. Here’s a summary of the key insights and topics discussed:
Key Takeaways:
Understanding the Customer Journey: Dr. Hill emphasized the importance of mapping and understanding the complete customer journey to identify touchpoints and opportunities for improvement.
Personalization Strategies: We discussed how to leverage data and insights to create personalized experiences that resonate with customers.
Technology Integration: Insights were shared on how inQuba’s advanced technology can streamline customer interactions and drive operational efficiency.
The Microsoft 365 Migration Tutorial For Beginner.pptxoperationspcvita
This presentation will help you understand the power of Microsoft 365. However, we have mentioned every productivity app included in Office 365. Additionally, we have suggested the migration situation related to Office 365 and how we can help you.
You can also read: https://www.systoolsgroup.com/updates/office-365-tenant-to-tenant-migration-step-by-step-complete-guide/
The Department of Veteran Affairs (VA) invited Taylor Paschal, Knowledge & Information Management Consultant at Enterprise Knowledge, to speak at a Knowledge Management Lunch and Learn hosted on June 12, 2024. All Office of Administration staff were invited to attend and received professional development credit for participating in the voluntary event.
The objectives of the Lunch and Learn presentation were to:
- Review what KM ‘is’ and ‘isn’t’
- Understand the value of KM and the benefits of engaging
- Define and reflect on your “what’s in it for me?”
- Share actionable ways you can participate in Knowledge - - Capture & Transfer
Freshworks Rethinks NoSQL for Rapid Scaling & Cost-EfficiencyScyllaDB
Freshworks creates AI-boosted business software that helps employees work more efficiently and effectively. Managing data across multiple RDBMS and NoSQL databases was already a challenge at their current scale. To prepare for 10X growth, they knew it was time to rethink their database strategy. Learn how they architected a solution that would simplify scaling while keeping costs under control.
3. What is a Learning Organisation?
What is the Reality?
What are my Choices?
Incident Reviews - things to Avoid
Incident Reviews - things to Encourage
What about holding people to Account?
A bit on Our process
Learning from Incidents
4. Our People
PRIVATE Car Sellers
Trade Car Dealers
30,000
15,000
Auto Trader Staff
Product & Tech Teams
850
275
Our Customers
5. Our Technology Platform
1.2 billion page views per month
70 million peak page views per day
15 million unique visitors per month
Supported by 100 live applications
6. Further Reading up front
Links:
John Allspaw - The Infinite Hows
Steve Shorrock - if it werent for the people
EuroControl - Systems Thinking for Safety
Lyndsay Holmwood - Blame-Language-Sharing
Sydney Dekker - Just Culture
Black Box Thinking –
Matthew Syed
People:
Steven Shorrock
Erik Hollnagel
Sidney Dekker
Matthew Syed
John Allspaw
Lindsay Holmwood
Dave Zwieback
Nancy Leveson
Field Guide to
Understanding
Human Error –
Sidney Dekker
Beyond Blame –
Dave Zwieback Nancy Leveson -
Engineering a Safer
World
Further Reading up front
31. Don’t go too Deep!
Environment
Capabilities
Behavior
Values and Beliefs
Identity
Contexts – WHERE?
Methods, Approaches – HOW?
Skills and Actions – WHAT?
What is important/true – WHY?
Sense of Self – WHO?
Dilts Model
38. Incident Review Prompts
(from The Field Guide To Understanding Human Error, by Sidney Dekker)
At each juncture in the sequence of events (if that is how you want to structure this part of the accident story), you want to get to
know:
• Which cues were observed (what did he or she notice/see or did not notice what he or she had expected to notice?)
• What knowledge was used to deal with the situation? Did participants have any experience with similar situations that was useful in dealing with this
one?
• What expectations did participants have about how things were going to develop, and what options did they think they have to influence the course
of events?
• How did other influences (operational or organizational) help determine how they interpreted the situation and how they would act?
Here are some questions Gary Klein and his researchers typically ask to find out how the situation looked to people on the inside at each of the critical
junctures:
Debriefings need not follow such a scripted set of questions, of course, as the relevance of questions depends on the event. Also, the questions can come across
to
participants as too conceptual to make any sense. You may need to reformulate them in the language of the domain.
Cues What were you seeing?
What were you focusing on?
What were you expecting to happen?
Interpretation If you had to describe the situation to your colleague at that point, what would you have told?
Errors What mistakes (for example in interpretation) were likely at this point?
Previous
experience/knowledge
Were you reminded of any previous experience?
Did this situation fit a standard scenario?
Were you trained to deal with this situation?
Were there any rules that applied clearly
here?
Did any other sources of knowledge suggest what to do?Goals What were you trying to achieve?
Were there multiple goals at the same time?
Was there time pressure or other limitations on what you could do?
Taking action How did you judge you could influence the course of events?
Did you discuss or mentally imagine a number of options or did you know straight away what to do?
Outcome Did the outcome fit your expectation?
Did you have to update your assessment of the situation?
Communications What communication medium(s) did you prefer to use? (phone, chat, email, video conf,
etc.?) Did you make use of more than one communication channels at once?
Help Did you ask anyone for help?
What signal brought you to ask for support or assistance?
Were you able to contact the people you needed to
contact?
39. Timelines
14:00 Alert
received from
Site confidence
15:15 Incident
communication
sent
16:00 Incident
closure comms
sent
1. Factual timeline entries
can be filled in prior to the
Review Meeting
40. Timelines
14:00 Alert
received from
Site confidence
15:15 Incident
communication
sent
16:00 Incident
closure comms
sent
1. Factual timeline entries
can be filled in prior to the
Review Meeting
13:10 Slow server
performance
observed by BIll
14:20 Bill spoke to John
about SC issues and
decided to recover DB
15:50 John finished DB
recovery
2. As a group,
overlay the basic
timeline with key
decisions and
junctures
51. We understand and truly believe that everyone did
the best job they could, given what they knew at the
time, their skills and abilities, the resources
available, and the situation at hand
We are here to learn and find solutions to improve
our ways of working
Why we are here:
52. Open Minded
Go back in time
No single ‘Root Cause’
How not Why
Things that help us learn
53. • Blaming people
• Human Error
• Arse Covering
• Points scoring
• ‘Trying Harder’
• Talking over people
Things that stop us learning:
54. After the review:
• Incident details recorded
• Actions (owners, dates) recorded
• Owned by Service Management Team
55. Further Reading up front
Links:
John Allspaw - The Infinite Hows
Steve Shorrock - if it werent for the people
EuroControl - Systems Thinking for Safety
Lyndsay Holmwood - Blame-Language-Sharing
Sydney Dekker - Just Culture
Black Box Thinking –
Matthew Syed
People:
Steven Shorrock
Erik Hollnagel
Sidney Dekker
Matthew Syed
John Allspaw
Lindsay Holmwood
Dave Zwieback
Nancy Leveson
Field Guide to
Understanding
Human Error –
Sidney Dekker
Beyond Blame –
Dave Zwieback Nancy Leveson -
Engineering a Safer
World
Further Reading Again
Private Sellers: us selling our Cars
Trade Car Dealers 15,000 - Independent dealers, Franchise dealers, Car Supermarkets
Availability at 99.99%
supporting products for Consumers, Private Sellers and Trade Retailers.
Supporting access across multiple platforms
Supporting Commercial and International Autotrader sites
e.g. Dealer Websites
Automotive leader for dealer websites with just under 5000 dealers’ sites hosted
Peter Senge – 1990 – the Fifth Discipline
Learning and transformation are central functions of the organisation – always changing , never steady state.
A Learning Organisation is a term given to a company that facilitates the learning of its members and continuously transforms itself.
A learning organisation is a place where people are continually discovering how they create their reality.
The loss of the stable state means that our society and all of its institutions are in continuous processes of transformation. We cannot expect new stable states that will endure for our own lifetimes.
We must learn to understand, guide, influence and manage these transformations. We must make the capacity for undertaking them integral to ourselves and to our institutions.
We must, in other words, become adept at learning. We must become able not only to transform our institutions, in response to changing situations and requirements; we must invent and develop institutions which are ‘learning systems’, that is to say, systems capable of bringing about their own continuing transformation. (Schon 1973: 28)
http://infed.org/mobi/the-learning-organization/
A story from Toyota’s origins when it used to build automatic looms. Upon hearing
that the plans for one of the looms had been stolen, Kiichiro Toyoda is said to
have remarked:
Certainly the thieves may be able to follow the design plans and produce
a loom. But we are modifying and improving our looms every
day. So by the time the thieves have produced a loom from the plans
they stole, we will have already advanced well beyond that point. And
because they do not have the expertise gained from the failures it took
to produce the original, they will waste a great deal more time than us
as they move to improve their loom. We need not be concerned about
what happened. We need only continue as always, making our
improvements.
The long-term value of an enterprise is not captured by the value of its products
and intellectual property but rather by its ability to continuously increase
the value it provides to customers—and to create new customers—through
Learning and innovation.
(Lean Enterprise p18)
And we all do this within our organisations right???
ITIL – continuous improvementDeming Cycle – PDCA
OODA
DMAIC – Six sigma lean process improvement
Our attitudes, culture and behavior prevent learning
WHY DO WE DO IT???
Fundamental Attribution Error:
How do we explain the behavior of others
It turns out there is we are biased towards.
Explain the behavior of others due to their personality
Explain our own behavior as a result of context.
We need to overcome this bias to learn from Incidents and other kinds of failure
Image
http://www.ffxiah.com/forum/topic/26676/fundamental-attribution-error
WHY DO WE DO IT???
We assume that
All accidents or incidents require a human mistake
The severity of the accident is proportional to the size of the mistake
Punishment acts as a deterrent to prevent issues happening in the future.
Need for Retributive justice
Punishment
Deterrent
We often diminish the need for restorative justice.
Preventing the issue happening again
WHY DO WE DO IT???
Hindsight BIAS - knew-it-all-along effect
is the inclination, after an event has occurred, to see the event as having been predictable, despite there having been little or no objective basis for predicting it.
Narrative written after the fact
Does not make sense
England football manager Fabio Capello – From Black Box thinking – Matthew Syed.
Came into English football in 2008 – 2012
He introduced a strict regime of diet, rules around lateness, bans for family members from training and tournements
He was pretty successful and lots of commentators put this down to
Retributive vs. Restorative Justice
This table illustrates the differences in the approach to justice between Retributive Justice and Restorative Justice. As you will see, Restorative Justice is much more community centric and focuses on making the victim whole.
Retributive Justice
Restorative Justice
Crime is an act against the state, a violation of a law, an abstract idea
Crime is an act against another person and the community
The criminal justice system controls crime
Crime control lies primarily in the community
Offender accountability defined as taking punishment
Accountability defined as assuming responsibility and taking action to repair harm
Crime is an individual act with individual responsibility
Crime has both individual and social dimensions of responsibility
Punishment is effective:
Threats of punishment deter crime
Punishment changes behavior
Punishment alone is not effective in changing behavior and is disruptive to community harmony and good relationships
Victims are peripheral to the process
Victims are central to the process of resolving a crime.
The offender is defined by deficits
The offender is defined by capacity to make reparation
Focus on establishing blame or guilt, on the past (did he/she do it?)
Focus on the problem solving, on liabilities/obligations, on the future (what should be done?)
Emphasis on adversarial relationship
Emphasis on dialogue and negotiation
Imposition of pain to punish and deter/prevent
Restitution as a means of restoring both parties; goal of reconciliation/restoration
Community on sideline, represented abstractly by state
Community as facilitator in restorative process
Response focused on offender’s past behavior
Response focused on harmful consequences of offender’s behavior; emphasis is on the future
Dependence upon proxy professionals
Direct involvement by participants
WHY DO WE DO IT???
Bad Apple Theory:
Complacency
We assume that systems and procedures are safe and reliable
It’s only a few ‘bad apples’
http://radar.oreilly.com/2014/11/if-it-werent-for-the-people.html
Steve Shorrock
Our view is often that the system is basically safe, so long as the human works as imagined. When things go wrong, we have a seemingly innate human tendency to blame the person at the sharp end. We don’t seem to think of that someone – pilot, controller, train driver or surgeon – as a human being who goes to work to ensure things go right in a messy, complex, demanding and uncertain environment.
Work as imagined
vs
Work as done
We don’t understand.
Trade offs
Completing pressures
Conflicting incentives
Procedures adapted for real world
Blame is easy
It removes accountability from the organisation
We don’t need to consider organizational changes, system changes,
(difficult things)
It removes the need for self criticism
It’s cheap
It’s quick
Miss Universe 2015
Steve Harvey – veteran TV presenter in America
Announced the winner as Columbia and not Miss Phillipines
It’s just one of those things that happen
Human Error
https://www.linkedin.com/pulse/how-bad-design-wrecked-steve-harveys-universe-eric-Thomas
It’s just one of those things that happen
Human Error
Lights,
Sounds
What was on the card?
What was on the teleprompter?
Blame impact:
Fewer issues reported
Culture of fear
Less responsibility taken – safety is someone else’s responsibility to implement.
The wrong data – incorrect accounts
Dishonesty – distortion
Denying error, diminishing the impact
Our attitudes, culture and behavior prevent learning
Often Learnt behavior from Leaders
Will prevent learning
John Allspaw – Blameless Postmortem – Web Operations
We need to find ways to allow practitioners to tell their stories
Without fear that there will be retribution
In a supportive atmosphere where failure is not stigmatized
Where we regularly talk about (celebrate) our mistakes and take ownership of improving things
This cycle of name/blame/shame can be looked at like this:
Engineer takes action and contributes to a failure or incident.
Engineer is punished, shamed, blamed, or retrained.
Reduced trust between engineers on the ground (the “sharp end”) and management (the “blunt end”) looking for someone to scapegoat
Engineers become silent on details about actions/situations/observations, resulting in “Cover-Your-Ass” engineering (from fear of punishment)
Management becomes less aware and informed on how work is being performed day to day, and engineers become less educated on lurking or latent conditions for failure due to silence mentioned in #4, above
Errors more likely, latent conditions can’t be identified due to #5, above
Repeat from step 1
Need a wide range of review attendees taking actions
Trust between engineers taking action (sharp end) and managers (blunt end)
Especially important to share these actions across teams, departments, disciplines
Things to avoid – managers taking no action, or all the actions!
Refer John Allspaw – Inifinte Hows
DILTS Model – logical levels - -levels of learning and change
Useful as a coaching aim
How the language you use can affect the impact and depth to which you get a response.
Asking Who and Why really probe deep through these logical levels
John Allspaw – infinite hows
1. A new release disabled a feature for some customers. WHY? Because a particular server failed
2.
Environment – Contexts
Behavior – Skills and Actions
Capabilities – Methods, Approaches, Strategies
Values and Beliefs – What is important and true
Identity – You sense of self
Why
Asks people to justify their actions
Leads to
Who
No single root causes with any incident involving complex systems (all our incidents)
Cherry picking of data to prove pre-existing ideas about what happened.
WHAT YOU FIND IS WHAT YOU LOOK FOR
Points scoring: It’s easy to use examples of when things go wrong to prove a point or win battles with others. This is generally cherry picking of information and unhelpful to us as an organisation. If unchallenged it will lead to more defensiveness, hiding/manipulation of data etc.
Our attitudes, culture and behavior prevent learning
Good psychological effect
States what’s expected
Frames the conversation
Example from Matthew Syed again – priming experiment and walking the corridor
Good example – Agile Prime Directive
"Regardless of what we discover, we understand and truly believe that everyone did the best job they could, given what they knew at the time, their skills and abilities, the resources available, and the situation at hand."
Open Minded
Everyone is expected to come to an incident review keen to learn new information and listen to the experiences and stories of their colleagues. It’s not acceptable to bring your pre-formulated, rigid ideas of what happened/causes/solutions.
Explore differences of opinion
Listen to peoples stories of how events unfolded
Focus on Going back in Time
Understand the nature of the events AS THEY UNFOLDED over time
Are we talking about ordinary routine work
Special event?
Something never seen before?
Consider the predictability of the even at the time.
what was known at the time.
Go back in time
What information was available to you at this point?
What cues, what alerts, what information was available
What other pressures did you have
Time pressure, multiple focusses
Actual vs Ideal
Timeline should probably be created by the people attending the incident review, but we’ve amended so that a ‘factual’ bare bones of the time line is pre-populated by the Incident owner prior to the meeting to save time.
Some facts can be added to the timeline before the meeting to save time – Duty Manager can collate this data from Chat, Logs, Emails etc.
When adding information as a group about decisions made , explore the differences between peoples perception of what happened
Be careful not to get trapped into ‘single root cause’ and listen to as many contributing factors as possible.
Actual vs Ideal
Some facts can be added to the timeline before the meeting to save time – Duty Manager can collate this data from Chat, Logs, Emails etc.
When adding information as a group about decisions made , explore the differences between peoples perception of what happened
Be careful not to get trapped into ‘single root cause’ and listen to as many contributing factors as possible.
Ensure everyone gets a chance to speak and be listened to by everyone
Need to keep the whole room to one conversation.
Actions shared, visible, completed
Don’t always have to have an action!
It might be that understanding how colleagues dealt with the incident and learning more about normal working of your organisation is enough.
Are you the right person to run the incident review ??
Are you seen as impartial??
I’ve done this !!! Give example of not doing this right.
Are you the right person to lead this Review?
Are you independent
Are you independent enough to be fair and impartial?
And be seen by others as such?
Celebrate the things that went well
(timeline shows how well response unfolded, can report on how well people worked together)
Not just pat on back
Analyse the things that worked well – good decisions that prevented more downtime, how people adapted what they knew to a new situation
How can the good patterns be replicated or enhanced even further?
If you truly understand what went well and HOW it went well – you can re-produce this is more situations.
Retrospectives
Reviews
If you only review the most serious of incidents – you will not get the atmosphere right, people will not be used to it
People will be defensive
So this is all great, but what about when people need to be held responsible for their actions?
Good PDF
http://www.saa.com.sg/saaWeb2011/export/sites/saa/en/Publication/downloads/JustCulture_ReportingtheLine_Accountability.pdf
Negligence (turning up to work drunk)
Malicious damage (intentionally trying to harm people or the organisation)
Incompetence (Making stupid mistakes, not following clear procedures)
Gross Misconduct
e.g.
Defined in a nursing malpractice situation, negligence means the following: The doing of something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do, under circumstances similar to those shown by the evidence.
http://ccn.aacnjournals.org/content/23/5/72.full
http://www.saa.com.sg/saaWeb2011/export/sites/saa/en/Publication/downloads/JustCulture_ReportingtheLine_Accountability.pdf
Accountability is often interpreted as blaming practitioners for mistakes. This creates a conflict between learning and accountability.
This paper proposes three simultaneous directions to achieve a Just Culture:
not using incident reports as evidence for disciplinary action,
deciding and getting broad support for who gets to decide what is acceptable and unacceptable behaviour
switching from blame and backward-looking accountability to forward-looking accountability.
We have an poor view of accountability
BLAME does not equal accountability
Blame has a massive cost
Blame limits accountability
We need to encourage forward-accountability
not using incident reports as evidence for disciplinary action, b)
deciding and getting broad support for who gets to decide what is acceptable and unacceptable behaviour and
c) switching from blame and backward-looking accountability to forward-looking accountability
Cost:
The fear of blame, sanction and punishment, however, is known to change the behaviour of practitioners. They might be induced to hide, downplay or redefine incidents, rather than reporting and sharing them (Merry & Smith, 2001), creating a culture of ‘risk secrecy.’ The possibility of disciplinary action (or worse, prosecution) creates a conflict between accountability and learning. Blame is known as the enemy of safety (Leveson, 2011).
Forward-looking accountability needs an environment which encourages sharing accounts and takes away the idea of blame
All Major Incidents and High Severity Incidents have a review
All failed large changes have a review (including things that should have been large)
All failed Releases have a review
We use a similar format for Team / Project retrospectives - certainly in atmosphere
All Major Incidents and High Severity Incidnets have a review
All failed large changes have a review (including things that should have been large)
All failed Releases have a review
We use a similar format for Team / Project retrospectives - certainly in atmosphere
Timeline written on wall
Paper prompts at the top are the ‘priming’ bit and read out at the start of the meeting
They are also emailed with the Incident Review invite.
We use a similar format for Team / Project retrospectives - certainly in atmosphere
State what we are here for:
State our approach:
A note from Martin Fowler on PRIMING
http://martinfowler.com/bliki/PrimingPrimeDirective.html
Open Minded
Everyone is expected to come to an incident review keen to learn new information and listen to the experiences and stories of their colleagues. It’s not acceptable to bring your pre-formulated, rigid ideas of what happened/causes/solutions.
Go back in time
It’s critical we avoid using HINDSIGHT – we need to understand what information was available at the time when decisions were made and actions were performed. Best way to do this is put yourself back in time – into the context of how things unfolded.
No single ‘Root Cause’
In complex systems (of people interacting with technology) there is never a single root cause. We often have many contributing factors to how events unfold – lots of those contributing factors are present all the time even when things go right. Stopping at one root cause will miss all this information.
How not Why
Questions that start WHY (or even worse WHO) tend to force people to justify actions, to attribute and apportion blame. WHY focuses the inquiry on people which is not what we want.
We want to gather information about how events unfolded – asking HOW thinks appeared, changed, worked, WHAT happened next, WHAT was expected. Questions around HOW, WHAT, WHEN are much more effective for this.
Blaming people: It’s a popular belief that we have basically safe systems and if you just sorted out the behaviour of a few ‘bad apples’ things would be OK. That’s not the way to improve safety and is generally a cop-out. Please see Agile Prime Directive for what we do believe.
Human Error: As above, we are all on the same side trying to do the best job we can. Everyone has variable performance and we need systems/processes etc that are better able to accommodate and expect that.
Arse Covering: Hiding information that could help us improve as an organisation would a terrible symptom of something that is wrong with our company culture. We need to make every effort to remove fear of judgement/consquences etc. from Incident Reviews. We need everyone to be open and honest.
Points scoring: It’s easy to use examples of when things go wrong to prove a point or win battles with others. This is generally cherry picking of information and unhelpful to us as an organisation. If unchallenged it will lead to more denfensiveness, hiding/manipulation of data etc.
‘Trying Harder’: We will never take an action to ‘be more careful’ or ‘try harder’ not to break things. We all try pretty damn hard already and that is never the solution we are looking for.
Talking over people: We can only have one conversation at a time if we are to get a shared understanding of what’s happened and what we can do about it.