Another made-up, or mis-spelled, word to grab attention. It’s been said many times that we are doomed to repeat the mistakes of the past (i.e. history repeats itself); often used in a national/international context I’ve found it can be true in almost any organisation. In the latter, the repeat cycle can be years or just days. Let me explain…

I’ll start with the “years” approach. I’ve visited hundreds of businesses in my working life, often to carry out assessments on behalf of customers. Looking at NCR records it’s clear that corrective actions are often only short-term. On the long term, I’ve found cases where companies are encountering problems that were fixed 15 years previously. So one has to ask why the fix has broken.

Let me describe what I refer to as the “handover fallacy”. Think of a rota with three eight-hour shifts; I’ll refer to them as A, B and C. A shift encounters a problem in a regular process – something unexpected happened but a fix is found and implemented. In the A to B handover, the problem and fix is discussed; there may be notes that are passed on and highlighted. B continues working the new way and doesn’t encounter the problem. In the B to C handover, the new way is mentioned, along with the fact that there are notes available, but since B didn’t experience the problem requiring the fix, it’s left at that. C realises the new way is creating extra work and looks to improve it; however, without knowing about the problem, an essential part of the fix is undone. It doesn’t create an immediate problem but, before long, it reappears. A “owned” the problem so it was important to handover full details. B didn’t “own” the problem so had no reason to handover more than the actual change. C is not irresponsible in seeking improvement but only has part of the story. This isn’t inevitable and most of the time, the fix stays fixed; and, of course, in a real business, the change will have been fully documented, communicated to all parties and incorporated into toolbox talks and training (well – in theory, perhaps, but that’s not always the practise). But problems do re-occur. In some industries running 24-hour operations (including my own sector, UK North Sea oil & gas exploration) we operate 12-hour shifts. These present fewer opportunities for the short-term memory loss as A hands over to B who then hands over back to A, etc. It’s not perfect but it offers a significant reduction in risk.

In many businesses, the longest individual staff members stay in the same role or team is around five years. Let’s assume that here. If we extrapolate the changes for a full team, we would expect to have a fully third generation team in post after 15 years. Now superimpose our three shift model. The first generation will have made ongoing improvements to their work processes and, when encountering problems, made appropriate changes. Remember, the processes needing change were not totally wrong and were working most of the time – it’s just that we rarely foresee all eventualities; the new process may have extra steps that, to somebody unaware of the problem, are unnecessary (which is probably why they weren’t originally included). The second generation handover and training will include the revised processes and, because the first generation owned the problems, they will have passed over much of the background. The third generation doesn’t get that and risk removing the extra steps that kept things smooth. Consequently, some of the problems encountered and fixed 15 years ago resurface.

It’s not a fixed 15 year period and not all problems will come back, nor does the real world work quite as I’ve described it – just don’t be surprised when it happens. And this isn’t an unknown phenomenon – if you look at Juran’s Breakthrough process you’ll see he points out the need to establish measure to “hold the gains” – or the C for “control” in DMAIC (six-sigma). Changes need to be managed for the long term else we are doomed to repeat the mistakes of the past. Which, perhaps, is inevitable anyway.


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