Presentation on theme: "Learning About Learning Progress in Lessons Learned at Los Alamos National Laboratory presented to the DOE Operating Experience Coordinators Workshop."— Presentation transcript:
1Learning About Learning Progress in Lessons Learned at Los Alamos National Laboratory presented to the DOE Operating Experience Coordinators Workshop May 5, 2010Bob StueweOperating Experience CoordinatorContractor Assurance Office – Performance FeedbackLos Alamos National Laboratory
2Bottom Line Results Take About Three Years to Manifest End of CY 2006FY 2010 (Now)163 processed per yearPass preliminary screeningNearly all DOE/HSSSafety10 internal per year200 web users/month250 in searchable archive?? document accesses per month?? searches/monthTrend OccurrencesTrack Communications2 FTEs1 FTE on the Trending800 processed per yearPass preliminary screeningMultiple pre-planned sourcesAll program/function areasinternal per yearweb users/month>2100 in searchable archive>30,000 document accesses per monthsearches/monthAnalyze/Trend Occurrences, CausesTrack Actions (risk-based)2.5 FTEs1.2 FTE on Analysis
3Learning About Learning Lessons About Effective Lessons Learned Programs Champion Learning, Not LessonsReliable Processes Build Trust and UseClarify Roles to Eliminate RedundancySupport Work ProcessesEnable Risk ManagementMore Focused Equals More EffectiveBuild and Use Indicators of EffectivenessEncourage Innovation
4Champion Learning Not Lessons Operating Experience Programs are Key to Knowledge Management World of Possible KnowledgeOperating Experience ProgramLearning happens in the work unit in many, many ways(Required reading, training, requirements updates, work team meetings, plan of the day, procedure updates, learning teams, process improvement teams, corrective action teams etc.)
5Champion Learning Not Lessons From the Criteria for Performance Excellence (MBNQA) Learning is one of the three pillars of organizational performance.Learning is referenced 103 times in 88 pages“The term “performance excellence” refers to an integrated approach to organizational performance management that results in (1) delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability; (2) improvement of overall organizational effectiveness and capabilities; and (3) organizational and personal learning.”“To be effective, learning should be embedded in the way an organization operates.”
6Champion Learning Not Lessons Know How Your Organization Learns and Support the Methods Nuclear and High Hazard FacilitiesConduct of Operations: required reading, procedures, FLM weekly meeting, critiques, facility lessons learned coordinators, etc.Subject AreasElectrical Safety Committee, Chemical Safety Committee, Glovebox Safety Committee, Security Incident Analysis, etc.Lower Hazard OrganizationsWorker Safety and Security Teams, Learning Teams, Management Meetings, mentoring, on-boarding, etc.InstitutionalManagement review boards, requirements updates, training updates, institutional web pages, etc.
7Reliable Processes Build Trust and Use Trust Requires Relationships – With Products/Services Used Operating Experience and Lessons Learned ProcessCollects, screens, risk-prioritizes, and distributes operating experiences and lessons learned from key external and internal sources using timely communications.Three risk-priority levels with different disposition/communication pathwaysLessons Learned and Operating Experience ArchiveCaptures relevant lessons and best practices reported by the Laboratory managers and workers, contractors, subcontractors, and from other DOE sites and external sources.Knowledge baseMirror: Translating Events into Actionable InformationCommunicates high-leverage actions, lessons learned and best practices associated with operating experience patterns and trends.
8Reliable Processes Build Trust and Use Process Management is Proven To Create Reliable Products/ServicesEstablish Process ManagementLean Six Sigma - Champion and Yellow BeltProcess Team (Weekly - Operations)Integration Team (at least Annually - Integration and Strategy)Benchmark (inside and outside DOE)Define Product/Service Quality SpecificationsPurpose -> Products/Services-> Customers-> Requirements -> Controlling characteristicsDefined processes (steps and roles) for each product (mapping)Set up Process Controls and ImprovementProgram Description, Procedures, Checklists, ToolsUse Contractor Assurance System: Goals, Measures, Assessments, Issues Mgt, Process ImprovementEstablish Task Roles (daily, weekly, monthly, quarterly, annual)Annual Improvement Plan (effectiveness and efficiency)Execute and Innovate
9Reliable Processes Build Trust and Use Reliable Processes Requires Reliable Operations MondayProcess TeamUpdatesUpcomingCommunications PlanOperationsImprovement PlanTuesdayIntegrationCAS Management TeamInstitutional Management Review BoardAs NeededWednesdayMIRROR TeamOrganized by sections of the publicationQuality review and improve key messages and actionsDesign year-end and next issueThursdayScreening TeamProcess Team and occasionally the site officeFinalize screeningDetermine dispositionsWrite headlinesPublish Weekly SummaryFridayWeek Close OutIn case extra time is needed to complete the weeks deliverablesBacklogs are deadlyDaily intake and preliminary screeningWork on products and services (MIRROR, lessons, support customers)Work on Communications Plan and Improvements Plan
10Clarify Roles to Eliminate Redundancy Functional Approaches Increased Costs, Decreased Effectiveness LL requirements embedded in many directives, guidesAlignment and Integration can save taxpayer moneyLANL approachOPEX program supports multiple functions – use an integration team to plan annual improvement (Safety, Security, Env Mgt, Project Mgt, Facilities, HPI, Training)Issue & Corrective Action Management - handles extent of condition for institutional/local, OPEX program helps with what’s in betweenQA/SCI – handles work-related suspect, counterfeit and defective items, OPEX serves as knowledge base, get directly involved at Urgent levelPlanned integration with internal security LL and Security Lessons Learned CenterOrganizational and Subject Area LL Knowledge Bases and Process align with and link to InstitutionalContractor Assurance System: Measures, Assessment Planning, Issue Effectiveness EvaluationSite office uses LANL screening and disposition process, oversight of higher risk
11Support the Work Processes Easy to Think About the “Push”
12Support the Work Processes Work is Always Underway – Don’t Try to Change Cars While Moving
13Support the Work Processes Beware of the Adverse Unintended Consequences of the “Push” Common Lesson from OPEX: Not Thinking Through a ChangeNuclear FacilitiesProcedures control the qualityModifying procedures include many steps, for good reasonConservation of Attention LawOnly so much time in a dayRushing to implement a lessons learned can create reworkResource Allocation is Not an OPEX RoleActing on a lesson competes for resourcesOPEX Coordinators do not know the daily priorities on the work floor
14Support the Work Processes Hard to Think about the “Pull” – But Equally Important
15Support the Work Processes Supporting Work Processes Requires a Knowledge Base MS SharepointReduced CostIT CostsProcess CostsAligns with Work ProcessesTopical Libraries (key systems)Alerts (individual and topical groups)How-To ToolsFull PDF search capability
16Enable Risk Management To Engage Senior Management – Help Reduce Risk Hazard inventory is pretty stable at the sitesSharing known or low hazards provides little value to management“New” and “Significant” Hazards important and valuedRisk ManagementAbout reducing consequence or probabilityWhat is the risk? (to the mission)How large are the potential adverse consequences?What are you doing to handle it?How likely are you to succeed?Should you do more?Requires knowledge of organizational processesRussian Hydro as an ExampleWhere Lessons Learned can add the most value to management.
17Enable Risk Management Risk-based Prioritization Matrix derived from O210.2 with Security from IMI levels Urgent and Caution matrix essentially identical to Order – will add Best Practice un futureUrgent = Immediate action is needed to ensure that the Laboratory is in a safe, secure, and environmentally sound mode relative to the information identified in the alert. Active engagement of relevant manager(s). Formal issues and corrective action tracking.Work PlanningProcesses (Line)TrainingDevelopment (Support)RequirementsURGENTMonitorSourcesScreenClarifyCommunicateCautionInformationalCaution = Timely action may be needed. Routine notification through Lessons Learned and Operating Experience Weekly Summary s and LANL Home Page. LANL managers determine relevance and take needed action.Informational = Future action may be needed. Posted to LANL Home Page if broadly applicable and actions clear. Important to knowledge base.
18Enable Risk Management Risk Levels Differ from Site to Site Pre-ScreeningPost Screening#HSS - GreenInformational21HSS - BlueCaution444HSS - Red6HSS - Yellow3865Urgent Lessons most commonly associated with DOE Safety Alerts and Advisories, defective safety items, and other sources
19Enable Risk Management Select Sources to Support Risk Management – Might Change over Time Primary Routine SourcesMonitoringFrequencyDOE HSS Server/Web (LL, Alerts, OE Summaries, Security Lessons Learned Center (SLLC))DailyPartner Alerts (Bechtel, BWXT, UC, etc.)As IssuedORPS (from Other Sites)Suspect Counterfeit/Defective ItemsU.S. Chemical Safety BoardMonthlyEnforcement Actions and GAO ReportsQuarterlyConsumer Products (CSPC, FDA)
20More Focused Equals More Effective Tailor Communication Methods to Audience and Media Capability
21More Focused Equals More Effective Weekly Summary – Management and LL Roles with PrioritizationRecipientsDivision Leaders and aboveNNSA Site OfficeLL Roles and Upon RequestAugments daily ORPSSpecific = RelevantDefine Most Specific CustomerSelect Words in HeadlineIntegrity CheckOrder (First and Last Most Read)Scan-able (6 most important/actionable; > 6 has lower read rate)
22More Focused Equals More Effective LANL Homepage to Reach Workers Directly Some Communication Overlap Helps EffectivenessMain UsersWorkersBroadest lessonsIncludes worker home safetySpecific = RelevantEven shorter headlinesPre-job brief is major customers
23More Focused Equals More Effective Internal Lessons Learned Submission – Content over Format Adobe Fill-able FormJust the FactsWord Docs too slow, costly, hard to share with DOEField Validation – reduce errorsFields support processingScreening and prioritizingInterface to DOE/HSSIncludes picture objectsSubmit Button linked to LL Archive and ProcessBecoming standard at facility level
24More Focused Equals More Effective LANL Mirror (Quarterly Publication) Translating Events into Actionable InformationEvents binned by systems and processesPatterns and trends (incidents, occurrences, causes)Year-End and Two-Year Running ReflectionUse statistics to identify changes/trendsHigh-leverage lessons/actions aligned with greatest performance gapsRecognition for developing and sharing lessons learned
25More Focused Equals More Effective LANL Mirror: Events Causes Checklist for Improvements
26Build and Use Indicators of LL Effectiveness Fact-based Improvement is the Objective Use CAS DashboardLL IndicatorsProcessing time performanceUrgent within 24 hoursCaution within 7 daysDocument Access RateSearch RateKnowledge InventoryInternal LL Generation RateLL Program ExecutionRoutine Process MilestonesProgress on Improvement PlanCorrective Actions
27Build and Use Indicators of LL Effectiveness Need measures than can help understand Cause and Effect
28Build and Use Indicators of LL Effectiveness Need measures than can help measure use for Work Planning
29Encourage Innovation LANL Performance Communication Center Modernizing CommunicationsChat with an ExpertBuilds Knowledge BaseBlogRole-based informationRelevant ToolsRelevant RequirementsBest Practices (coming soon)Custom version of LL FormRecognition
30Encourage Innovation Sub-Unit Approaches Evolve as their Learning Processes Mature R&D key lessons included in “On-Boarding” materials for new hires (might become a best practice)Local LL Archives Linked to Institutional ArchiveProject ManagementEngineeringD&DMaintenanceFacilitiesLearning Teams (linked to HPI implementation)
31Learning About Learning Progress in Lessons Learned System at LANL Questions?