Lessons Management Best Practice Guidance: Annexes (HTML)

Question 1

ANNEX 1: Linked Documents and Resources

Accepted Answer

1.1 - Linked doctrine and guidance:

1.2 - Helpful reading and resources to support lessons analysis

Five Whys (PDF, 189KB) - to inform deeper understanding of related issues and root cause
Bowtie model: to exploring causal factors and mitigation opportunities - Systems thinking tools: to map out connections and understand complexities
Qualitative analysis: to help look for patterns in words, phrases, and responses
HM Government’s Aqua Book: Guidance for producing quality analysis for government
The NATO Alternative Analysis Handbook: A set of publicly shared analysis techniques
PHIA Common Analytical Standards: Common Analytic Standards to ensure a consistent standard of rigour, integrity, language and best practice across the UK intelligence assessment community

1.3 - Helpful reading and resources to support lesson implementation and evaluation

HM Government’s Magenta Book: HM Treasury guidance on what to consider when designing an evaluation
HM Government’s Orange Book: Management of risk - Principles and Concepts
Better Evaluation: A knowledge platform and global community to create, share and support use of knowledge about how to better plan, manage, conduct and use evaluation]
“IN CASE” Framework: a simple, transferable, policy and communications tool to help anticipate potential for any unintended behaviours impacts during intervention

Question 2

ANNEX 2: Glossary

Accepted Answer

Term	Explanation
After Action Reviews (AARs)	A method of evaluation used to collate and examine learning when outcomes of an event have been particularly successful or unsuccessful, to avoid a particularly successful or unsuccessful event, to avoid failure and promote success in the future.^{[footnote 1]}
Analysis	The study of a whole by thoroughly examining its parts and their interactions^{[footnote 2]}, to identify patterns, trends and themes in data.
Cold Debrief	A structured event or meeting, ideally held within days of the event, to review experiences, outcomes, and capture learning.
Deep dive	Internal group sessions that offer space for detailed consideration and exploration of specific issues or thematic areas.
Hot debrief	An event or meeting held straight after an exercise or incident to capture any urgent feedback, important observations and immediate actions, before those involved disperse.
Focus groups	Facilitated group discussions to examine and explore shared, lived experiences of an event or views on a topic.
Key performance indicators (KPIs)	A measurable target that can be used to track progress toward a specific organisational objective, as an indicator of performance.
Lesson	An update in knowledge or understanding that has been gained through experience.^{[footnote 3]}
Embedded Lesson	A change implemented in response to a lesson identified, that has since been integrated and consolidated in context, evidenced as retained over time, and is consistently demonstrated in practice.
Embedding	The process of monitoring, assessing, and assuring the integration and retention of implemented learning to consolidate, normalise and habituate changes in response to a lesson identified.
Lesson Identification	The process of capturing, analysing, reviewing, validating, reporting, and sharing lessons evidenced by information captured from an experienced event, exercise or emergency.
Lesson Identified	An evidenced conclusion, based on analysis of observations and insights, describing a problem/issue, details a root cause, and sets out a course of action to achieve positive improvements in practice.^{[footnote 4]}
Lesson Implementation	The process of leading, planning and acting on lessons identified to achieve improvements that can be evidenced through monitoring, evaluation and reporting on objectives, outputs and outcomes.
Lesson Implemented (‘Learned’)	An identified lesson that has been actively addressed through a lesson implementation process, resulting in measurable change(s) and positive, evidenced improvements in behaviour and practice.
Lessons Management	A strategic, organised approach to, and oversight of, planned processes and procedures to achieve evidenced learning from experience, in a continual, consistent manner.
Lesson Prioritisation	The process of organising lessons identified, assessing the risk of recurrence and agreeing a priority level for implementation action.
Notable Practice	A practice observed as an effective way of doing something, resulting in a beneficial and/or better than expected outcome that could be replicated or scaled to strengthen future resilience.
Observation	A singular, documented perspective or opinion on a noteworthy problem or practice, in the content of a specific incident, exercise, project or report.^{[footnote 5]}
Recommendation	A proposed, viable course of action based on an evidenced lesson, that has been constructed in a SMART manner, and can be acted upon either to reinforce a positive finding or drive improvement.
Transactional Recommendations	A resolvable challenge with tangible/known cause(s) and a clear course of action (e.g., process improvement opportunities,changes to existing plans). Implementation: 1-12 weeks.
Situational Recommendations	A situation-specific challenge with an identified organisation or people group. Implementation method is clear (e.g., training), but action requires situational awareness, or has situational constraints (e.g., existing training schedule). Implementation: 3-12 months.
Transformational Recommendations	A significant, complex challenge spanning network(s) or system(s). Causal factors tend to be less well defined, viable actions require strategic ‘bigger picture’ delivery mechanisms and increased stakeholder engagement. Implementation: 12-24 months +
Validation	The action of checking or confirming the accuracy, integrity, and quality of a lesson identified.^{[footnote 6]}

Question 3

ANNEX 3: Example Learning Capture Templates

Accepted Answer

1. Observation Capture Template (E.g., for capturing individual observations)

Date	-
Event / Exercise
Observer details (*)	(*)Optional, depending on any instructions for anonymity or requirement for contact details
Location
Title	Short, concise, one sentence summary of a significant issue or practice
Observation	Description of the problem or practise experienced and/or observed
Discussion	Details relating to situational context, consequences, wider impacts
Conclusion and Recommendation	Summary of views on the observation, including any proposed actions and/or prescriptions to the problem, for consideration

2. Cold Debrief Template (E.g. for capturing observations in a group context)

Date of Incident / Event:	-
Location:
Type of event
(e.g., incident, exercise, training, other)
Name(s) of debrief team:
Location of debrief:
Time and date of debrief:

Names of attendees and the organisations they represent can also be recorded.

Incident / Event overview (summary of what happened)

Who was involved? (departments/organisations/agencies)

Who took the lead? (departments/organisations/agencies)

What went well and why? (Summary of successful and/or notable practices)

What were the notable areas for improvement? (Description and detail of issues, gaps and challenges experienced)

How could things be done differently next time? (Optional early thinking on potential options to address/resolve/improve issues can be included)

Key Points of Learning

(Key findings to support identification of lessons)

No.	Learning Point	Observer	Organisation	Thematic Area	Action Required	Progress Update

Lead debriefing organisation/department	-
Lead debriefer name
Lead debriefer signature
Date

Governance of Debrief Report:

Report sent to:

Date:

Report reviewed by:

Date:

Question 4

ANNEX 4: Worked Example - High-Quality Lesson Identified

Accepted Answer

Three components of a high-quality ‘Lesson Identified’

Date	-
Event / Exercise
Observer details (*)	(*)Optional, depending on any instructions for anonymity or requirement for contact details
Location
Title	Short, concise, one sentence summary of a significant issue or practice
Observation	Description of the problem or practise experienced and/or observed
Discussion	Details relating to situational context, consequences, wider impacts
Conclusion and Recommendation	Summary of views on the observation, including any proposed actions and/or prescriptions to the problem, for consideration

Worked Example

Category	Explanation
Context:	The provision of agreed, accurate and timely information to the public during a response plays a vital role during an emergency response. There is a requirement for the organisation to maintain arrangements to warn the public and keep them informed in the event of an emergency.
Problem:	During the response, limited knowledge of senior communication clearance processes, and inconsistent lines of communication to those with authority to clear, led to frustration and delay in the release of timely, accurate information to the local community. This had a negative impact on the response, with members of the public congregating at the scene instead of avoiding the area. It also created space for misinformation to spread on social media, and resulted in the perception that the organisation was slow to respond. If unaddressed the problem could recur and hamper future responses, impacting the ability to warn and inform the public, maintain safety at the incident location and avoid negative reputational perceptions.
Proposed action: (prescription)	A review of communication clearance processes is required. Stepped procedures should be agreed, documented and made visible in the operations centre to mitigate the risk of this problem recurring.

Question 5

ANNEX 5: Lessons Management Register and Implementation Action Tracker

Accepted Answer

Term	Explanation
After Action Reviews (AARs)	A method of evaluation used to collate and examine learning when outcomes of an event have been particularly successful or unsuccessful, to avoid a particularly successful or unsuccessful event, to avoid failure and promote success in the future.^{[footnote 1]}
Analysis	The study of a whole by thoroughly examining its parts and their interactions^{[footnote 2]}, to identify patterns, trends and themes in data.
Cold Debrief	A structured event or meeting, ideally held within days of the event, to review experiences, outcomes, and capture learning.
Deep dive	Internal group sessions that offer space for detailed consideration and exploration of specific issues or thematic areas.
Hot debrief	An event or meeting held straight after an exercise or incident to capture any urgent feedback, important observations and immediate actions, before those involved disperse.
Focus groups	Facilitated group discussions to examine and explore shared, lived experiences of an event or views on a topic.
Key performance indicators (KPIs)	A measurable target that can be used to track progress toward a specific organisational objective, as an indicator of performance.
Lesson	An update in knowledge or understanding that has been gained through experience.^{[footnote 3]}
Embedded Lesson	A change implemented in response to a lesson identified, that has since been integrated and consolidated in context, evidenced as retained over time, and is consistently demonstrated in practice.
Embedding	The process of monitoring, assessing, and assuring the integration and retention of implemented learning to consolidate, normalise and habituate changes in response to a lesson identified.
Lesson Identification	The process of capturing, analysing, reviewing, validating, reporting, and sharing lessons evidenced by information captured from an experienced event, exercise or emergency.
Lesson Identified	An evidenced conclusion, based on analysis of observations and insights, describing a problem/issue, details a root cause, and sets out a course of action to achieve positive improvements in practice.^{[footnote 4]}
Lesson Implementation	The process of leading, planning and acting on lessons identified to achieve improvements that can be evidenced through monitoring, evaluation and reporting on objectives, outputs and outcomes.
Lesson Implemented (‘Learned’)	An identified lesson that has been actively addressed through a lesson implementation process, resulting in measurable change(s) and positive, evidenced improvements in behaviour and practice.
Lessons Management	A strategic, organised approach to, and oversight of, planned processes and procedures to achieve evidenced learning from experience, in a continual, consistent manner.
Lesson Prioritisation	The process of organising lessons identified, assessing the risk of recurrence and agreeing a priority level for implementation action.
Notable Practice	A practice observed as an effective way of doing something, resulting in a beneficial and/or better than expected outcome that could be replicated or scaled to strengthen future resilience.
Observation	A singular, documented perspective or opinion on a noteworthy problem or practice, in the content of a specific incident, exercise, project or report.^{[footnote 5]}
Recommendation	A proposed, viable course of action based on an evidenced lesson, that has been constructed in a SMART manner, and can be acted upon either to reinforce a positive finding or drive improvement.
Transactional Recommendations	A resolvable challenge with tangible/known cause(s) and a clear course of action (e.g., process improvement opportunities,changes to existing plans). Implementation: 1-12 weeks.
Situational Recommendations	A situation-specific challenge with an identified organisation or people group. Implementation method is clear (e.g., training), but action requires situational awareness, or has situational constraints (e.g., existing training schedule). Implementation: 3-12 months.
Transformational Recommendations	A significant, complex challenge spanning network(s) or system(s). Causal factors tend to be less well defined, viable actions require strategic ‘bigger picture’ delivery mechanisms and increased stakeholder engagement. Implementation: 12-24 months +
Validation	The action of checking or confirming the accuracy, integrity, and quality of a lesson identified.^{[footnote 6]}

Event prefix suggestions EX– Exercise (+number) e.g.,EX674; IN – Incident (+number); EV - Event/Training (+number)

(*) Status suggestions

No action	Pending	Assessing	Active	Implemented	Embedding
Reviewed but no taken forward	Reviewed but not prioritised for
action at this time	Lesson/ Recommendation in prioritisation process or planning appraisal	Lesson being actively implemented at present time	Implementation Action Plan delivered and evaluated	Implementation evaluation successful, progressed to consolidation and integration

Implementation Action Tracker

Date	Event ID	Lesson ID	REC detail	Priority level	Status	IMP Action Owner (Senior/ Accountable)	IMP Delivery Lead (PoC/ Responsible)	Key Contacts	Action start date	Review date(s)	Est. end date	M&E details/ IMP progress	Key docs (link)

Question 6

ANNEX 6: Example Lessons Management Maturity Matrix[footnote 7]

Accepted Answer

Term	Explanation
After Action Reviews (AARs)	A method of evaluation used to collate and examine learning when outcomes of an event have been particularly successful or unsuccessful, to avoid a particularly successful or unsuccessful event, to avoid failure and promote success in the future.^{[footnote 1]}
Analysis	The study of a whole by thoroughly examining its parts and their interactions^{[footnote 2]}, to identify patterns, trends and themes in data.
Cold Debrief	A structured event or meeting, ideally held within days of the event, to review experiences, outcomes, and capture learning.
Deep dive	Internal group sessions that offer space for detailed consideration and exploration of specific issues or thematic areas.
Hot debrief	An event or meeting held straight after an exercise or incident to capture any urgent feedback, important observations and immediate actions, before those involved disperse.
Focus groups	Facilitated group discussions to examine and explore shared, lived experiences of an event or views on a topic.
Key performance indicators (KPIs)	A measurable target that can be used to track progress toward a specific organisational objective, as an indicator of performance.
Lesson	An update in knowledge or understanding that has been gained through experience.^{[footnote 3]}
Embedded Lesson	A change implemented in response to a lesson identified, that has since been integrated and consolidated in context, evidenced as retained over time, and is consistently demonstrated in practice.
Embedding	The process of monitoring, assessing, and assuring the integration and retention of implemented learning to consolidate, normalise and habituate changes in response to a lesson identified.
Lesson Identification	The process of capturing, analysing, reviewing, validating, reporting, and sharing lessons evidenced by information captured from an experienced event, exercise or emergency.
Lesson Identified	An evidenced conclusion, based on analysis of observations and insights, describing a problem/issue, details a root cause, and sets out a course of action to achieve positive improvements in practice.^{[footnote 4]}
Lesson Implementation	The process of leading, planning and acting on lessons identified to achieve improvements that can be evidenced through monitoring, evaluation and reporting on objectives, outputs and outcomes.
Lesson Implemented (‘Learned’)	An identified lesson that has been actively addressed through a lesson implementation process, resulting in measurable change(s) and positive, evidenced improvements in behaviour and practice.
Lessons Management	A strategic, organised approach to, and oversight of, planned processes and procedures to achieve evidenced learning from experience, in a continual, consistent manner.
Lesson Prioritisation	The process of organising lessons identified, assessing the risk of recurrence and agreeing a priority level for implementation action.
Notable Practice	A practice observed as an effective way of doing something, resulting in a beneficial and/or better than expected outcome that could be replicated or scaled to strengthen future resilience.
Observation	A singular, documented perspective or opinion on a noteworthy problem or practice, in the content of a specific incident, exercise, project or report.^{[footnote 5]}
Recommendation	A proposed, viable course of action based on an evidenced lesson, that has been constructed in a SMART manner, and can be acted upon either to reinforce a positive finding or drive improvement.
Transactional Recommendations	A resolvable challenge with tangible/known cause(s) and a clear course of action (e.g., process improvement opportunities,changes to existing plans). Implementation: 1-12 weeks.
Situational Recommendations	A situation-specific challenge with an identified organisation or people group. Implementation method is clear (e.g., training), but action requires situational awareness, or has situational constraints (e.g., existing training schedule). Implementation: 3-12 months.
Transformational Recommendations	A significant, complex challenge spanning network(s) or system(s). Causal factors tend to be less well defined, viable actions require strategic ‘bigger picture’ delivery mechanisms and increased stakeholder engagement. Implementation: 12-24 months +
Validation	The action of checking or confirming the accuracy, integrity, and quality of a lesson identified.^{[footnote 6]}

Question 7

ANNEX 7: Process Pillars: Aide Memoires

Accepted Answer

Process Pillar 1: Lesson Identification

Step 1: Capture

Observe
Record
Collate

Step 2: Analyse

Trends
Themes
Insights

Step 3: Identify

Context
Problem
Prescription

Step 4: Validate

Review
Check
Challenge

Step 5: Report

Findings
Lessons Identified
Recommendations

Disseminate - Communicate - Connect

Process Pillar 2: Lesson Prioritisation

Step 1: Organise

Record
Store
Share

Step 2: Appraise

Authenticated
Supported
Actionable

Step 3: Assess

Risk
Likelihood
Impact

Step 4: Assign

Discuss
Agree
Own

Step 5: Review

Summarise
Conclude
Disseminate

Process Pillar 3: Lesson Implementaiton

Step 1: Lead

Responsibility
Accountability
Ownership

Step 2: Plan

Strategy
Design
Baseline

Step 3: Act

Communicate
Deliver
Practice

Step 4: Monitor

Measure
Record
Validate

Step 5: Evaluate

Objectives
Outputs
Outcomes

Step 6: Report

Describe
Discuss
Share

Process Pillar 4: Embedding Change

Step 1: Plan

Map
Align

Step 2: Integrate

Educate
Enable

Step 3: Monitor

Track
Check

Step 4: Assure

Test
Exercise

Step 5: Review

Assess
Evaluate

Step 6: Mature

Retain
Refine

NHS England: Patient safety learning response toolkit (2022) ↩
NATO, JALLC: The NATO Lessons Learned Handbook, Fourth Edition, 2022 (PDF, 1,844KB) ↩
- Adapted from NATO, JALLC: The NATO Lessons Learned Handbook, Fourth Edition, 2022 (PDF, 1,844KB)
↩
Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) ↩
Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) p.33 ↩
For a fuller definition of ‘validation’ in the context of civil protection, please see: Exercise Best Practice Guidance ↩
Informed by: Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) and BS 65000: 2022 Organisational Resilience – Code of Practice ↩

Category	Explanation
Context	What was observed and where?
Problem (or Practice)	What were the underlying cause, issue or influencing factors? What did the notable practice involve and why was it effective? What is the rationale for updating or amending existing ways of doing things?
Proposed action (prescription)	What action is required for improvement? How could/why might positive improvements be achieved in response?

Date	Lesson source (Event)	Lesson owner (PoC)	Lesson Identified	Threat/ Hazard (NRR)	Thematic Learning area (category)	Unique REC ID (number)	REC (Detail)	Priority level	Status*	As applicable	As applicable	As applicable
										Oversight (Senior/ accountable PoC)	IMP Action wonder (PoC)	Notes/ document links (e.g., IMP Action Plan)	Progressed to EMB? (Y/N)

Maturity Approach	Passive Assumed (1)	Reactive Subjective (2)	Managed Objective (3)	Adaptive Reflective* (4)	Generative Reflexive** (5)
Identification	Lessons assumed as ‘learned’ during the event.	Ad-hoc lesson identification, according to requirement.	Lessons reliably identified/overseen, with planned, documented approach.	Lesson identification integrated into wider governing and policy arrangements.	High-level interest and upward reporting of identified lessons and reviews.
Identification	Potential for issues to recur is minimised.	Identification by assumption, not analysis.	Analysis and validation reliably support objective, quality lessons.	High-quality, credible lessons are reliably identified and used to inform foresight/ innovation.	High quality, reliable processes extend to inform credible capture of lessons from near misses/ normal work.
Identification	No/minimal process for and documentation of identified lessons.	Variable documentation, according to preference.	Consistent documentation demonstrates focus on finding and fixing problems.	Thresholds are in place to direct proportionate documentation, based on event scope/scale.	Proportionate dentification process proactively extended to wider reports, events and reviews.
Prioritisation	Failure to assess the risk of issues recurring in the future.	Assessment of risk is minimal, subjective and ad-hoc.	Assessment of risk is consistent, reliable and objective.	Objective assessment of risk is informed by expert insights and/or wider partners.	High risk, priority actions are aligned and integrated with wider strategic objectives to help expedite action.
Prioritisation	No prioritisation Focus on blame over improving the response.	Minimal/ ad-hoc prioritisation. Focus on reputational impacts.	Priority levels agreed to inform organised action. Decisions documented. Focus on safety/security.	Prioritisation considers common consequences in other risk areas. Focus includes wider resilience.	Accountable prioritisation that is regularly reviewed. Focus includes wider resilience and horizon scanning.
Implementation	Lessons rarely considered for action	Unstructured/ ad-hoc action according to requirement	Action is organised, agreed, tracked and delivered in line with documented plans	Action is comprehensive and collaborative change is well communicated and managed.	Implementation action is fluent, reliable and agile, with established processes and success in managing change
Implementation	No oversight or senior leadership interest.	Oversight, senior buy-in and authority to enact change is inconsistent.	Reliable support for implementation action is evident. Ownership and authority for change is in place.	Strategic, top-down approach consistently provides proportionate responsibility, accountability, and ownership for actions	Invested, senior oversight extends to continually improve implementation action and management of change
Implementation	No behaviour changes.	No/minimal records of implementation planning and action tracking. Minimal change evidenced.	Action consistently documented, monitored and evaluated. Some behaviour changes evidenced/validated.	Behavioural changes consistently achieved, evidenced, validated and assured.	Behavioural changes routinely validated, assured and matured in line with wider organisational activity.
Embedding	Embedding not considered, or assumed to be passive/ organic	Active embedding considered but ad- hoc, and difficult to evidence.	Active embedding is understood, valued, planned and delivered to retain learning and normalise change.	Embedding progress is monitored/ assessed at strategic and operational levels.	Established embedding processes are agile and integrated across the organisation.
Embedding	No indicators of embeddedness apparent	Few indicators of embeddedness apparent.	Indicators of embeddedness can be evidenced.	Multiple indicators of embeddedness are consistently evidenced and proactively monitored	Multiple indicators of embeddedness are present over time, indicting permanence of change.

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ANNEX 1: Linked Documents and Resources

1.1 - Linked doctrine and guidance:

1.2 - Helpful reading and resources to support lessons analysis

1.3 - Helpful reading and resources to support lesson implementation and evaluation

ANNEX 2: Glossary

ANNEX 3: Example Learning Capture Templates

Key Points of Learning

ANNEX 4: Worked Example - High-Quality Lesson Identified

ANNEX 5: Lessons Management Register and Implementation Action Tracker

ANNEX 6: Example Lessons Management Maturity Matrix[footnote 7]

ANNEX 7: Process Pillars: Aide Memoires

Process Pillar 1: Lesson Identification

Step 1: Capture

Step 2: Analyse

Step 3: Identify

Step 4: Validate

Step 5: Report

Step 6: Share

Process Pillar 2: Lesson Prioritisation

Step 1: Organise

Step 2: Appraise

Step 3: Assess

Step 4: Assign

Step 5: Review

Process Pillar 3: Lesson Implementaiton

Step 1: Lead

Step 2: Plan

Step 3: Act

Step 4: Monitor

Step 5: Evaluate

Step 6: Report

Process Pillar 4: Embedding Change

Step 1: Plan

Step 2: Integrate

Step 3: Monitor

Step 4: Assure

Step 5: Review

Step 6: Mature

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ANNEX 6: Example Lessons Management Maturity Matrix^{[footnote 7]}