Guidance

Lessons Management Best Practice Guidance: Executive Summary (HTML)

Published 30 September 2024

Executive Summary

Government is determined to learn the lessons from exercises and emergencies. Doing so strategically, skilfully and successfully is part of a commitment to prepare as best we can for the future.^{[footnote 1] [footnote 2]}

Context

The importance of learning lessons in the civil contingencies resilience context is reflected in legislation^{[footnote 3]}, national standards^{[footnote 4]}, and good practice^{[footnote 5]} guidance across sectors and stakeholders. It is here that lessons play a vital role in continually improving the emergency response, preventing the repetition of past mistakes, and reducing losses in the event of disruption. However, challenges in closing the loop between identifying lessons and actively achieving evidenced, embedded improvements in practice have been documented.^{[footnote 6] [footnote 7]} Building on existing best practices in lessons management, this guidance is an important step in addressing those challenges, and closing that loop.

In publishing the Lessons Management Best Practice Guidance, the Cabinet Office recognises the importance of learning from both successes and failures in the civil contingencies resilience context. It is also acknowledged that top-down accountability and oversight, with visible, senior leadership engagement and a communicated commitment to the management of lessons is vital if measurable improvements in practice are to be realised and retained.

About the Guidance

The aim of the Lessons Management Best Practice Guidance is to inform, encourage, and equip senior leaders, central government departments, agencies, arms-length bodies, and wider resilience professionals in the effective management of lessons. It anchors learning into the core principles of the UK’s Resilience Framework^{[footnote 8]}, and represents a practical step- change in the way that lessons are managed in concept and practice.

Objectives: This guidance has been developed to deliver against the following objectives:

• to support and strengthen the management of lessons in the civil contingencies’resilience context
• to support and inform the identification of evidence-based lessons, from a range of learning sources, including emergency exercises and incidents
• to support and inform the prioritisation and practical implementation of learning in response to lessons identified
• to support and inform the retention of implemented learning, through consolidation and embedding of change within and across organisations

Structure: In line with these objectives, the guidance comprises the following sections:

• Lessons Management
• Lesson Identification
• Lesson Prioritisation
• Lesson Implementation
• Embedding Learning and Change

Scope: The guidance is non-statutory and non-mandatory. Nothing within it adds additional obligations to users. It is to be read in conjunction with other existing guidance, linked in Annex 1.

Duty of Candour

It is vital in every aspect of Lessons Management to acknowledge the sensitivity, candour, and care with which lessons from incidents, and the people they pertain to, should be treated. This is especially pertinent in cases where tragedy and trauma, including loss to lives, livelihoods and/or the environment have been experienced.^{[footnote 9]}

The Lessons Management Framework

Lesson Management refers to a strategic, organised approach to, and oversight of, planned processes and procedures to achieve evidenced learning from experience, in a continual, consistent manner. The Lessons Management Framework (Figure 1) comprises four key processes that are required for successfully closing the loop between identifying a problem, and achieving lasting, practical improvements in response.

These key processes (Lesson Identification, Lesson Prioritisation, Lesson Implementation and Embedding Change) span strategic and operational activity, within the wider context of continual improvement. The framework can be flexibly applied and/or adapted to inform learning arrangements across contexts, and in support of wider goals to strengthen organisational resilience.^{[footnote 10] [footnote 11]}

Putting Lessons Management into Practice

Each of the four processes have been broken down into practical steps.

These steps are informed by best-practices from the UK and beyond.

They are set out briefly in the process summaries below, and further expanded in the full guidance document. Print-friendly ‘Aide Memoires’ that visualise each of the key processes with their practical steps can be found in Annex 7.

Process 1: Lesson Identification

• Capture
• Analyse
• Identify
• Validate
• Report
• Share

Lessons are identified from a range of sources, including emergency exercises, incidents and reviews. In the resilience context a ‘Lesson Identified’ is an evidenced conclusion, based on analysis of observations and insights from experience. It describes and documents a problem or issue, details a root cause, and succinctly sets out a course of action to achieve positive improvements in practice.^{[footnote 12] [footnote 13]} The end goal of the identification process is to capture high-quality^{[footnote 14]} evidence-based lessons that can inform the generation of SMART (Specific, Measurable, Achievable, Relevant, and Time-bound)^{[footnote 15]} recommendations for onward action. Notable, positive practices that achieve better than anticipated outcomes, may also be identified during a lesson capture process.

The Importance of Analysis

Analysing information (i.e., observations, debriefs, feedback) about what went well, and what could be improved is an important step in lesson identification. Practitioners can look for learning ‘trends’, ‘themes’ and ‘insights’ to inform a credible evidence-base for lessons.^{[footnote 16]} This approach can help to mitigate identification inaccuracies. It can also inform an increased understanding of root issues, prevent misguided recommendations, and increase legitimacy for action amongst stakeholders later on.

Once identified, a report summarising the findings, lessons and recommendations can be produced. This is ideally disseminated within three months of the conclusion of the exercise, incident or other learning event.

Process 2: Lesson Prioritisation

• Organise
• Appraise
• Assess
• Prioritise
• Assign
• Review

Lesson prioritisation involves a strategic assessment of the risk that would be posed should an identified problem or issue recur in practice.^{[footnote 17]} The production and maintenance of an organisation-wide Lessons Management Register, that brings lessons from a range of sources in a single, centralised space, can help when assessing risk to inform priority actions. With consistent data column headings (e.g. thematic capability areas, hazard/threat, risk scenario) it can be easier to spot recurring problems, and scope opportunities to address similar issues in a single intervention.

An example Lessons Management Register can be viewed in Annex 5.

Assessing the Risk of Recurrence

Risks associated with identified lessons can be assessed in terms of the likelihood and the impact of the issue occurring again. Existing inequalities and vulnerabilities should be taken into account during this process. Helpful assessment criteria and an example prioritisation matrix, informed by National Risk Assessment methodologies^{[footnote 18]}, the Joint Emergency Services Interoperability Principles (JESIP)’s Joint Organisational Learning Guidance^{[footnote 19]} and the Community Resilience Development Framework^{[footnote 20]}, are detailed in the Lesson Prioritisation section on page 16.

Once the risks of an identified issue remaining unaddressed have been considered, a ‘Priority Action Level’ can be assigned to identified lessons. Priority Action Levels can inform decisions about which lessons to address first, whether any ‘quick wins’ can be actioned in the near-term, and how resources might be prioritised to inform delivery of mid- or longer term lesson implementation projects.

Process 3: Lesson Implementation

• Lead
• Plan
• Act
• Monitor
• Evaluate
• Report

The lesson implementation process involves the delivery of tangible learning actions to deliver improvements in practice. An implemented lesson is one that has become ‘learned’ through successful delivery and completion of a planned implementation process to address the identified issue. The end goal of implementation is evidenced, measurable changes and improvements in behaviour and practice.

Best practice advocates for a strategic Implementation Action Plan, to be agreed within six months following the conclusion of the exercise/learning event.

Key Facilitating Factors

Responsibility, accountability, and ownership for actions and deliverables are key drivers in the achievement of successful lesson implementation projects. Visible, top-down leadership of, and a commitment to, learning lessons and implementing change is vital to ensure implementation projects progress in a timely manner, are seen through to completion, and deliver measurable improvements in practice.

The ‘why, what, who, when, where, and how’ (5W1H) methodology can be applied to support development of a clear, agreed plan, with documented implementation objectives, outputs (e.g., deliverables), and outcomes (i.e., measures of success). These can then provide a framework for in-process monitoring and a post-implementation evaluation.

Process 4: Embedding Change

• Plan
• Integrate
• Monitor
• Assure
• Review
• Mature

The embedding process focuses on making positive changes ‘stick’, after they have been successfully implemented. The goal is to retain key learning, sustain new, more effective ways of working, and prevent resolved issues from recurring in the future. Aligning embedding efforts with existing organisational goals, structures, and reporting schedules, can minimise duplication and deliver a more sustainable, integrated approach.

Practical Embedding

The word ‘embedding’ is commonly used, but not always well operationalised in practice. Practical examples of embedding include: ‘Education’ (knowledge/ training), ‘Equipping’ (skills/behaviours) and ‘Enabling’ (shaping culture and/

or environment).^{[footnote 21]} It may be helpful to consider what measurable embedding indicators would look like in specific organisational contexts.

Please see full guidance and Annexes for further detail and supporting pages.

1. HM Government, Oral statement to Parliament: Covid-19 Inquiry Module One, July 2024 ↩

2. Government response to Preparing for Extreme Risks: Building a Resilient Society (PDF, 329KB) ↩

3. Civil Contingencies Act 2004 ↩

4. National Resilience Standards for Local Resilience Forums (LRFs) ↩

5. Emergency Preparedness ↩

6. Treasury Minutes Government Response to the Committee of Public Accounts (PDF, 2.7MB) ↩

7. Government response to Preparing for Extreme Risks: Building a Resilient Society (PDF, 329KB) ↩

8. UK Resilience Framework (PDF, 6MB) ↩

9. Hillsborough Charter ↩

10. HM Government, Organisational Resilience Guidance for UK Government Departments, Agencies and ALBs (2024) ↩

11. BS 65000: 2022 Organizational Resilience – Code of Practice ↩

12. Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) ↩

13. The NATO Lessons Learned Handbook Fourth Edition (2022) (PDF, 1,844KB) ↩

14. Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) ↩

15. Homeland Security Exercise and Evaluation Program (HSEEP) (2020) (PDF, 2.9MB) 6-1 ↩

16. Australian Institute for Disaster Resilience:Lessons Management Handbook (2019) (PDF, 1,212KB) ↩

17. JESIP Joint Organisational Learning Guidance (2017) (PDF, 1,646KB) ↩

18. HM Government, National Risk Register 2023 ↩

19. Adapted from: JESIP Joint Organisational Learning Guidance (2017) (PDF, 1,646KB) ↩

20. HM Government, Community Resilience Development Framework, 2019 (PDF, 635KB) ↩

21. HM Government, National Protective Security Authority Embedding Security Behaviours: using the 5Es (2023) ↩