Case study: lessons management capability in emergency management and beyond
Heather Stuart, NSW State Emergency Service and Mark Thomason, South Australian Country Fire Service
Lessons management is a small but growing capability across the emergency management sector. This case study explores how a number of emergency services organisations have collaborated to grow this capability both internally and across the sector.
Emergency services organisations (ESOs) face both internal and external scrutiny of their operations through formal reviews. The level of external scrutiny has been increasing over the years, beginning with the Royal Commission into the 1939 Victorian bushfires and peaking with the 2009 Victorian Bushfires Fires Royal Commission. These reviews have changed community expectations of ESOs. No longer is it sufficient for them to just respond—and generally respond well—to events. Agencies now need to demonstrate not only that lessons have been identified (or learnt as we commonly see in the media) but that the resultant change in activities or behaviours has been effective and that, as a result, the delivery of services to the community has improved. As a result of these challenges, many ESOs have established a lessons management capability.
At the beginning of 2011, the NSW State Emergency Service (NSW SES) established its Lessons Learned Branch. The aim of the Branch was to help the service learn lessons from both corporate and operational activities that would result in improved organisational performance. This was the first lessons management capability for the State Emergency Services nationally. While not a direct response to a formal enquiry or review of the activities of the operations of the NSW SES, the development of this capability followed reviews in other states and was seen as a proactive approach to improving the services delivered to the communities of NSW.
The South Australian Country Fire Service (CFS) had developed a lessons capacity following the Wangary Fires in 2005. The Wangary fire and other fires on that day were the most destructive fires, in terms of loss of life and property, that the CFS had seen since the Ash Wednesday fires in 1983. Given the losses, community grief and the Coronial inquest into this event, CFS recognised that a more formal approach into learning from these events was required and that the service owed it to the community to demonstrate improvements as soon as possible. This was the first time that a formal approach had been utilised in CFS for collecting, analysing and theming lessons.
As part of the research undertaken to develop the capability, the NSW SES Lessons Learned Branch established a relationship with the National Security Capability Development Division of the Attorney-General’s Department. This Division had already developed a capability for evaluating strategic exercises and identifying lessons from these. Work had also commenced on translating these learnings into improved response plans and exercising.
With a growing interest in lessons management nationally, the Attorney-General’s Department provided the linkages to connect a number of agencies to share their lessons frameworks and their learnings about the implementation.
In late 2011, Emergency Management Australia hosted a lessons workshop that brought together a diverse range of agencies from across the emergency management and national security sector to discuss and explore lessons management. It was soon discovered that the majority of agencies were in a similar position of attempting to establish a lessons framework and developing strategies to implement the lessons identified. For many of the agencies, conducting debriefs was routine with observations collected and varying levels of attempts made to resolve or action each issue raised within those debriefs. However, this was not demonstrated to be sustainable given the number of debriefs conducted, the capacity of the lessons management practitioners and traction for the capability within the organisations. As a result, observations were rarely analysed and trends were often not used as a means of elevating critical issues. At this stage, for all agencies involved in lessons management, the concept of producing meaningful outputs was challenging.
During the lessons workshop it became apparent that the development of a lessons capability for an organisation was usually confined to one or two individuals who had some organisational knowledge as well as experience in, or a passion for, organisational development. These people were largely working in isolation within their organisation, with limited opportunities for collaboration, sharing ideas or exposure to alternate views on lessons management.
The challenge therefore for all lessons practitioners was to leverage opportunities that would provide benefits to the lessons processes and, as a result, the organisation, as well as opportunities for their personal development. The need and desire for a lessons practitioner network was clearly identified at the workshop, however, before true collaboration and leveraging of opportunities could occur the individual practitioners needed to form relationships and establish a sense of trust between each other. Only then would it be possible to fully share ideas and concepts, areas of poor performance in their agencies and their own limitations in establishing a lessons capability.
A number of attendees from the initial lessons workshop began tentatively to establish their own networks—sharing their knowledge, experience, tools and ‘tricks of the trade’. For both NSW SES and CFS this collaboration resulted in the discovery of strategies for managing large volumes of data, learning the value of trend analysis, the importance of publishing results and the approaches used by lessons managers to gain support for the capability from across their agency. As information was shared and explored the relationship between the practitioners from these agencies developed and a level of personal trust was established.
Following the lessons workshop, the Attorney-General’s Department instigated the development of a Lessons Management Handbook (Australian Disaster Resilience Handbook 8: Lessons Management, 2013). The Attorney- General’s Department, NSW SES, CFS, Fire and Rescue NSW, Victoria Police, the Country Fire Authority and the (then) Emergency Management Queensland came together as a working group to share their knowledge and experience and develop better practices for lessons managers, with the output being the Lessons Management Handbook. This collaboration saw the development of a standard terminology for lessons management and a concept for common coding and analysis of observations across many ESOs. The working group travelled to most states and territories to share their learnings, promote lessons management and the handbook, as well as widen the lessons practitioner network. Through these activities the relationships between the lessons practitioners in the working group strengthened. The members of the working group began to share their lessons frameworks and results of their lessons management activities. As their collaboration increased so did the levels of trust in each other and their agencies. This resulted in open sharing between the agencies of observations of organisational performance, lessons identified and internal publications such as newsletters, standard operating procedures and operational bulletins. Information on the barriers within each organisation that prevented lessons being learnt was also openly shared. This process of close collaboration and sharing helped each of the agencies to develop their own lessons capabilities further, as well as contributing to the development of a resource that is now assisting many other agencies and individuals across the country who are interested in lessons management and organisational development.
As a result of the collaboration on the lessons handbook a common gap in knowledge of data analysis was identified by the lessons practitioners. Fire and Rescue NSW led the way by organising a joint workshop where observations from agencies could be shared and a consistent approach to data analysis developed. This collaborative workshop involved sharing data, discussing events and agency procedures in detail and identifying the root causes of poor performance. The workshop furthered the skills of all participants and resulted in several lessons common across the participating agencies being identified. These ‘national lessons identified’ were developed into a report and circulated at national, state and agency levels. The open sharing of data regarding agency performance that resulted in the development of these national lessons would not have been possible without the previous close collaboration of the participating agencies.
From their initial contact the lessons managers from NSW SES and CFS identified a number of synergies between their agencies. Although combat agencies for different hazards, the observations, lessons identified, suggested treatment options and communication challenges were similar. Both agencies rely on a geographically dispersed volunteer workforce that presents additional challenges including conducting debriefs in a timely manner, communicating lessons identified and having altered procedures or governance implemented. The lessons managers from these two agencies shared information and experiences in relation to these challenges, which in turn has led to the interstate exchange of lessons practitioners after major events. These exchanges began with the invitation from CFS to NSW SES to assist with promoting lessons management to their senior leadership team and this was followed by a invitation to a larger group of lessons practitioners to assist with the analysis of data and identification of lessons post the major fires of 2014. In 2017, NSW SES invited practitioners from a number of states to assist with the collection and analysis of data from the 2016 floods in western NSW. The previous collaboration and sharing of skills and knowledge between the lessons practitioners had established the relationships that now provided the additional resources that enabled the respective host agencies to analyse thousands of observations gathered during large-scale events, identify lessons and provide reports for their respective agencies in a timely manner. The lessons identified from this collaboration now form the basis for continuous improvement within the agencies.
In summary, collaboration between lessons practitioners in the emergency management sector has provided opportunities for agencies to develop a common approach to collecting, coding and analysing data. Learning lessons as a lessons practitioner is greater than the process itself and an individual agency’s activities. Sharing of experiences, organisational challenges and successes provides opportunities for practitioners to leverage from each other, keep pace with good practices and support the lessons capability in the participating agencies. The synergies gained through this collaboration between lessons practitioners across the emergency management sector has contributed to strengthening the lessons capability in each of the participating agencies and has resulted in greater achievements in this sphere than agencies would have achieved working in isolation.