About this Presentation
This presentation describes a number of undesirable effects (UDEs) associated with not learning from previous events such as people making serious or costly mistakes: people are unable to pinpoint the flawed paradigm; when significant change occurs people operate under the wrong or old paradigms; etc. Learning the right lesson from a specific event is critical so a control system must be able to quickly identify and correct faulty paradigms within the organization. We conduct a thinking processes (TP) analysis with the objective of identifying the flawed paradigm. The author describes a paradigm in TOC terms as a small cause-and-effect tree. The existence of a flawed paradigm might be exhibited as a gap in expectation or performance (a surprise). The gap can be treated as the DD' of an evaporating cloud (EC). In the current reality tree (CRT) the cause of the gap is hypothesized and validated. The differences between the typical TP analysis using many UDEs and this type of analysis using one UDE are discussed. The flawed paradigm is identified and analyzed using the cloud and the future reality tree. The full seven-step learning from experience process is outlined and some implementations are provided. A fictional case is provided to illustrate the process.
What Will You Learn
To help you get the most value from this session, we’ve highlighted a few key points. These takeaways capture the main ideas and practical insights from the presentation, making it easier for you to review, reflect, and apply what you’ve learned.
This presentation reframes organizational mistakes and surprises as signals of flawed paradigms rather than just operational failures. Its central insight is that real learning begins when a team investigates the gap between what it expected to happen and what actually happened.
A major takeaway is that organizations often learn the wrong lesson from events because they stop at the first plausible explanation, blame individuals, or swing to the opposite paradigm instead of identifying the deeper flawed assumption that drove the outcome.
The session introduces a structured “learning from experience” process built on TOC thinking tools: identify the surprise, verbalize the expectation-outcome gap, test hypotheses, isolate the flawed paradigm, update it, and then use an FRT and negative branch analysis to translate the new understanding into better processes.
It also shows that this kind of learning is as much cultural as analytical. Fear of guilt, weak cause-and-effect reasoning, and undocumented expectations all block effective feedback, while a structured, blame-reducing process can spread better thinking across the organization and create broader managerial improvement.
Instructor(s)
Eli Schragenheim
Eli Schragenheim is a well-known international management educator, author and consultant active in various fields of management. He worked with a huge variety of organizations all over the world, including public-sector organizations, industrial, high-tech and start-ups. Since he had joined Dr. Eliyahu M. Goldratt, the famous creator of the Theory of Constraints (TOC) in 1985, Eli Schragenheim had taught, spoke at conferences, and consulted all over the globe. Eli Schragenheim is the author of several books on various aspects of management. His last book, Throughput Economics – Making Good Management Decisions, together with Henry Camp and Rocco Surace, was published in July 2019. Eli Schragenheim first book Management Dilemmas (1998) showed a variety of problematic situations in management and the rigorous analysis leading to the right solution. Next he collaborated with William H. Dettmer in writing Manufacturing at Warp Speed. In this book the new concept of Simplified-DBR, now a key concept in production planning according to TOC, was introduced. He collaborated with Carol A. Ptak on ERP, Tools, Techniques, and Applications for Integrating the Supply Chain, and with Dr. Goldratt and Carol Ptak on Necessary but Not Sufficient. In 2009 his book Supply Chain Management at Warp Speed, with William H. Dettmer and Wayne Patterson was published. In March 2015, Eli has opened a blog, now containing more than 140 articles on various topics in TOC that everybody can access.