
Big Spring, a giant karst spring in The Ozarks, Missouri. It produces water at the rate of approximately 469 cubic feet per second. That's equivalent to 459 Olympic-sized swimming pools per day. But although the spring is the source of a stream that feeds the Current River, the spring isn't the source of the water. The aquifer is the proximate source. But even before that, the source is rain. And before that the oceans. And before that, … The hydrosphere is cyclic.
Defect streams, unlike the hydrosphere, are rarely cyclic. They do have root causes, some of which are subtle. Photo (cc) Kbh3rd courtesy WikiMedia.
In many kinds of knowledge work the quality of the output is important enough that we require the people who perform the work to meet specified quality standards. When they don't, we intervene to take corrective action. That corrective action often requires changes to the way the work is performed, with the hope that the changes will lead to improved output quality. Sometimes this approach works well. But at other times, even though the changes seemed to bring about the desired improvement at the pilot scale, the results of the full-scale intervention are disappointing.
This post explores a plausible explanation of disappointing results of some interventions intended to address defects in knowledge work. That explanation depends on a model of how defects arise based on the idea of defect streams and their sources.
For concreteness, consider the case of an organization engaged in deploying a software security platform. That platform will support a large number of applications that an even larger number of people use in the course of their daily work. To ensure that users can do their work in a secure environment, it's important that the deployment meet strict security criteria — for the platform itself and for each application.
Defect streams
The people performing the work are required to follow complex procedures to ensure that each software application can be used safely. Although the procedures are similar in large part, they differ in detail depending on the type of software being installed, and on the particular product and release of that product. If the person performing the work executes it incorrectly, the evidence of the error might not appear immediately. Often, the error is discovered by the Quality Assurance team, which reports the error in a weekly defect report. We can regard these errors as comprising a defect stream.
Defect sources
Streams Those who devise procedure changes
to reduce the incidence of defects
must provide the resources necessary
to adopt their recommendationshave sources. We usually assume that the sources of the errors lie somewhere within the organization that is executing the deployment. Although it's common to assert that the cause of the errors is shoddy work by the people who last touched the defective work product, their behavior might not actually be the root cause.
Three possible candidate root causes are below:
- Unfunded mandated effort
- Announcing a procedure or procedure change is an important step in taking corrective actions. But unless the people who execute the procedure have access to the resources and time required to learn a procedure, or to learn about the latest changes, they cannot afford to acquire the knowledge they need to execute the altered procedure correctly.
- Those who design interventions intended to reduce the volume of the defect stream must provide the resources necessary to adopt the changes they are recommending. Absent those necessary resources, the people who execute the procedures in question will scrounge equivalent resources from someplace else. The result, often, is formation of new defect sources that feed the old defect streams, or which create new defect streams.
- Misallocating the cost of procedure competence
- The cost of procedure competence is the cost of training the people who execute the procedure, plus the cost of ensuring their continued competence after training is complete. We usually allocate that cost to the business unit in which those people perform their work. But in many cases, that allocation is erroneous. And it might even be the root cause of the defects.
- For example, consider a cumbersome and overly complicated procedure. In an extreme case, the procedure can be so gratuitously complex that nobody can apply it correctly with regularity. Defects are inevitable. Should not the cost of these defects be charged to the poor design of the procedure? Said differently, should not the cost of the training required to prevent defects be charged to the poor design of the procedure?
- That is, the cost of procedure competence ought not to be borne solely by the business units responsible for executing the procedure. Some of the costs might be due to procedure design. Allocating some costs to the unit responsible for the procedure design helps to ensure that procedures are designed with learning costs and execution costs in mind.
- Frequent changes in procedures
- Those who execute the procedures need to understand the procedures to avoid making errors. If changes are frequent, they need to monitor the status of procedures so that they'll be aware of changes that can affect their work. That monitoring activity competes with other responsibilities for their attention.
- The cost of a procedure change should include more than the cost of designing the change. Training and retraining are real costs. The unit that makes the change must provide resources to the units that must execute the change.
Although these observations are expressed in terms of defects in work product, they apply equally to compliance with policies. To see how, consider policies to correspond to procedures in the discussion above, and deviations from policy to be defects. Top
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