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Vishwadeep Khatri

Instruction Creep

Instruction Creep is increase in the number of instructions over time to such an extent that the they overlap with each other making them complex and ambiguous


An application-oriented question on the topic along with responses can be seen below. The best answer was provided by Ram Kumar Chaudhary on 8th May 2020


Applause for all the respondents - Pradeepan Sekar, Shashikant Adlakha, Satyajit Das, Ibukun Onifade, Tushar Maradwar, Ram Kumar Chaudhary, Rajeshwari, Senthilkumar G, Ajay Sharma


Also review the answer provided by Mr Venugopal R, Benchmark Six Sigma's in-house expert.


Q 259. Even with detailed SOPs, workers are unable to follow the instructions and end up making errors. Usually the RCA obtained is - 'I forgot'. Could there be an issue in the way SOP is written? What is Instruction Creep and how can process owners avoid it while creating process SOPs?


Note for website visitors - Two questions are asked every week on this platform. One on Tuesday and the other on Friday.

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Commonly understood definition of instruction creep is documentation or codified knowledge leveraged for process execution becoming overbearing and loosing effectiveness.


Documented process knowledge resides in the form of SOP's ( standard operating procedures) in organizations. These are usually step level instructions on how to execute a process and has day to day relevance in operations management, training, regulatory compliance and audit for adherence to laid procedures as well as best practices. Amazing isn't it so many different objectives/lens to look at SOP's. Can the process operator still make mistake in executing process task, the answer is BIG YES. Let's decode why this happens


1. SOP documents over a period of time become like Epic running into pages ( 2-3 pages to over 500+), process operators start trusting their own experience and knowledge then referring to bulky SOP's for reference while executing process. This happens in most cases due to unhealthy practices around SOP management (e.g., long gaps between SOP reviews, low quality indexing, not-removing redundant sections from the document, delegation of responsibility for SOP's to lowest level).


2. Poor design of SOP's (e.g., objective of SOP's, layout, content and indexing of content, visual versus text heavy, searchability within SOP, on Word document/Excel versus on Digital platform). Mostly SOP's are designed to cover the content comprehensively to ensure compliance versus usability. Process operators find it difficult to search information in SOP's when they need it the most while encountering new situation or scenario. This results in process operators struggling to figure information and making mistakes


3. Delayed updating of SOP's, in high demand variation environment usually SOP's don't keep pace with changing nature of process. Lack of timely updating results in poor knowledge dissemination and mistakes when process operators encountered an exceptional scenario.


4. Lack of monitoring discipline of SOP compliance, organizations usually lack mechanism to monitor adherence to SOP by process operators usually in ITes space apart from sampled transactions. Few organization don't have tracking when did the process  operator last read the SOP resulting in dilution of SOP adherence and subsequent mistakes


5. Over-leverage staff, there are large variety of processes with significant demand variability leading to cross skilling of process operators across multiple of processes, which they usually don't execute in normal course of day. In special events, when they are assigned to execute a process on which they are cross-skilled, usually they end up making mistake due to nuances in the process


How can process owners avoid instruction creep in SOP's?


1. Process owners should be directly engaged in review of the SOP's atleast once a quarter

2. Only keep the relevant/current process in SOP's and move historic process to appendix or archive

3. Improved UX of SOP's via digital platforms for quick review, updation, dissemination with SOP workflow

4. Making SOP's visual or voice enabled versus textual

5. Tracking usage of SOP's, usage improves process operators will ensure SOP's are live and relevant 



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Benchmark Six Sigma Expert View by Venugopal R

Instructions are created for a process with the intent of being followed to maximize consistency while executing a process. This discussion can be in the context of a SOP for a business process or for Work Instruction for a production process. Over a period of time, instructions get amended based on inputs, feedback, changes and for continuous improvements. The amendments could be addition of steps, exceptions or changes. The bulk of information in the instruction or SOP grows and the chances for interpretation variation increases, thus defeating the original intent of ensuring consistency.


Most large organizations had the practice of maintaining voluminous procedures and instructions even before the days of ISO 9000. However, with the advent of the international QMS standards, the practice of creating various levels of SOPs and instructions received higher impetus and awareness. Work instructions are even displayed, often with pictures and sketches at the respective work stations. Most of us would have noticed that, for repeated processes and operations, people do not keep referring to SOPs and instructions. Then, the question arises, why do we need to have such SOPs and instructions?


Some of the reasons to have SOPs and instructions would be:

  1. They serve as ready reckoners and reference documents.
  2. They serve as documents against which process audits can be conducted to assess the extent of compliance.
  3. They are useful while performing RCAs to assess whether the issue has happened due to non-compliance to laid down procedures.
  4. They will be useful while training / re-training employees.

For most critical processes, operator (or processor) certification is essential, the criteria for which will include not only the knowledge about the process, but also the skills and ability to perform the task consistently correct. The certification criteria has to be included in the respective SOPs and it is important to ensure that visible evidence is available on the work stations that the person performing the task is certified.


Some actions necessary to keep “Instruction creep” under check:

  1. Periodic reviews of the SOPs and Instructions are essential to ensure the updation all its contents, improve sequencing, simplify the contents and reduce interpretation ambiguities.
  2. Identify and introduce as much automation, visual & audio based andons, and mistake proofing, so that the efforts to follow instructions will be simplified.
  3. Have clear certification criteria for all critical processes and ensure compliance to certification process and usage of certified personnel.
  4. SOPs for business processes need to be built-in as part of the Enterprise workflows, with necessary checks and balances.
  5. For critical activities or decisions that still need a human judgement, institute a process by which such decisions cannot be executed by single individual.

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Standard Operating Procedures:

         SOPs are the documents which describes the actions to be taken under several circumstances, it also lays who, what, when and where for the important actions. It provides clear and concise guidelines.

         SOP should be the document which is serving at higher level and the detailed instruction should be described only in work instructions and only the reference of those work instructions will be provided at SOP. So that the SOPs will be clear, simple and concise.

         Otherwise it results in instruction creep.

Instruction Creep:

Instruction creep occurs when the procedures are increasing in a system with more details in such a way that it causes severe damage to the progress of the organization. Instructions are made to retain or continuously improve the success of the organization, but in turn when they go complex or abundant, causes the failure.

Instruction creep occurs in most of the organization. Usually it happens when the procedures are framed without questioning them, by change in thoughts of the people who create it or by changes in the set of people who make use of it.

If the instruction creep persists in the Standard operating Procedures of the system, it will often result in addition, substitution, or modification of the procedures. It often results in the overlapping of the communication and in lack of clarity, efficiency, communication, and consistency.

         Believing that the people will read all the instructions in SOP with the attention, irrespective of their volume or complexity of the instruction is the most common reason for the instruction creep. Sometimes the procedures are made with deliberate intent to control the people without reviewing them with the concerned people or without collaborating with the users.


Ways to overcome the instruction creep:


Best Practices:

1.   SOP should be clear and concise.

2.   Easy to understand.

3.   Possible pictorial representation to avoid reading of volumes.

4.   Segmentation on the instructions. So required document can be accessed at the time when it is needed.

5.   Introducing more Poka yoke rather than procedures or instructions.

6.   Routine training on the procedures



         SOP can comprise of checklist. Set of instruction should be comprised into checklists with which we can ensure that all the instructions have been followed. Checklist should be made in such a way that the users find it easy and helps them to follow procedures without missing any steps.

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Standard operating procedures govern all the routine and complex activities in an organization. While utmost care is usually taken in writing SOPS according to quality standards like ISO 9000, keeping in sync with the organization’s internal policies and detailed instruction of each activity being narrated, many of the SOPS(Manual  or online) do not have  requirements such as  associated  documents or computerised system  to record the proof that all the tasks are actually performed according to the instructions in SOPS. This requirement is sometimes deliberately not included, as these may be audited in  various  external audits of the company. This results in  employees not adhering to the instructions, especially if they are complex ones and giving the lame excuse that –“I forgot”. Also this kind of non compliance can happen when hard copies/soft copies of SOPs are not available at all the workplaces of the organization.

Instruction creep refers to increasing  number and complexity of instructions, due to changing rules and guidelines from time to time . This  happens especially in complex organizations. The constant change and addition of inputs, leads to modification of instructions and considerable overlap , with loss of clarity and effective communications. Regardless of the length or complexity of the instructions, instructions are often perceived at  same level and antagonize each other, without proper collaboration. 



Ways to avoid instruction creep with well-organized  SOPS:

-       Instructions to be written in clear and concise manner.

-       To be written always from a practical perspective and taking the view and background of the employees, who will be using it on a constant basis.

-       Instructions must be written in a step by step manner, without having an overlap.

-       Instructions must be written in simple language with brief sentences, rather than expressed as in technical language or as a jargon. These instructions may be hardly understood by few employees, leading to confusion and chaos amongst other employees.

-       Directions need to be straightforward with no choices  usually and  even if it needs to be there- the situation and option must be clearly stated. ‘Must’ word be used, rather than  ‘May’, ‘should’- which really have no concrete meaning and do not give a clear cut direction to employees,




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The full form of SOP means "Standard Operating Procedure". SOP is a process document and its main purpose is to provide step-by-step instructions on how to perform a particular work/job activity, such as installation of GT, manufacturing of solar panels or record keeping, etc.

During initial period of time most SOPs are presented as text documents, but it has been observed that many times the job procedure was not able to understand by certain percentage of technicians or supervisors, as they are the responsible persons those who had to perform the job and therefore, it led to lot of rework and quality issues. So, after thorough investigating, it was found out that the SOPs are either written in very high technical language, lengthy and complicated instructions or sometimes the communication misinterpretation between the working personnel to the supervising personal.  Therefore, to avoid such circumstances, the SOPs are written in simple text, small line step content, easy to understand and now they also contain images, small videos and 3D modeling for better understanding and to help clarify the instructions.

Instruction creep occurs when instructions from an organization are increased in so much in number and size with time that finally they are uncontrollable. Instruction creep is very common in complex organizations, where rules and guidelines are created by changing groups of people over extended periods of time. The constant state of variability in these groups are often leads them to add or amend instructions, rather than clarifying or integrate the existing ones. This can result in considerable overlap in the message of orders, at the expense of clarity, competence, and communication, or even of stability.

Instruction creep can be controlled or avoided in SOPs by keeping policies, procedures and standards transparent and accessible to all employees for most effective outcome. Subsequently additions to policy should not to be considered unless:

1.    There should be a real problem that needs solving, not just a hypothetical or recognized problem.

2.    If the proposal is implemented is likely to make a real, positive difference or effect.

3.    All suggested requirements have a clear concord.

4.    All instruction language should be as clear or simple as possible and ensure that addition context are placed in a logical order, and do not obscure the meaning of the surrounding text.

5.    It is usually better for the organization that the policy or guideline may to be lenient rather than too strict. As, it will increase the effectiveness / output of the employee and better co-ordination between the employee and employer.


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Instruction creep is a common problem especially in large organizations. Standard operating procedures are usually modified frequently once any lapse is perceived by people responsible for maintaining order in the process. This continuous addition often leads to a complex guideline that most workers find tedious to read through or implement completely. In fact, most workers do not read their usually voluminous SOPs not to talk of following the contents. Many guidelines have been rendered ineffective because of this anomaly. The following steps can be taken to avoid instruction creep;

1.       SOPs should only be created only when there is a real problem to be solved, not just by someone’s perception. A review committee can be established to review any new SOP and give approval only when the SOP is targeted at a real challenge. This will eliminate unnecessary accumulation of SOPs .

2.       Precise language should be used when creating SOPs to eliminate confusion during implementation. Volume of words should be kept minimum, unnecessary repetitions should be avoided when creating guidelines. Guidelines can be translated using visual aids if possible. It is said that a picture is worth a thousand words, this has been proven to be the most effective way of communication whenever a sizeable number of people are involved.

3.       Policy makers need to involve the workers that will implement a policy when drafting it. Their inputs should be given consideration when drafting SOPs. Doing this will make them have a perfect understanding of what is expected of them, it will also improve their level of compliance and cooperation when the SOP is implemented.

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What is Instruction Creep??

Many businesses choose to implement standard operating procedures by displaying written documents in areas where they will be clearly visible to all employees, but gradually overtime instructions increase in numbers and size until they are uncontrollable and this situation called INSTRUCTION CREEP. It result in complex procedures which often misinterpreted, followed with great irritation/, or ambiguity/ignored. This can lead to damage the success of organisation.

Organisations where rules and guidelines are created by changing groups of people over extended periods of time, Instruction creep is quite common. Due to this situation such groups often leads them to add or modify instructions, rather than simplifying or consolidating existing ones. This can result in considerable overlap in the message of directives, at the expense of clarity, efficiency & consistency of communication.


How process owners can avoid instruction creep while creating process SOPs?


Using workflow chart or pictorial view is a great way to create an interactive database of information rather than a cumbersome document. 


These are 5 ways by which process owners can avoid instruction creep while creating process SOPs

Develop a list of your Business processes

To get started, manager must think that what kink of duties employees perform in their jobs every day. It will allow them to begin creating a detailed list of processes that need standard operating procedures and at same time look for any redundancies. This list will serve as a starting point for creating standard operating procedure.

Plan the process

In this step, we need to decide on a format for process, e.g step by step work flow chart or pictorial view, after this we can create a template. Also we need to decide how standard operating procedure will be made visible to each employees, whether it will be a written copy posted or will a copy be available online.

 Talk with employees and SMEs

Now we have our list of processes and we have created our template, we need to talk to our employees. This is important because we can’t fully understand the process unless we have spoken with the people who actually perform it on a daily basis. Only speaking with management is not enough.

Write and review the process

Once we have spoken with our employees, immediately add  notes to the template. From there we can review standard operating procedure with employees once again and obtain input from subject matter experts. we should also determine who will be responsible for oversight and maintenance of the standard operating procedure. Take trial with new employees and ask him to perform task based on SOP only, based on this update SOP if required.

Maintain the process

This is very important step i.e. maintain, after SOP is written, In order to remain technology relevant and useful, we must maintain and define frequency to update/display it as per process requirement. At same time Team for writing and updating SOP should not be change frequently.

Standard operating procedures are time-consuming to create at first but the benefits are worth it. It will save a lot of time and frustration down the road and enable succes of organisation.

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Instruction creep usually is the result of exhaustive documentation and very lengthy documentation which becomes very tough to manage over a period of time.Often the issue while creating SOP's is having the documentation done in a very complex manner which has multiple handoffs, with different groups of people updating the same at different times on account of which understanding the message.Also, when it is too lengthy it is very difficult for the people  to pay attention to the document. Also when there is a new learning or a process exception that the teams encounter they fail to update the same or they update the SOP and miss sharing the new learning with the larger team, this would either result in repeat errors since the other team members are still using the older versions or increase number of touch points where the associate is constantly asking questions and the customer/stakeholders feels it is repetitive and they have already covered with the other team member

Process owners can avoid instruction creep while creating the SOP's by following few simple steps :

1.Keep the SOP very simple so it is easy for the users to intrepret and use

2.Keep the exception log as a separate section in the SOP since that would need more attention as they are all new learnings that the team might have to revisit more often, this has to be discussed with the team as part of their meetings to emphasis the importance

3.Add clear topics and hyperlinks so that the team visits only the relevant sections

4.Adding process maps as part of the SOP would be impactful since it is very easy for the doer to visually connect vs going through a detailed document

5. Proper version control and change log of documents need to be maintained with storage of the same in a centralized repository, this way the latest updates do not get missed

6.Follow the steps in the SOP to complete a task  to check if it actually works

7.Add the key risks related to the process and accordingly create a checklist as part of the SOP so the team can use it as a quick summary to check the quality of output

8.Always get the SOP sign off from the stakeholders to ensure the scope is right and the issue resolution is accurately captured



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Q 259. Even with detailed SOPs, workers are unable to follow the instructions and end up making errors. Usually the RCA obtained is - 'I forgot'. Could there be an issue in the way SOP is written? What is Instruction Creep and how can process owners avoid it while creating process SOPs?


Instruction Creep:

Instruction Creep is a phenomenon and Operational Science & Engineering driven that occurs common in Large Organization. Short and Simple descriptions, straight to the point should allow knowledge to become accessible for respective learners. Instruction creep can also lead to uncertainty and misunderstanding, it will also affect the bonding and internal relations ship within the same organization.


Could there be an issue in the way SOP (Standard Operating Procedure) is Written?

SOP is written by Project Delivery Team and collaboration with operational team together in most of the organization. Project delivery team must be in a position to engage and should have a strong collaboration with operations team till to complete the Integrated Standard Operational Procedure Document (SOP’s) without errors.


The following Key Process and Technical Skills are required to complete the SOP:

1.     Engagement

2.     Collaboration

3.     Respect

4.     Performance

5.     Verification

6.     Validation.

For every incident in large organization, based on RCA (Root Cause Analysis) or 5 whys techniques, either standard operational procedure document not been updated, or Person not reading the instructions, or not understand the instruction clearly, or Technological gap and Skill gap only.

When instructions appear to be overwhelming made human to do more mistakes in Operational activity. Step by step standard procedure document to be prepared by project delivery team along with operational team together based on the number of exercises/iterations/simulations are done by operations team. Over all, the final collective inputs from various team would definitely helpful to achieve the strong SOP’s in large organization before handing over to Business Operations.


What is Instruction Creep and how can process owners avoid it while creating process SOP's:

Instruction Creep is a phenomenon and Operational Science & Engineering driven that occurs common in many Organization. Short and Simple descriptions, straight to the point should allow knowledge to become accessible for respective learners.

The large organization should have the following practice to revisit their Business Analysis beyond the Projects while creating strong process SOP’s.

Business Analysis Beyond the Project:

1.     Pre-Project (Project Rationale)

2.     Project (Delivery)

3.     Post Project – Benefits Realization.

We need to analyze the following Business Analysis Knowledge Area while Project (Delivery) phases, it is possible that information creep could be avoided before handing over to Business Operations.  

1.     Strategy Analysis (Business Requirements),

2.     Requirement Analysis and Design Definition (Stakeholder & Solution Requirements) and

3.     Solution Evaluation (Transition Requirement: Proof of Concept, Prototype)


My Personal View about Instruction Creep:

Instruction Creep is a phenomenon and Operational Science & Engineering driven that occurs common and we need to have an ideality to achieve zero errors in SOP’s written in large organization. Instructions creep may happen with respect to Project delivery schedule pressure or Cost overrun in any projects. This has to be planned in well advance. We need to engage constantly with the vendors and contractors for number of simulations along with project execution team/operations team together before SOP’s written or before handing over to Business Operations. There may be a gap in Project delivery versus Operations team with respect to project delivery schedule pressure or cost overrun.

Employers may represent one person from Operational Excellence, HSE, Cyber Security, Business Communication (In Country Value), Ethics and Behavior, Regulatory Compliance, Diversity and Inclusiveness (D&I), Change & Knowledge Management, Training, Auditing and Social Responsibility team together with project team while under critical project development phases in large organization so that their collective inputs will be helpful to avoid information creep. It will also helpful to deliver the SOP’s without errors and added value to the bottom line of large organization.


Scenario 1: The following simple matrix shows the overall output for Strong SOP’s written.


1.     There are three team together would be having various iterations/simulations schedule separately for the same critical project before handing over to Business Operations.

2.     Standard Operational Procedure (Initial) steps performed by respective team for the same project.

3.     GAP analysis would be done based on the Lessons learnt (Initial) prepared by respective team.

4.     After analyzing the GAP, Lessons learnt (Final Version) and Standard Operational Procedure (SOP – Final Version) document would be released after performing final simulation with same team before handing over to Business Operations.





Standard Operational Procedure Document (SOP):

SOP- Standard Operational Procedure Document may have a short and simple explanations to the point and allow knowledge to become accessible to users.

SOP should also contain about document authorization and document controller along with revision history in case of any future change. For any change in SOP, we should have the Change Management process request along with proper evidence to get an approval from respective function.


The following Major elements to be included in SOP’s:

1.     Document Authorization.

2.     Revision History

3.     Related Business Process

4.     RACI Matrix

5.     Architecture (Logical Architecture, Physical Architecture)

6.     Assets List/Asset Register Lists.

7.     Business Communication, Vendor & Contractor details.

8.     Technical Design, Support Document references.

9.     Performance Monitoring

10.   Step-out and Approval.


Plan-Do-Check-Act Cycle:

PDCA is a method used in Business that can enable team to control and improve process continuously (Continuous Improvement). This cycle could be followed with number of iterations so that the respective SOP (Standard Operational Procedure) document will be delivered without errors.





Thanks and Regards,

Senthilkumar Ganesan,

Email: senthillak@gmail.com

Mobile: +91-7598124052


Instruction Creep.docx

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“The best SOPs are the product of iterative process. Get a draft SOP displayed as fast  as possible and make optimizations over time”

SOP stands for standard operating procedure. It is the best tool to bring the standardization in process and reduce the variation due to operator’s way of doing a job. Generally a good SOP includes process parameters, product parameters, SOP identification and traceability no. and the flow of process with in an operation with PPE guidelines and do’s don’ts. But it has been noticed over time that even the detailed SOPs are available and displayed properly, still operators end up doing mistakes. And after analysis RCA found mostly is – ‘I forgot’.

It has been seen that when instructions increases in number and size doing optimization over time, instruction creep occur. And it can be insidious and damage the success of large groups, originating the ignorance of the KISS principle (acronym for keep it simple, stupid) resulting in complex procedures (opposite to simplified) which are generally misunderstood, followed by ignorance. Instruction creep is common in large organizations, where guidelines are created by changing people groups over period of time. This results in adding of more instructions rather than simplifying existing ones. Over period of time, instructions will start over lapping at the cost of clarity, efficiency, consistency and communication. The biggest irony of instruction creep is that SOP makers believe that people read instructions with same level of comprehension, no matter how complex those instructions are.

Instruction creep can be and must be removed by the process owners keeping in mind at the time of SOP making and adding on instruction while optimization.

Just follow “KISS principle”, i.e. follow “ keep it simple, stupid” rule.

Whenever adding more instruction, considering the earlier instructions and make visible to operator what they are supposed to read again and again. Keeping guidelines and SOPs to the point is the key to remove instruction creep and most effective way of preserving transparency. Addition of instructions should be in case of real problem not just a perceived problem or hypothetical problem. The addition if implemented  should make a real or positive difference and all implementations should have a clear consensus. All instructions must be as clear as possible.

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Instruction Creep is a phenomenon that plagues not just the SOPs but every situation where a set of instructions has to be followed. Most recent example could be the COVID-19 guidelines and instructions by the Central government that all states and district administrations must follow. The volume of these instructions is humongous and hence the administrators have a tough time understanding and following them.


The best answer to this question has been provided by Ram Kumar Chaudhary.


Ajay Sharma's answer is also worth a read as he has highlighted the KISS principle.


Also review the answer provided by Mr Venugopal R, Benchmark Six Sigma's in-house expert.



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