Quality is a System

quality isn't something you make - it's something that comes from the system

Most people talk about quality as if it lives in the work. A bug appears, a failure slips through, or a customer reports something odd, and the instinct is to hunt for the moment it went wrong. We look for the action or the person closest to the event.

But quality isn’t a property of the product. It’s the property of the system that produces the product.

I didn’t fully understand this until the first time I read Zen and the Art of Motorcycle Maintenance - a book I still re-read every few years. Pirsig doesn’t hand the reader a definition of quality. Instead, he treats quality as something lived. Something you cultivate. Something that emerges from care.

When he tunes the motorcycle, the work isn’t just technical. It’s personal. He notices the tension of the bolt, the sound of the engine, the feel of the road. Quality becomes the meeting point between intention and action. It shows up when the mechanic is fully present with the work.

This reframes quality from a property of objects to a behavior of people in context. Quality isn’t what you check at the end. It’s what you express throughout the process.

That’s where the arc to systems thinking begins.

It Starts With Care

Pirsig’s view is intimate. It’s about care, attention, and the relationship between the person and the work. He suggests that quality appears when someone brings their full presence to what they’re doing. It’s not flashy. It’s usually quiet. But it’s unmistakable.

Teams feel this too.
A designer who sweats the details because they care how the customer feels.
An engineer who chooses clarity over cleverness because they care about the next person reading the code.
A product manager who slows down a meeting because they care about alignment.

In these moments, quality isn’t an act. It’s a behavior.

But care alone doesn’t scale. Care without structure becomes opinion. Care without clarity becomes conflict. Care without flow becomes exhaustion. For quality to show up reliably, the environment around that care has to support it.

That’s the bridge to systems.

The Blame Trap

Every leader has lived the same pattern. Something breaks. A meeting forms. Someone asks, “Who missed this?” The conversation narrows to the final step in a long chain. The spotlight lands on the person closest to the failure.

It feels satisfying because it offers the illusion of a root cause. But it isn’t the truth.

If expectations are vague, if handoffs are rushed, if signals are hidden, or if information travels through side channels, then the system is shaping the outcome long before anything goes wrong.

Systems create behaviors. Behaviors create outcomes. Blame never repairs the system.

Pirsig’s philosophy pushes us to look inward. Systems thinking pushes us to look outward. Quality emerges when those perspectives meet.

The Three Forces of Quality

Three forces need to align for quality to appear consistently.

The first is clarity. People need to know what good looks like. Not the aspirational version. The useful version. The one you can rely on when you’re choosing between two imperfect options.

The second is flow. Work needs to move at a pace that supports thoughtful decisions. When a system pushes people too fast, they do what humans do under pressure. They cut corners. They rely on memory instead of feedback. They assume alignment that isn’t there.

The third is feedback. Quality needs a feedback loop tight enough that people can see the effects of their decisions before it’s too late to adjust.

Clarity, flow, and feedback turn individual care into collective quality. They let Pirsig’s philosophy scale.

Drifting Into Failure

This is where Sidney Dekker sharpens the story.

In Drift Into Failure, Dekker argues that major failures almost never come from dramatic mistakes. They come from small, reasonable adjustments made under local pressures. A shortcut here. A workaround there. A relaxed rule that felt too rigid. Each decision seems harmless at the moment. Some even feel smart.

But each choice nudges the system a little off center. Over time, the drift becomes the new normal. When failure finally shows up, it looks sudden. It isn’t. The system drifted into it.

People don’t drift because they’re careless. They drift because the system encourages it. Behavior comes from motivation, and systems shape motivation far more than leaders like to admit.

Quality works the same way. It doesn’t fail because someone didn’t care. It fails because the environment made caring impossible, impractical, or unrewarded.

That’s why leaders need to pay attention to quiet signals. Small moments are early warning signs.

I’ve seen this pattern play out many times.

A few years ago, I worked with a team responsible for a core internal service. Under pressure to ship faster, they streamlined their workflow. Nothing dramatic. They skipped slow integration checks and postponed cross-team reviews they considered “nice to have.”

Each decision made sense on its own. Small tradeoffs under real constraints. The team wasn’t reckless. They were trying to keep up.

For a few weeks, things looked great. Build times dropped. Releases sped up. Leadership praised them for “moving at the speed of the business.”

Then they hit a wall.

During a routine deployment, a subtle incompatibility between two services slipped through. It didn’t break immediately. It created slow, intermittent failures that looked like network issues. Teams chased false flags for hours. Monitoring lit up. Customers felt the lag. We spent days sorting through long Slack threads trying to find the ‘one thing’ that went wrong.

When we dug in, nothing pointed to a single mistake or person. The team had made a chain of small, rational adjustments. Each step saved time. Each step seemed harmless. But together, those steps removed the system’s ability to see the drift.

We didn’t have a bug. We had a system quietly falling out of alignment.

That was when I understood Dekker’s point. These weren’t careless people. They were good engineers in a system that rewarded speed at all costs, and left quality to chance.

The Hidden Cost of Heroes

Once you treat quality as a system, hero culture becomes a warning sign.

Every company has that late-night savior. The person who can debug anything. The one everyone calls when something catches fire. The person whose calendar reads like a timeline of emergencies.

But if one person keeps saving the day, the system is failing the day.

Hero worship hides structural issues. It normalizes drama. It teaches teams to admire exhaustion. It signals that quality requires extraordinary effort instead of a well-designed environment.

Healthy systems make heroes unnecessary.

The System You Built is the System You Get

One of the hardest truths in systems thinking is that your current system is producing the outcomes it’s designed to produce.

If teams rush, the system rewards speed over understanding. If people stay silent, the system punishes honesty. If quality is inconsistent, the system makes it inconsistent.

People want to do good work. The system determines whether they can.

Every time I’ve dug into a persistent problem, I’ve found something structural beneath it.
A missing expectation.
A misaligned incentive.
A communication pattern built on hope.
A feedback loop stuck in amber.

Fix the structure and the symptoms fade. Ignore the structure and the symptoms keep returning.

Accountability Without Blame

Some leaders worry that if we blame the system, we’ll lose accountability. But accountability and blame aren’t the same.

Blame looks backward. Accountability looks forward. Blame isolates individuals. Accountability examines conditions. Blame shuts people down. Accountability opens them up.

I’ve said in many retrospectives that the mistake a person made is rarely the point. The real issue is that we created a system where the mistake was easy to make. That’s the part we need to fix.

A system grounded in accountability creates psychological safety. People speak earlier. They ask for help sooner. They raise concerns without fear. The system becomes adaptable. Adaptable systems produce quality.

Quality isn’t a Department

When quality is defined as defect prevention, someone becomes the final backstop. A tester. A senior engineer. A reviewer. That burden grows until the role becomes impossible.

When quality is defined as a system behavior, the burden dissolves.

Quality becomes the outcome of how people shape the system together. Leaders create clarity. Product defines constraints. Engineering builds the architecture. Design shapes the experience. And everyone contributes to the environment that supports or undermines the work.

Quality becomes the outcome of shared care in a system built to support it.

The Quiet Cracks of Failure

The quiet moments matter most. A half-explained requirement, a rushed kickoff, the missing context, or a dependency discovered too late. None of these moments look like failures when they happen. They look normal. But they build up. They create friction, and friction turns into confusion, then inconsistency, then customer pain.

Leaders who notice these moments see the drift before the failure.

Systems Beat Heroics

Organizations move fast. Ambiguity is constant. Signals cross. Expectations shift. Under that pressure, heroism feels easier than systems design. But heroism is fragile. Systems endure.

This is the shared lesson from Pirsig and Dekker.
Pirsig shows that quality begins with care.
Dekker shows that systems decide whether care survives contact with reality.

Quality isn’t a checkpoint. It’s the reflection of a system shaped by clarity, flow, feedback, and human intention.

The Real Point

Quality shouldn’t surprise us. It should be what happens when a system is designed to support the people inside it. A system that helps them stay attentive. A system that prevents drift. A system that rewards care instead of chaos.

Quality becomes real when the system is built for it.

That’s the work.