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Documenting Roles, Not Just Rules: A NIST Project That Got Personal

TL;DR: Most companies document policies. I documented roles: which person is responsible for which piece of which policy, and the procedure each role follows. The NIST engagement ran four to five months of interviews, C-suite down, department by department. It made the policies bulletproof, nobody could claim they didn’t know a task was theirs. It also revealed something uncomfortable: the CFO didn’t know what segregation of duties was, and once he learned, he opposed it.

A client hired me to build their NIST documentation, and I took an approach most policy projects skip. The standard deliverable in this world is a policies-and-procedures manual: here’s our access-control policy, here’s our change-management procedure, signed, dated, shelved. That’s what most companies still produce, and it’s why most policy manuals are furniture. I wrote a manual on NIST 800-53 early in my writing career, a big project and nine months of consulting. That standard gets really nitty gritty, all the way down to the lowest level, and it was a pain in the butt.

I documented roles. For every policy, the manual named which role was responsible for which piece of it, and gave each role its own procedure to follow. Not “checks shall be authorized and issued under appropriate controls” but this person authorizes, following this procedure; this different person issues, following that one. The policy stopped being an abstract statement about the company and became a set of specific obligations attached to specific chairs.

Policy-only manuals compared with role-level documentation.
Aspect Standard policy manual Role-level documentation
What it states A policy or procedure, signed, dated and shelved Which role owns which piece of each policy, with its own procedure
Example Checks shall be authorized and issued under appropriate controls This person authorizes; a different person issues, each with a procedure
How it is built Often from a template Four to five months of interviews, C-suite down, department by department
Accountability Room for “I didn’t know that was my job” Nobody can claim a task wasn’t theirs
Gaps Stay hidden in everybody’s assumptions Surface when answers disagree and drafts go back to the people described
Payoff Most manuals end up as furniture Auditors love it and incident reviews resolve in minutes

Four to five months of interviews

You can’t write role-level documentation from a template, because the roles are facts about the organization, and the only place those facts live is in people’s heads. So I interviewed everybody I could get my hands on, C-suite down, department by department, for four to five months.

Any board that lets its CFO both approve and cut checks is betting the company on one person’s character.

Some people cooperated. Some were unhappy about it and did it anyway. Some simply didn’t, and against the C-suite a consultant has very few levers. When an executive declines to engage with the documentation of his own controls, the documentation notes what it can and the gap remains, visible to anyone who later asks why. That was upside down, because the people with the most authority over the controls were the ones most free to skip the conversation about them.

How do you document roles for segregation of duties?

The method was interviews, and the craft was in what the interviews extracted.

Policies tell you what should happen; only people can tell you who does each piece of it, and their answers disagree in instructive ways. Ask three people who approves a vendor change and you may get three names. That mismatch is a finding in its own right, and it’s the most useful thing an interview like that can produce.

Every one of those disagreements was a place where accountability existed in nobody’s job and everybody’s assumption, and reconciling them, in writing, with names attached to roles and roles attached to procedures, was the actual work of the four to five months.

The drafts then went back to the people they described, and that’s where the second round of truth arrived.

Reading your own responsibilities in print concentrates the mind. Some people discovered obligations they had been carrying informally for years; a few discovered obligations they’d assumed belonged to someone else, and the someone else had assumed the reverse. Every such gap closed on paper was an incident that would never need a post-mortem.

How the role-level NIST documentation was builtThe method behind a NIST documentation project that mapped policies to roles. Four to five months of interviews ran from the C-suite down, department by department. Disagreements about who does each piece were treated as findings, reconciled in writing with roles tied to procedures, and the drafts went back to the people they described to close the remaining gaps.How the role-level NIST documentation was built1IntervieweveryoneC-suite down,department bydepartment, forfour to five months2FlagdisagreementsThree names forone approver is afinding, not noise3Reconcile inwritingAttach names toroles and roles toprocedures4Return thedraftsPeople read theirownresponsibilities inprint5Close the gapsObligations eachside assumed theother held getassigned
How the role-level NIST documentation was builtThe method behind a NIST documentation project that mapped policies to roles. Four to five months of interviews ran from the C-suite down, department by department. Disagreements about who does each piece were treated as findings, reconciled in writing with roles tied to procedures, and the drafts went back to the people they described to close the remaining gaps.How the role-level NIST documentationwas built1Interview everyoneC-suite down, department by department, forfour to five months2Flag disagreementsThree names for one approver is a finding,not noise3Reconcile in writingAttach names to roles and roles toprocedures4Return the draftsPeople read their own responsibilities in print5Close the gapsObligations each side assumed the otherheld get assigned

Role-level documentation came from interviews, reconciled disagreements and drafts returned to the people they describe.


The CFO wanted to approve the checks and cut them too. That’s the shape of fraud, not a workflow preference.
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Why does the CFO matter in segregation of duties?

The revealing moment of the project involved segregation of duties, the control that says the person who authorizes a payment mustn’t be the person who executes it. This is one of the oldest fraud controls in existence, and I assumed everyone in finance knew it instinctively.

The CFO didn’t know what it was. That surprised me. What came next surprised me more: once he understood it, he opposed it. He wanted to be able to cut checks even though he approved them. He wasn’t confused about the control; he objected to the constraint, meaning he wanted to retain exactly the combination of powers the control exists to separate.

We wrote the segregation into the roles anyway. And the reason the control justifies its inconvenience isn’t hypothetical to me. At another company I worked with, a colleague uncovered an employee cooking the books, systematic fraud from inside the finance function, and that person went to jail. Fraud happens where one person holds both sides of a transaction. The CFO who wants both sides isn’t describing a threat, necessarily. But he’s describing the shape of one.

Any board that lets its CFO both approve and cut checks is betting the company on one person’s character. I’d never advise a client to make that bet, however much they trust the person in the chair, because the control protects a CFO who’s doing nothing wrong too.

My take

Document who does each piece of every policy, by role, and hand the drafts back to the people they describe. If three people give you three different names for who approves a vendor change, you’ve found a gap, and gaps like that turn into incidents. Keep segregation of duties even when the CFO objects. No board should let one person both approve and cut checks. The control protects an honest CFO too.

Why is role-level documentation bulletproof?

The payoff came in accountability. With policies mapped to roles and roles mapped to procedures, nobody could weasel out with “I didn’t know that was my job.” It’s right there in the manual: your role owns this step, here’s the procedure, and here’s where you bypassed it. Auditors love this structure, incident reviews resolve in minutes instead of meetings, and the organization gets more honest, because ambiguity was where the dishonesty used to hide.

For executives writing about governance, this is the material readers can’t get from the structure documents: what NIST implementation looks like when it meets an actual org chart, an actual reluctant executive, and an actual fraud down the hall. The frameworks are public and everyone quotes them. I’d push any executive who has lived through a project like this to write about the resistance, because leaving it out produces one more governance book that reads like the standard it describes.

For more from this series, see The Cybersecurity Hub: breaches, audits, and hard-won security lessons from more than three decades in the trenches.

Frequently Asked Questions

What is segregation of duties?
A control that splits critical transactions between people, so the person who authorizes a payment isn’t the person who executes it. It exists because fraud concentrates where one person holds both sides of a transaction.
What makes NIST documentation effective instead of shelfware?
Mapping every policy to named roles, each with its own procedure. Role-level documentation removes the “I didn’t know it was my job” defense and gives auditors and incident reviews a precise accountability trail.
How long does a NIST documentation project take?
The engagement I led ran four to five months, built on interviews across the entire organization from the C-suite down. The duration is driven by interviews, because role responsibilities exist only in people’s heads until documented.

Sources

About the Author
Richard Lowe, professional ghostwriter

Richard Lowe is a professional ghostwriter and author with 113+ books authored and 54+ ghostwritten. Before writing full time he spent 33 years in enterprise technology, including 20 years as Director of Computer Operations and Technical Services at Trader Joe's. He writes nonfiction, fiction and memoir, and works with executives and experts on books that build authority.

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Disclaimer

The views and opinions expressed in this blog post are solely those of Richard Lowe and are based on personal experience and research. This content is for informational purposes only and should not be construed as professional legal, financial, accounting, or business advice. Always consult with qualified professionals before making important business or legal decisions. Richard Lowe is not a lawyer, accountant, or licensed professional advisor, and this content does not establish any professional relationship.