How to Use
a Fishbone Diagram
Presented by Elisabeth Swan
Managing Partner & Executive Advisor
at GoLeanSixSigma.com
3/16/17 1
Our Expert: Elisabeth
• Managing Partner &
Executive Advisor at
GoLeanSixSigma.com
• Master Black Belt
• Certified Executive Coach at
Burnham Rosen Group
• BA in English Literature from
Columbia University/Barnard
College
• Born in the UK
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• Ask a question
• Answer polls
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Today’s Agenda
• What is a Fishbone (aka Cause & Effect or Ishikawa)
Diagram?
• Why and when should we use a Fishbone Diagram?
• What’s the right way to build a Fishbone Diagram?
• Are there any ways not to use a Fishbone Diagram?
• What do “proper” Fishbones look like?
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The “Y” and the “X”
The Y The X
•Y • X1, X2…
• Dependent • Independent
• Output • Input
• Effect • Cause
• Symptom • Problem
• Monitor • Control
• Garbage Out • Garbage In
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Pseudo Equation
Y = ƒ(x1, x2…xn)
?
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Y and X at Bahama Bistro
X Speed of
Service
X Menu Item
Availability
Food
Freshness
X
Customer
Order
Satisfaction Accuracy
Y X
X Ambience
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What Is a Fishbone Diagram?
Fishbone Diagram: aka “Ishikawa” or “Cause & Effect”
is a method of structured brainstorming to get to
root cause
• Conducted in groups
X X
• Uses categories
• Uses hierarchy
Y
X X
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Fishbone Diagram
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Poll #1:
What’s your experience with Fishbone
Diagrams?
A.Totally new to me
B.I use them but not sure I’m using them
effectively
C.I know about them but don’t use them
D.I use them all the time – great tools
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How to Construct
Issue or “Y” in “Fish Head”
Two methods:
1. Pre-Label Fishbones
• Transactional Categories
• Manufacturing Categories
2. Brainstorm and affinitize
root causes into categories
that are process specific
• Groupings become
“Fishbone” labels
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1. Pre-Label
Advantages
• Easy to set up
• Causes unexpected ideas
• Does not require upfront work
• Can combine with brainstormed
categories
Disadvantages
• Limits ideas
• Not focused on the process
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Manufacturing Categories
Standard Specific
Operating Parts or
Procedures Materials
Operator or Variation Environment
Design Engineer (physical,
political, etc.)
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Transactional Categories
Process
Software Documentation
Separate Environment
Job Functions (physical,
political, etc.)
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2. Affinity Analysis
• More focused on specific
process
• Organic
• Involves group
• Good to practice Affinity
Analysis – generic
organizational
technique
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Brainstorming
Menu Food
Service
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Fishbone Diagram
Service Menu Food
The Y
Customer
Satisfaction
Ambience Presentation Ordering
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Poll #2:
Which method do you use to build
the Fishbone Diagram?
A. I use the standard Manufacturing or
Transactional labels
B. I brainstorm and affinitize categories first
C. I just pick labels that seem appropriate given the
issue
D. None of the above
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Fishbone Diagram Example
Service Menu Food
Too slow
Stale
Bread
Limited Storage
Kitchen takes too
long with lunch Options
orders
Why such
variation in
Too Noisy customer
Radish is
only garish satisfaction?
Dropped Method is
dishes Vendor complicated
availability
Ambience Presentation Ordering
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Turn Into Measures
Service Menu Food
Too slow
Service Cycle Age of Stale
Time Bread Bread
Limited
# Options Options
Why such
variation in
Noise levels # Available customer
garnishes Radish is
above 100 satisfaction?
Too Noisy only garish
decibels
# dropped # Steps to
Method is
dishes” per Dropped order
complicated
hour dishes
Ambience Presentation Ordering
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Looking for Correlation
Customer Satisfaction
Service Cycle Time
X
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Caution: Solutions Masquerading…
Service Menu Food
Not enough Too slow Need more
inspection Stale
waitress
Missing Bread
training
“Fusion” Limited
Options Options
Why such
variation in
Need to Increase customer
Should build Condiments Radish is
only garnish satisfaction?
booths
Too Noisy Lack of Method is
automated complicated
ordering
Ambience Presentation Ordering
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Fishbone Trap
Category Category Category
Insufficient
Staff Inadequate
Training
Lack of
Automation
Why is this
problem
Lack of
Lack of happening?
software
Inspections
“Lack of”
X
Category Category Category
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Solutions è Measurable Causes
•Lack of training è Level of operator
knowledge
•Procedure not followed è % of time
procedure followed
•Inadequate staffing è # of man hours
utilized
•Lack of inspection è % returned meals
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Level of Training
•Run by teenagers
•Assume turnover
•Build processes
with visual
management
•Low need for
training
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Number of Inspections
• Add time (waste)
• Cause delays
• Initiated by
failures
• Provide false
sense of security
• Never removed
“We inspect
because we expect
a defect”
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Automation Myths
Myth 1: No need to address this issue now –
Software “X” is coming
Myth 2: Software “X” will solve the process issue
Myth 3: Automation will streamline the process
https://image.freepik.com/free-vector/multimedia-desktop-pc- 30
illustration_72147494127.jpg
Solution Parking Lot
Solutions
• Have Joey do everything
• Outsource the cooking
• Get rid of Marketing
• Close early
• Switch to Italian food
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“Red Herring” Root Causes
• Beware of solutions masquerading as problems
• Key phrases: “Lack of…”, “Insufficient…”, “Inadequate…”
• Don’t assume training is the issue
• Is process too complicated?
• Clean up process before automating
http://www.libationlab.com/wp-content/uploads/2011/08/redherring.png 32
One Fishbone Leads to Another…
Service Menu Food
Age of
Service Cycle Bread
Time
# Options
Why such
variation in
Noise levels customer
# Available
above 100
garnishes satisfaction?
decibels
# dropped # Steps to
dishes” per order
hour
Ambience Presentation Ordering
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New Fishbone Diagram
Point-of-Sale # of steps to
Kitchen
prep Layout Food Types
Software
# Steps
%
# Steps between
transactions # Sandwiches # items taking
required for stations
stuck taking > 10 mins too long to
restocking
during rush prepare
# staff
# of items
allowed to use
system taking > 15 mins
to cook Why do food
orders take so
Packaging long for lunch
“Not my job”
process for customers?
thinking
pick-up varies
# wrong
# Staff special orders # Servers
allowed to who don’t
cross-train turn in orders
right away
Political Servers
Environment Documentation
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The Five Whys
• Repeatedly ask “Why”
• Work the causal chain
• Done by those in the process
• Could be more or less than
5 “Whys”
Benefits:
• Simple – no stats
• Get past symptoms
• Good for processes involving
human factors
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Five Whys Example
http://clipart-library.com/clipart/33678.htm
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Fishbone and Five Whys
Packaging process
for items for pick-
up varies
# Servers who don’t
turn the orders in
right away
Kitchen Layout Servers
Could lead to nested fishbones
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Five Whys Template
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Multi-Voting
• Count the number of
options Options
• Root causes It’s Marketing’s fault
Lack of new software
• Solutions
Not enough staff
• Customer Comments Need more inspection
Need a new manager
• Divide by 3 Need more money
• Hand out N/3 Dots to
each person
• Narrow the list
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Multi-Voting
Point-of-Sale # of steps to
Kitchen
prep layout Food Types
Software
# items take
# Steps
% too long to
Restocking between
transactions # Sandwiches prepare
requires stations
stuck take > 10 mins
walking # steps
during rush
# staff
# of items
allowed to use
system take > 15 mins
to cook Why do food
orders take so
Packaging long for lunch
“Not my job”
process for customers?
thinking
pick-up varies
Clarity of
instructions # Servers
who don’t
turn in orders
Special right away
Orders
Political Servers
Environment Documentation
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Next Steps
•Fishbone is a structured brainstorming –
not proof
•Team decides where to focus
•Must create hypothesis statements
•Verification can take many forms
•Depends on the process and issue
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Poll #3:
What’s your experience with
Fishbones “gone wrong”?
A.They are populated with solutions
B.They are not paired with the 5 Whys
C.They are not verified
D.Some combination of above
E. None of the above – all good!
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Validating Methods
Observe
• Watch the process and
see the issue in action
Compare
• Where problem is/isn’t
Use Data
• Caution
Use Stat Tools to Test Hypothesis
• Try to “disprove” the Null Hypothesis
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Hypothesis & Data Example
Hypothesis: As
Order Cycle Time
number of waitress
“courtesy” food pick
ups increase, lunch Y
order cycle time
increases
# Courtesy Pick-ups
X
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Fishbone Review
Build the Fishbone
• Conduct in groups (not party of one) – more brains, more ownership
• Brainstorm and clarify labels (physical or political environment?)
• Populate the fishbone – bony is good – not limited to one page
• Don’t worry about “where” a cause goes – as long as it’s included
• Consider what causes process “variation” not just defective units
• Turn causes in to measures - set up for verification
Expand the Fishbone
• Use 5 Whys to dig past symptoms
• Watch for solutions masquerading as problems – use Solution Parking Lot
• Keep and update Fishbone – organizational knowledge
Verify the Fishbone
• Multi-vote and prioritize potential root causes to research
• Form hypothesis statements & and select verification method
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Today We Covered
• What is a Fishbone (aka Cause & Effect or Ishikawa)
Diagram?
• Why and when should we use a Fishbone Diagram?
• What’s the right way to build a Fishbone Diagram?
• Are there any ways not to use a Fishbone Diagram?
• What do “proper” Fishbones look like?
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Q&A
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