ISHIKAWA DIAGRAM

( FISHBONE ANALYSIS )

VOLTAIRE I. TUMANGAN, RN
ASSISTANT CHIEF NURSE
 OBJECTIVES

Learners will be able to:

1.Use the “ 5 Whys “ process with a group to

identify factors that contribute to less-than
optimal performance on a specified
performance metric.

2.Use a fishbone diagram to identify factors that

contribute to less-than optimal performance on
a key performance metric.
 OBJECTIVES

Specifically:

•Get clear on the nature of a problem and why

it’s occurring
•Identify contributing factors and how they’re
connected
•Determine the best course of action for
correcting a setback
DEFINITION
 ROOT-CAUSE ANALYSIS

Is the identification and analysis of factors

that are contributing to a specific outcome or
problem.

It is an essential tool for quality improvement.

It is intended to reveal key relationships

among variables, and the possible causes
provide additional insight into process
behavior.
 USES

1. To analyze a complex issue when there are

multiple causes.
2. For identification of all potential root causes
for an effect or a problem.
3. A different point of view
4. To uncover bottlenecks and identify where
and why a process does not work.
5. For accelerating a process when transitional
ways of problem-solving take long time.
 Categories of CAUSES that may
underlie a problem

1. Human – involve someone doing something

wrong, not doing something that should be
done.

2. Physical – include failures of materials such

as broken or missing equipment.

3. Organizational – include processes,

procedures, and policies that are
contributing to a problem.
5 WHYs ANALYSIS
 5 WHYS?

Is a technique developed to help identify the

causes of an underlying problem.

It involves asking and answering the question

“ why? “ 5 times or as many times in an effort
to uncover the causes or end the causal chain.

It can be a good way to get an individual or

group thinking more deeply about the factors
underlying their performance before deciding
how to approach improvement efforts.
Steps for Conducting the 5 Whys

1. Work with members or group to identify the

problem they want to solve or prevent.

2. Ask the question “ why “ 5 times or until the

group members agree they have identified
the root cause of the performance issue or
problem.

3. Identify and implement solutions based on

findings.
 Sample of 5 “ Whys “ Process

Problem : Recently, patients have stopped coming to health

education class

Why 1? : Patients forget to come or are not sure when classes are
happening.
Why 2? : Staff member who usually makes reminder calls to patients
is not making the calls.
Why 3? : She does not have the list of patients to call.
Why 4? : Current lists are not being created.
Why 5? : The person assigned to create these lists from the electronic
health record system is out on leave.
 Sample of 5 “ Whys “ Process

Solutions suggested by 5 “ whys “

1.Assign an additional staff person to fill in and create

reports when the person responsible is out.
2.Give the outreach caller direct access to the data and
train her to generate her own up-to date lists.

The group can then discuss these solutions and consider

testing them using the “ PLAN DO STUDY ACT “ process
DEFINITION
 Ishikawa Diagram

Are causal diagrams that show the potential

causes of a specific event.

visual map that functions as a problem-solving

tool.

Also called Fishbone Diagram, Herringbone

Diagram, Cause and Effect Diagram, Fishikawa.
 ADVANTAGES

Helps identify cause and effect relationships

Helps develop in-depth joint brainstorming

discussion

Works well with the 5 Whys to drill down to a

root cause quickly

Helps prioritize relevant causes, allowing you to

address underlying root causes
 DISADVANTAGES

Irrelevant potential causes can cause

confusion

Complex issues may lead to a messy diagram

Based on opinion rather than evidence; it

needs testing to prove results
THE 6 M’s
 MANPOWER

The operational and/or functional

labor of people engaged in the
design and delivery of a product.
 METHOD

a production process and its contributing

service delivery processes. Frequently,
processes are found to have too many steps,
signoffs, and other activities that don’t
contribute or create much value. When not
streamlined, simplified and standardized,
processes can be confusing and hard to follow.
 MACHINE

systems, tools, facilities and equipment used

for production. Often, machines, tools and
facilities with their underlying support systems
are mismanaged or incapable of delivering a
desired output due to technical or
maintenance issues.
 MATERIAL

raw materials, components and consumables

needed to produce a desired end product.
Materials are often mismanaged by way of
being incorrectly specified, mislabeled, stored
improperly, out of date, among other factors.

The materials needed to produce a quality

product cannot be ignored
MOTHER NATURE ( ENVIRONMENT )

environmental factors that are unpredictable

and uncontrollable like weather, floods,
earthquakes, fire, etc. While many
environmental factors are predictable and can
be considered manageable, there are some
unavoidable environmental factors that some
facilities find they are not prepared for.
 MEASUREMENT

manual or automatic inspections and physical

measurements (distance, volume, temperature,
pressure, etc.). At times, measurements can be
inconsistent, making it hard to use the data to
form repeatable conclusions that help nail down
a consistent cause.
Drawing a Fishbone Diagram

1. Draw the head on the right which contains

the problem ( effect or issue ).
2. Draw a straight line from the head, leading
to the left. This is the backbone.
3. Identify the areas, broad level categories, to
be studied.
4. Analyze the causes from these categories
that contribute to the effect.
5. Break down the causes into sub-causes, till
you can not drill down further causes.
CREATING A FISHBONE DIAGRAM

1. IDENTIFY THE PROBLEM

2. Brainstorm the major categories of causes
3. Identify possible causes
4. Analyze the diagram
SAMPLES OF ISHIKAWA DIAGRAM
SAMPLES OF ISHIKAWA DIAGRAM
SAMPLES OF ISHIKAWA DIAGRAM
SAMPLES OF ISHIKAWA DIAGRAM
SAMPLES OF ISHIKAWA DIAGRAM
SAMPLES OF ISHIKAWA DIAGRAM
 PLAN-DO-STUDY-ACT

method is a way to test a change that is

implemented. Going through the prescribed four
steps guides the thinking process into breaking
down the task into steps and then evaluating the
outcome, improving on it, and testing again.
Most of us go through some or all of these steps
when we implement change in our lives, and we
don't even think about it. Having them written
down often helps people focus and learn more.
 PLAN

I plan to:
Here you will write a concise statement of what you plan to
do in this testing. This will be much more focused and
smaller than the implementation of the tool. It will be a
small portion of the implementation of the tool.
I hope this produces:
Here you can put a measurement or an outcome that you
hope to achieve. You may have quantitative data like a
certain number of doctors performed teach-back, or
qualitative data such as nurses noticed less congestion in the
lobby.
 PLAN
Steps to execute:
Here is where you will write the steps that you are going to take in
this cycle. You will want to include the following:

The population you are working with—are you going to study the
doctors' behavior or the patients' or the nurses'?
The time limit that you are going to do this study—remember, it
does not have to be long, just long enough to get your results. And,
you may set a time limit of 1 week but find out after 4 hours that it
doesn't work. You can terminate the cycle at that point because you
got your results.
 DO

Do
After you have your plan, you will execute it or set it in
motion. During this implementation, you will be keen to
watch what happens once you do this.

What did you observe? Here you will write down observations
you have during your implementation. This may include how
the patients react, how the doctors react, how the nurses
react, how it fit in with your system or flow of the patient
visit. You will ask, "Did everything go as planned?" "Did I have
to modify the plan?"
 STUDY

Study
After implementation you will study the results.

What did you learn?

Did you meet your measurement goal?
Here you will record how well it worked, if you
meet your goal.
 ACT

Act

What did you conclude from this cycle?

Here you will write what you came away with for this
implementation, whether it worked or not.
And if it did not work, what you can do differently in your
next cycle to address that.
If it did work, are you ready to spread it across your entire
practice?
 SAMPLE OF PLAN-DO-STUDY-ACT
Plan
I plan to: test a process of giving out satisfaction surveys and getting them filled
out and back to us.

I hope this produces: at least 25 completed surveys per week during this campaign.

Steps to execute:
We will leave the surveys in the exam room next to a survey box with
pens/pencils.
We will ask the nurse to point the surveys out/hand them out after vitals and
suggest that while they are waiting they could fill out our survey and put it in box.
We will see after 1 week how many surveys we collected.
 SAMPLE OF PLAN-DO-STUDY-ACT

Do
What did you observe?

Upon self report, most nurses reported they were good with
pointing out or handing the patient the survey.
Some patients may need help reading survey, but nurses are
too busy to help.
On a few occasions, the doctor came in while patient filling
out survey so survey was not complete.
SAMPLE OF PLAN-DO-STUDY-ACT

Study
What did you learn? Did you meet your measurement goal?

We had 24 surveys in the boxes at the end of 1 week. This

process worked better.
 SAMPLE OF PLAN-DO-STUDY-ACT

Act
What did you conclude from this cycle?

Approaching patients while they are still in the clinic was

more successful.

Most patients had time while waiting for the doctor to fill out
the survey.

We need to figure out how to help people who may need help
reading the survey.
 CONCLUSION

The Fishbone Diagram is a very important tool in identifying the

root cause though its development is time-consuming

The Ishikawa Diagram is use across different industries like

manufacturing, project management and service industries.

The value of Ishikawa Diagram depends on how to develop

diagram.

The experience level, knowledge, critical thinking, training, etc,

of people involved play a major role in the successful drafting of
the fishbone diagram.
 CONCLUSION

It is important to involve experienced experts to draft the

Fishbone Diagram and ask multiple “ whys “ to find the root
cause.

The Ishikawa Diagram is also a great way to find out and

prevent quality problems before they even arise.

It can be use to troubleshoot before there is trouble.