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New Twist in Designing a Fishbone Diagram

The Root Cause Tail

Current Design
Experience has shown that traditional fishbone diagrams can be confusing to teams As new ideas are entered, words get jumbled and lost in the mix

* Copied from diagrams.net on 02 Apr 2011

Clearing up the Fishbone


My new design to the fishbone has the development the same, but with minor additions Obtaining the vital few for further breakdown Incorporating the 5 Whys Adding visual clarity for team focus

When to use the Tailed Fi shbone


Just like the current fishbone diagram is utilized, in the tailed version, you need the same factors One must have factual data of the process (not peoples opinions, or perceptions) Two best utilized in complex process where there are many factors that could lead to your problem

Starting Out
Draw your fishbone as normal Put your problem statement in the head There are two ways to categorize the side fins Pre-categorize Categorize based off themes from teams brainstormed ideas The teams attitude and engagement

For Teams Still in the Forming/Stor ming Stage Most fishbones are built with the 4 or 6 Ps, 4 or 6 Ms, 8 Ss etc.

Pre-categorize:

In a non-manufacturing process I like the 4 Ps

Following three I use every time:


Place (or work center) People (those doing, leading and supplying to the job) Policy (rules and regulations that direct the job)

The next two I switch between (or can use both)

For teams in the Norming/Performin g Stage After team has brainstormed ideas for
causes of the problem Generate themes based off commonality of multiple ideas

Post-categorize

Themes help to provide better clarity for the team, and allow them to feel more in control of the process

Recommended for experienced facilitators

Made-up scenario on training of ne w Categories employees


Plant Brainstorme d Causes
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

Problem Statement

Finding the Vital Few


Next I bring color to the fishbone by allowing people to vote Use the N/3 method

Number of items brainstormed divided by 3 Facilitator choice if multiple votes can be used on single item

Would not recommend if more than one antagonist on team attempting to achieve personal agendas

Allow team to vote most likely cause to problem for each category

Made-up scenario on training of ne w employees


Plant
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

If tie in one category, I let the team do a one minute commercial for each person (no interruptions, everyone gets a turn) . Then I re-vote (with a different color marking). If still a tie, it wont matter come next round (usually).

Moving towards Root Ca use


Now I change the color of the vote and have everyone mark the one item in all categories that is the most likely culprit of our problem statement One vote per person

Made-up scenario on training of ne w employees


Plant
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

Winner!!!!

Conducting 5 Whys
Now that the team has put their focus on one item; conduct 5 Why analysis 5 Why is just the title; Just keep asking until someone says, Because God said so.

5 Why on our Example


Why are training manuals outdated? Because no one updates them Why no one updates them? No ones responsibility Why is it no ones responsibility? Never needed it before Why was it never needed before? Old computer system was easier to

Visualize the Root Cause


Now that you have root cause, make it visual on the diagram

Made-up scenario on training of ne w employees


Plant
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

New computer system requires more screens to navigate and more data req for entry

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

Adding Depth and Clarity


The colored votes allow separation of the brainstormed causes The tail of the fish is what guides its direction where as the side fins help push it along So I then speak it like this to gain understanding of the root cause (see next slide)

Made-up scenario on training of ne So, our root cause guides our contributing factors, leading to our w employees headache!
Plant
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

New computer system requires more screens to navigate and more data req for entry

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

Showing Root Cause Elim inates Contributing Facto Next I walk through each brainstormed rs
items (contributing factors) to see if solving the root cause also eliminates the contributing factors

If majority are also solved then I know I have root cause. If not, then you must re-evaluate (never had this happen)

Made-up scenario on training of ne Creating Standard Workemployees form of a w in root causeUser Guide could eliminate
Plant
Workstation s Non-Std Customers provide unique scenarios to trainee

Example:
People
People Trained differently Lack of Experience

New computer system requires more screens to navigate and more data req for entry

Trainers are not always most experienced

New computer system

No standard interview for Training manuals new hires outdated

Product

Policy

No standard for competency testing New hire placed with first available employee seen by manager

Employee training is inconsistent leading to nonstandard time frames for new hire competency

Items with an X could be solved by the solution to root cause

Summary
Tail Root Cause Categories and Brainstormed Ideas Contributing Factors Head Problem Statement Result a visual understanding of a

Questions, Comments, C onstructive Criticism or P Contact me by email at: raise


mark.adamsusaf@gmail.com Developed by Mark Adams, LSS BB Developed and shared for crosstalk purposes only