1. QI Tool: The Fishbone Diagram
EIS Quality Learning Network
May 10, 2010
Ishikawa diagrams (also called fishbone diagrams or cause-and-effect diagrams) are diagrams that show the causes of a certain event. Common uses of the Ishikawa diagram are product design and quality defect prevention, to identify potential factors causing an overall effect. Each cause or reason for imperfection is a source of variation. Causes are usually grouped into major categories to identify these sources of variation. The categories typically include:

2. Quality Improvement Tools
What tools can help my HIV care program analyze information and make decisions?
Remember, like data, the quality improvement tools are not ends in themselves, their purpose is to support quality improvement. This Tutorial will answer the question, “what tools can help my HIV care program analyze information and make decisions?” 2

3. Organizing “Theories of Cause”
Process problems are often caused by:
Methods
Materials
Equipment
Environment
People
The tool we will review today helps us draw a picture of possible causes.
When looking at reasons why a certain process is not working, several categories of problems emerge. In general, process problems are caused by:
The methods that are followed to do the work
The materials that are used
The equipment that is used
The environment in which the work takes place, or
The people in the process.
Again, it is important to remember, when we talk about people, that we aren’t talking about individuals doing a bad job. By “people,” we mean something that is common to the way people do their work: the skills they have, for example, or a common attitude in the workplace. 3

4. Fishbone Diagram
Organizes and displays all causes and sub-causes that may influence a problem, outcome, or effect
Helps push people to think beyond the obvious causes, (money, time) to find some causes that they can fix/improve
Helps organize potential solutions and make clear who should be involved in solutions
Encourages a balanced view
Demonstrates complexity of the problem
Also called:
Ishikawa diagram or Cause and Effect diagram
Proposed by Kaoru Ishikawa in the 1960s, who pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management. 4

5. Common Categories People: Anyone involved with the process
Methods: How the process is performed and the specific requirements for doing it, such as systems, policies, procedures, rules and regulations
Measurements: Data generated from the process that are used to evaluate its quality
Equipment: computers, tools etc. required to accomplish the job
Materials: Raw materials, parts, pens, paper, etc. used to produce the final product
Environment: The conditions, such as location, time, temperature, and culture in which the process operates

6. Creating a Fishbone Diagram
Skeleton
Equipment
Environment
Computer
System down
for routine
maintenance
Low show rate
for appointments
Patients
Patient unaware
of appointment
Procedures
People 6

7. Example: Low Show-Rate for Medical Appts.7

8. Example: Delayed Test Results

9. Fishbone Diagram: Practice (20 Minutes)
Practice Problem: Low return for confirmatory tests Please select a facilitator/recorder & report back to full group
Write down the problem (fish head)
Decide on categories and draw skeleton (e.g., Environment, People, Equipment, Materials, Procedures, Policies, Measurements)
Brainstorm as many possible causes as you can and fill in the diagram
Ask “why does this happen?” 3 to 5 times
Check for logic, completeness and balance
Constructing a cause-and-effect diagram is not complicated; the diagram’s value comes from the quality of the thinking, not the prettiness of the picture. Here are the basic construction steps:
•Define the “effect,” the problem you are seeing - the more specific, the better – and write it down on the right of the flip chart, or put it on a Post-it™ note at the right of a large, empty wall.
•Decide on your categories. The standard areas are those in our example, methods, materials, equipment, environment and people, but you can also use major process steps if that is easier. A team should use categories that best fit their improvement needs. Make them fit your problem.
•Then, brainstorm possible causes. Follow the rules of brainstorming: get ideas out, no criticism. Consider using Post-it™ notes: one idea per note; At first, don’t try to arrange the ideas on the “bones”, concentrate on getting the ideas out and written down.
•As you do this, begin to ask “why” 3 to 5 times. For a given idea, ask, “why might this cause be contributing to the effect?”
•Aim for lots of ideas; when the discussion wanes, ask for “just one more.” Many teams shoot for possible causes.
•When you finish, check to see if the diagram is logical, complete and balanced. Are all categories covered? Is the full range of possible causes explored? 9

10. Have the Diagram, Now What?
Need to test the theories
Think of the cause-and-effect diagram as the jumping-off point for your quality improvement work. It will help you identify the theories you want to test and to conduct PDSA Cycles, your engine for improvement.
On to your quality improvement work! 10

11. Resources
NQC Quality Academy On-line Training, Module 14: Useful QI Tools
NationalQualityCenter.org/QualityAcademy
American Society for Quality (ASQ)
Ishikawa, Kaoru Introduction to Quality Control (Translator: J. H. Loftus) 1990
Nancy R. Tague The Quality Toolbox, American Society for Quality 2005