1. travel
2. tourist destinations
3. theme parks

Use a School of Fishbones to
analyze and resolve process
issues
Grace L. Duffy, LSSMBB, CMQ/OE
Quality Management Division
Objectives
• Apply a recognized process tool in innovative
ways to guide analysis and resolution
• Engage in risk management dialog relative to
potential process solutions
• Discuss additional applications for the School of
Fishbones
October 30 and 31, 2014
Orlando, Florida
A School of Fishbones
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Cause and Effect Diagram
Force and Effect Chart
Solution and Effect Diagram
Cause and Effect Diagram with C/N/X*
Success and Effect Diagram
Duffy, Grace L; Modular Kaizen; Continuous and Breakthrough Improvement,
Quality Press, Milwaukee, WI, 2014
* Robert A. Cartia, At Your Fingertips; Combining cause and effect diagrams
and check sheets aids problem-solving efforts, Quality Progress, March 2014.
October 30 and 31, 2014
Orlando, Florida
Cause and Effect Diagram
• Displays the factors that are thought to affect a particular
output or outcome in a system
• Also known as an Ishikawa Diagram or Fishbone
The diagram helps show the relationship of the parts (and
subparts) to the whole by:
• Determining the factors that cause a positive or negative
outcome (or effect)
• Focusing on a specific issue without resorting to complaints
and irrelevant discussion
• Determining the root causes of a given effect
• Identifying areas where there is a lack of data
October 30 and 31, 2014
Orlando, Florida
Cause and effect diagram for customer
confusion in reception area.
October 30 and 31, 2014
Orlando, Florida
Force and Effect Chart
• Is designed to identify barriers to agreement among
team members concerning a specific situation.
• It combines features of the cause and effect diagram
with the dialogue of a force field analysis
•
Using the traditional “fishbone” structure, the right side
of the header bone identifies barriers to attaining the
desired effect, while associated left side entries describe
possible solutions to minimize the barrier identified on
the right hand side of the “bone.”
Duffy, Grace L; Modular Kaizen; Continuous and Breakthrough Improvement,
Quality Press, Milwaukee, WI, 2014
October 30 and 31, 2014
Orlando, Florida
Force Field Analysis
Figure 1 Force Field Analysis Diagram
Issue: Meetings starting late
Ideal state:
+ Driving forces
Use time effectively.
Help plan other
activities.
Value all members
equally.
Publish agenda.
To start meetings on time
Restraining forces -
Changing priorities.
Overcommitted
schedules.
Low team morale.
Lack of meeting
notice.
October 30 and 31, 2014
Orlando, Florida
Force and effect chart: positive and restraining forces
for customer confusion in reception area.
H = High
M = Medium
L = Low
October 30 and 31, 2014
Orlando, Florida
Solution and Effect Diagram
• A derivative of the cause and effect diagram
• Analysis is now focused on a solution rather than the
cause
• The Solution and Effect Diagram is useful when a
problem solving team needs to consider the complexity
of a proposed outcome and take an objective look at all
the contributing factors.
• Use of the structured fishbone leads participants to
consider both the primary and secondary solutions to a
problem by delving into the details in more depth.
October 30 and 31, 2014
Orlando, Florida
Cause
Solution
How?
How?
How?
Why?
How?
Why?
Why?
Why?
How?
Effect
Solution
Why?
Effect
Solution
Cause
S = Solution Category
Cause
C = Cause Category
Relating the Solution and Effect Diagram to the Cause and Effect Diagram
Bialek, Ron, Duffy, Grace L., Moran, John W.; The Public Health Quality Improvement Handbook, ASQ Quality Press, Milwaukee, WI, 2009. Pp. 185 187
October 30 and 31, 2014
Orlando, Florida
Expanded example of high-priority force and effect
diagram using the 5 Whys technique
Why 1
Methods
Machine
Sign in and screening
processes not defined
Lengthy sign in and
screening process (H)
No commitment to process
improvement
Why 2
Senior management unaware
of benefit of proc. imp.
No process
improvement training
Poor lighting (M)
Why 3
Increase lighting
Senior management Why 4
not introduced to proc imp
Customer confusion in company
reception area
Provide facility directory
and training to reception
staff and backup
Fix equipment
Quality manager has Why 5
not scheduled exec briefing
Receptionist not
knowledgeable
of office locations (H)
All entrants to
reception area are
quickly and clearly
directed to destination
Correct signage
Rebalance existing assets
Personnel
Security screening
equipment not reliable (H)
Signage incorrect (H)
Budget frozen (H)
Materials
October 30 and 31, 2014
Orlando, Florida
Solution and effect diagram showing use of 5
Hows for high-priority action.
October 30 and 31, 2014
Orlando, Florida
Typical Solution and Effect Categories
–
–
–
–
–
–
–
4 M’s – Manpower, Materials, Methods, Machinery
People
Policies
Equipment
Life style
Environment
Etc as appropriate to the situation under analysis
October 30 and 31, 2014
Orlando, Florida
Cause and Effect Diagram with C/N/X
C = Control factor
N = Noise factor
X = Experimental
factor
Robert A. Cartia, At Your Fingertips; Combining cause and effect diagrams and check sheets aids
problem-solving efforts, Quality Progress, March 2014.
October 30 and 31, 2014
Orlando, Florida
Cause and Effect check sheet example
Test bulb process
Machine causes: Lighting
FAQs
1.
2.
3.
4.
5.
6.
Put on protective gloves, eyewear
Remove fixture cover
Reseat or clean off bulb
Replace bulb if burned out
Replace fixture cover
Test for proper function
Machine causes: Lighting
1.
2.
3.
4.
Test bulb
Test starter for fluorescent
Clean fixture
Reposition fixture for better
exposure
Robert A. Cartia, At Your Fingertips; Combining cause
and effect diagrams and check sheets aids problemsolving efforts, Quality Progress, March 2014.
Clean fixture process
1.
2.
3.
4.
5.
6.
7.
8.
Put on protective gloves, eyewear
Turn off fixture
Remove fixture cover
Remove dirt, etc. from fixture
Clean off bulb(s)
Clean fixture cover
Replace fixture cover
Test fixture for proper function and
October 30 and 31, 2014
increased lighting
Orlando, Florida
Success and Effect Diagram
• A quality improvement tool used to analyze a successful
process
• Use the Success and Effect Diagram to understand
successful processes as insight into improving other
processes.
• When the Success and Effect Diagram is finished, the
next step is to decide what few “What’s” to expand upon
to support the team in future improvement efforts. This is
a case of playing to your strengths.
October 30 and 31, 2014
Orlando, Florida
Success and effect diagram:
top-level correspondence project.
Methods: Wide and
open communication
channels
Machines:
Document mgt
system in place
For face to face,
written and
electronic documents
Same software as
executive office
Organization
and beyond
Required release updates
and features installed
Strong partnerships
Documents to executive
office reliable and timely
Confidence to try
additional quality
projects
Docs are on-time, accurate,
and consistent with applicable policy
“5” WHATS
Expectations set for deadlines
and policy requirements
Strengthen relationship
with Senate and WH staff
More face to face
contact
Roles and
targets clear
Formal document
preparation manual in
place
Materials: Strong
level of trust
Top level
correspondence
project
Basic QI
knowledge in
practice
Able to apply QI
tools to new situations
People: Strong
internal team
October 30 and 31, 2014
Orlando, Florida
School of Fishbones provides better focus
Cause and Effect
Force & Effect
Solution and Effect
C & E Check Sheet
Success and Effect
Sustainability
October 30 and 31, 2014
Orlando, Florida
DISCUSSION AND CLOSE
[email protected]
Cell: +1 (352) 406-8262
October 30 and 31, 2014
Orlando, Florida
October 30 and 31, 2014
Orlando, Florida