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FISHBONE DIAGRAM :
ANALYSIS TOOL
BRIG (DR) HEMANT KUMAR
PROF & HOD (COMMUNITY MEDICINE
& Dr. Narayanan G (CLINICAL TUTOR)

2.
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BOXOFFICE
FLOP
SCRIPT BUDGET
ENVIRONMENT MARKETING
Poor story
Lag in story telling
Dramatic dialogues
Dull opening
Political
Other films released
Heavy budget
Huge film sets
Song locations
Teaser and trailer
Heavy expectations
Over marketing
Detached story
Unrealistic
Delay in shoot
Not Season
Multistar
Cast and crew
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OVERVIEW
• History
• Root cause analysis
• Principles of RCA
• Fishbone analysis
• History and Introduction
• Goals and objectives
• Categories
• Field of application
• How to draw and analyze a fishbone diagram
• Applications of fishbone analysis
• Critical analysis
• Conclusion
• References
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“Quality is not an act , it is a habit.”
“Total quality management or TQM is an integrative
philosophy of management for continuously improving
the quality of products and processes.”
*Marketing management,Kottler&Keller
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ROOT CAUSE ANALYSIS
“ Root cause analysis is a structured team process that
assists in identifying underlying factors or causes of an
adverse event or near-miss ”
*Marketing management,Kottler&Keller
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BASIC IDEA OF RCA
• RCA is based on the basic idea that effective management
requires more than merely “putting out fires” for problems that
develop, but finding a way to prevent them.
• Essentially, RCA means finding the specific source(s) that
created the problem so that effective action can be taken to
prevent recurrence of the situation.
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1. RCA is a diagnostic and analytical tool
2. Effective RCA is a systematic process
3. Effective implementation of RCA requires a fundamental
shift in attitudes and mindset
4. RCA requires supportive organizational and
management cultures
5. Persistence and sustainability in the RCA effort
PRINCIPLES OF RCA
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6. RCA is an efficient and economical process
7. Effective problem statements and event descriptions are
helpful, or even required
8. RCA can help transform a reactive culture into a forward-
looking culture and it also reduces the frequency of
problems occurring over time within the environment
9. RCA requires a collaborative, multidisciplinary team effort
10. The focal points of RCA are corrective measures of root
causes and not simply treating the symptoms of a problem or
event
Contd..
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CPAR RESPONSE
*US Dept of Commerce,2014 13

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RCA TOOLS AND TECHNIQUES
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KAORU ISHIKAWA(1915-1989)
QUOTES BY ISHIKAWA
1) “ Quality control starts and
ends with training..”
2) “ In Management, the first
concern of the company is the
happiness of people who are
connected with it. If the people
do not feel happy and cannot
be made happy, that company
does not deserve to exist..”
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HISTORY
• Dr. Kaoru Ishikawa, invented the fishbone diagram (1960’s)
• In KAWASAKI IRON FUKAI WORKS, JAPAN
• Therefore, it is often referred to as the Ishikawa diagram
• He was the first quality guru to emphasize the importance of the
“internal customer,” the next person in the production process.
• He stressed that quality initiatives should be pursued at
every level of the organization and that all employees should be
involved
*Japaneese quality control,1963
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DEFINITION
• Also called as CAUSE & EFFECT DIAGRAM
“ Fish bone diagram is a visualising tool for
categorizing the potential causes of a problem in
order to identify its root causes ”
*Ishikawa,1952
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INTRODUCTION
 Visual diagram, named for its resemblance to a fish backbone
and ribs
 Fishbone analysis begins with a problem and the fishbone
provides a template to separate and categorise the causes
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GOAL
• The main goal of the Fishbone diagram is :
“ To illustrate in a graphical way the relationship
between a given outcome and all the factors that
influence this outcome ”
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OBJECTIVES
• The main objectives of this tool are:
1. Determining the root causes of a problem.
2. Focusing on a specific issue without
resorting to complaints and irrelevant discussion.
3. Identifying areas where there is a lack of data.
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CATEGORIES OF FISHBONE DIAGRAM
MANUFACTURING
(5 M’s)
1. Machine
2. Method
3. Material
4. Measurement
5. Man power
MARKETING
(8 P’s)
1. Product
2. Place
3. Price
4. Promotion
5. Process
6. People
7. Performance
8. Physical evidence
SERVICE
(5 S )
1. Surroundings
2. Suppliers
3. Systems
4. Skills
5. Synchronization
* Guide to quality control,1968 22

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WHEN SHOULD A FISHBONE DIAGRAM
BE USED?
• Need to study a problem/issue to determine the root cause?
• Want to study all the possible reasons why a process is
beginning to have difficulties, problems, or breakdowns?
• Need to identify areas for data collection?
• Want to study why a process is not performing
properly or producing the desired results?
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DELAY FOR OPD
CONSULTATION
PEOPLE PROCESS
EQUIPMENT MANAGEMENT
Delay in MRD file
Appointment system (only 10 patients)
Wrong reporting
Busy schedule
of doctors
Communication
gap between
Doctor and Staff
OT
Cases
Rounds
Emergency Cases
Walk in patients
Patients take time in filling
registration form
Language problem
Breakdown of equipment
HIS system is slow
Non availability of pen
Unexpected leave by consultant
Difficulty in taking lift and finding place
Queue
system
not
followed
Non
availabil
ity of
Queue
barriers
Height of the desk is
more
Delay in Registration process
Doctors will be available in IMS instead of
HRC OPD (Sometimes)
*Mrs.Sindhusree,Ajims25

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FIELD OF APPLICATION
1. Focus attention on one specific issue or problem.
2. Focus the team on the causes, not the symptoms.
3. Organize and display graphically the various theories about
what the root causes of a problem may be.
4. Show the relationship of various factors influencing a problem.
5. Reveal important relationships among various variables and
possible causes.
6. Provide additional insight into process behaviours
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MODEL OF A FISHBONE DIAGRAM
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STEPS IN FBD
STEPS IN FISH BONE DIAGRAM
Prerequisite to be met
I. Identify the problem
II. Work out the major factors
involved
III. Identify Possible causes
IV. Identify Specific Factors
V. Detailed levels of causes
VI. Analyze your diagram 28

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Prerequisite
• Gather a group of people that are knowledgeable about the problem
for a Brainstorming process
• The group should be made up of all staff available from the service
• They should start with a mind-mapping exercise to evoke ideas and
issues (causes) that are related to or affect the problem (effect);
• Use paper so the final diagram can be written up
• A facilitator should act as a note taker and keep the group on track
• It is for Preventing members from being side-tracked by tangents,
which detracts from the event at hand and could prevent them from
developing a strong action
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Step 1 - Identify and clearly define the
outcome or effect to be analyzed
• Write down the exact problem you face
• Where appropriate, identify who is involved, what the problem
is, and when and where it occurs
• Everyone must clearly understand the nature of the problem
and the process/product being discussed
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EXAMPLE
• For example: Pilot study of My thesis
• My thesis topic : “A Comparitive Study Of Clinico-
epidemiological Profile Of Depression Among Geriatric
Population In Urban And Rural Field Practice Area Of A
Medical College In Mangalore”
• Problem is : Increased time on finishing questionnaire while
doing Data collection of Pilot study
Increased time to
finish questionnaire
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Step 2 - Using a chart pack positioned so that everyone can
see it, draw the spine and create the effect box
• Draw a horizontal arrow pointing to the right. This is the spine.
• To the right of the arrow, write a brief description of the effect
or outcome which results from the process.
• Draw a box around the description of the effect.
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EXAMPLE
Problem :
• Increased time on finishing questionnaire while doing Pilot
study
Increased time to
finish
questionnaire
(Spine)
(Effect/Problem)
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Step 3 - Identify the main causes contributing
to the effect being studied
• Labelling the major branches of the diagram
• Establish the major causes, or categories, under which other
possible causes will be listed.
• Write the main categories your team has selected to the left of
the effect box, some above the spine and some below it.
• Draw a box around each category label and use a diagonal line
to form a branch connecting the box to the spine.
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EXAMPLE
• We identified the following factors, and adds these to the
diagram.
MATERIAL METHOD PEOPLE ENVIRONMENT
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INCREASED TIME
TO FINISH
QUESTIONNAIRE
MATERIAL METHOD
ENVT PEOPLE
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Step 4 - For each major branch, identify other specific
factors which may be the causes of the effect
• Identify as many causes or factors as possible and attach them
as sub branches of the major branches
• Fill in detail for each cause
• If a minor cause applies to more than one major cause, list it
under both
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INCREASED TIME
TO FINISH
QUESTIONNAIRE
MATERIAL METHOD
ENVT PEOPLE
GDS too long
Too many questions
Difficult to comprehend
Morning hrs
inmates busy
Working hours
Rainy season
Self administered questionnaire
Language barrier
Compliance with filling questionnaire
Difficulty in understanding
Not cooperative
Old age
Similar questions
Interpretation of Likert
scale tough
Time consume
Due to rain,
approach to houses
are difficult
Suspicious
Not interested
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Step 5 - Identify increasingly more detailed levels of
causes and continue organizing them under
related causes or categories
• You can do this by asking a series of why questions.
• You may need to break your diagram into smaller diagrams if
one branch has too many sub branches.
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Step 6 – Analysis of the problem
• You should have a diagram showing all of the possible causes of
the problem that you can think of
• Analysis helps you identify causes that warrant further
investigation.
• Since Cause-and-Effect Diagrams identify only
Possible Causes, you may want to use a Pareto Chart to help
your team determine the cause to focus on first.
• Depending on the complexity and importance
of the problem, you can now investigate the
most likely causes further.
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Contd..
• Look at the “balance” of your diagram, checking for comparable
levels of detail for most of the categories.
i. A thick cluster of items in one area may indicate a need for
further study.
ii. A main category having only a few specific causes may
indicate a need for further identification of causes.
• Look for causes that appear repeatedly. These may represent
root causes.
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INCREASED TIME
TO FINISH
QUESTIONNAIRE
MATERIAL METHOD
ENVT PEOPLE
GDS too long
Too many questions
Difficult to comprehend
Morning hrs
inmates busy
Working hours
Rainy season
Self administered questionnaire
Language barrier
Compliance with filling questionnaire
Difficulty in understanding
Not cooperative
Old age
Similar questions
Interpretation of Likert
scale tough
Time consume
Due to rain,
approach to houses
are difficult
Suspicious
Not interested
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* Academy of Economic Studies43

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EXAMPLES OF FISHBONE DIAGRAM
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APPLICATIONS OF FISHBONE DIAGRAM IN
HEALTH CARE
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1. INADEQUATE HIV SCREENING
* Assessment and improvement of HIV screening rates in a Midwest primary care practice : a quality
improvement study,BMJ 2015 46

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2. A CASE STUDY
• A group of staff from an outpatient clinic wanted to understand
what caused the common problem of long waiting times for
outpatient appointments.
• They held a meeting with all the key staff involved in the
outpatient clinic, so as to include all parties in the exercise.
• The group asked a member of their trust’s service improvement
team to facilitate the session and support them in writing up
• The team involved in the outpatient clinic met together and
started by agreeing the problem statement, which the facilitator
then wrote on a flipchart
*Nursing Times 16.04.13/ Vol 109 No 15 / www.nursingtimes.net 47

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*Nursing Times 16.04.13/ Vol 109 No 15 / www.nursingtimes.net 48

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3. DISCHARGE DELAY
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4. DIAGNOSTIC ERROR
*Fishbone diagrams in health care,Johnblack associates
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5. HEALTH CARE DELIVERY QUALITY
*Fishbone diagrams in health care,Johnblack associates 51

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6. IMPROPER DISPOSAL OF BMW
*Tools&techniques for Total quality management 52

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7. POOR QUALITY OF CARE
*Fishbone diagrams in health care,Johnblack associates 53

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APPLICATION OF FISHBONE DIAGRAM IN
OTHER FIELDS 54

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1. BOSTON DRAWING
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*Bostonmagazine,2004 56

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2. LATE ARRIVAL OF STUDENTS
*SIMSREE snehal,Bharathiya vidya bhavan,Rajasthan 57

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3. POST OFFICE LONG LINES
*Business economic times 58

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4. PRODUCT QUALITY
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5. CREATIVE BLOCK
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ADVANTAGES
 Helps determine root causes
 Encourages group participation
 Uses an orderly, easy-to-read format diagram of cause and
effect relationships
 Indicates possible causes of variation
 Increases knowledge of the process by helping everyone to
learn more about the factors at work and how they relate
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DISADVANTAGES
 They create a divergent approach to problem solving, where the
team expends a great deal of energy speculating about potential
causes, many of which have no significant effect on the
problem.
 This approach can leave a team feeling frustrated and hopeless.
 They are typically based on opinion rather than evidence.
 The simplicity of a fishbone diagram can be both its strength
and its weakness.
 As a weakness, the simplicity of the fishbone diagram may make
it difficult to represent the truly interrelated nature of problems
and causes in some very complex situations.
 Extremely large space required to draw
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CONCLUSION
 Fishbone analysis provides a template to separate and categorise
possible causes of a problem by allowing teams to focus on the
content of the problem, rather than the history.
 It is useful in root cause analysis, which is increasingly being used in
health services to improve safety and care quality
 A successful way of using fishbone analysis is to encourage a group of
staff who are involved with a service or clinical pathway to work
together to identify all possible causes of a problem
 On completing this exercise, the solutions will likely be identified and
an action plan for next steps can be drawn up
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TAKE HOME MESSAGE
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REFERENCES
1. Esmail A (2011) Patient safety in your practice. Pulse; 71: 3, 22-23.
2. Galley M (2012) Improving on the Fishbone - Effective Cause-and-effect Analysis:
Cause Mapping. www.fishbonerootcauseanalysis.com
3. Hughes B et al (2009) Using root cause analysis to improve management.
Professional Safety; Feb: 54-55.
4. American Society for Quality, Fishbone diagram http://www.asq.org/learn-about-
quality/causeanalysis- tools/overview/fishbone.html
5. Balanced Scorecard Institute, Basic tools for process improvement, Module 5 –
Cause and Effect diagram http://www.balancedscorecard.org/files/c-ediag.pdf
6. Ishikawa, Kaoru (1986). Guide to Quality Control. Tokyo, Japan: Asian Productivity
Organization.
7. Walton, Mary (1992) The Deming Management Method, Mercury Business Books
8. Marcelin et al. BMC Medical Informatics and Decision Making (2016) 16:76
65

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9. Quality circle - effective management tool in biomedical waste handling, d.
Debdatta, L moushum. Source: academy of hospital administration, vol 26, no 1,
jan-jun 2014
10. Total Quality Management by Poornima M
11. NHS Scotland (2007) Clinical Governance: Educational Resources. Edinburgh: NHS
Scotland. www.clinicalgovernance.scot.nhs.uk
12. NHS Institute for Innovation and Improvement (2008) Improvement Leaders
Guide. Coventry:
13. NHSIII. tinyurl.com/nhsi-leaders
14. Pearson A (2005) Minimising errors in health care: Focussing on the ‘root cause’
rather than on the individual. International Journal of Nursing Practice; 11: 141.
15. Senge P et al (1994) The Fifth Discipline Fieldbook Strategies and Tools for
Building a Learning Organisation.
16. New York NY: Doubleday Tschannen D, Aebersold M (2010) Improving student
critical thinking skills through a root cause analysis pilot project. Journal of
Nursing Education; 49: 8, 475-478.
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