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Fishbone Diagram

Purpose The fishbone diagram, also referred to as a cause-and-effect or Ishikawa diagram, is used to investigate the causes of an effect or problem. It is often complementary to other tools such as flow charts and cycle time charts which can identify the locations of problems in a process (but not necessarily the causes).

How it Works, What it Means Like many tools, fishbone diagramming is often done with a work team. The process works well when multiple team members think together about the circumstances and events that might lead to the effect of focus.

The fishbone name for the diagram is derived from the shape of the diagram – the problem or effect of focus is placed on the center line of the diagram with lines extending out from this center point indicating domains, or areas of focus. From these lines, extend additional lines identifying specific potential contributing “causes”. Together, this network of lines appears “fishbone” like but is often an effective way to help a work team brainstorm all of the factors that may contribute to a specific phenomenon or problem

An Example An early childhood program has been assessing children twice yearly on a multi-domain measure. In spite of improvements over time in multiple domains such as literacy, numeracy and math, science, and physical development, social and emotional outcomes continue to lag the others for all children in the program. The program would like to make adjustments to curriculum and services, but it not sure where to begin. The team decides to complete an analysis of all of the potential causes.

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In the example above, four domains of potential causes are identified by staff after the initial problem statement is articulated: classroom, staff, community, and parents. These can be thought of as groups of factors that might contribute to the persistently low, unchanging social- emotional domain scores of children. (Note that it is not necessary to have any particular number of potential cause domains – in this example, only four are identified by staff although there is room for six. Likewise, the diagram can be extended as needed.)

Within each domain area staff must then “dig deeper” to identify the factors within these domains that are relevant. In the case of the staffing domain, the team decided that one contributing factor could be that two teachers were not renewed and the teacher to child ratio increased. Another possible factor is that staff have not received updated training for social and emotional development for children and the last training curriculum was from ten years ago.

Another causal domain identified is the community. The program is located a low-income neighborhood and since the recession, there has been an increase in violent crime and an increase in economic stress. The latter has been aggravated by many families reaching the five-year limit for TANF which has created more financial stress.

After working through each domain area, team members then discuss which of the factors they may be able to change or influence. For example, program leadership commits to identifying and securing low cost and more current training for staff for social and emotional development. To more actively address the increased economic needs of families, staff decide to connect with

Growing Evaluability Together GrEaT their county social services agency to identify a more up-to-date list of community resources for families including food pantries and emergency assistance.

Remember If team members have a hard time identifying the main causal domains, the group can begin with basic categories (e.g. program, community, leadership) just to get discussion started.

Work groups can prompt discussion by repeatedly asking “why does this happen?” as they walk through the diagram.

The fishbone exercise can be undertaken with other methods such as post-it notes on walls as well as white boards and markers.

Groups can identify which of the branches of the fishbone are directly within the control of the program (e.g., staff training) and which are not (e.g. local economic conditions) to explore what potential solutions can be employed depending upon locus of control.

Consider making the fishbone a living tool, placing it in a public area for staff to review, reflect on, and add to over many days or weeks.

Teams can consider reviewing research on cause and effect with specific complex problems such as in the example above.

Sources: Tague, N. R. (2005). The quality toolbox. 2nd Ed. American Society for Quality. Milwaukee, WI: Quality Press.

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