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Fishbone Exercise First Fishbone Kaoru Ishikawa, Organizational Theorist (1915-1989) Cause & Effect Diagram Kaoru Ishikawa • Kaoru Ishikawa (石川 馨 Ishikawa Kaoru, July 13, 1915 – April 16, 1989) was a Japanese organizational theorist, Professor at the Faculty of Engineering at The University of Tokyo, noted for his quality management innovations. • He is considered a key figure in the development of quality initiatives in Japan, particularly the quality circle. • He is best known outside Japan for the Ishikawa or cause and effect diagram (also known as fishbone diagram) often used in the analysis of industrial processes. Outcome: Bad Coffee How and why does the system produce bad coffee? 1. Procedures 2. Equipment 3. Materials 4. People Learning to Improve Learning how to see the system. We want to make visible the actual organizational structures and policies at work. This is an essential context for identifying promising changes and testing specific courses of action. The question we are asking in the first segment this afternoon is this: Why do we get the outcomes that we currently do? When answering this question we tend to see the system through our particular lens. That is why we do this as a group. Individually we only provide a partial view. We want to see the whole system. What are we attempting to improve? • We know that our current system is not inclusive. We aren’t the same as we were in 1950, but we are also not where we want to be in 2020 or 2050. This lack of inclusion is a reproduced reality – socially reproduced outcomes. • At the center of our analysis is the student. We want our “system” to be at the service of all of our students. • How do our students experience the system? How can we view the system through a student lens? • We want a user-friendly system. We also know that there is variation • We want to achieve high quality performance under a variety of conditions. • We know that practices such as reciprocal teaching, or high quality feedback, or positive teacher-student relationships are powerful practices. • We also know that high leverage practices must be implemented carefully in respect to each context in which implementation takes place (e.g., grade level, geographic locations, various levels of funding, different kinds of leadership). • We assist and coach one another in our efforts to achieve better outcomes. The Five Whys • 5 Whys is an iterative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. • The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?". • Each answer forms the basis of the next question. • The "5" in the name derives from an anecdotal observation on the number of iterations needed to uncover the problem. Toyota Traditions • "Why did the robot stop?" • The circuit has overloaded, causing a fuse to blow. • "Why is the circuit overloaded?" • There was insufficient lubrication on the bearings, so they locked up. • "Why was there insufficient lubrication on the bearings?" • The oil pump on the robot is not circulating sufficient oil. • "Why is the pump not circulating sufficient oil?" • The pump intake is clogged with metal shavings. • "Why is the intake clogged with metal shavings?" • Because there is no filter on the pump https://www.toyota-global.com/company/toyota_traditions/quality/mar_apr_2006.html Outcomes of Fishbone Diagram the system • Each major bone represents a key factor thought to contribute to an unsatisfactory outcome. • Smaller bones capture the details that emerge from the conversations about these factors. • Typically we look for 5-6 major cause and effect factors. Sharing the Consequences • While one might contest any given reason shown in the fishbone diagram, one fact clearly stands out: No single person, process, or resource is to blame (68). • The task of creating a fishbone diagram precedes our next step of highlighting some of the positive efforts we have made or are making in our current contexts. • Let’s do the fishbone exercise first. What’s working well right now? Section 2 30 minutes RCT (average) Treatment Effect: Reading Recovery N=141 schools 16 14 12 It’s a success -- 10 lets spread it! 8 6 4 2 0 -0.5 -0.3 -0.1 0.1 0.3 0.5 0.7 0.9 1.1 1.3 1.5 1.7 1.9 Effect Size Distribution of RCT Treatment Effects: Reading Recovery N=141 schools 16 14 12 10 8 Count 6 4 2 0 -0.5 -0.3 -0.1 0.1 0.3 0.5 0.7 0.9 1.1 1.3 1.5 1.7 1.9 Effect Size Distribution of RCT Treatment Effects: Reading Recovery N=141 schools 16 14 12 10 Positive 8 Undesirable / Weak Deviants (14%) Count Outcomes (16%) 6 4 2 0 -0.5 -0.3 -0.1 0.1 0.3 0.5 0.7 0.9 1.1 1.3 1.5 1.7 1.9 Effect Size Practices that achieve positive outcomes • No system is perfect. We need to continually improve and produce better prepared teachers. • What’s working well right now in your system to produce teachers with the skills needed to support the diverse range of students in inclusive classrooms? • Look at the Fishbone, inside these systems there are examples of positive outcomes, practices that helped participants achieve better outcomes. • Where are things working well? What’s next? Where to go from here? Section 3 30 minutes Targets for Improvement • Based on reviewing your system and identifying positive deviance, or what is working well, what is the best area to initially address in improving the preparation of teachers for inclusive classrooms? • What is the highest leverage area that will give you the most bang for the buck? • What are the next steps as you move forward with this improvement activity? • What roles, processes, policies, and contexts are possible targets for improvement? Report Out Section 4 30 minutes Tactical Starting Point • What is the high leverage area you’ve identified? • What are next steps for addressing this area of improvement? • What outcomes do you expect from this program improvement? • Take a picture of your results and post them on a slide? Thank you! Facilitation by: Steve Kroeger, EdD, James McLeskey, PhD, and Judith Monseur, PhD, Assistant Director, UC Systems Development & Improvement Center and Ohio Deans Compact Art work used with permission.
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