A new twist on fishbone diagrams where a tail is added to provide better visual and clarity for team members in achieving root cause analysis.

1. New Twist in Designing a Fishbone Diagram The Root Cause Tail

2. Current Design Experience has shown that traditional fishbone diagrams can be confusing to teams As new ideas are entered, words get jumbled and lost in the mix * Copied from diagrams.net on 02 Apr 2011 http://www.diagrams.net/tag/fishbone-diagram

3. Clearing up the Fishbone My new design to the fishbone has the development the same, but with minor additions Obtaining the “vital few” for further breakdown Incorporating the “5 Whys” Adding visual clarity for team focus

4. When to use the Tailed Fishbone Just like the current fishbone diagram is utilized, in the tailed version, you need the same factors One – must have factual data of the process (not peoples opinions, or perceptions) Two – best utilized in complex process where there are many factors that could lead to your problem

5. Starting Out Draw your fishbone as normal Put your problem statement in the head There are two ways to categorize the side fins Pre-categorize Categorize based off themes from teams’ brainstormed ideas The team’s attitude and engagement by the time we reach root cause determine which one I use

6. Pre-categorize: For Teams Still in the Forming/Storming Stage Most fishbones are built with the 4 or 6 P’s, 4 or 6 M’s, 8 S’s etc. In a non-manufacturing process I like the 4 P’s Following three I use every time: Place (or work center) People (those doing, leading and supplying to the job) Policy (rules and regulations that direct the job) The next two I switch between (or can use both) Product (products used within the process) Process (steps taken within the process; Non-Value Added)

7. Post-categorizeFor teams in the Norming/Performing Stage After team has brainstormed ideas for causes of the problem Generate themes based off commonality of multiple ideas Themes help to provide better clarity for the team, and allow them to feel more in control of the process Recommended for experienced facilitators

8. Example:Made-up scenario on training of new employees Categories Plant People Workstations Non-Std People Trained differently Lack of Experience Brainstormed Causes Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Product Policy Problem Statement

9. Finding the Vital Few Next I bring color to the fishbone by allowing people to vote Use the N/3 method Number of items brainstormed divided by 3 Facilitator choice if multiple votes can be used on single item Would not recommend if more than one antagonist on team attempting to achieve personal agendas Allow team to vote most likely cause to problem for each category The attempt is to achieve top item per category

10. Example:Made-up scenario on training of new employees Plant People Workstations Non-Std People Trained differently Lack of Experience Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Product Policy If tie in one category, I let the team do a one minute commercial for each person (no interruptions, everyone gets a turn) . Then I re-vote (with a different color marking). If still a tie, it won’t matter come next round (usually).

11. Moving towards Root Cause Now I change the color of the vote and have everyone mark the one item in all categories that is the most likely culprit of our problem statement One vote per person

12. Example:Made-up scenario on training of new employees People Plant Workstations Non-Std People Trained differently Lack of Experience Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Policy Product Winner!!!!

13. Conducting “5 Whys” Now that the team has put their focus on one item; conduct “5 Why” analysis 5 Why is just the title; Just keep asking until someone says, “Because God said so.”

14. 5 Why on our Example Why are training manuals outdated? Because no one updates them Why no one updates them? No ones responsibility Why is it no ones responsibility? Never needed it before Why was it never needed before? Old computer system was easier to navigate Why was older system easier to navigate Less screens to navigate and less data required for entry

15. Visualize the Root Cause Now that you have root cause, make it visual on the diagram

16. Example:Made-up scenario on training of new employees People Plant Workstations Non-Std People Trained differently Lack of Experience Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system requires more screens to navigate and more data req for entry New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Policy Product

17. Adding Depth and Clarity The colored votes allow separation of the brainstormed causes The tail of the fish is what guides it’s direction where as the side fins help push it along So I then speak it like this to gain understanding of the root cause (see next slide)

18. Example:Made-up scenario on training of new employees “So, our root cause guides our contributing factors, leading to our headache!” People Plant Workstations Non-Std People Trained differently Lack of Experience Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system requires more screens to navigate and more data req for entry New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Policy Product

19. Showing Root Cause Eliminates Contributing Factors Next I walk through each brainstormed items (contributing factors) to see if solving the root cause also eliminates the contributing factors If majority are also solved then I know I have root cause. If not, then you must re-evaluate (never had this happen)

20. Example:Made-up scenario on training of new employees Creating Standard Work in form of a User Guide could eliminate root cause People Plant Workstations Non-Std People Trained differently Lack of Experience Customers provide unique scenarios to trainee Employee training is inconsistent leading to non-standard time frames for new hire competency Trainers are not always most experienced New computer system requires more screens to navigate and more data req for entry New computer system No standard interview for new hires No standard for competency testing Training manuals outdated New hire placed with first available employee seen by manager Policy Product Items with an X could be solved by the solution to root cause

21. Summary Tail Root Cause Categories and Brainstormed Ideas Contributing Factors Head Problem Statement Result – a visual understanding of a single root cause built and owned by the improvement team

22. Questions, Comments, Constructive Criticism or Praise Contact me by email at: mark.adamsusaf@gmail.com Developed by Mark Adams, LSS BB Developed and shared for crosstalk purposes only