Ishikawa Diagram

• Where are the quality problems and which problems should I tackle first?
• Ishikawa / Fishbone / Cause & Effect Diagrams
• Process Mapping
• Five Whys
• Pareto Charts
• Failure Modes & Effects Analysis
• Root Cause Analysis

Description:

The Ishikawa diagram (a.k.a. fishbone diagram or cause and effect diagram) is a simple tool that a group can use to brainstorm and map out the possible causes of a quality problem.  This is an important step because many QI teams often jump into trying to fix a specific cause of a problem without thinking through what all the other causes might be.  

Step-by-step Instructions:

The diagram is constructed as follows:

1. Put the name of the quality problem in a box at the right of the diagram.
   
   
2. To the left of this box draw a central line (the spine), and from this central line draw diagonal lines (“fish bones”) representing different groupings of causes of problem.  In the attached example we provide a sample grouping designed for the Canadian health care system:  Patients, Providers, Policies, Processes & Procedures, Plant (Equipment). 
   
   Other commonly used groupings include:
• The six M’s (Machine, Method, Materials, Measurement, Man and Mother Nature (Environment))
• The four S’s (Surroundings, Suppliers, Systems, Skills)
• Equipment, Process, People, Materials, Environment, and Management Pick a grouping that makes the most sense for your organization and problem, or design your own. 
  
  
3. Ask participants to identify different causes along each of the different groupings and list them along the appropriate diagonal line. 
   
   
4. Participants may take any of the particular causes and then draw a line and more branches off the line to describe other factors which contribute to the cause. 
   

Variant:  Process-Style Ishikawa Diagram

First, identify some of the key processes involved in delivering a service where you are concerned about quality.  Plot these processes in a horizontal sequence.  Draw diagonal lines from each process.  Ask participants to identify problems arising at each process and plot them along each diagonal line.  

Sample Ishikawa diagrams. (See below)





Ishikawa Diagrams:  Tips for Facilitators

After putting the major categories onto the fishbone, allow plenty of opportunity for group creativity in identifying different causes.  However, if participants run out of ideas, or if they are debating only problems of not enough staff or resources, then try out the following potential causes within each category to stir discussion. 

Patients
Consider:

• Motivation level
• Level of knowledge about their own condition or health care system
• Family (structure, supports)
• Occupation
• Economic barriers
• Convenience to patient (hours, location)
• Other patient preferences
  

Providers
Consider: 

• right # of people
• working hours
• team composition
• teamwork
• workplace culture
• job descriptions
• level of training
  

Policies
Consider:

• professional regulations on scope of practice
• privacy legislation
• union rules
• hospital policies
• workplace safety rules & regulations
• payment policies for health professionals
• other laws & regulations
  

Processes & Procedures
Consider:

• are things done in right order?
• Handoffs where things are lost or miscommunicated
• Unclear processes
• Inconsistent processes
• Processes that are ignored
  

Plant (Equipment)
Consider:

• equipment reliable? Breakdowns?
• Equipment up to date?
• Equipment optimally located?
• Layout of building / department
• quality of patient space / work environment
• hours of operation