Continuous Improvement & Benchmarking
Consider the major categories of causes. These are commonly things like people, customers,suppliers, equipment, processes, systems, environment, policies or procedures and so on. Note -they can be whatever you want, so long as they relate to the problem. Limit the major categoriesto between 4 and 6 (fewer is okay). Label the diagonal bones on the fish with these major categories.
Brainstorm causes as a team. As ideas are given write them on the diagonal bones in thecategory to which they relate. When ideas are suggested, ask “why” or “what causes that” andwrite sub-causes as small bones off big ones. Keep asking “why”. Keep going until all ideas areexhausted.
4. Agree the most likely causes
Review the ideas especially the underlying ideas - underlying themes, common to several areasof the diagram, will emerge. Take note of these. Discuss the ideas and rank the causes in order of likely importance.
5. Verify likely causes
Review existing data for evidence of which causes are most important. If the data is unavailableor ambiguous, gather fresh data aimed at distinguishing between possible causes.
20% of schoolchildren startyear without textbooksIncorrect booksorderedBooks orderedtoo lateTeachersnot trainedin orderingsystemChildren don’ttake proper careof booksTeachers takebooks to other schools whenthey leaveBooks deterioratedNotstoredproperlyNew curriculumlist sent toolateHead Teachersforget to sendorders in timeNewcurriculum listsent too late
124025431.doc Created: 30-Oct-04 Revised: 14-Mar-05 © 2004 ADB Institute2 of 8