Tag Archive: fishbone diagram

Getting to the Root of It

September 25, 2014Blog, , , , , , , , , , , ,

root causeNicole and I have stumbled into a bit of a theme these days, talking about the basic activities involved in Process Improvement and sharing with you some user-friendly and simple templates. First, we wrote about how to actually map a process, and next we covered how to look at that process map and assess which steps are a waste of effort – i.e., they add no value. Both those blog posts include handy templates which you can edit and manipulate to suit your needs.

So now what?

In Nicole’s example, we learned that External Failures were taking 56% of the total time involved in completing a process. Since External Failures are clearly non-value-add steps, that is where we will focus. It may seem obvious, but often it’s over-looked so I’ll say it again: start your process improvement work on the steps that offer the most efficiency opportunities.

The next step then, is to look closely at the External Failures and think about what might be some root causes for them. By reducing or eliminating them, not only will we reduce the chance of upsetting a customer, but we will reduce the amount of time it takes to complete the overall time to do the process.

Root What Now?

Root cause. The main thing that is causing a process to fail. Here’s an example: a customer’s dessert arrives and it is burnt. What might the root cause be for that? There may be a few of them, so let’s brainstorm. The customer received the burnt cake because:

  • the server wasn’t paying attention
  • the oven was too hot
  • the recipe was wrong
  • the chef wasn’t watching the oven
  • the oven timer was broken

There are a few examples of why the cake might be burnt. Are they root causes? Nope. They are sub-causes. Let’s dig deeper:

  • the server wasn’t paying attention because:
    • he/she was rushing
  • the oven was too hot because:
    • the thermostat was broken
  • the recipe was wrong because:
    • the chef made it from memory
  • the chef wasn’t watching the oven because:
    • he/she was receiving an order of fresh vegetables during dinner service
  • the oven timer was broken because:
    • it hasn’t had any maintenance in 5 years

So are those root causes? Maybe. Let’s take a look:

  • the server wasn’t paying attention because:
    • he/she was rushing because:
      • three servers called in sick and there was no backup plan
  • the oven was too hot because:
    • the thermostat was broken
  • the recipe was wrong because:
    • the chef made it from memory because:
      • he/she learned it from someone else who didn’t write it down
  • the chef wasn’t watching the oven because:
    • he/she was receiving an order of fresh vegetables during dinner service because
      • the delivery truck was late
  • the oven timer was broken because:
    • it hasn’t had any maintenance in 5 years

Brainstorming with Fish

We’re getting closer. We have a few root causes in there now, and a couple of others might even be able to go further. A great way to do brainstorming like this is to think in terms of categories of what could possibly go wrong. You can use whatever categories will work for you or your business, but some common ones include:

  1. Equipment
  2. Process
  3. People
  4. Materials
  5. Environment
  6. Management

fishbone
A tool we love to use originated in Japan in the ’60s. Known by several names (Ishikawa diagram, Cause-and-Effect diagram, and Herringbone diagram, to name a few), we use the most common title – the Fishbone Diagram. This diagram is nothing more than a brainstorming tool that helps groups think about potential root causes of a problem or issue. Lucky for you, click on this Fishbone Template for you to use in your next brainstorming session. It will download automatically.

Here are the steps in using it:

  1. At the “head” of the fish, write the problem you want to address.
  2. At the end of each of the “bones” of the fish, write the categories you’d like to use. (Whichever ones will stimulate the best discussion.)
  3. You can start brainstorming sessions several ways. One we like to use is to give everyone a stack of sticky notes and a pen. Ask them to look at the categories and write down as many potential causes as they can – one per sticky note. Now have everyone put their sticky notes on the wall, clustered in the six categories. Discuss and add more (because people always think of more). Remove duplicates.
  4. Draw a line towards each “bone” and write the potential cause on it.
  5. Ask if there are any further “bones” that might go off of the one you just wrote. If there are, then draw a line connected to that line.
  6. Keep going until you’ve written down all the ideas, and then ask if there are any more.
  7. Done!

Now you have a big list of ideas, and the trick is to figure out which one of those is the most impactful. How do you know which one(s) to fix first? Well, Nicole will tell you that next week… so stay tuned!

Until next week,

Ruth

PS – details on our new course, Leading Process Change, are coming within the next few days. Stay tuned to our Twitter (@whiteboardcons) and Facebook feeds, not to mention our website.

Process Improvement via The Whiteboard Way© – Step Three

November 9, 2013Blog, , , , ,

This week we continue our series on The Whiteboard Way© by taking you through what just might be the “favourite” phase in the process improvement journey – “Imagine It!”

Why is it the favourite phase? Well, it’s because most people have a solution in mind when they start this journey, and up until now we haven’t allowed them to even suggest it. We were all about  problem definition in Step One (remember, no solutions) and then the visual representation by drawing the current state in Step Two. In the third phase, we finally get down to business and talk about some possible ways to fix the problem.

Finally! I Can Just Implement My Idea, Right?

Um, no. Sorry. There are a few things we need to do to make sure that your idea not only will fix the problem, but that it’s also the best place to start. Sometimes great ideas are trumped by new ideas that we find in the first few steps of Step Three. If you can hang in a little longer, what we want to do next is brainstorm all the possible causes for the problem you designed in Step One, and drew in Step Two.

We’ve been looking at three different problem statements in this series:

  •  In the last 3 months we have had to fix this issue 6 times for four customers, causing dissatisfaction for our customers and wasted processing time for our staff.
  •  Each month we are 5-7 days late completing this process, impacting other departments and generating late fees for the company.
  •  This piece of work costs the organization $5,000 per month. Best practices in similar companies is half that amount.

Let’s take a closer look at the first example. It seems that we’ve sent the wrong thing to our customers 3 times in 6 months. Our shipping manager is pretty sure that it’s because we hired 4 new people in the warehouse, and they’re just not using the shipping system properly. He’d like to do some training for them – it will cost $1,500 a person to attend a two day course, and will require hiring temps to backfill while they’re off at training.

In “Imagine It”, the first thing we have to do is think of all the potential reasons for the mis-shipped products. We love to use a tool called a Fishbone Diagram to help people come up with “root causes” for the problem. This diagram is best drawn on a big whiteboard or brown roll-paper on the wall. At the head of the fishbone you put the problem “Mis-shipped products”. Each of the bones in the spine represents a common category of root causes. These categories are designed to trigger thoughts while brainstorming – participants use them to think of all the things in that category that could possibly impact the outcome.

A completed Fishbone Diagram for this issue might look like this.

Screen Shot 2013-11-09 at 6.32.38 PM

Actually, it would probably look much messier and with dozens more ideas. But let’s run with this one.

Our shipping manager’s idea of training being the big concern is right there on the fishbone, under the “People” category. But during the brainstorming session, someone pointed out that there have been a few power outages recently and that all the picking had to be done manually. Also that the website had been updated, and that customers in Vancouver had called in with issues using the online order forms.

Suddenly, the training idea has taken a back burner until the other ideas are investigated. It doesn’t mean it’s a bad idea, or even the wrong idea – it’s just that a little more investigation is needed first.

In this case, it turns out that the power outage was the root cause – each mis-shipment was linked directly to times when the picking process had to be done manually.

Now What?

A few things. First, you might want to investigate why you’re having so many power outages! Is it a freak of nature or do you have electrical issues? Second, how can you improve the manual picking process? Use your new process mapping skills to look at the current process and see where there might be room for improvement and ways to prevent mistakes from happening (the Japanese term for this is Poke Yoke – error proofing).

You might want to prove that the new process will work too. That’s the topic for next week.

Until then, please leave a comment – anything! Process questions, ideas for an upcoming blog, your thoughts on the Maple Leaf’s’ chances this year. Whatever!

Ruth.