Cause and Effect Fishbone Diagram

Fishbone diagrams, also known as cause-and-effect diagrams, or Ishikawa diagrams, are created using a structured brainstorming process. As with all brainstorming activities, all ideas are listed without judgement or filtering. They are used to capture the insights and ideas of everyone involved in a particular problem. The diagram is structured around 5 categories that prompt us to consider multiple causes of a problem or effect. The categories most often used in primary care are known as the 5 Ps, or:

• Providers and staff
• Patients and families
• Procedures and processes
• Places (or equipment)
• Policies

When teams are just beginning to do improvement projects, the fishbone diagram activity supports an environment of trust that values the contributions of each team member. 

Tips

1. To start the process, draw the fishbone diagram as shown. Then have the group phrase the problem in the form of a question; what causes this problem to happen? I.e., what causes appointments to start late? Place this question in box on the right (the head of the fish)
2. Ask the group to come up with the things they believe cause this problem. They can write them on post-it notes to be placed on the diagram, or a facilitator can write them onto the diagram during verbal brainstorming. Because this is brainstorming, ideas are being gathered (perhaps clarified) at this stage, it is best not to discuss the merits or relative importance of the ideas.
3. See if any categories of causes are empty, or if any have the majority of causes. If so, ask the group to think of causes that may be related to the less populated fishbone spines.
4. Once the ideas have been gathered, the group can identify those that they want to explore further. This can be done using another tool such as the 5 Whys, a Defect Check Sheet, Process Mapping, or some other tool.
5. This fishbone diagram can also be used as a place holder for issues that the group will come back to and address in the future.

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