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The first live presentation of this webinar was so popular that we’re doing an encore presentation!

The Fishbone (aka Cause & Effect or Ishikawa) Diagram is a seemingly simple method of conducting structured brainstorming around the root cause of a process problem. So why is it so hard to get it right?

In this 1-hour Introductory Webinar we’ll walk through some classic ways to build a Fishbone Diagram, we’ll show you some of the common missteps and we’ll provide examples of what they look like when they’re properly executed. Join us for a guided tour of the Fishbone!

Webinar Level

  • Introductory


  • What is a Fishbone (aka Cause & Effect or Ishikawa) Diagram?
  • Why and when should we use a Fishbone Diagram?
  • What is the source of ideas for a Fishbone Diagram?
  • What are the 3 biggest Fishbone challenges?
  • Tips & tricks for Fishbone Diagrams

Learning Objectives

By the end of this webinar you will be able to:

  • Define a Fishbone Diagram
  • Describe when and where to use Fishbone Diagrams
  • Outline the sources of root cause ideas to populate Fishbone Diagrams
  • List the challenges encountered when using Fishbone Diagrams
  • Recognize best practices for building Fishbone Diagrams

Webinar Slides

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5 Whys & Fishbone Diagram Training -

5 Whys & Fishbone Diagram Training
Single Module

For a better understanding of the Fishbone Diagram and an overview of Lean Six Sigma, check out our 5 Whys & Fishbone Diagram Training!

Original Webinar Transcript

Tracy: Hi everyone! Welcome to’s webinar. Thanks for spending some quality time with us today. We’ve got lots of people registered for this particular webinar. And we are the Lean and Six Sigma go-to improvement method website. All over the world, we try to help people minimize cost, maximize profits, and develop better teams while creating happier customers.

So every month, we craft webinars just for you, just for our audience and our global learner community. We hope to simplify concepts and tools of Lean and Six Sigma so that you can understand and apply them more easily and be more successful.

Today’s webinar is titled How to Use a Fishbone Diagram. I’m Tracy O’Rourke and I’m a managing partner at And today’s presenter is also a Managing Partner at, my colleague, the wonderfully talented and consummately knowledgeable, Elisabeth Swan.

Hi, Elisabeth.

Our Expert: Elisabeth

Elisabeth: Hi, Tracy. Thank you.

Tracy: She also has starred in the Pirates of the Caribbean. I’m just kidding. Let me tell you a little bit about Elisabeth. She is a Master Black Belt and consultant, and coach, and trainer for over 25 years. She has helped many organizations like Amazon, Charles Schwab, Target, Volvo, Alberta Health Services, Starwood Hotels, and many others successfully apply Lean Six Sigma to achieve their goals. I believe she is an awesome writer and blogger. If you haven’t read any of her blogs, you are missing out, and they are free on our website. So definitely search for Elisabeth Swan and her blogs.

How to Interact

So before we get started, we’re going to do a few housekeeping notes. So during the webinar, all attendees will be in listen-only mode. At the end of the presentation, we’ll have a question and answer session. And please feel free to ask any questions throughout the webinar. Just enter them in the question section of the webinar control panel. And if we don’t answer all questions during the webinar, we’ll be sure to post the answers on our website at so you have them.

And I will say that we will be sending out copies of all slides because we always get that question as well as the video on YouTube so that you can hear the recording as well.

Let’s Interact!

So let’s start with our first activity. We would like to know where are you from, so in the question window, please type in where are you from. Lisa Goldberg was the fastest there. She says she is from Bronx, New York. Thank you, Lisa. Speedy.

We’ve got lots of friends joining us from all over the world. We’ve got lots of people from the United States but also internationally, which is why I love to find out how late people are up at night because they want to hear Elisabeth talk about her knowledge on these webinars. So Bronx, New York. Tacoma, Washington. Richmond, Virginia. Chicago, Illinois. Vancouver. Ann Arbor, Michigan. Canada. Rapid City. South Dakota. Seattle. Washington. Gurnee, Illinois. Massachusetts. Elizabethtown. Look at that! In Kentucky. Did you know there’s a town named after you, Elisabeth?

There’s Boston, Indianapolis, Salt Lake City, Fresno, Manila, Philippines. Welcome. Costa Rica, Timbuktu. I wonder if they were joking there. Philippines. Oshawa, Ontario. Saskatchewan, Canada. I’ve been there. Kingston, Jamaica. Welcome everyone. Thank you for participating. We’ve got lots of people from all over the world.

So, I am going to hand it over now to our presenter, Elisabeth Swan.

Who Is

Elisabeth: Thank you, Tracy. Thank you for you warm introduction. I’m sorry I can’t see all of you but I’m happy all of you joined us. As Tracy said earlier, we’ve both been with Go Lean Six Sigma since its inception. And our mission is to make it easy for you to build your problem-solving muscles. So that means that we simplify complex concepts. We’ve made our training extremely practical and I think really enjoyable.

We provide a running case study at the Bahama Bistro. We’re going to use it today. That’s a restaurant where the team applies all the tools.

Aside from this webinar series, we’ve got blogs, podcast, book reviews, lots of other info. As Tracy mentioned, all free. And we’ve used and taught Lean Six Sigma for decades because it’s the best toolkit for problem solving.

We’ve Helped People From…

And lucky for us, there’s a growing list of companies who agree with us. So here are some of the folks that we’ve worked with. We’ve got bricks and mortar. We’ve got online companies, diverse industries, healthcare, financial services, manufacturing, and government.

And the reason is because Lean Six Sigma is about problem solving. In our experience is that if you have an organization, you’ve got problems. So like you, these companies want to be the best at problem solving. So you’re in good company.

So more on benefits later but let’s review our agenda for the day.

Today’s Agenda

So, what is the fishbone diagram? Also called a Cause & Effect Diagram, also called an Ishikawa Diagram for its creator, Ishikawa. And I’ve also heard people call it a Fishikawa, just putting it all together. Why and when should we use the fishbone diagram? What’s the right way to build one? And are there any ways not to use a fishbone? What are the traps and what do proper ones look like?

The “Y” and the “X”

So let’s get back to these basics, the Y and the X. These are the symbols we use when we discuss cause and effect. Y is the effect or the issue and the Xs are what we’re trying to understand. And the fishbone lets us explore the relationship between the Y and all these Xs, these potential problems, these inputs. So we’re looking at what’s causing the impact.

Pseudo Equation

This is what we call the pseudo equation because it’s really just trying to get across that relationship I’m describing. So this is happening. We’re doing the deepest in the analyze phase of DMAIC and we’re looking for root cause. And this equation is not really mass but it’s important. It’s saying that a Y or the output is a function of all these different Xs, these different inputs and causes and problems and factors. And some are important and others don’t matter.

And fishbone diagrams provide a structured way to brainstorm potential Xs so that we can get down to a critical X. We’re trying to find those critical Xs that impact our life. So Y is a function of X1, X2, X3, X4. We’re trying to look for critical Xs.

Y and X at Bahama Bistro

So here, this example is from the Bahama Bistro and they’re measuring customer satisfaction. There are lots of factors that impact customer satisfaction, the time it takes the servers to serve you, the freshness of the food, the level of the lighting.

In this case, customer satisfaction is the Y and these aspects of their experience are the Xs. And we want to improve this Y. We have to determine which of these are critical Xs so we can make effective changes. They might suspect that the faster the service, the happier the guests or cleaner the restaurant, the happier the guests. Those are all potential Xs, which brings us to our fishbone diagram.

What Is a Fishbone Diagram?

So what is it? It’s basically a structured brainstorming method. It encourages what we’ve called divergent thinking, sort of go wide. Consider the world of possibilities about what’s impacting the Y. It’s not logical thinking process. So it’s important to consider the next steps when you use the fishbone.

Fishbone Diagram

But first, we’ll take a look at the structure and how to build one. So the effect of the Y, the causes of the Xs, and this is just an image of the fishbone template that we have on our site. It makes it look incredibly orderly and that you just sort of list your categories and then enumerate all of your causes. When actually, fishbones are not neat and orderly. They are messy. They’re on flipcharts. There are scribbles everywhere. The goal is to get them kind of fuzzy with bones. You want them really messy.

And where the Bahama Bistro is trying to brainstorm the causes that affect a category like customer satisfaction and when the team runs out of ideas, they move to a different category. So we have the categories we saw. It could be the speed of the service. It could be the ambiance. We’re looking for what impacts that effect.

Poll #1

So let’s do a poll with you guys. We’re trying to get just a level set here to understand what’s your experience with fishbones. So I’m going to launch that. OK. Poll is launched. Tell us what your experience is.

Tracy: While we’re waiting for the poll to come in, I will say that this is one of my favorite tools. And very often, I use this in almost every project that I’ve worked in or other people have worked in because it is so helpful.

Elisabeth: It is. It’s a basic. It’s one of those 80-20 rule. It’s one of the tools that use 80% of the time. OK. Well, it looks like we’re getting to a critical point with this poll. I’m going to close it and share it. What do you see, Tracy?

Tracy: OK. So, our number one poll selection was I don’t know – I know about them but don’t use them, 42% of people said that.

The next is, I use them but not sure I’m using them effectively, 23%. 21% say totally new to me, and 14% say I use them all the time, it’s a great tool.

Elisabeth: Well, in terms of the 80-20 rule, 80% of our participants today are looking for some help with this because either it’s new, they’re not sure they’re using it effectively or they know about them but they don’t use them.

Tracy: Yeah.

How to Construct

Elisabeth: So let’s come back and move on and give people some ideas. First question is how to construct them. They Y, the issue is in the fish head. And as you say Tracy, the head stinks.

Tracy: The fish head always stinks.

Elisabeth: And we got two methods. One, pre-label. You got some standard transactional categories. You have some standard manufacturing. Or two, you could brainstorm and affinitize. Let’s take a look at what that is. Root causes into categories. They’re a process-specific. The groupings become fishbone labels.

1. Pre-Label

So first off, pre-labeling. This is easy. There is ready-made for you. It might drive the ideas in a particularly helpful way that you wouldn’t have thought of. There’s no upfront work. But it’s limiting. And these labels aren’t process-focused.

Manufacturing Categories

So manufacturing, these are the standards if you’re looking for some preset labels for a manufacturing process. And the thing to consider here is what do we mean by method? And one way to think about that is we’re really talking about the standard operating procedures. So what has been documented?

And the materials. You can actually separate that into separate bones with specific parts on each bone. You’re not limited to six. You classically see a fishbone with six bones. But if you’ve eaten a fish, you know there are more than six bones. So specific parts materials, separate that if you need to.

Man Power, you don’t have to leave it that broad. You could label different bones with different job descriptions, different operators.

Measurement, we’re usually talking about the variation in the measurement like what if a scale being used – there are two different scales and they are calibrated differently so it causes a variation in the measurement.

And then there’s this category which is classic, Mother Nature. As you can tell, they tried to go for six Ms, right? So environment turned into Mother Nature. But what if weather doesn’t impact the process? What could environment be? It could be the physical layout, if that matters, or it could be the political environment. What are the ramifications culturally? So those are classic manufacturing.

Transactional Categories

And these are classic transactional or service industry category. So systems, there you’re talking generally about software. What are the applications that impact what we’re doing?

Process once again, what’s the documentation, job description, things like that.

People, again, you could have separate job functions in place. It could be again, physical, political environment. What’s the cultural impact?

2. Affinity Analysis

So this is the second one, right? So the first one is just choose some of those standards. You’ve got some nuances there but those are standard.

Now, we’re going for method two, and that’s affinity analysis. And this is freeform brainstorming again. You do it with a group. Always do fishbones with a group, affinity analysis with a group. This is a group tool. This is not for a party of one. You can have fishbone parties with other people but not by yourself. You want the group knowledge.


So the idea is first to come up with some ideas of what could be the root cause. So back to the Bahama Bistro, they’re trying to understand what is driving customer satisfaction up or down? Then they would brainstorm free form. It’s best to do it silently so that everyone gets their ideas on the board. It’s really easy to handle duplicates so that’s OK. So you brainstorm free form. And then you assign one or two people to figure out what are the natural categories here?

So they start to look at, these things all sound like they had to do with the menu. Or these things are sounding like they’re related to service. And again, this is talking about freshness. This is talking about quality of ingredients. Well, that’s food.

So these categories start to emerge and then you label them. And that helps you figure out what you want to name the categories of the fishbone that is process-focused. So if we look at the Bahama Bistro, their fishbone might look like this. They’ve customized it. They’ve only got six bones and they could have more but they can start here. So those are the categories where they’re going to look for root causes that will drive customer satisfaction.

Poll #2

So let’s get another – some more information from you guys. Which method do you use? Those of you that use the fishbone already, what do you use? And you’ve got – well, if you don’t use it, you can choose D. No problem. But let’s get some info from you guys. I’m going to launch. OK.

Tracy, what do you see?

Tracy: It’s funny. I find that manufacturing tends to like to pre-label and create very structured brainstorming around those labels or the labels that you had shared. But in transactional, I find that brainstorming just on Post-its and then organizing them later, affinitizing them into categories and then putting them on the fishbone seems to work really well.

I find that brainstorming just on Post-its and then organizing them later, affinitizing them into categories and then putting them on the fishbone seems to work really well

Elisabeth: Yeah. And that is also driving some interaction with the team. They’re getting to think about it upfront, sort of watching how these categories form. So anything that builds that interaction, that engagement or ownership, I think that’s a good thing.

Tracy: Yeah. And I would just add too that if the labels, if you’ve tried doing this and the labels seem to block brainstorming, just move to a different way. You don’t have to stick with just the labels. You can just say, “OK, forget the labels. What do you guys think some of the root causes are?” And then have them brainstorm. And people have tried the labels just to try it on and see if it worked and then they’ve changed it.

Elisabeth: Good. OK. So I’m going to close and launch this. What do you see?

Tracy: OK. So we have a tie for first place if you will. The first one is, I brainstorm and affinitize categories first, which is great, 30%, 30% said none of the above, which is very interesting. I wonder what they do. And then followed by, I use the standard manufacturing or transactional labels, 23% or 17% say, I just pick the labels that seem appropriate given the issue.

Elisabeth: Yeah. I think that people are not using any of it, was giving that as an out in case there are people that have joined that have never used a fishbone, right? So it would make sense for them to choose a method. But it’s interesting. There’s a big group of people doing this in an affinitize method, which is good. I think that one is pretty effective.

Fishbone Diagram Example

OK. Thank you for that, everybody. So let’s look at the Bahama Bistro example. So we’re still with their issues around why the variation in customer satisfaction. And they’ve started brainstorming. They even started brainstorming another layer down, and that’s helpful because we’re often brainstorming superficial causes or symptoms and we need to dig a little. And these are good.

But as we said earlier, fishbones enable structured brainstorming. And it’s important to think about what are the next steps once we’ve brainstormed. And so, teams are going to eventually have to test or verify which of these is a true root cause. It really helps to think in terms of measurement. And this might be new to a lot of you but I think it’s incredibly high impact. And I’ll show you what that looks like.

Turn Into Measures

So instead of saying that the service is too slow, we can say, “We think service cycle time is causing the variation in customer satisfaction.” Instead of saying limited options, we’ll say, “The number of options is somehow correlated with the customer satisfaction.” Stale bread becomes age of bread. Too noisy becomes the noise levels above a 100 decibels, and they thought that was because of all the dropped dishes. Well, you can count number of dropped dishes per hour. Just get somebody out there on the floor listening for the crashes.

So this is starting to make the relationship between the Xs and the Ys much clearer. It pulls us closer to testing our theories by using these measures. So if you think about this, how might this look for the team? What would they then measure if they’re trying to understand does the service cycle time the time that it takes to deliver food? How does that impact the customer satisfaction ratings?

Looking for Correlation

So they’re going to take a look at a scatter plot, right? So there’s a nice easy visual where it shows that as the cycle time increases, customer satisfaction decreases. That is a classic negative correlation. And if they got these kinds of results then they’re on to something. So service cycle time looks like a critical X in terms of customer satisfaction and it’s worth pursuing. And I think those measures just that a really easy sort of connection to make for a team when you’re working with them.

Caution: Solutions Masquerading

Now, on the flipside, what Tracy and I often see as something completely different and I will show you an example of that, we don’t see too slow. We see things like there’s not enough waitress training, there’s missing fusion options on the menu, the food, we need more inspection of those stuff getting out there, we need to increase the number of condiments, we should build booths. That would cut down on the noise. And there’s not enough automated ordering.

Fishbone Trap

We see what we call solutions masquerading as problems. And this is a constant. And usually, these are the things that tip you off. Any time you see the words “lack of”, the word “insufficient”, the word “inadequate”, those are red flags. That’s why we put them in red. Any time you see those then you know you’ve got solutions on your fishbone diagrams. And fishbone diagrams are in the analyze phase. We’re trying to analyze our problem. We’re trying to get to the root cause. Solutions come in the improve phase.

Not saying there might be some – not be some great ideas here but they’re not going to help us get to root cause. If anything, they take us off course and have us solving problems before we’d really verified what our problems truly are. And that’s the idea. We’re brainstorming potential problems then we’ve got to verify.

So watch out for these. These are the things we see. And see some themes. We see the theme of they need more, they need more inspection, they need more automation. I’m going to come to those in a second.

Solutions → Measurable Causes

But I want you to think about it in another way. Let’s flip that and say, “OK, if you think lack of training is an issue then let’s find a way to measure the level of operator knowledge.” So how much do people know? And then we could think about how to solve that problem.

If you say procedures aren’t being followed, what percent of the time are they not being followed?

Inadequate staffing. Well, what’s the utilization of man hours?

Inspection is an issue. Inspection of what? What is the defect you’re looking at? Let’s measure the percent of returned meals.

So get some data around these so that you can make more robust decisions when you get to the improve phase.

Level of Training

Now, let’s come back to those three bugaboos. Let’s come back to training, inspection, and automation. So training, and this is a really interesting thing. So process improvement might result and often does result new or updated training. But it’s good to consider the need for training first.

And fast food outlets are great examples because, I don’t know how to put this, but they’re basically run by teenagers and as far as we know they’re generally not poisoning a lot of people. So how are these teenagers running these businesses so successfully? And what they have are incredibly visually managed processes.

If you think about cash registers don’t have numbers. They basically have pictures of food. Just hit a small fries. You just hit a medium fry. So they’ve really taken the translation out, the process is visual, where things go, what’s the order of the steps, because they plan for high turnover. They plan to hire constantly and they don’t have time to do a lot of training. So they build their processes and don’t need it.

Do we have processes that are too complex? We could measure that by saying, “Well, how many steps are there?” And that would help us understand. Is this too complex?

Do we have processes that are too complex?

I remember Tracy and I worked with a financial services company that they had 100 steps roughly to deposit a check. Now, I know that everyone on this call has probably deposited a check, and it doesn’t take 100 steps. So how complicated are our processes and do they need to be?

Number of Inspections

How about inspection? Inspections, they add time. That’s one of the delays that’s an 8 wastes. They’re initiated by failures. They might provide a false sense of security. And what do we mean by that?

Research shows that if somebody downstream – somebody upstream knows that somebody downstream is going to check their work then they are more likely to be less vigilant. The attitude is, “Somebody else is going to take a look at this. I don’t have to work too hard or check it too closely.” So that increases errors.

They also never get removed. Once they are instituted even if the failure rate is down to nothing, they’re permanent. It’s very hard to get rid of the inspection step. So always watch out before inserting inspections and try to understand what’s the defect we’re inspecting for, right? That’s the only reason we’re doing is because we expect something to go wrong. Could we measure how bad that is first? And then in the improve phase, if it is a big deal then let’s try to prevent it. Let’s do some mistake proofing.

Automation Myths

And lastly, automation. I’ve worked with a lot of teams where we talked about solving something and they’d say, “You know what? Automation X. Software X is coming. It’s going to solve all this. So there’s no – really no need to even go down this road.” And I talked to them a year later, it’s still coming. A year later, it’s still coming.

So there is this sort of it’s coming aspect that I find. You could have saved a lot of money, a lot of time, and a lot of frustration if you just fix it back at the time you addressed it. Or, the assumption that’s going to solve everything.

Software sounds great in theory but when it actually arrives, it’s got whole host division that brings with it. It doesn’t necessarily solve things. It doesn’t necessarily streamline the process. So I find that it’s better to think about what is it we can do to streamline this process before automating. Do we even need this process? You should maybe even be automating it. So those are three things we went on to that you should be vigilant.

Solution Parking Lot

And the great tool which is kind of simple that Tracy and I both love is the Solution Parking Lot. So when people come up with this solution, if you see “lack of”, “inadequate”, “insufficient” on the fishbone, grab it, put it on the solution parking lot. These are just jokes but it’s really helpful that people hear – they feel heard. They feel like you’re listening to them, that you’re taking their ideas in.

You don’t want to be the DMAIC police and say, “Hey, it’s analyze. We’re in analyze phase. You can’t give me any solution ideas. We’re not in improve yet.” We don’t need to be dismissing things that could be helpful but we want to do our due diligence before we entertain them.

So keep this running list. You’re going to need it. You’re going to appreciate it when you get into the improve phase. Really simple.

“Red Herring” Root Causes

OK. So the solution parking lot was one solution. But in general, look out for these “Red Herrings” we call them. Beware of solutions masquerading as problems, don’t assume training is the issue, and clean up a process before automating it.

One Fishbone Leads to Another

OK. Let’s come on to another topic about fishbones, and that is one fishbone can lead to another. So this is the one we started with. So this was the issue with customer satisfaction, the variation in customer satisfaction. And one of the biggest, Xs, the critical X that came out of this was service cycle time. Well, that deserves its own effort. So let’s move to a whole new fishbone with the issue in the front now turning into why do food orders take so long at lunch?

New Fishbone Diagram

And now, you see the team has done a really good job of using measures to understand it, like the number of steps between stations. Does that impact the time? The number of steps required for restocking during rush, does that impact the time? Does the number of special orders or wrong special order impact time? The time that the percentage of transactions that get stuck in the point of sale or the cash register software.

So now, they have reset. They’re really setting themselves up to understand which of these is correlated to the service cycle time. And they can go immediately and collect the data and figure that out. So they are set.

But there’s another thing to do with the fishbone. We talked about getting to the next level. So what’s underneath these?

The 5 Whys

So another way to form new fishbone is to ask the 5 Whys. And the 5 Whys, this comes to us from Sakichi Toyoda who is the founder of Toyota Industries. It’s also called the 5-year-old tool, just keep asking why. It’s great for many, many arenas in process improvement but it’s specifically known in the root cause arena.

So you are basically looking down the causal chain and it’s simple. This is not a complicated thing. It just says let’s take some time to do that.

5 Whys Example

So let’s look at a classic one. Some of you may have heard it before. This one happened with the Jefferson Memorial and it’s actually a true story. Someone just recently sent me one of the original articles about when this was done a long time ago.

But the issue was – the problem they were looking at was the marble of this monument was deteriorating. So they want to understand what’s causing that. And the first level of Whys, they found out they were washing it too often with detergent. So repeated cleaning was eroding the marble. So they said, “Well, why is that happening?”

And if they didn’t want to do the 5 Whys, they could have started experimenting with different detergents or not washing it as often which might have caused some unsightly monuments. But they asked why. And it turns out that the local pigeons were visiting the monument and they weren’t leaving it in the condition in which they found it.

So the monument really did need to be washed frequently. But then it begs the question, why so many pigeons? Now again, you could do something, non-pleasing, get rid of the pigeon some other way. But they said, “Well, why are the pigeons flocking to this monument? What’s the deal?” And they said, “Well, they’re attracted by the spiders. So there are spiders on this monument that are pigeon food basically. And they asked the question, some Toronto roll here, why so many spiders?

And it turns out, the spiders are attracted by the local nuts. You might call them no-see-ums or midges, little black flies. And what it turned out, they asked the last question, why so many little black flies? That they were attracted to the lights.

Now, they know why they’re lighting up the monument. That’s not a mystery. So they can stop the Whys right there. And it led to an elegant solution where they just delayed the lights a half hour. They delayed past the swarm time for the little black flies so they didn’t come out then there were no spiders, not so many pigeons, not such a need to clean up the monument.

So the idea is to keep digging to get to root cause so you solve it as opposed to sort of dealing with the symptoms, trying to figure out what to do with the pigeons, trying to figure out what to do with the spiders. Just keep digging until you get to something that you can impact.

Fishbone and 5 Whys

OK. So here is a potential 5-Why on the Bahama Bistro fishbone. So they said kitchen layout was one of the categories. And they said that the packaging process for items for pick-up varies. And why is that? Well, the minutes to assemble the pieces varies. But why is that? Well, the number of items that are not in the central area impacts it. Why is that? Well, forks don’t sit in with the condiments. OK. Fair enough.

Another one was the number of servers who don’t turn in the orders right away. And they said well, why is that happening? Well, servers are stopping to pick up food for other servers. And they said well, why are they doing that? Well, it’s as a courtesy. They figured they received your order. They will go get your order. But then in turn, they’re not getting their orders into the kitchen very fast.

So this might spun yet again more fishbones. This could be layers and layers of fishbones, which is great. Just keep digging. These things should be messy.

5 Whys Template

But we also have a template for the 5 Whys. And another name for this tool is Why Because. So you can see. You can – there’s the Why 1, Why 2. And you could have one Why. You could have 5. You could have 10. But it’s basically saying, why is this happening? Because of this. But why is that happening? Because of this. So it’s a helpful tool. It helps you basically – our templates are ways of documenting it so you have it to go into your storyboard. The reality is, the best way to use them is they’re messy on flipcharts and Post-its and things like that.


So next up, we come to And Then What. So I’ve brainstormed. It’s structured brainstorming but it’s all over the place. So what do I do? Well, multi-voting helps you work with a team again. You work with a group people to figure out, “Well, which should we tackle first? What should we go try and verify?” Because brainstorming is one thing but now, we’ve got to verify what is the actual root cause or root causes. What are the critical Xs?

And you can use multi-voting with root causes. You could do it when you get to solution. You could do it when the customer comments to figure out voice of the customer. But the basic idea is you count up all your options. You divide them by 3. You hand in over 3 dots to each person and they all put their dots up.

So if you had 21 options up there and you gave everybody 7 votes and they put their dots on 7 different ones, there is an option called Chicago Style where you can put more than one dot on one option but you got to clarify that with the team upfront and you could have dominate one option by putting a whole mess of votes on it.

Alright. So that’s multi-voting. And it produces a prioritization. That got the most dots. It’s marketing’s fault. So that’s what you want to go down. But let’s get back to the real one.

For the Bahama Bistro, they picked out these two big vote getters. They said, “The packaging process, we think that’s a big one. And then the servers not getting their orders turned into the kitchen right away. We want to tackle those.” Fair enough.

Next Steps

So then what? The fishbone is just brainstorming. Then what? Well, we’ve got to decide where to focus. We got to create a hypothesis statement and then we got to verify it. And that can be a bunch of different methods. It depends on the process and the issues.

Poll #3

So let’s do another poll with you guys. We just gave you tons of information. Let’s come back and understand, do you experience a fishbone going wrong? If you don’t, I got option E for you. But let’s just go and understand what do you guys see. Those of you that use them, what do you see?

Tracy, what do you see?

Tracy: One of the first things I see with fishbones gone wrong is the fish head is not stinky. So the whole idea is that the effect is supposed to be an undesirable effect that you’re trying to avoid and it’s not – it’s sort of like where do we want to go for our company retreat? And they use it as a brainstorming tool and not necessarily brainstorming root causes. So it’s really important. That’s the one I see the most is that the fish head is not as stinky, undesirable effect that you’re trying to avoid or mitigate.

Elisabeth: We’re just brainstorming.

Tracy: We’re just brainstorming. It’s really interesting because what I like about the fishbone is it’s a tool to brainstorm root causes. Most people have never brainstormed root causes. We brainstorm solutions like you say. And so that’s why you start to see solutions on some of these fishbones. But I think if you have a stinky fish head then people are clear on, “Oh, we have to brainstorm root causes, not solutions.”

Elisabeth: Yeah.

Tracy: So that’s the one I see the most. OK.

Elisabeth: Alright. We’ve got a good number of votes in. Let’s see what these guys say.

Tracy: Right. 39% say some combination of the above, 18% say none of the above all good, and then we’ve got the all of the above are divided by they’re not verified or they are populated with solutions and then 10% say they are not paired with 5 Whys.

Elisabeth: Well, I’m kind of encouraged that people are pairing it with the 5 Whys. I’m going to use the inversion of the 10% and assume that people are seeing more 5 Whys than not, which is great. That’s actually a nice thing.

OK. So they are seeing some fishbones gone wrong too. Alright. Well, let’s come back and move on to reviewing what we’ve talked about.

Validating Methods

So the validating methods, and this is not really the topic for today. It’s just acknowledging that after the fishbone, you’ve got to validate root cause. So there are different options. You can observe. Watch the process. See the issue and action and validate it just that way or listen. I’ve heard that happen to call centers where people will – they call it split-ends. Everyone will jump on when there’s a high call volume to listen in and what’s see the problem.

Or you can compare. One distribution center is having a problem, the other one isn’t. What’s different? Why is that one having it and not that? So that comparison might be a way to validate.

You could use data. And the caution there is that you could be cherry picking and getting data that proves your point. And then the sort of the other end of the scale is using a stat tool. You’ve got hypothesis test you can use to disprove the null. We have a whole another webinar about that. Feel free to look at it and watch that one. It’s very helpful. So, we’ve got these options.

Hypothesis & Data Example

In Bahama Bistro, they decided to use a scatter plot once again. Their hypothesis was, as the number of waitress courtesy food pick-ups increased, lunch order cycle time also increased. So they plotted the data and they saw, “Aha! Positive correlation, as these pick-ups increased, the order cycle time increases.” So that is verification. That’s helpful.

All right. And that’s basically the flow of what you’re trying to do. You brainstorm then you’re looking for the 5 Whys to get a little bit deeper. And then you’re multi-voting what you want to go research. They’re already listed as measures. You go and collect that data. Compare it. Do the correlation. See what you got.

Fishbone Review

All right. So let’s do a little review. So build the fishbone in groups. Get some other brains. Get some people who have a different experience of the process than you. That’s going to drive both better, potential ideas. It’s also going to drive more ownership. If people can do that with you, they’re more likely to listen to you when you start talking about some of the changes. And they’ll give you some ideas too. They’ll help you fill up your solution parking lot.

Brainstorming clarifies the labels. So either do with an affinity analysis or use the standard but clarify them. They can be – you can have more than six.

Exactly what do we mean by environment? Is it physical? Is it political?

Populate it. You want it fuzzy with bones. You’re not limited to six bones. You’re not limited to one page. You always see it with six. It doesn’t have to be six.

Don’t worry about where root cause goes. People often, when they’re brainstorming they say, “Well, where does this one go? Does this one go up on environment or is this people?” Whatever. Get it up there. Make sure that it’s on the board somewhere so you can then use it. Figure out how to measure it and then also how to use the 5 Whys to dig deeper.

Consider what causes process variation, not just effective units. So why does this fluctuate as opposed to why is it over 5 days or why is the percent of defects greater than 90? But what’s the variation about? And that’s where the measures will help you understand that correlation. And turning those causes into measures sets you up for verification.

So, expand the fishbone. Use the 5 Whys. Dig past the symptoms. Watch for solutions masquerading as problems. Use your solution parking lot.

Keep and update the fishbone. This is an interesting idea. If you think about it, the sources of variation on any particular issue, they’re not necessarily going to go away. This is organizational knowledge and this should be managed. You should keep that fishbone. That should be added to over time. Maybe some sources of variation go away. Maybe some of them are new. But that should be something that you keep a hold of for that process. So keep and update fishbones.

And lastly, you have to verify root cause. So multi-vote, prioritize potential root causes to research, form hypothesis statements, and then figure out how you’re going to verify. It could be something as simple as observation. It could be a hypothesis test. You have to verify a root cause before moving on to improve.

You have to verify a root cause before moving on to improve.

Today We Covered

OK. So today, we looked at what is a fishbone, why do we use it, when do we use it, what’s the right way to build it, what are the ways not to use it, and what do they look like when they’re done right.

Q & A

And that brings us to you guys coming up with questions for us. So go ahead. Write those right into the question section. We’re going to give you time to populate the questions and we’re going to give you a little bit of information while you do that. OK.

Getting Started

So one is, if you have not experienced any of this training, the Yellow Belt is free. That’s 8 hours. If you have not ever taken Yellow Belt, that is a very good, very solid primer on Lean Six Sigma. It gives you the whole DMAIC process with the Bahama Bistro. And if that is very helpful, then you can move on to Green Belt, Black Belt, there’s Lean only training, lots of really helpful training.

Just-In-Time Podcast

We also have podcasts. The latest podcast is they always include lots of tips about apps you can use, they’ve got the latest Lean Six Sigma books. They also have questions. We have people using Lean Six Sigma in the use, sort of what are the success stories out there, different industries. This latest one is an interview. That always includes an interview. There are special guests, and this is Dodd Starbird. And he wrote the new book, The Joy of Lean. This is a great detailed book on how to do time studies. So those are the podcasts.

We also have – what’s the next webinar, Tracy? I think that’s you.

Tracy: Yeah. The next webinar is regarding process walks. So what we’re finding is people schedule process walks and they are not sure what to talk about to give people an orientation through a process walk. So that is going to be what our next webinar is about is – as a matter of fact, you would actually be able to forward it people to view before they do a process walk as an orientation. And we’ll be doing some polls as well.

Elisabeth: Awesome. That’s great. Process walks are I think a staple with all process improvement projects.

Q & A

OK. So that brings us back Q&A. Tracy, what are you seeing for questions?

Tracy: Yes. So we have a couple of questions for you, Elisabeth. And one of them is, “Will you email out the YouTube link?” Yes, we will do that.

The question Julio has is, “Is there a maximum or minimum of causes for the cause and effect diagram?”

Elisabeth: That’s kind of an easy one. No. It’s not even it depends. It’s just no.

Tracy: Yes. How do you put a time limit on brainstorming for root causes? And if so, what is the typical timeframe?

Elisabeth: That’s a good question because when we do improve, we often try to limit it so that people sort of move quickly and we’ll say, “Five minutes. Go.” And I think fishbone is a little different because you have all these different categories. I will say that a good rule of thumb is brainstorm a bone, a category, and as soon as you hear people dying down, move immediately to the next bone. So keep them moving from bone to bone.

You can go back but I’d say just listen for when activity and idea starts to slow and move it. You can always come back. But you want to keep energy going. So I think that’s a better guideline.

Tracy: OK. Thank you. Very helpful. So here’s one from CC. So if you come out of a fishbone diagram and a hypothesis and then discover it was not the correct one, do you build off the old one or start over with a new fishbone diagram?

Elisabeth: So that one does get a depend. So that I think you can go back to the fishbone. That’s a good idea. But you may also start looking at where didn’t we do? Is there something in there that required another level? So say you took off one angle on your fishbone. Maybe that one requires another branch. But that one is really highly process-specific I would say.

Tracy: OK. Good. Thank you. We also have a couple of questions. So this one is how granular should the problem be? For example, should it be a particular error that is occurring with high frequency or the process where the error occurs?

Elisabeth: I’d go for specific. And I think just what I showed, you can have those nested fishbones. You might know already that that’s what you want to focus on, that one error, so go for it. But you may start with a broader question around that process. Why that process have variation in meeting its SLAs or whatever? And then sort of that might drive you down to specifics like why is this particular error happen. What seems to be the biggest one? So I think it could go both ways.

Tracy: Thank you. So another question for you. What is the best way to communicate to others when you see that there are too many solutions in the fishbone?

Elisabeth: So, this is a matter of expectations. So the first thing I would do, when you’re brainstorming with everyone, just have – appoint other people to help you watch out for solutions.

So train everybody upfront. Just say, “It’s natural. We’ve all been trained. We’ve been told by our bosses, ‘Bring me solutions. Don’t bring me problems.’ So we have this leaning anyway. But here’s what we need to watch out for. So help me pick out any time you see, lack of, inadequate, insufficient, and help me grab those and put them up on this page right up here on the wall that says, ‘Solution Parking Lot’ because those are going to be vital. They’re important. We’re going to need them in the improve phase.”

So don’t make people feel bad. But you can enlist people in helping you watch out for it and then helping you build that solution parking lot. I mean consider that an asset. It’s just not part of root cause brainstorming.

Tracy: Very good. Thank you. Yes, I would agree. So using that solution parking lot can be really helpful for that.

So another question for you, Elisabeth, is there a good range or number of participants for a good brainstorming session for root causes? I’m concerned that it may be too crowded, that there are a lot of unnecessary inputs?

Elisabeth: So, you want people who have some experience of the process. So you don’t want – I sort of think of it like I would a project team. Maybe 5 to 7 people is when you’re maxing out. And after that, you probably have what I call passengers, people that are there but they’re so many folks vying for airtime that they don’t contribute.

And if you really need a big group like honestly, there are 10 people that should be involved because they’re stakeholders, because they really have different perspectives on the process, then use Post-it notes. Use silent brainstorming and put the Post-its right on the fishbone. And that way, they’re not vying for airtime. They can sit there, write their ideas, populate the fishbone. If there are duplicates, no problem. They can just put the Post-its right over each other.

But my experience is that people do not have a problem with crowds. They have a problem with submitting fishbones they did completely by themselves. I see that way more often.

Tracy: OK. Good. Thank you. Another question for you. Are we required to prove a hypothesis after finding root cause?

Elisabeth: Yeah. Yeah. I mean why would you want to go and figure out solutions when you don’t even really know the problem? And sometimes it’s not hard to do. Like I said, you could go watch the process in action. You could get some basic process data. It requires a little bit of work but that’s what problem-solving is about. You got to figure out what the issue is before you solve it. But doesn’t mean you have to do a hypothesis test. You don’t have to go all the way to hypothesis testing with no hypothesis although some problems require that. But it does mean you got to figure out some method.

Tracy: That’s kind of the whole point of DMAIC, right? I mean it’s basically saying make sure you know the root cause before you jump to solution. And if you’re just going to jump to solution then you don’t need DMAIC. Just go jump to solution.

Elisabeth: Yes, really. It’s a quick win or a quick hit or something where it’s obvious then yeah, you just be just going and doing it.

Tracy: OK. Good. Another question. Approximately, how much time is effective to set aside to do a fishbone exercise?

Elisabeth: I usually see people setting aside an hour. They may not use. But they’ve got people carving out time. They’re not arriving late for a half hour and then bobbing out early because they got to get somewhere else. So just allow – carve out an hour for it and people will be happy when you say, “OK, I think we got good stuff. You can move along now.”

Tracy: Good. OK. So a couple of other questions. One of them was, this is pretty rush, so we’re getting down to – the nice thing is we’ve allocated a lot of time for Q&A and we don’t have as many questions. So if you have a question, please submit it in the question window.

Someone asked, “How do you apply this in service?”

Elisabeth: The same way as manufacturing. You’re still sort of isolating an issue. So the Bahama Bistro example, we just provide a service. They’re looking at cycle time of delivering basically a service to a customer. And so, you’re looking at what are the things that get in the way of service.

And it’s especially helpful I think sometimes in service because manufacturing, it’s almost like, we’ll, there’s only so many parts, there’s only so many machines. But in service, there are a lot of different nuances. There are a lot of hand-offs between departments. There’s a lot of checking. There’s a lot of reporting. So it’s really helpful to expand all the places where things can go wrong inside of a transactional process. That’s a good question.

And Tracy, if they are – moving into their questions, that’s OK. We can give them the gift of time. It’s only 5 minutes.

Tracy: Right.

Elisabeth: I know one question they haven’t asked. Am I taking cold medicine? Yes, I am. Thank for very much for asking that.

Tracy: Yes. Elisabeth had laryngitis yesterday. So we’re lucky she got her voice back today. OK. And one last question. And it’s not related to the fishbone. It’s more related to broadly. I’ll just answer it since you’re on the phone, which is what’s the difference between Lean Six Sigma and just Six Sigma training? So they want to know what Six Sigma without Lean.

Elisabeth: Well, it would just lack of all the Lean tools. And Tracy just mentioned one, a process walk, otherwise known as a gemba walk. It’s a classically Lean tool although I think a fabulous way of both understanding the process, gathering data, and creating a process map. So that I think you have – in the improve phase, there are tons of Lean tools.

You also have options like using an A3, another Lean tool, which is sort of a documentation and a problem-solving method.

So it’s really just saying you have the options of both toolkits. And if it’s just Six Sigma, you’re just leaving out the Lean toolkit. You don’t get all the bonus Lean tools, which would be a shame.

Tracy: Yes. And then I’m going to say this one last one because Lisa typed it twice. Can I find an employer that will teach me Six Sigma?

Elisabeth: You don’t have to. You can just do free Yellow Belt training and then you’ll know Six Sigma. But you can certainly look out for – what did you say?

Tracy: I said that’s a good answer.

Elisabeth: Yeah. But I mean you can certainly look for organizations that do Six Sigma and look for jobs where it’s active. I mean we were all just in San Diego and took a tour of the San Diego Zoo and they have a Lean – a guy running Lean Six Sigma at the zoo, which I wouldn’t have expected that. But this is a great zoo. They are a part of saving endangered species and reentering species into the wild. And they are using these techniques to make sure they’re doing it as fast and as effectively as possible. So it’s everywhere.

Tracy: It is everywhere. That’s true. OK. I’m going to go ahead and wrap it up now. So thank you for joining today’s webinar. We hope you enjoyed the webinar today and that you felt like your time was well-spent on this webinar and that you’ve found it helpful. Please share your feedback with us by completing the survey presented when the webinar ends. We value your feedback. We look at your comments.

Actually, this particular webinar was created because people were requesting it when they were giving us feedback in the webinar comments. So we will definitely move forward to design additional webinars with your feedback.

So that concludes our broadcast today. Thank you very much everyone. And we appreciate, the whole team at is very happy that you joined us. And don’t forget, we also have the free template for the fishbone with a hundred other free templates online. So don’t forget to grab that one as well. Have a great day.

Elisabeth: Thanks everybody. Bye.

Elisabeth Swan

Elisabeth is a Master Black Belt at, the co-author of The Problem-Solver’s Toolkit and co-host of the Just-in-Time Cafe. For over 30 years, she's helped leading organizations like Amazon, Charles Schwab and Marriott International, Inc. build problem-solving muscles with Lean Six Sigma to achieve their goals.

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