Chapter 6

Fishbone diagram (Ishikawa cause and effect)

Introduction
Wherever the fish are, that’s where we go.”
Richard Wagner

Fishing is an enjoyable pastime. Successful fishermen know that being prepared and patient is
key to achieving their goal of getting that prized picture and/or catching dinner. If you are
successful with the latter, the day’s catch is carefully prepared to ensure the quality of the meat
and to avoid as many bones as possible. However, the probability of encountering a bone is
high and when encountered, the search begins to identify and remove all bones.
That tenacity and patience to find all of the fish bones is emblematic of the fishbone diagram
(also called Cause-and-Effect diagram,
Ishikawa diagram). The fishbone diagram
process starts with the identification of a few
prominent bones (major categories), which
are then used to find deeper ones. It is a
brainstorming tool used to flesh out the root
causes (bones) of a problem, organize them
into manageable categories, and serve as a
visual method to aid laboratorians in their
root cause analysis (RCA).

OBJECTIVES

The main goal of the Fishbone diagram is to illustrate in a graphical way the relationship
between a given outcome and all the factors that influence this outcome. The main objectives of
this tool are:

1. Determining the root causes of a problem.

2. Focusing on a specific issue without resorting to complaints and irrelevant discussion.
3. Identifying areas where there is a lack of data.

The Fishbone Diagram is a tool for analyzing process dispersion. It is also referred to as the
"Ishikawa diagram," because Kaoru Ishikawa developed it, and the "fishbone diagram," because

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 the complete diagram resembles a fish
skeleton. The diagram illustrates the main
causes and subcauses leading to an effect
(symptom).

It is a team brainstorming tool used to

identify potential root causes to problems.
Because of its function it may be referred to
as a cause- and-effect diagram.

In a typical Fishbone diagram, the effect is usually a problem needs to be resolved, and is
placed at the "fish head". The causes of the effect are then laid out along the "bones", and
classified into different types along the branches. Further causes can be laid out alongside
further side branches. So the general structure of a fishbone diagram is presented below.

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FIELD OF APPLICATION
The Fishbone diagram could be applied when it is wanted to:
1. Focus attention on one specific issue or problem.
2. Focus the team on the causes, not the symptoms.
3. Organize and display graphically the various theories about what the root causes of a problem may be.
4. Show the relationship of various factors influencing a problem.
5. Reveal important relationships among various variables and
possible causes.
6. Provide additional insight into process behaviors.

DESCRIPTION
Dr. Kaoru Ishikawa, a Japanese quality control statistician, invented the fishbone diagram. It is often also
referred to as the Ishikawa diagram. The fishbone diagram is an analysis tool that provides a systematic
way of looking at effects and the causes that create or contribute to those effects. Because of the function
of the fishbone diagram, it may be referred to as a cause-and-effect diagram. The design of the diagram
looks much like the skeleton of a fish. Therefore, it is often referred to as the fishbone diagram. A cause-
and-effect diagram can help identify the reasons why a process goes out of control. Often the fishbone
diagram can be used to summarize the results of a brainstorming session, identifying the causes of a
specified undesirable outcome. It helps to identify root causes and ensures a common understanding of
the causes.

The steps for constructing and analyzing a Cause-and-Effect Diagram are outlined below:

Step 1 - Identify and clearly define the outcome or effect to be analyzed2.

Formulate the problem and write it in a box on the right side of the diagram. Everyone must clearly
understand the nature of the problem and the process/product being discussed. If everyone is not clear
on the purpose of the session, the session will not resolve the problem. In this step the following rules
have to be be applied:
• Decide on the effect to be examined. Effects are stated as particular quality characteristics, problems
resulting from work, planning objectives, and the like.
• Use Operational Definitions. Develop an Operational Definition of the effect to ensure that it is clearly
understood.
• Remember, an effect may be positive (an objective) or negative (a problem), depending upon the issue
that’s being discussed.
• Using a positive effect which focuses on a desired outcome tends to foster pride and ownership over
productive areas. This may lead to an upbeat atmosphere that encourages the participation of the
group. When possible, it is preferable to phrase the effect in positive terms.
• Focusing on a negative effect can sidetrack the team into justifying why the problem occurred and
placing blame. However, it is sometimes easier for a team to focus on what causes a problem than
what causes an excellent outcome. While you should be cautious about the fallout that can result from
focusing on a negative effect, getting a team to concentrate on things that can go wrong may foster a
more relaxed atmosphere and sometimes enhances group participation.

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You must decide which approach will work best with your group.

Step 2 - Use a chart pack positioned so that everyone can see it, draw the spine and create the effect
box.
• Draw a horizontal arrow pointing to the right. This is the spine.
• To the right of the arrow, write a brief description of the effect or
outcome which results from the process.
• Draw a box around the description of the effect.

Step 3 - Identify the main causes(G) contributing to the effect being studied.
These are the labels for the major branches of your diagram and become categories under which to list
the many causes related to those categories.
• Establish the major causes, or categories, under which other possible causes will be listed. You should
use category labels that make sense for the diagram you are creating.
• Write the main categories your team has selected to the left of the effect box, some above the spine
and some below it.
• Draw a box around each category label and use a diagonal line to form a branch connecting the box to
the spine.

Step 4 - For each major branch, identify other specific factors which may be the causes of the effect
• Identify as many causes or factors as possible and attach them as subbranches of the major branches.
• Fill in detail for each cause. If a minor cause applies to more than one major cause, list it under both.

Step 5 - Identify increasingly more detailed levels of causes and continue organizing them under related
causes or categories. You can do this by asking a series of why questions.
You may need to break your diagram into smaller diagrams if one branch has too many subbranches. Any
main cause (3Ms and P, 4Ps, or a category you have named) can be reworded into an effect.

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Step 6 - Analyze the diagram. Analysis helps you identify causes that warrant further investigation. Since
Cause-and-Effect Diagrams identify only Possible Causes, you may want to use a Pareto Chart to help
your team determine the cause to focus on first.
• Look at the “balance” of your diagram, checking for comparable levels of detail for most of the
categories.
• A thick cluster of items in one area may indicate a need for further study.
• A main category having only a few specific causes may indicate a need for further identification of
causes.
• If several major branches have only a few subbranches, you may need to combine them under a single
category.
• Look for causes that appear repeatedly. These may represent root causes.
• Look for what you can measure in each cause so you can quantify the effects of any changes you
make.

BENEFITS
• Helps determine root causes
• Encourages group participation
• Uses an orderly, easy-to-read format to diagram cause and effect relationships
• Indicates possible causes of variation
• Increases knowledge of the process by helping everyone to learn more about the factors at work and
how they relate
• Identifies areas for collecting data

References:

Retrieved from https://www.techtarget.com/whatis/definition/fishbone-diagram

https://seedsoflaboratoryquality.com/2018/06/01/fishbone-diagram-the-meat-of-root-cause-analysis/

1. American Society for Quality, Fishbone diagram http://www.asq.org/learn-about-quality/cause-analysis-

tools/overview/fishbone.html
2. Balanced Scorecard Institute, Basic tools for process improvement, Module
5 – Cause and Effect diagram http://www.balancedscorecard.org/files/c-ediag.pdf
3. Ishikawa, Kaoru (1986). Guide to Quality Control. Tokyo, Japan: Asian Productivity Organization.
4. Walton, Mary (1992) The Deming Management Method, Mercury Business
5. Public Health Infrastructure, Fishbone (Ishikawa) Diagram (Example) http://www.phf.org/infrastructure/
PublicHealthFishbone.pdf
(accessed on 8/8/2007)

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Chapter 7
SWOT analysis (Strength, Weaknesses, Opportunities,
and Threats)

Introduction

A SWOT analysis helps find the best match between environmental trends (opportunities and
threats) and internal capabilities.

• A strength is a resource or capacity the organization can use effectively to achieve its
objectives.

• A weakness is a limitation, fault, or defect in the organization that will keep it from
achieving its objectives.

• An opportunity is any favourable situation in the organisation's environment. It is

usually a trend or change of some kind or an overlooked need that increases demand for
a product or service and permits the firm to enhance its position by supplying it.
•
• A threat is any unfavourable situation in the organization's environment that is potentially
damaging to its strategy. The threat may be a barrier, a constraint, or anything external
that might cause problems, damage or injury.
•
In general, an effective strategy is one that takes advantage of the organization's opportunities
by employing its strengths and wards off threats by avoiding them or by correcting or
compensating for weaknesses.

WHAT IS A SWOT ANALYSIS AND WHY SHOULD YOU USE ONE?

SWOT stands for: Strength, Weakness, Opportunity, Threat. A SWOT analysis guides you to
identify your organization’s strengths and weaknesses (S-W), as well as broader opportunities
and threats (O-T). Developing a fuller awareness of the situation helps with both strategic
planning and decision-making.

The SWOT method was originally developed for business and industry, but it is equally useful in
the work of community health and development, education, and even for personal growth.

WHEN DO YOU USE SWOT?

A SWOT analysis can offer helpful perspectives at any stage of an effort. You might use it to:
• Explore possibilities for new efforts or solutions to problems.

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 • Make decisions about the best path for your initiative. Identifying your opportunities for
success in context of threats to success can clarify directions and choices.
• Determine where change is possible. If you are at a juncture or turning point, an
inventory of your strengths and weaknesses can reveal priorities as well as possibilities.
• Adjust and refine plans mid-course. A new opportunity might open wider avenues, while
a new threat could close a path that once existed.

SWOT also offers a simple way of communicating about your initiative or program and an
excellent way to organize information you've gathered from studies or surveys.
Figure from https://www.wordstream.com/blog/ws/2017/12/20/swot-analysis

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WHAT ARE THE ELEMENTS OF A SWOT ANALYSIS?

A SWOT analysis focuses on Strengths, Weaknesses, Opportunities, and Threats.

Remember that the purpose of performing a SWOT is to reveal positive forces that work
together and potential problems that need to be recognized and possibly addressed.
We will discuss the process of creating the analysis below, but first here are a few sample
layouts for your SWOT analysis.
Ask participants to answer these simple questions: what are the strengths and weaknesses of
your group, community, or effort, and what are the opportunities and threats facing it?

Internal External

Strengths Weaknesses Opportunities Threats

If a looser structure helps you brainstorm, you can group positives and negatives to think
broadly about your organization and its external environment.

Positives Negatives

• Strengths • Weaknesses
• Assets • Limitations
• Resources • Restrictions
• Opportunities • Threats
• Prospects • Challenges

Below is a third option for structuring your SWOT analysis, which may be appropriate for a
larger initiative that requires detailed planning. This "TOWS Matrix" is adapted from Fred
David's Strategic Management text.

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 STRENGTHS WEAKNESSES
1. 1.
2. 2.
3. 3.
4. 4.

OPPORTUNITIE Opportunity-Strength (OS) Opportunity-Weakness (OW)

S Strategies Strategies
1. Use the strengths to take Overcome weaknesses by taking
2. advantage of opportunities advantage of opportunities
3. 1. 1.
4. 2. 2.

THREATS Threat-Strength (TS) Strategies Threat-Weakness (TW) Strategies

1. Use strengths to avoid threats Minimize weaknesses and avoid
2. 1. threats
3. 2. 1.
4. 2.

David gives an example for Campbell Soup Company that stresses financial goals, but it also
illustrates how you can pair the items within a SWOT grid to develop strategies. (This version of
the chart is abbreviated.)

STRENGTHS WEAKNESSES
• Current profit ratio • Legal suits not resolved
increased • Plant capacity has fallen
• Employee morale high • Lack of strategic
• Market share has management system
increased

OPPORTUNITIES Opportunity-Strength (OS) Opportunity-Weakness (OW)

• Western European Strategies Strategies
unification • Acquire food company • Develop new Pepperidge
• Rising health in Europe (S1, S3, O1) Farm products (W1, O2,
consciousness in • Develop new healthy O3)
selecting foods soups (S2, O2)
• Demand for soups
increasing annually

THREATS Threat-Strength (TS) Threat-Weakness (TW)

• Low value of dollar Strategies Strategies
• Tin cans are not • Develop new • Close unprofitable
biodegradable biodegradable soup European operations
containers (S1, T2) (W3, T1)

This example also illustrates how threats can become opportunities (and vice versa). The
limitation of tin cans (which aren't biodegradable) creates an opportunity for leadership in
developing biodegradable containers. There are several formats you can use to do a SWOT

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analysis, including a basic SWOT form that you can use to prompt analysis, but whatever format
you use, don't be surprised if your strengths and weaknesses don't precisely match up to your
opportunities and threats. You might need to refine, or you might need to simply look at the facts
longer, or from a different angle. Your chart, list or table will certainly reveal patterns.

LISTING YOUR INTERNAL FACTORS: STRENGTHS AND WEAKNESSES (S, W)

Internal factors include your resources and experiences. General areas to consider:
• Human resources - staff, volunteers, board members, target population
• Physical resources - your location, building, equipment
• Financial - grants, funding agencies, other sources of income
• Activities and processes - programs you run, systems you employ
• Past experiences - building blocks for learning and success, your reputation in the
community

Don't be too modest when listing your strengths. If you're having difficulty naming them, start by
simply listing your characteristics (e.g.., we're small, we're connected to the neighborhood).
Some of these will probably be strengths.

Although the strengths and weakness of your organization are your internal qualities, don't
overlook the perspective of people outside your group. Identify strengths and weaknesses from
both your own point of view and that of others, including those you serve or deal with. Do others
see problems--or assets--that you don’t?

How do you get information about how outsiders perceive your strengths and weaknesses? You
may know already if you've listened to those you serve. If not, this might be the time to gather
that type of information. See related sections for ideas on conducting focus groups, user
surveys, and listening sessions.

LISTING EXTERNAL FACTORS: OPPORTUNITIES AND THREATS (O, T)

Cast a wide net for the external part of the assessment. No organization, group, program, or
neighborhood is immune to outside events and forces. Consider your connectedness, for better
and worse, as you compile this part of your SWOT list.
Forces and facts that your group does not control include:
• Future trends in your field or the culture
• The economy - local, national, or international
• Funding sources - foundations, donors, legislatures

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 • Demographics - changes in the age, race, gender, culture of those you serve or in your
area
• The physical environment (Is your building in a growing part of town? Is the bus
company cutting routes?)
• Legislation (Do new federal requirements make your job harder...or easier?)
• Local, national or international events

HOW DO YOU CREATE A SWOT ANALYSIS?

WHO DEVELOPS THE SWOT?

The most common users of a SWOT analysis are team members and project managers who
are responsible for decision-making and strategic planning.

But don't overlook anyone in the creation stage!

An individual or small group can develop a SWOT analysis, but it will be more effective if you
take advantage of many stakeholders.

Each person or group offers a different perspective on the strengths and weaknesses of your
program and has different experiences of both.
Likewise, one staff member, or volunteer or stakeholder may have information about an
opportunity or threat that is essential to understanding your position and determining your
future.

WHEN AND WHERE DO YOU DEVELOP A SWOT ANALYSIS?

A SWOT analysis is often created during a retreat or planning session that allows several hours
for brainstorming and analysis. The best results come when the process is collaborative and
inclusive.When creating the analysis, people are asked to pool their individual and shared
knowledge and experience. The more relaxed, friendly and constructive the setting, the more
truthful, comprehensive, insightful, and useful your analysis will be.

HOW DO YOU USE YOUR SWOT ANALYSIS?

Better understanding the factors affecting your initiative put you in a better position for action.
This understanding helps as you:
• Identify the issues or problems you intend to change
• Set or reaffirm goals
• Create an action plan

IN SUMMARY
A realistic recognition of the weaknesses and threats that exist for your effort is the first step to
countering them with a robust set of strategies that build upon strengths and opportunities. A
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SWOT analysis identifies your strengths, weaknesses, opportunities and threats to assist you in
making strategic plans and decisions.

Here’s the SWOT analysis example based on our fictional restaurant:

As you can see, this matrix

format allows you to quickly
and easily identify the various
elements you’ve included in
your analysis.

References:
Retrieved from:
https://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/
swot-analysis/main
https://www.investopedia.com/terms/s/swot.asp

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