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Continuous Improvement & Benchmarking

Investigate problems

 Analyze

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2 Continuous Improvement & BenchmarkingInvestigate problems

Learning objectives

• Have the skills to:

• Complete a fish bone diagram

• Complete a why-why diagram

• Know where to apply these tools

• Know how to apply these tools

• Extract information from them

• Distil the information into goodroot cause analysis

Fish boneWhy-whyApplyInformationRoot cause

analysis

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3 Continuous Improvement & BenchmarkingInvestigate problems

Root cause analysis

Simple tools to develop

knowledge of underlying

or „root‟ causes. 

Use either Fishbone or Why-Why diagram.

Fishbone diagram

provides structure.

Why-Why can givedepth.

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4 Continuous Improvement & BenchmarkingInvestigate problems

People jump to a solution on their best guess.

However, there are usually many underlying causes to

be addressed.

Fishbone diagram helps to identify the underlyingcauses.

Underlying causes also called “root causes”. 

Tries to group them under main headings or bigger 

bones. Eventually extend to the smaller bone, which would be

observed as root causes.

Fishbone Diagram

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Fishbone Diagram

Effect  Problem Causes  

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Fishbone Diagram

Effect  Problem Causes  

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7 Continuous Improvement & BenchmarkingInvestigate problems

Fishbone Diagram

Define problem - write in the box (the fish‟s head).

Define major cause categories - draw as diagonal

bones onto the backbone.

Brainstorm list of possible causes.

Place the brainstormed causes into major 

categories, draw as rib bones onto diagonals.

For each cause ask "why does it happen" - list

answers as branches off the cause.

 Agree most likely causes.

Next step: verify likely causes.

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8 Continuous Improvement & BenchmarkingInvestigate problems

Materials People

Procedures

20% of schoolchildren startyear withouttext books

Incorrect

books ordered

Books

ordered too

late

Teachersnot trainedin orderingsystem

Children don’t

take propercare of books

Teacherstake booksto otherschoolswhen they

leave

Books deteriorated

Notstored

properly

Fishbone - Example

Newcurriculum list

sent too late

Head Teachersforget to sendorders in time

Newcurriculum

list sent too

late

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9 Continuous Improvement & BenchmarkingInvestigate problems

Develop Fishbone

diagrams in a group

session with thepeople who know

the problems well.

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10 Continuous Improvement & BenchmarkingInvestigate problems

Review the diagram

in a later session to

check whether you

have thought of 

everything.

Collect informationto decide the most

important root

causes

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11 Continuous Improvement & BenchmarkingInvestigate problems

Why –Why Diagram

Structures brainstormed

ideas towards problem

root causes.

Use it: When the team needs to

deeply explore possible

root causes.

To present root causeson a single diagram,

showing how they are

related.

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12 Continuous Improvement & BenchmarkingInvestigate problems

Why-Why Analysis

To find root causes:

State the problem.

 Ask “Why?” 

Write down causes.

 Ask “Why?” again. 

Repeat until root causes are found.

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Develop Why-Why

diagrams in a groupsession with the

people who know

the problems well.

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14 Continuous Improvement & BenchmarkingInvestigate problems

Review the diagram

in a later session to

check whether you

have thought of everything.

Collect information

to decide the mostimportant root

causes

Wh ? Wh ? Wh ? Wh ? Wh ?

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Medicalsupplies notreceived asexpected

Storewithheldstock

Why? Why? Why? Why? Why? 

Couldnot readorder form

Did notbelieveorder

Supplieslow

Order formnot filled outcorrectly

Tendercalculationunder-estimateddemand

Storeout ofstock

Supplierslow

Poorhandwriting

Form hard tounderstand

Unclearinstructions

Instructionswritten byStore Mgr,not end user

Poor formdesign

Pastexperiencethat Aid Postsover- order

Mistake bystore

Unexpecteddemand

Store notaware offorwarddemand

Notworking withCommunityHealth

Aid Postsorderingjust in case

Experiencethat Storealways givesless thanorder

Store doesn’t believe Aid Postrequirements

Store alwaysrunning low onsome critical stocks

Lack of QC

Lack of training

Lack of trustbw store &users

No trainingprogram

InefficientfinanceprocessFinance slowto approve

Aid post workersdo not take care

Do not understandconsequences

Shippingslow

Example

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Disclaimer 

The views expressed in this Toolkit are the views of the authors and do not necessarily reflect the views or policies of the Asian Development Bank (ADB) or Asian Development Bank Institute (ADBI), or their Board of Directors, or the governments they represent. ADB and ADBI do not guarantee the accuracy of the data included in this CD-ROM and accepts no responsibility for 

any consequences of their use. Terminology used may not necessarily be consistent with ADB official terms.