Tailed Fishbone for Premortem
18
The Tailed Fishbone Adapted to a Premortem
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This is a follow-up to my Root Cause Analysis Tool, Tailed Fishbone. It utilizes the tool in regards to a Premortem, similar to an FMEA. Allows a better visual understanding and clarity to team delegated to improving a process/problem as well as the Champion responsible.
Transcript of Tailed Fishbone for Premortem
The Tailed Fishbone Adapted to a
Premortem
Purpose
Premortem helps identify potential causes of death to a project By using the Tailed Fishbone as tool of choice,
you can limit the potential causes to the critical few
Ultimately you have “Keys to Success” to help ensure project success and sustainment
When to use
After all aspects of the Kaizen (RIE) have been accomplished minus the Out Brief Must have countermeasures in place or
identified Results realized or projected Can be done prior to close-out of project, if
intent is solely to be used to ensure sustainment
Starting Out
Draw your Tailed Fishbone as normal Put “Project Failed” in the head Create Side-fin categories
If accomplishing during the event, and you used the Tailed Fishbone for RCA, use the same categories used before
Brainstorming Potential Causes
You can use post-it notes, round robin, popcorn exercises This is dependant on the facilitators abilities,
team engagement, and time available My preference is to verbally brainstorm around the
room until ideas are no longer offered I only use this method on the Premortem and not the Tailed
Fishbone for RCA
Example:Made-up scenario on training of new employees
Place People
Product Policy
Products are not placed at every station
No one uses checklists
Resistance to Change
Products are not updated as required
Not required to use new products
Project Failed
No schedule to evaluate success or to adapt changes required
Leaders do not emphasize value of change
Problem Statement
Categories
Brainstormed Causes
No one owns the products
Finding the Vital Few
Next I bring color to the fishbone by allowing people to vote Use the N/3 method
Number of items brainstormed divided by 3 Facilitator choice if multiple votes can be used on
single item Would not recommend if more than one antagonist on team
attempting to achieve personal agendas
Allow team to vote most likely cause to problem for each category
The attempt is to achieve top item per category
Example:Made-up scenario on training of new employees
Place People
Product Policy
Products are not placed at every station
No one uses checklists
Resistance to Change
Products are not updated as required
Not required to use new products
Project Failed
No schedule to evaluate success or to adapt changes required
Leaders do not emphasize value of change
Winning Votes
No one owns the products
If only one item in a category, it is automatically top-voted and so I do not require people to vote on it. It however, should be voted on in next round of voting
Moving towards Critical Few
Now I change the color of the vote and have everyone mark the one item in all categories that is the most likely culprit of our problem statement Can only vote on the winner of the previous
category One vote per person
Example:Made-up scenario on training of new employees
Place People
Product Policy
Products are not placed at every station
No one uses checklists
Resistance to Change
Products are not updated as required
Not required to use new products
Project Failed
No schedule to evaluate success or to adapt changes required
Leaders do not emphasize value of change
No one owns the products
Don’t worry if tie, this is where the Tailed Fishbone separates from an RCA tool to a Premortem tool.
Winners!!!!
Conducting “5 Whys”
Now that the team has put their focus on the critical few; conduct “5 Why” analysis 5 Why is just the title; Just keep asking until
arguing over theology.
5 Why on our Example
Why will there be resistance to change? No one understands the value of the new checklists
Why no one will understand the value? They do not work as prescribed
Why do they not work They become out of date
Why are they out of date? No one updates them
Why does no one update them? No ones responsibility
5 Why on our Example
Why is there no schedule to evaluate changes Is not owned by anyone to make schedule
Why does no one own making changes No POC assigned
Why no POC assigned Didn’t think of it till now
Critical Causes
As you see, mostly all critical causes will all boil down to one contributing factor
Take the top voted critical items anyways to help ensure confidence by team and allow them to concentrate on the “keys to success” in addition to the action plan
Keys to Success
Now list out the countermeasures given to each root cause of the critical factors you did a 5-why analysis on
These will be titled “Keys to Success” and presented in the Out Brief to the Champion at the end, prior to last slide for questions
Example:Made-up scenario on training of new employees
Place People
Product Policy
Products are not placed at every station
No one uses checklists
Resistance to Change
Products are not updated as required
Not required to use new products
Project Failed
No schedule to evaluate success or to adapt changes required
Leaders do not emphasize value of change
No one owns the products
These were contributing factors
No one ownsthe requirement to update the StdWrk products
This is our ultimate cause of death
Summary
Tail Root Cause
Categories and Brainstormed Ideas Contributing Factors
Head Problem Statement
Result – a visual understanding of a single root cause built and owned by the improvement team
Questions, Comments, Constructive Criticism or Praise
Contact me by email at: [email protected]
Developed by Mark Adams, CI Black Belt Developed and shared for crosstalk purposes only
Link to Tailed Fishbone for Root Cause Analysis can be found here: http://www.slideshare.net/orsonandshiris/tailed-
fishbone-slide-show-9300981
