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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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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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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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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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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.
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