A new project represents an opportunity to change things for the better and, with the appropriate tools, to intervene on the root causes (root cause analysis) avoiding the risk of considering only the most evident aspects (the creaking wheel).  

To establish the areas of intervention, we have a range of tools, among which the indispensable fishbone diagram stands out, which combines brainstorming and mind mapping techniques to discover the relationship of cause and effect. The aim is to push to consider all the possible causes of a problem, allowing the work group to free itself from perceptions to acquire a more complete perspective thanks to the visual framework that is created under the eyes of all.  

The instrument, which you can find under various names (cause-and-effect diagram, Ishikawa, Fishbone, fishbone…), has different methods of approach. Let’s see a practical approach within a working group to get a more complete vision in a short time.  

The problem is posed as the head of the fish (facing right) and the causes extend to the left like the bones of the skeleton; the ribs branch off from the back and denote the major causes, while we can branch off for the deeper causes. These causes mimic the bones of the fish skeleton. Fishbone construction can branch out to as many levels as needed to determine the causes of the underlying problem. 

Phase 0: The team 

The working group must be complete and there must be some functions that are directly involved in the process. We must always check that it is the right opportunity to collect everyone’s thoughts. This choice will prove successful for the entire duration of the project and increases the chances of optimal change management.  

Fase 1: Brainstorming  

  1. Choose a facilitator – someone who helps keep time and who makes sure to keep the focus on the problem by moderating the group dynamics. This person will explain the rules of brainstorming and collaboration, and if the conversation stagnates in one aspect, she will have to give input to spice up the exchange.  
  1. Give a second person the role of recorder, who will write the inputs of the brainstorming session, so that everything is recorded. The documentation could range from a simple list to the use of a complex post-it system, but direct data entry into the fishbone diagram could also be valid if experienced. 
  1. Give a person the role of client and give him the task of explaining the problem to the group. The customer presents for ten minutes without interruption. In this time, aspects will emerge that had not been considered until then and it will be possible to pay attention to perceptions regarding cause and effect relationships.  

The facilitator can document key points on a shared board, important numbers, organizational structure and the like to make sure everyone has the same understanding. At the end of this session it is necessary to articulate the problem in clear terms (for example “why do some orders take twice as long to process?”) And to mark it as the head of the fishbone diagram. 

  1. In the next step, the group is free to ask questions to clarify some points. They must be open-ended questions that allow the client to elaborate their own answers. Some examples may include: 
  • Why is this important to you? 
  • If you could resolve 1 issue within 90 days, what would it be? 
  • This problem, why was it not there before? 
  1. At this point, we give space to the discussion among the participants to understand where to intervene. The client joins in documenting the contributions with the documenter, but does not participate except to give clarifications. This point is important to avoid a dynamic of “justifications” that the facilitator must avoid.   

At the end of the brainstorming, it is possible to allow the client, the facilitator and the recorder to participate by inserting 1 input each and thus adding further points of view. 

Step 2: Enter data into the cause / effect diagram 

At the end of the data collection phase, the inputs are classified (associated to each by label) and we classify them in the fishbone. If necessary, we can use the “5 Why” tool and let the first evaluation mature until we reach a more complete vision.  

If you’re not sure which labels to use, this list might be a good place to start: 

  • Process 
  • People 
  • Equipment 
  • Materials 
  • Measurement 
  • Environment 

How to define what is the right label? 

Understanding what the right label is is not always easy: in many cases, the problem has a different profile if you look at it from a new point of view. Let’s take an example 

Problem – “Incomplete request because documents are missing or presented in an outdated template” 

Why? – “Because they are processed on the computers of individuals” 

Why? – “Because the online template is not the latest version”  

Why? – “Because the person following the update has left and we have not completed the handover” 

Why? – “Because the training takes too long” 

For example, we could hypothesize that a problem is related to the “Process”, but following the questions we could then associate it with “People” – in which the causes that led some employees not to receive the training could be analyzed – and, from there, move on to “Equipment” and ask yourself if the tools are too complex or if the off-boarding and on-boarding phase requires interventions.  

To overcome this problem, we use 3 principles: 

  1. Make sure that each area of intervention is manageable by the group involved in the brainstorming (remit of competence), in order to have an impact in the short term;  
  1. Distribute the causes so that different departments collaborate in the resolution in a collective way and that there is no imbalance between one team or another, attributing all the responsibility for the change to one party; 
  1. Identify which aspects can be automated to take advantage of the momentum created by brainstorming and bring tangible improvement without waiting for the end of the project. 

How to use the completed diagram? 

Once the diagram is fully documented, it should be shared with the project sponsor to report progress and acknowledge the team’s contribution.  

The next step will be an effort / impact matrix to assess which areas of intervention have the greatest potential.  


Eight Twenty is the certified technology partner that makes the transformation and innovation process of companies easy, safe and fast with the use of proprietary hardware and software combined with the strength and flexibility of Business Process Management (BPM), the cloud and EDGE technology.  
The contribution of Eight Twenty allows, thanks to technology, to stabilize and optimize processes, thus obtaining a series of activities and automations for continuous improvement.  
Eight Twenty offers already proven solutions, ranging from purchasing to billing departments, or develops a tailor-made solution together with customers and partners. 

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