Quality And Safety Learning Corner

Cause-and-Effect (Fishbone) Diagram: A Tool for

Generating and Organizing Quality
Improvement Ideas
Augustine Kumah ,1 Chinwe N. Nwogu,2 Abdul-Razak Issah,3 Emmanuel Obot,4 Deborah T. Kanamitie,1
Jerry S. Sifa,5 Lawrencia A. Aidoo6

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1
Quality Directorate Nyaho Medical Centre, Accra, Ghana
2
Department of Healthcare Management, University of Kyiv Mohyla Academy, Kyiv, Ukraine
3
Department of Health Information Management, College of Health, Yamfo, Ghana
4
Department of Anesthesia, 37 Military Hospital, Accra, Ghana
5
Department of Public Health, University of Ghana Hospital, Accra, Ghana
6
Department of Nursing, Ghana Health Service, Cape Coast, Ghana

Address correspondence to Augustine Kumah (augustinekumah@gmail.com).

Source of Support: None. Conflict of Interest: None.
Submitted: Oct 22, 2023; First Revision Received: Nov 9, 2023; Accepted: Dec 1, 2023
Kumah A, Nwogu CN, Issah A-R, et al. Cause-and-effect (fishbone) diagram: a tool for generating and organizing quality
improvement ideas. Glob J Qual Saf Healthc. 2023; 00:000–000. DOI: 10.36401/JQSH-23-42.
This work is published under a CC-BY-NC-ND 4.0 International License.

Keywords: cause and effect, fishbone diagram, quality improvement tool

LEARNING OBJECTIVES in a way that resembles the bone of a fish (Fig. 1).[2]
Another name for the fishbone diagram is an Ishikawa
1. Introduce the concept of a fishbone diagram as a diagram (named after its creator).[3,4] The fishbone dia-
quality improvement tool. gram and the “five-whys” technique[1,5] are commonly
2. Provide useful tips for creating an effective fishbone used together to identify the root cause of a problem.
diagram. Advantages of the fishbone diagram include:
3. Understand how a fishbone diagram can be used in a
healthcare setting (case study). • Narrows the scope of an investigation to be more
manageable or actionable.
• Generates possible causes that we can act on.
INTRODUCTION
• Effective use of time and resources.
• Visualizes the relationships between all possible
Improvement requires changes to be made. Indeed,
one of the questions in the Model for Improvement causes for a focused problem.
• Establishes a shared understanding of the possible
asks “What change can we make that will result in
improvement?[1] Ideas for change are not automatically causes and solutions.
• Enables logical discussion of the next steps for testing
generated by these tools, but they help analyze prob-
lems in detail, and in doing so, potential solutions may changes.
• Documents which causes are targeted for data collec-
be easier to identify. In the healthcare field, a cause-
and-effect diagram (fishbone diagram) is a tool that tion or have already been verified with data.
assists in analyzing the root cause of a quality-related
problem, such as poor performance or safety incidents.
FISHBONE DIAGRAM STRUCTURE AND
This tool allows the team to focus on the root cause of a
PROCESS
given problem instead of the symptoms. When there is
more than one root cause, the team may need to
address each one with a separate fishbone diagram • The “head” of the fishbone diagram is the focused
process. problem.
A fishbone diagram is a visual aid that displays the • The long bones represent the possible main causes
relationship between the various factors that contribute (i.e., categories) and how they are related to the
to a particular effect or problem (i.e., causes and effects) problem.

Global Journal on Quality and Safety in Healthcare 2023 | Volume 00 | Issue 00 | 1

jqsh.org
2 Kumah et al: Cause-and-effect (fishbone) diagram

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Figure 1. Fishbone or cause-and-effect diagram. Reprinted from Kumah and Forkuo-Minka[6] with permission.

• The short bones represent the possible contributing fishbone is that it could generate both irrelevant and
factors and specific causes and how they are related to relevant potential root causes of the problem. This
the main causes. could result in the implementation of change ideas or
improvement strategies that might end up not
The steps for creating a fishbone diagram are listed in
addressing the problem.
Table 1. Useful tips for creating an effective fishbone
diagram are provided below.
CASE STUDY
• Draw the diagram on a large flip chart or dry-erase
board. In 2018 and 2019, Nyaho Medical Centre (NMC)
• Ensure there is enough space between the major catego- recorded a high number of needlestick injuries among
ries on the diagram to add minor detailed causes later. staff.[6] This led to the launch of a campaign to raise
• When brainstorming causes, have team members awareness of needlestick injury risks, processes for
write each cause on sticky notes and ask everyone in reporting and collecting data, and the initiation of a
the group to identify one cause. Keep going through quality improvement project aimed at reducing needle-
the rounds, uncovering more causes, until all ideas are stick injuries among staff at NMC. A fishbone diagram
exhausted. was developed to identify and visually display the many
• Encourage all individuals to participate in brainstorm- possible causes (Fig. 1) related to the high incidence of
ing activities and voice their own opinions. needlestick injuries in the facility. This process helped
• Organize causes into relevant categories such as mate- the facility to test improvement ideas that ultimately
rials, methods, equipment, environment, and people. led to the reduction of needlestick injuries in NMC
• A multi-voting technique, like having each team from 11 cases in 2018 to 2 cases in 2021.
member identify the top three possible root causes,
can help identify the most likely root causes of all the SUMMARY
ideas generated. Request that every team member put
three tally marks or colored sticky dots on the fish- When improvement is needed, identifying the under-
bone near the root causes that they think could be lying factors and causes of problems can be achieved
addressed. One risk or disadvantage of the use of the through a structured team process that uses the
 Quality And Safety Learning Corner 3

Table 1. Steps to drawing a fishbone diagram

Step No. Description
1 Draw a fish, starting with a box on the right-hand side of a landscape page, centered vertically on the page, to represent the “head.”
In the box, write the problem statement (or effect) that you want to examine.
2 Starting from the middle of the box you made, draw a horizontal line across the page to the left.
3 Come up with a plan and determine the main reasons for the outcome.
4 Create long “fishbones” by drawing diagonal lines above and below the horizontal line, then label each line with a relevant category.
Create a box that surrounds each label. In a classic cause-and-effect diagram, the usual categories are materials, methods,
equipment, environment, and people.

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5 Draw a few short lines extending from each long line to represent contributing factors as they relate to the possible main causes. Ask,
why does this happen? List all possible reasons for the problem. If causes are related to multiple categories, they can be repeated.
6 As needed, draw more branch bones from the causes to demonstrate sub-causes. Investigate the causes by asking “why” until you
have uncovered sufficient detail. When the cause is sufficiently specific, it is possible to test a change and measure its effects.

fishbone diagram for root cause analysis. Understand- England, NHS Improvement. Accessed Nov 20, 2023.
ing the contributing factors and main causes of failed https://www.england.nhs.uk/wp-content/uploads/2021/
processes or systems can aid in the development of 12/qsir-cause-and-effect-fishbone.pdf
measures that can sustain improvement, which is criti-
4. Tague NR. Fishbone diagram (Ishikawa)—cause and effect
cal in a healthcare setting.
diagram. In: The Quality Toolbox. ASQ Quality Press;
2005:247–250.
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