[WITH SLIDE CONTENTS, REPORTER’S POSSIBLE EXPLANATION, AND REFERENCES IN
APA FORMAT)
Slide 1: Introduction
• Slide Title: Root Cause Analysis Using Fishbone Diagram
Reporter’s Explanation:
- Welcome to today's presentation on Root Cause Analysis (RCA) using the Fishbone Diagram.
- RCA is a structured method used to identify the underlying causes of problems or events.
- The Fishbone Diagram, also known as the Ishikawa Diagram, helps visualize the various factors
contributing to an issue.
Note: What Is an Ishikawa Diagram? An Ishikawa diagram is a diagram that shows the causes of an event and
is often used in manufacturing and product development to outline the different steps in a process,
demonstrate where quality control issues might arise, and determine which resources are required at specific
times.
Slide 2: What is Root Cause Analysis?
• Root Cause Analysis (RCA) is a problem-solving technique that aims to identify the
underlying factors causing issues or unexpected events. It involves a systematic
process of determining the primary cause of a problem by answering questions like
"what happened," "how did it happen," and "why did it happen.” (Holifahtus
Sakdiyah et al., 2022)
Reporter’s Explanation:
- Root Cause Analysis (RCA) is a systematic approach to identify the underlying causes of problems or
events.
- It focuses on addressing the fundamental reason(s) for an issue rather than just its symptoms.
- RCA aims to prevent the recurrence of problems by eliminating their root causes.
Slide 3: Why Use RCA?
• Systematic Problem-Solving: By following a structured process consisting of defining
problems, collecting data, analyzing data, identifying root causes, and suggesting
corrective actions, RCA ensures a systematic approach to problem-solving (Holifahtus
Sakdiyah et al., 2022).
• Prevention of Future Failures: RCA is useful for avoiding future failures by pinpointing
the initial causes of issues, leading to long-term improvements and preventing
recurrence of similar problems (Holifahtus Sakdiyah et al., 2022).
Reporter’s Explanation:
RCA helps organizations:
- Improve processes and operations.
- Reduce the occurrence of problems or failures.
- Enhance decision-making based on data-driven insights.
- Foster a culture of continuous improvement.
Slides 4-5: Fishbone Diagram Overview
Figure 1. Sample Fishbone Diagram (Holifahtus Sakdiyah et al., 2022)
• A fishbone diagram, also known as a cause-and-effect diagram, is a visual tool used in
root cause analysis to identify possible causes of a problem (Centers for Medicare and
Medicaid Services, n.d.).
• The main purpose of a fishbone diagram is to assist teams in brainstorming and
understanding the root causes of an adverse event or near-miss. By visually mapping
out possible contributing factors, it helps in developing corrective actions to address
the identified causes (Centers for Medicare and Medicaid Services, n.d.)
Reporter’s Explanation:
- The Fishbone Diagram, also called the Ishikawa Diagram or Cause-and-Effect Diagram, is a visual tool for
RCA.
- It resembles the skeleton of a fish, with the problem statement at the head and branches representing
various factors contributing to the problem.
Slides 6-7:
Main Categories of Fishbone Diagram based on Holifahtus Sakdiyah et al.’s (2022) study:
1. Material (Raw Materials): This category includes the materials used in the process, their quality,
and how they impact the outcome.
2. Machine (Machinery): Refers to the equipment or machinery involved in the process, including
its condition, maintenance, and efficiency.
3. Man (Labor): Encompasses the human element, such as skills, training, and workforce-related
factors.
4. Method: Focuses on the procedures, processes, and methods used in the operation, including their
effectiveness and adherence.
5. Environment: Covers the external factors and conditions that can influence the process or
outcome, such as temperature, humidity, and workspace layout
Reporter’s Explanation:
- The main categories typically include:
- Material (Raw Materials)
- Machine (Machinery)
- Man (Labor)
- Method
- Environment
These categories help identify main causal factors leading to a detailed analysis of problems and solutions.
Slides 8-9: Steps for Conducting RCA with Fishbone Diagram (Holifahtus Sakdiyah et al.,
2022)
• Step 1: Define the Problems - Identify the specific issues or delays in decision-making within
the company.
• Step 2: Determine Main Categories or Factors - Categorize the main factors causing the
identified problems, such as man, method, machine, material, and environment.
• Step 3: Identify the Cause of the Problem - Analyze each category to pinpoint the root
causes contributing to the delays in decision-making.
• Step 4: Analyze the Problem with a Diagram - Create a fishbone diagram to visually
represent the cause-and-effect relationships and further analyze the underlying factors
affecting decision-making delays
• Step 5: Develop Solutions - Generate and prioritize solutions to address the root causes.
• Step 6: Implement and Monitor - Implement the chosen solutions and monitor their
effectiveness over time.
Slide 10: Example
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Figure 2. Fishbone Diagram on Improving Production Efficiency
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Slide 11: Benefits of RCA with Fishbone Diagram (Holifahtus Sakdiyah et al., 2022)
• Preventive Approach: RCA with Fishbone Diagram allows focusing on preventing problems
rather than just solving them, leading to long-term commitment and sustainable improvement
within the company.
• Identification of Causal Factors: The Fishbone Diagram helps in identifying main causal
factors such as material, machine, man, method, and environment, which can be detailed to
determine the root cause of the problem.
• Improved Decision-Making: By using Fishbone Diagrams, organizations can improve
decision-making processes, reduce costs, standardize operations, and provide education and
training for employees in decision-making activities.
Slide 12: Conclusion
• By encouraging team members to explore various cause categories and sub-causes,
the fishbone diagram facilitates a comprehensive analysis to identify root causes and
prevent future occurrences (Centers for Medicare and Medicaid Services, n.d.)
Reporter’s Explanation:
- Root Cause Analysis using the Fishbone Diagram is a valuable tool for identifying and
addressing the underlying causes of problems.
- By visualizing the various factors contributing to an issue, organizations can implement
targeted solutions to prevent recurrence and drive continuous improvement.
- Incorporating RCA into organizational practices fosters a culture of problem-solving and
innovation, ultimately contributing to improved performance and efficiency.
Slide 13: References:
• Sakdiyah, S. H., Eltivia, N., & Afandi, A. (2022). Root Cause Analysis Using
Fishbone Diagram: Company Management Decision Making. Journal of Applied
Business, Taxation and Economics Research, (1), 566-576. DOI:
10.54408/jabter.v1i6.103
• Centers for Medicare and Medicaid Services. (n.d.). How to Use the Fishbone Tool
for Root Cause Analysis. https://www.cms.gov/medicare/provider-enrollment-
and-certification/qapi/downloads/fishbonerevised.pdf
[End of Presentation]
