- Okwaho runs a small roofing company and introduced team-based bonuses for timely project completion to address scheduling backlogs. However, this has coincided with a rise in workplace accidents and injuries over the past 5 months.
- He is now questioning if the incentive system may be motivating unsafe work practices in the rush to complete jobs on time and earn bonuses. Three significant accidents have occurred, including a new employee falling from a roof while unharnessed.
- Okwaho must balance productivity targets with safety and consider revising the incentive system to avoid further injuries while still maintaining efficiency and profitability. The case examines the linkage between compensation design and employee motivation and safety behaviors.
Disclaimer Use of this tool is not mandated by CMS, nor does
1. Disclaimer: Use of this tool is not mandated by CMS, nor does
its completion ensure regulatory compliance.
Overview: Root cause analysis is a structured team process that
assists in identifying underlying factors or
causes of an adverse event or near-miss. Understanding the
contributing factors or causes of a system failure
can help develop actions that sustain the correction.
A cause and effect diagram, often called a “fishbone” diagram,
can help in brainstorming to identify possible
causes of a problem and in sorting ideas into useful categories.
A fishbone diagram is a visual way to look at
cause and effect. It is a more structured approach than some
other tools available for brainstorming causes
of a problem (e.g., the Five Whys tool). The problem or effect
is displayed at the head or mouth of the fish.
Possible contributing causes are listed on the smaller “bones”
under various cause categories. A fishbone
diagram can be helpful in identifying possible causes for a
problem that might not otherwise be considered
by directing the team to look at the categories and think of
alternative causes. Include team members who
have personal knowledge of the processes and systems involved
in the problem or event to be investigated.
Directions:
The team using the fishbone diagram tool should carry out the
steps listed below.
2. ● Agree on the problem statement (also referred to as the
effect). This is written at the mouth of the
“fish.” Be as clear and specific as you can about the problem.
Beware of defining the problem in terms
of a solution (e.g., we need more of something).
● Agree on the major categories of causes of the problem
(written as branches from the main arrow).
Major categories often include: equipment or supply factors,
environmental factors,
rules/policy/procedure factors, and people/staff factors.
● Brainstorm all the possible causes of the problem. Ask “Why
does this happen?” As each idea is given,
the facilitator writes the causal factor as a branch from the
appropriate category (places it on the
fishbone diagram). Causes can be written in several places if
they relate to several categories.
● Again asks “Why does this happen?” about each cause. Write
sub-causes branching off the cause
branches.
● Continues to ask “Why?” and generate deeper levels of causes
and continue organizing them under
related causes or categories. This will help you to identify and
then address root causes to prevent
future problems.
Tips:
● Use the fishbone diagram tool to keep the team focused on the
causes of the problem, rather than
3. the symptoms.
● Consider drawing your fish on a flip chart or large dry erase
board.
● Make sure to leave enough space between the major
categories on the diagram so that you can add
minor detailed causes later.
● When you are brainstorming causes, consider having team
members write each cause on sticky notes,
going around the group asking each person for one cause.
Continue going through the rounds, getting
more causes, until all ideas are exhausted.
How to Use the Fishbone Tool for Root Cause Analysis
Disclaimer: Use of this tool is not mandated by CMS, nor does
its completion ensure regulatory compliance.
● Encourage each person to participate in the brainstorming
activity and to voice their own opinions.
● Note that the “five-whys” technique is often used in
conjunction with the fishbone diagram – keep
asking why until you get to the root cause.
● To help identify the root causes from all the ideas generated,
consider a multi-voting technique such
as having each team member identify the top three root causes.
Ask each team member to place
three tally marks or colored sticky dots on the fishbone next to
what they believe are the root causes
that could potentially be addressed.
4. Examples:
Here is an example of the start of a fishbone diagram that shows
sample categories to consider, along with
some sample causes.
Here is an example of a completed fishbone diagram, showing
information entered for each of the four
categories agreed upon by this team. Note, as each category is
explored, teams may not always identify
problems in each of the categories.
Facts gathered during preliminary investigation:
● Time of fall: change of shift from days to evenings
● Location of fall: resident’s bathroom
● Witnesses: resident and aide
● Background: the plan of care stipulated that the resident was
to be transferred with two staff
members, or with one staff member using a sit-to-stand lift.
● Information from interviews: the resident was anxious and
needing to use the bathroom urgently. The
aide was helping the resident transfer from her wheelchair to
the toilet, without using a lift, and the
resident fell, sustaining an injury. The aide stated she did not
use the lift because the battery was
being recharged, and there was no extra battery available. The
aide stated she understood that the
resident could be transferred with assist of one.
●
5. Disclaimer: Use of this tool is not mandated by CMS, nor does
its completion ensure regulatory compliance.
With this information, the team proceeded to use the fishbone
diagram to better understand the causes of
the event.
The value of using the fishbone diagram is to dig deeper, to go
beyond the initial incident report, to better
understand what in the organization’s systems and processes are
causing the problem, so they can be
addressed.
In this example, the root causes of the fall are:
● There is no process in place to ensure that every lift in the
building always has a working battery.
(One battery for the lift on this unit is no longer working, and
the other battery was being recharged.)
● There is no process in place to ensure timely communication
of new care information to the aides.
(New transfer information had not yet been conveyed to the
aide. The aide’s “care card” still indicated
transfer with assist of one for this resident.)
The root causes of the event are the underlying process and
system problems that allowed the contributing
factors to culminate in a harmful event. As this example
illustrates, there can be more than one root cause.
Once you have identified root causes and contributing factors,
8. Abstract
Okwaho runs a roofing company that has seen a dramatic
increase in workplace accidents and
injuries. In the same timeframe he introduced team-based
bonuses based on timely project
completion. He considers the role that his newly designed
compensation system may play
in motivating safety behavior. Okwaho further considers how to
balance his profitability and
productivity targets with community needs and socially and
legally responsible management
practice.
Case
Learning Objectives
By the end of this case, students should be able to:
• apply the expectancy and equity theories of motivation in
order to assess the relative merits of an
incentive system;
• evaluate the link between incentive system design and safety
behaviors;
• design incentive systems to balance productivity and safety-
based priorities;
• assess the benefits and drawbacks associated with temporary
project teams.
Blood, Tears, Questions, and Other Unfortunate Developments
Okwaho walked up the path to a small, tidy home on his First
Nations urban reserve and reluctantly knocked
on the door. Chances were the community had already relayed
the bad news while he’d been at the hospital
9. with Joseph, but regardless he felt a moral obligation to face
Joseph’s mother directly and explain the
accident. Joseph was a 19-year-old who worked for Okwaho as a
roofer. He had been hired three months
previously. It had been his first fulltime job. Now, after
Joseph’s terrible fall today, resulting in a badly broken
arm, it was unclear whether he would ever regain enough
mobility to be able to work as a roofer again.
Okwaho did not have to wait long on the porch. Within
moments Joseph’s mother answered and Okwaho’s
heart fell. He could see by her red-rimmed eyes and wet face
that she had been crying. She knew about
the accident already. Other family members quickly crowded
around her supportively, looking at him. Okwaho
had trouble meeting their eyes. He felt like he’d failed them, his
new employee, and their entire community.
“May I come in?” he asked gently, despite his trepidation. The
door opened further and he went into the warm
home, trying to find some way to explain what had happened.
Later, at the office, Okwaho looked over this latest accident
report and sighed to himself. He knew it looked
bad, especially given the company’s other recent safety issues.
People might think he was an irresponsible
business owner, but Okwaho had provided detailed safety
training and the needed harnesses and other
personal protective equipment were always available on job
sites. He just couldn’t understand it. Joseph was
a good kid who paid close attention to instructions. Why hadn’t
he been harnessed in properly? Okwaho felt
terrible for Joseph and his family, but he was also worried about
his ability to staff upcoming jobs. The injured
worker would be away for an indefinite period. This was the
third significant accident in five months, and it
was simply unacceptable. Something was going very wrong with
11. were more difficult or technically complex than others), and
then he would create a self-managed project
team. The team, which could have anywhere from three to eight
people, would work together until the project
was complete and then they would move on to the next one.
Okwaho tried to balance the teams such that
they had adequate supervision and the “kids” were well placed
to learn from others with more experience, but
he also considered individual personalities and personal
preferences for commercial versus residential work.
Even with those considerations, the team composition varied
tremendously from one project to the next so
people wouldn’t work with exactly the same colleagues from
one day or week to the next.
The Backlog and Incentives
Five months earlier Okwaho had noticed that many of the
projects were taking longer than expected.
This created scheduling problems as jobs got backlogged.
Customers got upset, in particular those whose
contracts involved temporarily removing entire sections of roof.
Customers doing planned renovations were
especially adamant about having all the work done before
winter. Nobody wanted roof work performed once
the snow began to fly! In fact, most of their winter business
came as a result of emergency repairs on roofs
damaged by winter storms.
In response to the backlogs, Okwaho decided to create a new
incentive. Before deciding on a specific bonus,
he read about expectancy theory and equity theory. These
theories made intuitive sense to him. Expectancy
theory simply stated that in order for people to be motivated
certain conditions needed to be met. First,
people needed to believe that their level of effort was positively
12. related to their performance (basically, if they
try harder, they will do better). Then, they needed to believe
that effort would lead to rewards. Finally, they
needed to believe that the rewards offered would be relevant
and personally valuable to them.
Equity theory was similarly straightforward. It stated that
people compare their own efforts and rewards to the
efforts and rewards of others. In addition to comparing
themselves to others they also compare their effort/
reward balance with prior jobs they have had and even their
preconceived expectations. Inequity (such as
another person needing to work much less hard to earn the same
amount) makes people unhappy and prone
to slacking off, leaving the organization, or distorting their
perceptions of themselves or others. Perceived
equity, by contrast, is motivating.
After much thought, Okwaho decided on a team bonus. He
would provide each project team with a target
completion date (as usual), but now if they met that deadline the
entire team would get a cash bonus. If
they did not meet the deadline for any reason other than weather
delays, there was no bonus. If delays
were caused by weather, they were given an extension that was
equivalent to the missed time. The bonus
depended on the project size and scope but ranged from USD 20
per team member for modest residential
projects requiring only one or two days to USD 150 per person
for extremely large corporate projects requiring
weeks.
The bonus was generally well received, although several senior
employees expressed surprise and dismay
that the “kids” would get the same as they would. Regardless,
the incentive seemed to accomplish its goals.
14. roof to hasten clean-up. He hadn’t seen his coworker down
below and the man had suffered a concussion.
There had even been an unusual driveway incident. One of his
employees had hit a parked, riderless child’s
bicycle while rushing to deliver some roofing materials to the
site. Nobody was hurt, and Okwaho had bought
a new bike for the outraged parents of the owner, but it was
oddly careless of the worker. All of these incidents
were also strange because in the two years before that they had
only had one significant accident. Okwaho
wondered if there could be any connection between his
incentive program and the recent poor safety record.
After some consideration he realized that he needed to rethink
things. He decided to …
Discussion Questions
• 1.
Evaluate Okwaho’s existing bonus system through the lens of
expectancy theory and equity theory.
What are the strengths and weaknesses of the incentive plan
when viewed through those lenses?
• 2.
Do you think the new incentive plan is impacting the safety of
this workplace? Explain your reasoning.
• 3.
What types of team incentive would maximize both efficiency
and safety while maintaining a
respectful workplace? Explain why your strategy would be
effective.
• 4.
What are the benefits and drawbacks of Okwaho’s self-directed
project team structure? Is it a good
16. Problem
Performance
Resources & Environment
Policies & Practices
Purpose
· Mission
· Vision
· Strategic goals
· Values
· Culture
People
· Trained
· Requisite knowledge, skills, abilities, experience
· Organizational structures/team
Process
· Work design
· Instructional/job aids
· Job descriptions
· Work procedures
· schedule
Performance
· Measurements
· Standards
· Behaviors
17. Policies & Practices
· Compliance guidelines
· Employment laws
· Company policies
Resources & Environment
· Budget
· Equipment
· Materials
· Time
· Working conditions
· Work space
·
Corrective Action Plan
Causal Factor
Issue to fix
What to fix
Urgency
(1= High; 2= medium; 3= low)
How to fix
Who will do the fix
When will it be fixed
Purpose
