Organizational culture has been a much written about topic over the past 20 years (Kemp & Dwyer, 2001). Although numerous definitions and descriptions emerge in the literature, there is a general agreement among researchers that organizational culture is "a system of shared meaning held by members that distinguishes that organization from other organizations." (Shein, 1985, p. 32).

The purpose of this paper is to explore the concept of organizational culture as it relates to the Department of Medicine of University X. Along the way, several theoretical definitions of organizational culture will be discussed and the characteristics of culture in organizations examined. The 9 X Tower Faculty Practice will be utilized as a model to illustrate the interplay of cultures seen within the organization.

The Department of Medicine will be described and contextually placed, for the reader, in the three organizations within which it operates. Finally, the Department's mission will be presented, and fulfillment of its mission discussed and related to the cultures and values of the Department's stakeholders.

In recent years, a number of researchers and theorists have attempted to define, quantify, understand, and operationalize the concept of organizational culture (Robbins, 1997). Although there are some differences in the terms writers use to describe observed phenomena, most agree that organizational culture is "a system of shared meaning held by members that distinguishes the organization from other organizations" (Schein, 1985, p. 32). Put more simply, organizational culture can be thought of as nothing more than "the way we do things around here" (Johnson, 1999, p. 74). An organization's culture, including its customs, traditions, and the way it goes about getting things done, is largely dependent upon the history of the company, namely how did the organization traditionally operate and how successful was this strategy (Dennison, 1990). Additionally, Schein (1983) observed that the vision of the organization's founders has a profound impact on company culture and also that organizational effectiveness is possible only when there is synchrony between an organization's mission and its culture. The purpose of this paper is to explore how the organizational culture of University X's Department of Medicine and its clinical practice operations "fits" with the Department's stated mission. This analysis of culture and mission will focus on the 9 X Tower Faculty Practice, one of the general internal medicine practice sites operated by the Department of Medicine.

The Department of Medicine of University X is a complex organization that operates and co-exists within three separate and distinct corporate entities. These include the hospitals of University X Health System (XHS) namely the Hospital of University X (HX) and P Medical Center (PMC), University X School of Medicine, and the Clinical Practices of University X (CPX). Though each of these organizations have separate corporate structures and leadership, they all feed up into the parent corporation, University X and its Board of Trustees.

In addition to being a member of the Department of Medicine, each of the Department's employees also works for one of these three groups who are responsible for the employees' salaries and benefits. The Department consists of 380 physicians employed by the University who also hold faculty appointment within the University's School of Medicine; 144 physicians in clinical fellowship positions and180 resident physicians employed by the HX and more than 1000 clinical and administrative staff on CPX's payroll. Medicine is the largest Department within the health system and the School of Medicine encompassing thirteen separate clinical specialties: allergy, pulmonary and critical care medicine, geriatrics, general internal medicine, infectious diseases, rheumatology, nephrology, hematology/oncology, cardiology and cardiovascular services, medical genetics, endocrine and diabetes medicine, experimental therapeutics and sleep medicine. The Department has annual revenues in excess of $50 million from research grants and approximately $49 million from its clinical practice operations based on performing 212,000 ambulatory patient visits, 35,000 inpatient visits and 20,000 procedures per year.

Overview of Organizational Culture

O'Reilly, Chatman and Caldwell (1991) identified seven characteristics, that when viewed as a whole, define the essence of an organization's culture.

1. Innovation and risk taking. To what degree are employee creativity, innovation and risk-taking encouraged?

2. Attention to detail. What is the expected level of employee precision and attention detail?

3. Outcome orientation. Does management focus more on outcomes or on the process and techniques used to achieve those outcomes?

4. People orientation. Does management consider how their decisions will affect the people within the organization?

5. Team orientation. Are work activities organized around teams rather than individuals?

6. Aggressiveness. Are people within the organization aggressive and competitive rather than easygoing?

7. Stability. Is the organization concerned with maintaining the status quo rather than growing or downsizing? (O'Reilly, Chatman, & Caldwell, 1991, p. 491.)

The authors suggest that these characteristics are present in all organizations to some degree, and that by assessing the seven properties in any company, the culture of the organization can be understood (p. 499). Numerous examples of determining an organization's culture through application of these principles can be found among today's corporations. Microsoft has a strong risk-taking personality and employees are encouraged to take chances, fail, and then learn from their mistakes (Gates, 1996). Some organizations have achieved success through a strong outcome-orientation focus. For Nordstrom's the desirable outcome is excellence in customer service while Ben & Jerry's Homemade is structured around preserving high ethical standards and social responsibility (Collins & Porras, 1994). Still other organizations can be defined by their strong people orientation. This is the case with Hewlett-Packard where the employees are vital to their culture and the organization is committed to recognizing the value and worth of its employees by having the employees share in the company's profits and success (Rogers, 1994).

Despite these assertions, there are often one or more subcultures operating within the dominant culture of the organization (Jermier, Slocum, Fry & Gaines, 1991). Sachmann (1992) defines the dominant culture as "the core values that are shared by the majority of the organization's members" (p. 19). Since this definition implies a common perception or a "shared meaning" among members of the organization, it is reasonable to assume that an organization will have only one dominant culture. This view of a dominant culture reflects the beliefs of the majority of members in an organization, but does not necessarily reflect the opinion of those in power.

In addition to the dominant culture, subcultures often develop within departments or separate geographical sites that reflect its members' common experiences, situations or problems. These subcultures will include the basic values of the dominant culture plus additional values unique to a group or department within the organization (Jermier, Slocum, Fry & Gaines, 1991).

Employees often learn and become aware of an organization's culture through stories, rituals, material symbols and language (Pettigrew, 1979). Stories are told and retold in companies about everything from past layoffs, success stories, and how mistakes were handled, to major organizational changes or relocations that have occurred. These stories serve to reconcile the present with the past, and are sometimes used to explain current practices (Boje, 1991). Rituals are repetitive actions that tend to express and reinforce the values of an organization. One well known corporate ritual is the awarding of pink Cadillacs by Mary Kay Cosmetics to their top salespeople each year. The annual glitzy awards ceremony is meant to acknowledge outstanding sales performance and convey to the entire sales force optimism that they too can achieve success (Beyer & Trice, 1987). One of the most direct ways for employees to learn about an organization's culture is through material symbols which include the company's location and facilities, attire of the staff, the automobiles top executives receive, the size of offices, and the elegance of furnishings. Lastly, organizations often use language or terminology as a means of identifying members of a specific culture or subculture (Deutsch, 1991). This language usually has meaning only to members of the organization that share in that culture. An example of this from the Department of Medicine is the employment of PSRs to work in the clinical practices. PSR stands for patient services representative and these employees function in a job that blends a traditional receptionist's role with billing and insurance skills.

The Department of Medicine has a tri-fold mission of providing education for the nation's future medical leaders, conducting cutting-edge research, and delivering excellence in patient care (University X Department of Medicine Mission Statement, 2001). This mission is realized through the Department's fifty-two clinical practice sites; its extensive educational programs for medical students, interns, resident physicians, clinical fellows and other clinical staff; and its impressive research programs making the Department the third largest recipient of National Institutes of Health grants in the nation.

With its complexity, the Department of Medicine presents an interesting study of organizational culture because it straddles, so to speak, three separate corporate entities that have both similar and at times conflicting interests. Further complicating the picture is the fact that its employees, in addition to defining themselves as part of the Department of Medicine, identify with only one of the involved institutions, University X, University X Health System (XHS), or the Clinical Practices of University X (CPX). As a result, cultural tensions are present and can be found in any one of the Department's clinical practice sites. The 9 X Tower Faculty Practice will be used to illustrate this conflict in cultures.

The 9 X Tower Faculty practice is a general internal medicine practice located on the 9^th floor of the X Tower Hotel. It consists of ten full and/or part-time primary care physicians who are employed by University X and hold faculty appointments as assistant professor, associate professor or professor of medicine, and 24 clinical, secretarial and administrative support staff employed by CPX. The practice provides care for more than 15,000 patients and performs approximately 22,000 outpatient visits each year.

Although the physicians and the support staff of the 9 X Tower Faculty Practice all work at the same location and espouse a common goal, namely to provide excellent quality patient care, they approach this mission from differing organizational cultures and orientations.

The practice's physicians, as appointed faculty of the University's School of Medicine, have a prescribed program for success laid out for them by the University structure. Appointments as assistant professor are good for an initial probationary term of six years after which the candidate must apply for a reappointment and promotion, often to the rank of associate professor. In order to be considered for a promotion and reappointment, the candidate must have demonstrated leadership in their field through either extensive lecturing on a national scale, publication of major works, or the acquisition of significant research grants as a principle investigator. Excellence as a clinical practitioner alone is not sufficient for reappointment. Candidates who are unable to show this level of scholarship are not reappointed to a second term and are given one year's notice that they must leave the University. These requirements are well known by the physicians at the start of their careers with University X and it is an established fact that not all of them will survive these rigors. Consequently, while physicians may desire to offer quality care and excellent patient service, their success within the University will ultimately be determined by the work they perform outside of the practice setting. This realization appears to become evident to physicians toward the end of the third year of their employment at which time they begin to reduce their clinical hours and activities to concentrate on research, writing or the lecture circuit. The 9 X Tower Faculty Practice is an excellent example to illustrate this point. Of the ten physicians working there: two are full-time clinicians and are in the first and third years of private practice respectively, one is primarily a researcher seeing patients only four hours per week, one divides her time 50/50 between research and clinical practice, and the other six physicians see patients between 8 to 24 hours per week filling the remaining time with lecturing, writing or other educational pursuits. The School of Medicine pays all the physicians and their salary is not dependent upon the number of patients they see or dollars collected.

Using the O'Reilly, Chatman and Caldwell (1991) model, the two most predominant cultural characteristics of the University's School of Medicine are a strong outcome-orientation personality that raises the idea of "publish or perish" to new heights, and a strong aggressiveness personality which fosters both inter and intra-institutional and departmental competitiveness (P. Elmer-Dewitt, 1995). This creates a very strong culture (Collins & Porras, 1994) for members of the University and serves as a potent device for guiding and shaping behavior. Within the practice itself, a weak subculture for people-orientation and customer service emerges for the physicians but it is always overshadowed by the dominance of the University culture and its mandated requirements for success.

In contrast to the physicians, the 9 X Tower Faculty Practice's nursing, secretarial and administrative staff are employed and paid by CPX whose goals are to achieve practice operational efficiency while providing excellent customer service in a patient-focused environment. To achieve these objectives, all CPX employees are socialized to a service environment that is customer friendly and receive two days of specialized training on how to create customer satisfaction in a clinical setting. Additionally, the staff performance appraisal process, upon which employees are dependent for raises or bonuses, is heavily weighted toward areas that measure customer service and overall patient satisfaction. This creates a strong CPX culture that demonstrates both an outcome-orientation and an attention-to-detail personality ( O'Reilly, Chatman & Caldwell, 1991). CPX employees learn fairly early in their employment that the road to success is paved by financial profitability from an efficient practice operation and happy, satisfied patients. A fairly strong subculture seen throughout CPX and present within the 9 X Tower Faculty Practice is a team-orientation personality. This rises from the realization that neither the stated goals of the organization nor personal success can be achieved alone by the individual, as each is dependent upon the successful completion of duties by others within the practice team (Wellins, Byham & Dixon, 1994).

The divergence of goals between the physicians and practice staff give rise to a number of interesting conflicts. One of these involves the verification of patient insurance and the collection of insurance co-payments and deductibles. As patients check in with the receptionist for their appointment with the physician, they are asked for their insurance card and if any changes in their demographics have occurred since their last visit. The receptionist then must update the automated scheduling and billing system, verify that the patient's insurance is valid, and collect any monies due today. The entire process can take as short as two minutes to as long as ten minutes depending on the number of changes that have occurred and if problems arise in the insurance verification process. The practice staff take this process very seriously as they know both their performance evaluation and practice profitability is dependent upon the job they do. In contrast, however, the physicians not only do not value the process, as their livelihood is not dependent upon practice income, but also view any procedures that may delay their patients and affect their release time from the practice, as an unnecessary intrusion on their medical autonomy. This scenario plays out on an almost daily basis creating a tension-filled practice environment. In an attempt to resolve this conflict, the Department of Medicine has begun educating physicians on the economics of physician practices. Additionally, the Department is in the process of renegotiating physician compensation packages, particularly bonus structures, and linking them to practice revenue in an attempt to align physician and staff values.

Consequently, what emerges within the 9 X Tower Faculty Practice becomes an interesting blend of cultures, values, goals, and needs that are sometimes aligned, as evidenced by the desire of both the physicians and the staff to have satisfied patients and good customer service scores; at other times in conflict, particularly in the areas of operational efficiency and profitability; but always inextricably woven together. The extent to which the Department of Medicine's overall mission is achieved in this practice, as in all of the Department's other practice sites, is a dynamic process relying on the delicate balance of cultural interests and players.

Organizational culture is a powerful determinant of employee behavior that plays an important role in the success of an organization and the achievement of its mission and goals. University X's Department of Medicine and its clinical practice sites including the 9 X Tower Faculty Practice exhibit a number of organizational cultures that both support the Department's mission and conflict with it. These factors create tension among the various employee groups and entities within the Department and serve to make the Department of Medicine an interesting study of organizational culture.