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Changing an Organization’s Culture: Louisiana State University Health Sciences Center School of Dentistry’s TigerCare Program

Key words: organizational culture, staff development, teamwork, communication, personnel evaluation, reward and recognition, evaluation, feedback

Submitted for publication 11/04/04; accepted 08/18/05

	Abstract

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Studies have shown that the culture of an organization could be the difference between success and failure in achieving its overall corporate goals and mission. Although some aspects of an organization’s culture are visible and tangible, such as the physical structure or overall cleanliness of the facility, other aspects are less tangible but just as apparent, like the helpfulness of the staff and the overall "attitude" of the organization. Private industry discovered many years ago that the key to creating a friendly and productive culture lies in the hands of the employees. TigerCare is a program that engages the civil service employees and provides them with the knowledge and motivation necessary to excel in their jobs and deliver the highest standard of customer service and job performance. It has helped the LSUHSC School of Dentistry develop employees who deliver excellent customer care. This article reports on the specific steps taken to improve the customer service culture and describes the results of the program after two years of implementation.

	Defining the Problems

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For years, students, patients, and coworkers at LSUHSC School of Dentistry reported episodes of bad attitudes, a lack of willingness to work, and general unhelpfulness among a core of the clinical staff. These problems existed despite the efforts made to address and correct problems as they arose. Many rules and policies were made in an attempt to correct the bad behavior. The rules, in most instances, did not correct the root problem.

After a careful evaluation, it was determined that the problem was universal. There was an atmosphere that existed in many areas that encouraged lack of effort and reinforced poor work performance and attitude. The problem was that the culture that existed throughout the organization was not in line with the service-oriented goals of the school. The culture of customer service was not being adequately addressed or given a high priority.

Organizational culture is the style or personality of the organization. It can be loosely defined as the shared assumptions, beliefs, and behavioral norms of a group. These beliefs are powerful influences on the way people live and act. They drive the organization and its actions. They guide how employees think, act, and feel. The culture defines what is "normal" and acceptable and how to sanction those who are not acting within the defined parameters.¹

This culture at the LSUHSC School of Dentistry had not developed overnight. For years, certain employees had been allowed to be inefficient and unhelpful. Many employees who were extraordinary performers were given increased workloads to absorb the inefficiencies of their coworkers, but these hardworking employees were very rarely recognized for the contributions they made to the team. In many instances, the poor performers had at one time been excellent employees who were now "burned out." In essence, the institution was responsible for creating a culture in which good employees were sometimes penalized by being given extra duties and poor workers were often not held accountable.

Evaluating the problem had to include an assessment of "the customer" of the dental school. Defining the customer for a clinical and academic institution is a bit more difficult than defining the customer of a traditional service-oriented business like a restaurant or hotel. The Merriam-Webster dictionary defines the word "customer" as "one that purchases a commodity or service."² When reviewed in this context, the School of Dentistry recognized patients, students, and guests as customers. Upon closer inspection, however, it became apparent that one group of "customers" had been excluded: our internal customers. The customer was redefined to include coworkers. In Super Service, the authors propose the following with regard to delivering great customer service: "One of the most important things you will learn is this: ‘My customer is anyone who isn’t me.’ This lesson is so critical to you as a professional service provider that it’s worth repeating: My customer is anyone who isn’t me! This definition of customers includes all the people inside and all the people outside your company: internal and external customers."³

One of the root causes in establishing an unhealthy culture at LSUHSC School of Dentistry was the dental school’s understanding of the state Civil Service system. Information on rules and regulations and how to enforce them had been verbally shared, but never formally disseminated. In many instances, the information communicated was incorrect or misinterpreted. This led to a lack of continuity in dealing with personnel issues and a belief that poor performance could not be corrected.

Another contributor to the problematic culture was the fact that employees were promoted into supervisory positions based on length of service and not based on leadership abilities or management experience. Many supervisors lacked formal training and were unfamiliar with management techniques in how to engage employees and establish both a desire to work and a loyalty to the school.

In addition, there was no formal communication format between the administration and the staff. This lack of communication caused excessive speculation about many issues, the development of rumors, and a lack of trust in the administration: "Studies have found that rumors emerge as a response to situations that are important to us, where there is ambiguity, and under conditions that arouse anxiety. Work situations frequently contain these elements, which explains why rumors flourish in organizations. The secrecy and competition that typically prevail in large organizations—around issues such as appointment of new bosses, relocation of offices, realignment of work assignments, and layoffs—create conditions that encourage and sustain rumors on the grapevine."⁴

All of these issues had contributed to low morale among much of the staff, which led to low employee compliance with many rules that were in place, along with poor job performance and limited job satisfaction. The employees were unaware of school expectations in customer service and job performance. Supervisors were frustrated in not being able to address poor behavior in employees. Students often complained of being treated indifferently or poorly by clinic employees, and patients sometimes complained of employee rudeness. Many of the effective employees were angry because their good attributes and job performance resulted in additional assignments or work, while the poor performers were asked to do less.

	Committing to and Preparing for Change

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By 2002, it was clearly time to address the employee culture of the school, and the dean, in consultation with others, made creating a new employee culture a top priority. Resources and money were committed, and the project became an integral part of the school’s new strategic plan. As the dean has repeatedly stated, the new vision was to now have an employee customer service and job performance culture more like the Ritz Carlton or Disney World rather than the Louisiana Department of Motor Vehicles.

Once a commitment is made, how does an institution go from business as usual to a workplace where customer service needs are the highest priority?

The first and most important step was the commitment to not accept the status quo and to create a crystal clear vision of a new workplace culture. The vision of a friendly, helpful, efficient, and fun environment was amplified with comparisons to Disney, the Ritz Carlton, and Marriott. The vision was to provide service that would "wow" even the harshest of critics. The vision was to develop, recognize, reward, and include in all school activities the outstanding School of Dentistry staff.

One might assume that the goal of establishing this new environment would be readily accepted. In reality, however, it was somewhat difficult to have everyone initially accept the concept. Accomplishing the goal meant change, and many people fear change. Others did not see the urgency of such a change or share in the passion for the new culture. Some thought the idea was just "silly," while others were threatened. It became evident that creating the new culture was a long-term goal that would require open communication, involvement, trust, and perseverance. The estimated time for completion was five years.

The dean began the process of moving from vision to implementation by appointing a full-time staff development and clinic supervision director. This commitment to a full-time director was critical to the future staff development and the implementation of the TigerCare program to enhance customer service. A background in business and dentistry and familiarity with the dynamics of the institution were all desired qualities for the new director.

After the appointment was made, the dean and new director then spent several months researching activities of successful corporate customer service and staff development programs. This resulted in the development of a loosely constructed six-part program that would hopefully lead to the anticipated culture change.

The initial program was presented to multiple groups of faculty, staff, administrators, and students. These groups did not suggest major changes, but did provide valuable input into potential problems and the general direction of the program. All groups were supportive, with the staff being the most enthusiastic. This three-month process of including employees, faculty, and students in the development process was key in creating acceptance of and excitement about the program. It set a good foundation that would be essential as the program developed.

	The TigerCare Program

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The TigerCare program consists of six themes, each critical to the development of a customer service culture. The six themes are 1) standards of service, 2) staff development, 3) supervisor development, 4) staff communication and celebration, 5) reward and recognition, and 6) hiring and orientation.

Standards of Service
An important part of establishing a customer-focused environment is the development of customer service standards. These customer service standards are expectations that are constantly communicated to every employee and to which every employee is accountable. These standards represent the philosophy and goals of the organization. As stated by the Disney Institute, "A service theme is a simple statement or concept that, when shared among all employees, becomes the driving force of service. . . . This vision serves as a rallying flag. It aligns the efforts of the cast members and establishes a foundation for their own behavior toward guests. For management, the service theme becomes a guiding precept. Every decision can be measured against it."⁵

Service standards are the operational criteria that ensure the consistent delivery of service. The service standards should be simple enough that every employee can memorize them, yet still be detailed enough to describe the expectations of every standard.

LSUHSC School of Dentistry established the acronym TigerCare as the service standard. The service standards consist of nine words, which add up to "TigerCare." A service statement to help define the individual words accompanies each standard (Table 1). The word "TigerCare" implies caring and nurturing and is easily remembered. Because each word or standard has a statement that is directly tied to that word, the true essence of the term is defined as it is applicable to the LSUHSC School of Dentistry.

Realizing that the development of the staff would play a major role in changing the culture and developing a customer service focus, the LSUHSC School of Dentistry made the commitment to actively invest in staff development, both with money and time. Customer service and staff training programs were developed, purchased, and provided to all employees. Employees were given time to attend the program. In fact, all employees who deal with the public in any way were required to attend the workshops. To ensure that all areas of the school remained operational, the development programs were held several times and delivered to small groups. Workshop topics included "The Customer Service Connection," "Handling Interpersonal Conflict in the Workplace," "Professionalism and Productivity for Nonsupervisors," "The Attitude Virus," and "Common Myths of Civil Service That Affect Good Performance."

The state of Louisiana has a training program called the Comprehensive Public Training Program (CPTP). All of the courses delivered by the CPTP are aimed at improving employee morale and performance and are geared to civil service employees. The classes are normally one- or two-day courses and are available free of charge to any state employee. The CPTP was a key resource to provide training to the employees of the LSUHSC School of Dentistry.

Supervisor Development
Training and development of supervisors have proven to be even more critical than training subordinates. Many supervisors are placed in a management role with limited or no leadership skills. Ensuring that supervisors understand and can implement the management tools to build a schoolwide team, reward and recognize employees who are exceeding expectations, and communicate effectively is vital in making changes to the culture.

To provide a model for our new cultural vision, we invited Baptist Health Care to share its story of successful cultural change with our supervisors and administrators. Baptist Health Care is a health care company that rose from mediocrity to become one of the most awarded customer service organizations in the country. The company has received numerous awards for its excellence in service and patient satisfaction, including winning the Malcolm Baldridge Award, being named in the Press Gainey Top One Percent of U.S. Hospitals in Patient Satisfaction, and being called the third best company to work for by Fortune magazine. The company’s evolution and activities were very effective in demonstrating that a true cultural change can occur.

Various training methods were used to teach the supervisors how to develop a positive, motivated work group, including courses given by the Louisiana state-sponsored CPTP program. Courses such as "Civil Service Essentials for Supervisors," "Common Myths That Affect Good Supervision," "Conducting Productive Employee Performance Reviews," and "Controlling Absenteeism and Tardiness in State Government" have been well received and very beneficial to the managers. Weekly training seminars for supervisors and managers are conducted at lunchtime every Monday. They are not mandatory, but have an attendance rate of 95 percent.

Communication and Celebration
Communication from the highest level of the administration with the staff plays a key role in establishing a customer service culture. To increase communication with the staff, the school established several activities.

First, the dean created the Staff Advisory Council. This council is comprised of staff representatives from various services in the school including clinics, housekeeping, security, secretarial, physical plant, and ancillary services. The twelve-member council meets four times per year with the dean and director of staff development to discuss issues important to the staff and to help plan events specific to them.

The dean also conducts Staff Forums, which all staff are invited to attend. The purpose of the forums is to 1) reinforce the principles that all staff are critical to the mission of the school, 2) thank the staff for all of their efforts, and 3) provide information on the plans and activities of the school. The goal is to create a feeling of staff involvement in the vision, mission, and goals of the school. These events are held four times per year on two separate days during lunchtime to accommodate areas of the school that must remain operational through lunchtime.

A newsletter created specifically for the staff is published monthly. The newsletter includes several different sections, including "A Message from the Dean," "Employee Spotlight of the Month," "Patient Satisfaction: What Are Our Patients Saying," "Tales of Customer Service Excellence," "Birthdays," and "Tiger Praise Award Winners." The newsletter has been extremely well received by the employees and has been effective in increasing communication with the staff.

Celebration is another key ingredient to achieving a positive customer service environment. Kouzes and Posner in The Leadership Challenge write:

All over the world, in every country, in every culture, people stop working on certain days during the year and take the time to celebrate. We hold elaborate parades to shower the hometown championship team with cheers of appreciation. We set off fireworks to commemorate great historic victories. We convene impromptu ceremonies in the company conference room to rejoice in the award of a new contract. We get together with colleagues at the end of a grueling work session and give each other high-fives for a job well done. Why? Why do we take time away from working to come together, tell stories, and raise our spirits? Sure we all need a break from the hectic pace of all our jobs, but celebrations are not trivial excuses to goof off. Celebrations are among the most significant ways we have to proclaim our respect and gratitude, to renew our sense of community, and to remind ourselves of the values and history that bind us together. Celebrations serve as important a purpose in the long-term health of our organizations as does the daily performance of tasks.⁷

The LSUHSC School of Dentistry uses celebratory events to build a sense of community. These events occur throughout the year and help to bring the staff together and encourage feelings of belonging and community. One tradition that has become a very large event is the Staff Appreciation Day. This yearly event is a day of fun and demonstrated appreciation for the staff. A theme is developed, many staff wear costumes, a picnic is provided, and a fun-filled event is conducted to honor the staff efforts. This past year included a talent show presented by the staff and faculty.

Other celebrations include numerous activities during the Annual Dental Assistant Week, a door decorating contest for the holiday season, and a Thanksgiving Feast hosted by many of the clinical staff. These events and more are important activities that bring people together and create immense good will among the employees.

Reward and Recognition
"We have a wealth of evidence that tells us that rewarding a behavior with recognition immediately following that behavior is likely to encourage its repetition," writes Collins.⁸ Countless surveys have been conducted to determine what people want the most from their workplace. Time after time the answer to that question is that employees want to be recognized for their contributions. Employees who get that recognition usually have a higher self-esteem, more confidence and willingness to take on new challenges, and a higher degree of loyalty and commitment to their jobs.¹

Employee reward and recognition is another key component of the TigerCare program. However, it should be noted that no one method will work for every person and thus it is important to establish several different mechanisms for reward and recognition.

One of our schoolwide recognition programs is called Tiger Praise. This is a system in which employees and students can be recognized by other employees, students, or patients for going above and beyond their job functions. Praise notes are posted throughout the school. If an employee performs beyond expectations, the person who is on the receiving end of this quality performance can write a Tiger Praise note for that employee. All of the notes are centrally collected and put in a presentation folder with a Tiger Praise pin and an invitation to the monthly Tiger Praise breakfast. Each monthly breakfast is celebratory in nature. The dean acknowledges all of the recipients at the breakfast and congratulates them for their outstanding service.

This program has worked exceedingly well for several reasons. First, it is rewarding specific behavior that the organization would like to see repeated. It publicly recognizes and rewards the employees, thereby creating role models for the rest of the organization. The program allows all who perform above and beyond to be rewarded. It does not single out just one winner, but allows for many winners and role models. It also empowers all employees to be able to promote a positive customer service culture and encourage good work performance.

The LSUHSC School of Dentistry also has an Employee of the Month program. The selected employee is given an invitation to the Tiger Praise breakfast at which they are pronounced the Employee of the Month. Each Employee of the Month receives a plaque, a balloon bouquet, a $50 cash award, and a reserved parking space for the month.

While providing schoolwide recognition opportunities has been important, all of the academic and administrative departments have also been encouraged to develop reward and recognition mechanisms specifically targeted to recognize departmental team members. These independent programs have been vital in promoting an atmosphere in which effort is recognized and rewarded.

The school has also made a concentrated effort to reward the employees who go above and beyond meeting the organizational goals by giving them highest consideration for promotion when these opportunities arise. By promoting the staff who work by the TigerCare philosophy, the school is rewarding the positive behavior of individuals and putting people in key positions to continue to advance the customer service theme.

Hiring and Orientation: Start Off on the Right Foot
The hiring and orientation process is one of the most important steps in developing a unified workforce. Choosing the right people to fill positions and orienting those new employees to the vision, mission, and goals of the organization are critical to creating and maintaining a productive, customer-focused environment.

How important is it to hire people with the right attitude? So important that Jim Collins devoted a whole chapter to this concept in his book Good to Great. He writes:

When we began the research project [what made some companies good and others great] we expected to find that the first step in taking a company from good to great would be to set a new direction . . . and then get people committed and aligned behind that new direction. . . .

We found something quite opposite. The executives who ignited the transformations from good to great did not first figure out where to drive the bus and then get people to take it there. No, they first got the right people on the bus (and the wrong people off the bus) and then figured out where to drive it. They said, in essence, "Look, I don’t really know where we should take this bus. But I know this much: If we get the right people on the bus, the right people in the right seats, and the wrong people off the bus, then we’ll figure out how to take it someplace great." . . . If you figure out "who," rather than "what," you can more easily adapt to a changing world.⁸

The LSUHSC School of Dentistry’s hiring process is now devoted to finding the right people and getting them in the right seats. Training the supervisors in the hiring and interviewing process has been a key element in finding the right people.

Once the new individuals are hired, the orientation process is the next step. Orientation for the LSUHSC School of Dentistry is no longer the review of benefits and leave privileges. It involves a more thorough introduction to the organization. The primary goal is to make every new employee feel as though they have just joined an elite club that has an exciting history and a very bright future. We incorporate segments of storytelling about the history of the institution. We review the strategic plan and outline our vision and mission for the school. Each facet of TigerCare is presented. The standards are emphasized as our directives on how to interact with coworkers, students, patients, and guests. The orientation session ends with a complete tour of the school. Every department is visited, and success stories about the various areas are told in an effort to engage the new employees and make them feel that they have joined a special organization.

Cost of TigerCare Program
As with any program, there are monetary costs involved in the operation of TigerCare (see Table 2). The bulk of the monies spent, other than the cost of the director, are related to the reward and recognition programs, training, and celebrating with the staff. Although the total dollars spent per year has varied slightly, the TigerCare program costs an average of $14,578 per year to operate, not including the director’s salary.

	Outcomes

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Believing that measuring employee job satisfaction would be an indicator of customer satisfaction, a baseline job satisfaction survey was distributed to all staff prior to implementing the TigerCare program. This was an unscientific survey designed to provide the administration with feedback that would be useful in determining which aspects of TigerCare were working and which needed to be reevaluated and possibly redesigned. The survey included questions like "The people I work with support each other," "I am satisfied with the recognition I receive when I do a good job," "Outstanding helpfulness to patients is recognized and rewarded," "Outstanding helpfulness to coworkers is recognized and rewarded," "I feel a sense of personal satisfaction when I do my job well," and "The overall morale in my department is good." The response scale was "Agree" or "Disagree." The survey was redistributed to all staff members one year later asking the same questions. The first year, 120 surveys were returned out of approximately 300 sent. The second year, 146 surveys were returned out of 300 sent. All survey responses were submitted anonymously.

The results suggest a positive change. All categories showed some improvement. Most improved more than 20 percent. Critical issues like overall job satisfaction (12 percent increase), morale in the department (27 percent increase), and being recognized for outstanding helpfulness to patients (29 percent increase) and coworkers (33 percent increase) indicated a positive improvement in job satisfaction and morale (Table 3).

Extensive evaluation systems based on customer service goals have been developed for all clinical areas. The goal is to ensure that each student or faculty member receives the attention and assistance needed to deliver quality patient care. These evaluations include questions such as "Is your dental assistant available throughout clinic time?," "Does your dental assistant seek out students needing help?," "Does your dental assistant have a professional and supportive attitude?," "Does your scheduling clerk keep your schedule filled?," "Does your scheduling clerk communicate openly and often?," and "Does your Patient Care Coordinator keep your mini clinic filled with available patients?" The evaluations are completed monthly by the students. With timely feedback, problems can be corrected before they spiral out of control, and employees who provide quality customer service are rewarded for their actions.

Senior Exit Interviews
Data gathered from senior exit interviews indicate a positive change in attitude toward the staff (Table 4). Of the fifty-three students in the graduating class of 2002, thirty-five made one or more negative comments about the staff. In 2003, the first year of the program, only fifteen of fifty-five students made negative comments. The graduating class of 2004, comprised of fifty-two students, made only four negative comments.

	Conclusion

Top Abstract Defining the problems Committing to and preparing... The tigercare program Outcomes Conclusion Postscript References

The TigerCare program was developed to initiate a cultural change and to create a caring, customer-focused atmosphere. The six-step plan was designed to define the desired culture, train the staff and supervisors in the new goals, build a better line of communication between the administration and the staff, celebrate the uniqueness of our organization, build a sense of pride and community, reward and recognize all employees who exceed expectations, hire people who want to work in this type of positive atmosphere, and orient new hires to this culture so that success is ensured.

After two full years of implementation, positive changes are noticeable, and the vision of what could be is much more of a reality than a dream. As demonstrated by the outcomes data, the general atmosphere of the school is friendlier and more helpful. The students have fewer complaints about the staff. The staff members have a better sense of how they are able to positively impact the entire school, and the staff survey indicates that a larger percentage are satisfied with their jobs. The TigerCare program has been a positive influencer in improving the productivity of the school and in creating a work environment where customers, both internal and external, are given the highest priority.

When comparing the benefits of the TigerCare program to the costs of operation involved, the total amount of money spent is miniscule in comparison to the positive perception of attitude changes in the staff, as expressed in senior exit interviews. Overall clinic revenue has increased 41 percent from 2002 to 2004, with only an 18 percent increase in overall clinic fees. Although no data directly tie this increase in productivity to the TigerCare program, we believe that the improved attitude and helpfulness of the staff contribute to the increase in student productivity.

It should be noted that we are aware that the final effectiveness of the program cannot be judged after only two years of implementation. As with all new programs, lessons learned during the early years will be applied to continually enhance the positive effects TigerCare has had on the school. Data will continue to be gathered to measure the effectiveness of this model in the long term.

	Postscript

Top Abstract Defining the problems Committing to and preparing... The tigercare program Outcomes Conclusion Postscript References

 
This manuscript was accepted for publication prior to the devastation caused when Hurricane Katrinia slammed into the Gulf Coast on August 29, 2005. The LSUHSC School of Dentistry (LSUSD), located in the heart of New Orleans, received extensive flooding and was severely damaged. As a of the hurricane, many of the school’s employees displaced and have relocated outside of Louisiana LSUSD has temporarily relocated to Baton where it has established a clinic, labs, and office to continue its mission of education, research, patient care. Due to the geographical constraints caused by this relocation, 53 percent of our civil vice employees were not able to report to work therefore, are no longer with the organization.

Although TigerCare does not presently in its previous form, the culture that was created this effort has helped the school to overcome extraordinary challenges faced during this time. This has been critical as the lines of job duties have blurred and everyone—faculty, and students—has had to pitch in to make the new campus in Baton Rouge a reality. The productive and efficient work ethics that were veloped, nurtured, and rewarded prior to Hurricane Katrina have proven to be invaluable in this rebuild ing effort.

Life has a way of reminding us that some are beyond our control. As much as we plan, set and organize our activities, we have to be that at any moment we may have to rethink and move forward the best we can. Our TigerCare program, although modified, has proven to be cal to the school’s survival, allowing us to at a high capacity and remain optimistic about future in the face of these uncertain times.

	Footnotes

 
Ms. Pousson is Director of Staff Development and Clinical Support, Office of the Dean, and Dr. Hovland is Dean—both at the Louisiana State University Health Sciences Center School of Dentistry. Direct correspondence and requests for reprints to Ms. Rebecca G. Pousson, LSUHSC School of Dentistry, 8000 G.S.R.I. Road, Bldg. 3110, Baton Rouge, LA 70820; 225-763-2844 phone; 225-763-2788 fax; rpouss{at}lsuhsc.edu.

	REFERENCES

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1. Johns G, Saks AM. Organizational behaviour: understanding and managing life at work. 5^th ed. Toronto: Addison, Wesley, Longman, 2001.
2. Merriam-Webster Dictionary Online: www.m-w.com/dictionary.
3. Gee V, Gee J. Super service: seven keys to delivering great customer service even when you don’t feel like it, even when they don’t deserve it. New York: McGraw-Hill, 1999.
4. Robbins SP. The truth about managing people and nothing but the truth. New York: Prentice-Hall, 2002.
5. Be our guest: perfecting the art of customer service. 5^th ed. New York: The Disney Institute, Disney Editions, 2001.
6. Bruce A, Pepitone JS. Motivating employees. New York: McGraw-Hill, 1999.
7. Kouzes JM, Posner BZ. The leadership challenge. 3^rd ed. San Francisco: Jossey-Bass, 2002.
8. Collins J. Good to great. New York: HarperCollins, 2001.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pousson, R. G. Articles by Hovland, E. J. Search for Related Content PubMed PubMed Citation Articles by Pousson, R. G. Articles by Hovland, E. J.