If you are a manager at any level in an organization, you need to care about culture. Specifically, you need to understand how your words and actions are affecting the values, beliefs and assumptions of the people within your sphere of influence, and particularly those who report to you. This goes well beyond behaving in a manner that is consistent with your organization’s values, although this is certainly important. The fact is that you make choices every day about the way you manage, do your work and interact with people that directly influence culture. This includes the way you go about planning and scheduling work, conducting meetings, making decisions, sharing information and so forth. This is true in every organization regardless of sector, industry, size or nationality.
Why is this important? The bottom-line is that managers affect culture and culture affects performance and not just financials either. Culture is a significant factor in determining the level of innovation, customer experience, safety, quality, reliability, employee retention, and so on. This plays out on a small scale at the group or department level, as well as large scale within business units and even entire organizations. When a significant number of managers are operating in a manner that demonstrates similar beliefs and a shared sense of purpose you have traction. This does not mean that they are doing things the same way, but it does mean that they are operating with a shared set of assumptions and beliefs about the right way to go about fulfilling their roles and responsibilities. This is evident in their behavior, the practices that they use, the heroes they celebrate, the stories they tell, and the structures, systems, and processes they design amongst other things. These various manifestations of culture in turn affect the way that work is done in terms of both efficiency and effectiveness. It determines to a large extent the ability of the organization to execute its strategy such as delivering an exceptional customer experience, high levels of patient safety, consistent execution and continuous innovation. It also directly impacts the employee experience thereby affecting engagement, satisfaction and retention. While this sounds good, what proof is there that it is in fact true?
Culture and Performance
Triggered by the global success of Japanese firms in the 1970’s, questions began to be asked about what it was that the Japanese were doing that was giving them this unexpected competitive advantage. The answer was, at least in part, that it was their culture that was making the difference in performance. Specifically, one study by Ouchi compared the culture and performance of American and Japanese firms and found that the higher level of success of the latter was the result of worker’s commitment and a unitary vision for a company’s performance. Furthermore, he suggested that the superior financial success of the Japanese firms was attributable to their culture and specifically to their attention to humanistic values such as concern for employee well-being and emphasis on consensual decision-making[i]. Similarly, Pascale and Athos attributed higher productivity in Japanese versus American firms to the formers focus on human relations[ii]. This was evident in their attention to employee well-being and skill development, as well as their team-based way of working that was anchored by a unified focus on organizational goals and performance. These observations were a catalyst for the surge of interest in the culture-performance link that led to the 1982 release of Peters and Waterman’s best-selling book, In Search of Excellence, and, in the same year, Deal and Kennedy’s Corporate Culture.
While the former describes organizations that achieved stellar results in large part because of the culture that their leaders created; the latter takes a prescriptive approach detailing the things that leaders need to pay attention to in order to create a healthy and high performing culture. The assertion that culture plays an important role in determining organizational performance continued with Denison’s 1990 book, Corporate Culture and Organization Effectiveness followed in 1992 by Kotter and Heskett’s book titled Corporate Culture and Performance. Both publications present factual evidence that the authors’ assert conclusively link organizational culture with the achievement of superior financial results. Books such as Bossidy, Charan and Burck’s (2002) Execution and Collins’ (2001) Good to Great continued this trend with their description of cultures that set certain organizations apart from the rest.
The Bad News
Unfortunately, many of the organizations cited as stellar examples of the cultures that other organization leaders should aspire to create ended up struggling or outright failing. For example, only two years after the release of In Search of Excellence, Business Week published a story reporting that a third of the supposedly “excellent companies” were in difficulty including Wang, Eastman Kodak, and Westinghouse[iii]. Within five years, the number no longer viewed as leaders in their industries had increased to two-thirds[iv]. Similar findings have plagued subsequent work. The three case studies of effective culture change described by Kotter and Heskett in their bestselling book Corporate Culture and Performance all have experienced significant challenges[v]. For example, the Nissan plant in Zama, Japan was closed in 1995, a mere three years after their book was released. Similarly, many of the organizations in Collins and Porras’ book Built to Last have gone through substantial performance challenges despite the assertion that they had developed “a blueprint for building organizations which will prosper into the twenty-first century and beyond”[vi]. Hewlett-Packard, IBM and Motorola are only a few examples. Furthermore, ten of the original eleven companies[vii] noted as stellar performers in Collins’ book Good to Great performed slightly worse than the Standard & Poor’s 500 during the 2009 recession[viii]. In fact, two of them, Circuit City and Fannie Mae had disastrous results with Circuit City filed for bankruptcy in 2008 closing the last of its stores in March 2009[ix]. Meanwhile, the U.S. government stepped in to shore up Fannie Mae hand-picking executives to run the company and pledging unlimited financial support currently projected to be somewhere in the vicinity of $154 Billion USD[x].
To make matters worse, the turn of the century introduced a new trend in the popular and academic literature being the tendency to blame culture for a wide range of well publicized negative outcomes. In an extreme example, Richard Mason in an analysis of the 2003 Columbia Space Shuttle disaster noted that “With respect to Columbia, and Challenger and Apollo before it, NASA’s culture proved to be lethal”[xi]. Culture was also cited as a primary contributing factor to the recall of nearly nine million cars by Toyota in late 2009. For example, Time.com quotes Jeffrey Kingston, director of Asian studies at Temple University in Japan, as saying, “Toyota is famous for having an arrogant culture. They’re so used to dealing with successes that when they have a problem, they’re not sure how to respond”[xii]. Among the long list of others is Enron, once the seventh largest firm in the United States, described as an organization whose culture put short-term financial results ahead of ethics and doing the right thing[xiii], a description also applied to Nortel Networks whose culture was once described as being one of deceit and manipulation[xiv].
In late 2009, Toyota Corporation recalled more than eleven million vehicles worldwide and, in January 2010, stopped production of several of its most popular vehicles. This unprecedented action was taken in response to 19 fatalities attributed to accelerator pedal flaws. Later investigations revealed that the problems were caused by the accelerator pedals getting caught in floor mats which resulted in the vehicle continuing to accelerate after the driver removed pressure (NHSTA investigation) as well as ‘sticky pedals’ in some Toyota models (internal investigation)[xv]. For a company that’s reputation for reliability and quality was a significant contributor to it being ranked as one of the world’s top ten leading brands and the world’s most valuable automotive brand in 2008[xvi], this was a stunning fall from grace. How could this happen? Specifically, how could an organization that had been a model of best practices in automotive manufacturing end up responsible for the deaths of nineteen people?
The answer may be found at least in part in the way it dealt with past allegations. Although the stuff literally hit the fan in late 2009, reports of ‘unwanted acceleration’ have been traced back to 2003 when an incident occurred during production testing of its Sienna minivan. An internal investigation determined that the problem was caused by a missing clip that allowed the trim panel to trap the accelerator pedal. The company decided that it was an isolated incident. It wasn’t until five years later that Toyota informed the NHSTA of the incident in response to a blanket request for information[xvii]. Recent news reports suggest that Toyota failed or refused to disclose vehicle problems to federal regulators over a period of years[xviii].
From 2003 through 2007, the NHSTA continued to receive reports of related problems with Toyota vehicles. One of the most high-profile incidents occurred in July 2007 with the death of Troy Edwin Johnson who was killed when a Camry accelerating out of control hit his car at approximately 120 m.p.h. The driver had been unable to slow the car for 23 miles leading up to the crash. Toyota eventually settled out of court with Johnson’s family for an undisclosed amount. Then, in August 2009, an off-duty highway patrolman and his family were killed when the Lexus ES350 they rented ended up in a runaway crash. The NHTSA and the California Highway Patrol investigation of the incident reported that the floor mat snagged the pedal causing the uncontrollable acceleration. In October of the same year, Toyota issued the first of a series of recalls affecting 3.8 million vehicles on the grounds that floor mats can trap the pedals[xix]. The recall exposed a larger problem: Toyota’s inability to resolve a brewing crisis that reportedly first surfaced in 2002 when complaints of sticky accelerators spiked.
What does this have to do with culture? At least three cultural factors appear to have contributed to Toyota’s problems. First is the reluctance to admit that there is a problem and face the shame and embarrassment that would accompany it. In a high-status company like Toyota this would be especially difficult. Second, there is the emphasis placed on respect and deference that prevents those lower in the organization from challenging and questioning the decisions of their superiors[xx]. Third, there is the hubris or arrogance of leaders which is largely a product of past success and public aggrandizement that cause them to believe in their own, and the organization’s, infallibility[xxi].
General Motors and British Petroleum
General Motors, once the largest automobile manufacturer in the world, filed for Chapter 11 bankruptcy on June 1, 2009[xxii]. By the end of 2009, the company had received $50 Billion USD in government bailouts with the U.S. government owning a 60% stake and the Canadian government a 12.5% stake[xxiii]. While conditions in the global economy undoubtedly were a major factor in GM’s problems, its “inward-looking century-old corporate culture” also played a central role in its demise[xxiv]. This included the following observations by Rob Kleinbaum, a GM executive:
“GM’s culture shows little tolerance for dissent, little appetite for making hard decisions and an insularity that has made it seem sometimes “tone deaf” to broader societal concerns like the environment.[xxv]”
“GM has promised profound and fundamental changes to the taxpayers, but there is little evidence that they are addressing the fundamental cultural issues that have driven so much poor decision making”[xxvi].
Then there is British Petroleum which is infamous for its role in the Gulf Oil spill of 2010. This is an organization that reportedly compromised its values of safety and environmental stewardship in pursuit of profits with catastrophic results[xxvii]. The impact on the environment and the people and communities of the Gulf coast is almost unfathomable. The effect on the company was also huge as illustrated by the announcement made on July 27, 2010 that it had a “net loss of $16.97 billion during the second quarter of 2010, with the oil spill costing $32.2 billion up to that point”[xxviii].
The Good News
At the same time, there are also organizations that have leaped to the forefront of their industries reportedly in large part as a result of their unique, positive cultures. Amongst these, the best known is probably Google, who at the time had a reported market capitalization of $196.33 Billion USD. This made it the ninth most valuable firm in the world and by far the most valuable internet information provider at almost seven times that of its closest competitor[xxix]. Google was also consistently ranked in the top five of Fortune’s ranking of the “Best Companies to Work For”[xxx] which is duly noted by the fact that the company received over 3,000 job applications per day[xxxi]. This is further highlighted by the fact that “nearly one in five (American university) undergraduate students, 17 percent, chose the web’s leading search engine (Google) as their ideal employer”[xxxii]. Based on these facts alone, there is absolutely no question that Google is a huge success but what made it this way? What is it about Google that separated it from its internet search engine competitors such as Yahoo, Microsoft (Bing) and AOL? While some people such as Microsoft’s CEO Steve Ballmer may argue that it is the result of being the first to “get it right”[xxxiii], there is a strong case in support of its culture as an important differentiating factor.
“The Google culture is probably one of the most positive, influential, all-encompassing, productivity-inducing environments the world has ever seen” said Kevin Ryan, a vice president at SearchEngineWatch.com, an industry newsletter”[xxxiv].
Google is renowned for the outstanding benefits that it provides to its employees, also known as Googlers. These include amongst other things, free snacks and meals, health care coverage from the first day with the company, generous tuition reimbursement, an assortment of entertainment and physical fitness options such as foozball, ping pong and yoga classes, not to mention dogs, lava lamps and massage chairs[xxxv]. While this is certainly unique and attractive, it is only one small piece of the picture. Google’s culture was crafted by engineers for engineers reflecting the influence of its founders, Larry Page and Sergey Brin, who were graduate students at Stanford when they started the company in 1998. As such, it has a strong laboratory feel in that it combines a relaxed, playful work environment with a deeply methodical, task-based engineer design system (think extreme attention to details) and big expectations in terms of employee behavior[xxxvi]. This is reflected in its loosely formed team-based structure comprised of Googlers with equal authority and a certain level of autonomy. There are few middle managers and senior managers are “so hands on, it’s hard to qualify them in a separate category”[xxxvii].
Autonomy plays out in a number of different ways. For one thing, Googlers are encouraged to take 20 percent of their time to work on things that interest them. This is where collaboration comes in. If an engineer has an idea for a new product, he or she seeks out other Googlers who have a similar interest and away they go. GMail and Google News are two products that were a result of this process. A Googler may also have an idea for an internal organization improvement such as expanding agile programming practices or fixing bugs that are irritants to customers[xxxviii]. In this case, he or she invites other Googlers to form a ‘grouplet’ which is a self-organizing team of individuals with a common interest. Grouplets “have practically no budget and they have no decision-making authority. What they have is a bunch of people who are committed to an idea and willing to work to convince the rest of the company to adopt it”[xxxix]. To make sure that the grouplets are aligned with the company’s interest and are not working at cross purposes, oversight is provided by grouplet organizers who meet once a week[xl].
Collaboration is also evident in the company’s famous hiring practices which invite existing employees to provide references and/or comment on applicants. This is facilitated by its applicant tracking system which matches applicants with existing employees based on the school that they graduated from and past work experience. Using this approach, recruiters can access the perspectives of Googlers who have a deep knowledge of the requirements of the job and culture when assessing the fit of potential hires. It also provides Googlers with an active role in building the community even if they aren’t part of the formal interview process[xli].
The point is not that organizations should try to emulate Google whose culture is deeply rooted in its own unique context (more on that later), but to provide evidence of a strong, positive culture that plays a huge role in the organization’s past and current success. Given Google’s emphasis on searching out new ideas and learning throughout the organization, this is also likely to continue long into the future. It is however only one of many organizations that provide anecdotal evidence of the link between culture and performance.
ING Direct, a Dutch owned company, shook up the financial sector with its direct to consumer and no fees business model. ING Direct is known for its ‘nonbanking culture’ referring amongst other things to its flat organization structure with few management layers. There are no titles and no offices. Everyone has the same metrics and is in the bonus program, which by the way are very meaningful. In this way, the company provides tangible evidence of one of its thirteen values “We will be for everyone”. It also tries to hire people who do not have prior banking experience, except in specialized areas such as risk. Instead, it emphasizes the fit between the person and the company’s values which are the same ones that are used to connect with its customers.
At ING Direct, it is about doing things differently which encompasses the way they conduct their business (on-line and through social media), their offer (it’s all about saving therefore no credit cards), as well as the way they work (their culture). To make this happen, the emphasis is on alignment with a shared sense of purpose, goals and values. Managers make sure employees know what to do but allow them a level of autonomy in how they do it[xlii]. By doing things differently, ING Direct transitioned from a 1997 experiment in North American on-line banking[xliii] to becoming the 18th largest bank in the United States in 2009 with $90 Billion in assets and $77.4 Billion in deposits[xliv].
Sisters of St. Mary Health Care
“In 2008, SSM Health Care began an ambitious effort to instill across the organization a culture of patient safety. The effort, called Always Safe . . . Every Day. Every Way focuses on clinical care; communications; and the commitment of all employees, physicians and administrators to the goal: Do no harm, which means zero preventable deaths and zero medical errors.”[xlv]
In the not-for-profit sector you don’t have to look any further than Sisters of St. Mary (SSM) Health Care. SSM Health Care is a Catholic health care system with approximately 22,000 employees, 5,800 physicians and nearly 3,900 volunteers operating in four states and serving more than two million people annually[xlvi]. It “owns 15 hospitals, has a minority interest in five hospitals, manages one hospital, has affiliations with 16 rural hospitals, owns two nursing homes, and has a variety of partnerships with physicians, including Dean Health Plan in Wisconsin”[xlvii]. Like ING Direct, it also does things differently and extremely well.
The first health care organization to receive the Malcolm Baldridge Award, SSM Health Care has an international reputation as a “pioneer in the use of quality measures to improve patient care”[xlviii] and has received numerous awards for quality, safety and employer of choice. To achieve its goal of exceptional patient safety and care, it has created a high reliability culture[xlix] that is characterized by “open communication, highly reliable processes, teamwork, the sharing of best practices, and accountability”[l]. This is evident in a wide range of practices and behaviors that aim to keep “patient safety top of mind with every clinician, employee and administrator in the system – all the time”[li]. For example, ‘incident intervention teams’ or ‘no harm teams’ examine near misses (incidents that could have happened but didn’t) to identify causes and develop solutions to prevent them from happening in the future. These prevention strategies are then rolled out across the entire health care system. Another example is its Clinical Collaboratives which are the cornerstone of the organization’s system-wide quality improvement efforts. The collaboratives consist of people from a wide range of professions such as medicine, nursing, pharmacy, infection control, pastoral care and case management working together to improve patient care in targeted clinical areas such as surgical care and congestive heart failure. Since 1999, more than 110 health care teams have participated in the collaboratives[lii].
The results of this continuing effort were impressive. In 2009, St. Mary’s Health Center was ranked 10th in the United States out of 4,400 hospitals for patient care in the areas of heart attack, heart failure, surgical care and pneumonia by the New York based Commonwealth Fund[liii]. In another example, one of its hospital reports that since 2001 it has reduced in hospital acquired infections that were often fatal and cost $30,000 to $90,000 each by 85%; lowered staph infections from 26 to 8 per thousand patients; decreased intensive care mortality from 5.5% to 3.3%; and, reduced acute diabetic complications from 13.5% to 5%[liv].
As for unionized (and non-unionized) environments, there is Southwest Airlines that managed to generate a level of loyalty among its employees that is rarely found in organizations of any kind[lv]. As an example, the New York Times noted that “Pilots often help clean up a cabin to speed up operations. Flight attendants have been known to lend a hand on their day off”[lvi]. This is forty years after it first burst onto the scene with its zany culture and low-cost offer that put fear in the hearts of its competitors. In this company, culture is viewed as the key differentiator that allows it to do things that other organizations only wish they could do. Here, employees understand that their success depends on the success of the organization. As a result, they go above and beyond what might be typically expected to help the company deliver on its promise of no frills, low cost service. The impact is readily apparent. During the 2009 recession when its competitors were losing billions of dollars, Southwest remained profitable despite soaring fuel prices flying “86 million passengers, more than any other airline within the United States”[lvii].
What Does This Tell Us?
So far, we have touched on organizations that have leveraged their cultures to drive innovation (Google), patient care and safety (SSM Health Care), and a low-cost operating model in a unionized (Southwest Airlines) and non-unionized (ING Direct) environment. Similar stories can also be found linking culture to delivery of an exceptional customer experience at the Four Seasons Hotels. The Four Seasons was ranked number two in Business Week’s 2007 ranking of top customer service organizations and number four in 2010[lviii]. Among the long list of things that the hotel does to embed customer service into every employee’s heart and mind is its ‘familiarization stay’. At the end of a seven-day new employee orientation, every employee from housekeepers to front-desk clerks stay one night at their hotel including free dining. After six months they can stay up to three nights for free and by ten years they get up to twenty free nights. In this way, each and every employee personally experiences what the customer does when they stay at the hotel[lix].
We could go on and on describing organizations that are leveraging their culture to execute their strategies and achieve outstanding performance but what does this prove? On the one hand, we have the good news provided by anecdotal evidence linking culture to performance. On the other hand, we have the bad news evident in the number of organizations that have demonstrated this link and later struggled or failed. With these mixed messages, it is no wonder that leaders are skeptical when it comes to the link between culture and performance and the prescriptions for achieving effective, high performing cultures that are provided in the popular literature[lx]. It therefore seems that the link between culture and performance warrants a closer look. Stay tuned for more to come.
Author’s Note: This article was written in 2010 but never published. While there are more recent case studies, the message remains the same…case studies and anecdotal evidence is inconclusive in determining the relationship between culture and performance.
[i] Ouchi & Jaeger, 1978; Ouchi & Johnson, 1978
[ii] Pascale and Athos (1981)
[iii] Business Week (1984)
[iv] Kim & Mauborgne (2005)
[v] Kotter & Heskett (1992)
[vi] Collins & Porras (1994)
[vii] Gillette was excluded from the analysis as it was acquired by Procter & Gamble in 2005 for $57 billion. P&G shareholders have seen a 23 percent decline in value during 2009.
[viii] Hawkins, J. (2009). Good to Great to Bust? Retrieved from ArkansasBusiness.com (http://www.arkansasbusiness.com/article.aspx?aID=112581.54928.124704)
[ix] Wikipedia (2011). Circuit City Stores. Retrieved from Wikipedia.org (http://en.wikipedia.org/wiki/Circuit_City_Stores.)
[x] Goldfarb, Z.A. (2010). Fannie Mae, Freddie Mac bailout cost likely to rise to $154 billion, agency projects. Retrieved from WashingtonPost.com (http://www.washingtonpost.com/wp-dyn/content/article/2010/10/21/AR2010102101941.html)
[xi] Mason (2004)
[xii] Saporito, Schuman, & Szczesny (2010)
[xiii] Sims & Brinkman (2003)
[xiv] Kalawsky (2005)
[xv] LaPonsie, M. (2010). 2010 Global Toyota Recall: Two Recalls Impact Nearly 8 million Toyota Vehicles Worldwide. Retrieved from Suite101.com (http://www.suite101.com/content/2010-global-toyota-recall-a197355#ixzz18wvYUeyk)
[xvi] ALG (2010). Toyota Recall Impacts Resale. Residual Value Report, 11 (2).
[xvii] Steinmetz, K. (2010). Toyota’s Safety Problems: A Checkered History. Retrieved from Time.com (http://www.time.com/time/business/article/0,8599,1962218,00.html#ixzz18xD348W)
[xviii] Rhee, J. (2010). Congress Blasts Toyota for Withholding Key Evidence, Secret ‘Books of Knowledge’. Retrieved from ABCNews.com (http://abcnews.go.com/Blotter/RunawayToyotas/congress-blasts-toyota-withholding-key-evidence-secret-books/story?id=9957579&page=1)
[xix] Steinmetz (2010)
[xx] Kingston (2010)
[xxi] Sheth, J. (2007). The Self-Destructive Habits of Good Companies…And How to Break Them. Upper Saddle River, NJ: Wharton School Publishing.
[xxii] BBC News (2009). GM enters bankruptcy protection. Retrieved from news.bbc.co.uk (http://news.bbc.co.uk/2/hi/business/8077255.stm)
[xxiii] Kim, S. & Lawder, D. (2010). GM repays U.S. loan, government loss on bailout falls. Retrieved from Reuters.com (http://www.reuters.com/article/idUSTRE63K56920100421)
[xxiv] Krolicki, K. (2009). GM culture: A problem that cash can’t fix? Retrieved from Reuters.com (http://www.reuters.com/article/idUSTRE52104N20090302).
[xxvii] Edersheim, E.H. (2010). The BP Culture’s Role in the Gulf Oil Crisis. Retrieved from blogs.hbr.org (http://blogs.hbr.org/cs/2010/06/the_bp_cultures_role_in_the_gu.html)
[xxviii] Reuters (2010). BP Launches Image Overhaul, Ditches CEO. Retieved from CNBC.com (http://www.cnbc.com/id/38423142)
[xxix] “Market Capitalization (Market Cap) is a measurement of business value based on share price and number of shares outstanding. It generally represents the market’s view of a company’s stock value and is a determining factor in stock valuation” (YCharts, 2011).
[xxx] Johansson, G. (2010). Google: The World’s Most Successful Corporate Culture. Retrieved from Suite101.com (http://www.suite101.com/content/google-the-worlds-most-successful-corporate-culture-a242303)
[xxxi] Petrecca, L. (2010). With 3,000 job applications a day, Google can be picky. Retrieved from USAToday.com (http://www.usatoday.com/money/workplace/2010-05-19-jobs19_VA_N.htm)
[xxxii] Wright (2008: 56)
[xxxiii] Johnson, B. (2010). Ballmer: Google’s culture isn’t responsible for its success. Retrieved from guardian.co.uk (http://www.guardian.co.uk/technology/2010/mar/03/microsoft-bing)
[xxxiv] Yung, K. (2007) Google’s engine for change. Knight Ridder Tribune News Service, 5 September: 1.
[xxxv] Johansson (2010); Yung (2007)
[xxxvi] Johansson (2010)
[xxxvii] Johansson (2010)
[xxxviii] “Agile programming is a product development approach that incorporates
feedback early and often, and was being done in a few scattered parts of the organization” (Mediratta & Bick, 2007)
[xxxix] Mediratta & Bick (2007)
[xl] Mediratta & Bick (2007)
[xli] Wright, A.D. (2008). At Google, It Takes A Village To Hire an Employee. HR Magazine: SHRM’s 2009 HR Trend Book, 53 (12), 56-57.
[xlii] Hitt, M.A., Ireland, R.D. & Hoskisson, R.E. (2009) Strategic management: competitiveness and globalization: concepts & cases. Mason, OH: South-Western Cengage Learning.
[xliii] Mueller, C. (2007). ING Direct’s Man on a Mission. Retreived fromTime.com (http://www.time.com/time/magazine/article/0,9171,1633064-1,00.html)
[xliv] RJ & Mackay (2010). SNL Financial’s top 50 biggest banks and thrifts in the U.S. Retrieved from RJandMackay.com (http://www.rjandmakay.com/rj-and-makay/snl-financials-top-50-biggest-banks-and-thrifts-in-the-us.html)
[xlv] SSM Health Care (2011). Who We Are. Retrieved from SSMHC.com (http://www.ssmhc.com/internet/home/ssmcorp.nsf/documents/who+we+are)
[xlvii] Wikipedia (2010). SSM Health Care. Retrieved from Wikipedia.org (http://en.wikipedia.org/wiki/SSM_Health_Care)
[xlviii] Wikipedia (2010). SSM Health Care. Retrieved from Wikipedia.org (http://en.wikipedia.org/wiki/SSM_Health_Care)
[xlix] By definition, highly reliable organizations are ones that operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Consistent with this perspective, SSM Health Care defines high reliability as zero errors over a long period of time. High reliability organizations are the focus of Managing the Unexpected: Assuring High Performance in an Age of Complexity by Karl E. Weick and Kathleen M. Sutcliffe (2001).
[l] SSM Health Care (2011). Patient Safety. Retrieved from SSMHC.com (http://www.ssmhc.com/internet/home/ssmcorp.nsf/documents/Patient%20Safety?opendocument)
[li] SSM Health Care (2011). Patient Safety. Retrieved from SSMHC.com (http://www.ssmhc.com/internet/home/ssmcorp.nsf/documents/Patient%20Safety?opendocument)
[lii] SSM Health Care (2011). Patient Safety. Retrieved from SSMHC.com (http://www.ssmhc.com/internet/home/ssmcorp.nsf/documents/Patient%20Safety?opendocument)
[liii] SSM Health Care (2010). Experience Exceptional: SSM Healthcare Report to our Communities: Top 10 in 2010: Ten Reasons Why Your Community is Better Because SSM is There.
[liv] Need reference from Sherrill
[lv] Mouawad, J. (2010). Pushing 40, Southwest Is Still Playing the Rebel. Retrieved from NYTimes.com (http://www.nytimes.com/2010/11/21/business/21south.html?_r=3&pagewanted=all)
[lvi] Mouawad, J. (2010)
[lvii] Mouawad, J. (2010)
[lviii] Business Week (2007). 25 companies where customers come first. Retrieved from articles.moneycentral.msn.com (http://articles.moneycentral.msn.com/News/25CompaniesWhereCustomersComeFirst.aspx?page=1); McGregor, J. (2010). Customer service champs 2010. Retrieved from Businessweek.com (http://images.businessweek.com/ss/10/02/0218_customer_service_champs/1.htm)
[lix] Business Week (2007). 25 companies where customers come first. Retrieved from moneycentral.msn.com (http://articles.moneycentral.msn.com/News/25CompaniesWhereCustomersComeFirst.aspx?page=1)
[lx] According to industry studies, The 2005 Canadian Corporate Culture Study reported that 82% of the executives that participated in their study believe that there is a direct correlation between culture and financial performance (Waterstone Human Capital, 2005).