What factors are important in formulating a
community hospital’s reputation?
Anne-Marie Males★
Ryerson University, Toronto (Canada)
A r t i c l e I n f o A b s t r a c t
Article Type:
Research Article
Article History:
Received: 2013-08-29
Revised: 2013-10-03
Accepted: 2013-10-04
Keywords:
Health communications
Reputation mangement
Community hospital
Hospital CEO
Corporate communications
There is a growing body of literature on the importance of corporate reputation and reputation management, but scant research that looks at reputation in the context of a community
hospital. Most hospital administrators agree that reputation
is important and suggest that it has an impact on operations,
but the nature of hospital reputation and how it is formed is
not well understood. This study explores hospital reputation
through a comprehensive literature review, in-depth interviews
with six Ontario hospital CEOs, two patient/community member focus groups and an on-line survey with patients and community members. The results of this study strongly suggest
that many models of corporate reputation are not directly applicable to hospitals especially when it comes to factors such as
leadership, innovation and financial performance that appear
in most corporate reputation models and measurement tools.
Personal experience and word of mouth are used to evaluate a
hospital on desired outcomes, and this research suggested that
those outcomes are strongly related to emotional appeal (feeling cared about) as opposed to clinical outcomes or results.
©Journal of Professional Communication, all rights reserved.
T here is a growing body of literature on the importance of corporate
reputation and reputation management. In the corporate sector, reputation is widely recognized as a critically important intangible asset that
impacts many areas of operations including sales and staff recruitment
and retention. It is recognized as having value, and some work has been done to
develop ways to measure reputation and apply a monetary value to it. The situation is different in the hospital sector, where there is scant research that looks at
reputation despite the industry’s size and importance in the U.S. and other parts
★Corresponding author (Anne Marie Males)
Email: [email protected], Tel. (+1 416) 265-1513
©Journal of Professional Communication, ISSN: 1920-685. All rights reserved. See front matter.
Journal of Professional Communication 3(1):125-155, 2013
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Males, A., Journal of Professional Communication 3(1):125-155, 2013
of the world.
According to industry analysts, healthcare and hospitals are big business.
In the U.S., hospitals account for over one-third ($718.4 billion) of the nation’s
healthcare expenditures and employ almost 4.7 million workers (Wallis, 2010).
In Canada, where healthcare is publicly funded, healthcare broadly and
hospitals specifically also have a large economic impact. In 2009, Canadian
hospital spending accounted for over $59 billion, or 29.1% of the total spent on
healthcare (Canadian Institute for Health Information, 2011).
Given the economic impact of hospitals there is surprisingly little academic literature or research that looks at a hospital’s reputation, how that reputation is formed or its impact on operations, especially in a Canadian context.
This paper, therefore, explores the nature of hospital reputation in Ontario through a comprehensive literature review, followed by research that
includes interviews with hospital CEOs, focus groups with hospital patients
and community members and an on-line survey for patients and community
members. Specific concepts explored include how a hospital’s reputation is
formed, what sources of information are used by patients and the community
and what impact a hospital’s reputation might have on overall operations including patient volumes, recruitment and retention, government support and
donor support.
This work is intended to help hospital administrators better understand
and be able to manage reputation in a competitive health care environment as
well as contribute to what is now a very small body of academic work in the
field of hospital reputation.
Research Questions
RQ1: How does reputation impact a hospital’s operations?
RQ2: What creates a hospital’s reputation and how important is personal
experience and word of mouth in that process?
RQ3: What are the sources of information used by patients and members
of the community in creating reputation? Are these the same ones cited by
hospital administrators?
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Literature Review
Lewellyn (2002) might have said it best when she referred to the academic literature on reputation as a “conceptual mess.”
From what reputation is, to how it is formed and then how to measure
it, academics and practitioners alike seem to agree on very little – except for
the fact that there isn’t a commonly agreed upon definition. (Barnett, Jermier,
Lafferty, 2006; Caruna, 1997; Chun, 2005; Davis, Chun, da Silva & Roper, 2001;
Fombrun, 2011; Gotsi & Wilson, 2001; Hutton, Goodman, Alexander & Genest, 2001; Lewellyn, 2002; Ponzi, Fombrun & Gardberg, 2011; Schwaiger, 2004;
Walker, 2010; Wartick, 2002).
Definition
Brown, Dacin, Pratt and Whetten (2006) posit that one of the reasons
reputation is difficult to define is that it crosses many fields, including organizational behaviour, marketing, communications, sociology, advertising and
public relations, with each field contributing its own terminology and understanding.
A simple dictionary definition of reputation reveals some key concepts
that appear in many of the academic definitions that follow:
Reputation: the beliefs or opinions that are generally held about someone
or something: his reputation was tarnished by allegations of bribery; a widespread belief that someone or something has a particular characteristic:
his knowledge of his subject earned him a reputation as an expert (Reputation,
2013).
Key concepts in this definition include the notion that reputation is a
belief; that is it something held in the mind of others about something, which
implies judgment. It is also based on a particular characteristic, or, by extension, a set of characteristics that are being judged by others.
The concept that reputation is a belief-based construct based on some
kind of informational inputs seems widely accepted in the literature.
Several academics have proposed definitions of reputation that seem
closely aligned with the dictionary definition including Barnett (2006), Bromley (1993), Chun (2005) and Grunig (2010):
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• “The essential features of reputation … are that there is some sort of estimation of its nature and value, and that this estimation is widely shared
by a group of people. Reputations are collective systems of beliefs and
opinions” (Bromley, 1993, p. 12).
• “Your reputation is what people say and think about you” (Grunig,
2010).
• Reputation is essentially the external assessment of a company or any
other organization held by external stakeholders. Reputation includes
several dimensions, including an organization’s perceived capacity to
meet those stakeholders’ expectations, the rational attachments that a
stakeholder forms with an organization and the overall net image that
stakeholders have of the organization (Waddock, 2000, p 340).
• “We typically think of reputation as attributed to an organization by its
multiple constituents based on their experience with the organization, its
performance, partners, and products in past periods; that is, reputation is
a kind of social memory” (Vendelo, 1998, p 122).
• A corporate reputation is a collective representation of a firm’s past
actions and results that describes the firm’s ability to deliver valued outcomes to multiple stakeholders. It gauges a firm’s relative standing both
internally with employees and externally with its [other] stakeholders, in
both the competitive and institutional environments. (Fombrun & Rindova, 1996, as cited in Fombrun & van Riel, 1997, p. 10)
• A corporate reputation is a stakeholder’s overall evaluation of a company over time. This evaluation is based on the stakeholder’s direct experiences with the company, any other forms of communications and
symbolism that provides information about the firm’s actions and/or
comparison with the actions of other leading rivals (Gotsi & Wilson,
2001, p 28).
The oft-cited Fombrun and Rindova definition (1996) brings an important concept into play that also appears in the Gotsi and Wilson (2001)
definition: the notion that reputation is somehow competitive; that it involves
a comparison with other similar companies or organizations. This aspect is
mentioned by other writers, including Deephouse and Carter (2005).
How reputation is created
With little agreement on what reputation actually is, there is also some
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question as to what impacts and creates it. Also at issue is the relationship
between quality, customer service, personal experience, word of mouth and
reputation, with little agreement as to how they are related and which might
be the cause versus the effect.
Most reputational writers agree that reputation is based on a variety
of factors or inputs rather than just one. The Chartered Institute for Public
Relations (2011) cites the quality of a product of service, leadership and/or
governance, finance performance and ethical and social commitments as the
cornerstones of reputation. Variations of these same factors are cited by many
academics, who frequently add additional dimensions to the mix.
Fombrun and van Riel’s research led them to develop what they call the
reputational quotient: six dimensions and 20 attributes they believe help make
up a company’s reputation (Fombrun & van Riel, 2004). The dimensions include emotional appeal, the quality of the products or services, financial performance, vision and leadership, workplace environment and social responsibility.
Dowling (2006) is adamant that good reputations are built on the inside
of a company. He believes the factors that create a good reputation are a solid
business model and strategy; good values, culture, products and services with
a strong customer value proposition. “In the long term, (corporate) behaviour
speaks louder than (public relations) words” (Dowling, 2006, p 64).
Lewis (2001) clearly supports Dowling’s notion that actions are more influential than public relations when creating, managing or damaging a reputation: “A reputation problem isn’t necessarily a failure of PR… most “PR
disasters’’ are actually disasters of reality. If a company lets down its customers… that’s a reality challenge – put it right” (Lewis, 2001, p 31).
Gaines-Ross (2006) identifies the top five drivers of reputation as high
quality products and services, effectively external communication, high quality management, a focus on serving customers and honesty.
Many writers like Gaines-Ross include quality products as part of the
reputational mix, but there appears to be widespread agreement that the quality of products alone is not enough to ensure a positive reputation.
Carmeli and Tishler (2005) explored the relationship between measures
of quality of products/services, customer satisfaction, perceived organization
reputation and performance measures in a study of companies in Israel and
concluded that quality products are not enough to ensure a good organizational reputation; those products and services also have to align with what the
consumer expects. “Only high quality products/services that meet customers’
expectations and assure customers’ satisfaction create a sufficient condition
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for a favourable organizational reputation” (p. 25).
A number of writers have pointed to the importance of direct experience
with a firm or organization in the formation of reputation (Andreassen, 1994;
Downing & Hillenbrand, 2005; MacMillian, Money, Yoon, Guffey & Kijewski,
1993).
Yoon, Guffey and Kijewski (1993) concluded that there are two major
sources of a company’s reputation: experience and information, and, according to Bonini, Court and Marchi (2009) how that information is communicated
is important, with positive reputation being created through transparency and
engaging a broad group of influencers through two-way communication. Other writers including Gaines-Ross (2006), Gray and Balmer (1998) and Flynn
(2006) have highlighted the critical role of communications/public relations in
the reputation formation process. In Gray and Balmer’s model (1998) corporate identity (the reality) is communicated to stakeholders through corporate
communications, which then creates reputation.
Traditional media also has a role to play in the formation of reputation,
and several researchers have flagged the importance of that role (Einwiller,
Carroll & Korn, 2010; Yoon, Guffey & Kijewski, 1993). Einwiller, Carroll and
Korn (2010) pointed out that consumers only turn to the media for some information related to reputation; generally aspects that they cannot observe
themselves.
Many writers also point to the importance of word of mouth information
(Andreassen, 1994; Coombs, 2007; Murray, 1991; Rynne, 1983) especially for
consumers/stakeholders with little or no direct experience with an organization. From the literature, the difference between word of mouth and reputation is unclear, and, if as Grunig (2010) suggests, one’s reputation is what
people say about you, they may be one in the same.
According to Silverman (2001) word of mouth is the most powerful force
in the marketplace:
What gives word of mouth most of its power is the fact that it is an experience delivery mechanism…indirect experience, that is, hearing about
other’s people’s experience – is actually much better than direct experience in many ways: Someone else is footing the bill and spending the
time, and you can pool the experiences of several people so as to have a
greater sample. (Silverman, 2001, p 49)
In writing about hospital reputation management, Rynne (1983) also
highlights the importance of word of mouth as preceded by personal experience: “A hospital’s reputation cannot be manufactured wholecloth because a
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hospital’s reputation, more than any other enterprise in the community, is
the result of the real stories people tell one another regarding their experiences with a hospital” (Rynne, 1983, p 59). In a study of consumers facing
a hypothetical purchase decision, Murray (1991) examined how information
is gathered and purchase decisions are made when considering the overall
impact of word of mouth. His study indicated greater confidence in personal
sources (i.e. word of mouth) when contemplating the purchase of a service
when compared a product purchase because of the experiential nature of a
service purchase.
The value of reputation
The academic and non-academic literature is united on one point concerning reputation: that a good reputation is valuable and that, conversely, a
bad reputation is a negative situation that should be remedied as quickly as
possible.
A favourable reputation, according to Fombrun (1990), gives a firm an
edge over its rivals that may enable it to charge premium prices, attract better
applicants, enhance their access to capital markets and attract investors.
The value of reputation is tied to its ability to cause stakeholders to take
(or not take) specific actions. Reputation, explains Fombrun and van Riel
(2004) affects the “likelihood of supportive behaviours from all of the brands
stakeholders” (p. 4).
Many writers draw a direct line from reputation to sales, with reputation facilitating the purchase decision and allowing firms to charge premium
prices (Carmeli & Tishler, 2005; Ipsos Mori, 2012; Vendelo, 1998).
But it’s not just sales; reputation is also believed to impact other key business functions and to be critically important to the bottom line:
Reputation is… important and not just because confidence in business
is low. It is important because the intangible factors of business (talent,
brand strength, patents, knowledge, technology, leadership, etc.) are rapidly replacing the tangible factors (real estate, machinery, inventory, etc.)
(Gaines-Ross, 2006).
Fombrun and van Riel (2004) and Davies (2002) place the value of a company’s intangible assets somewhere between 55 and 95 per cent of a firm’s
book value, while Davis (2002) points out that despite this high value, most
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firms do not protect their reputational assets in the same way they protect
their tangible assets.
Cravens, Goad-Oliver and Ramamoorti (2003) suggest that reputation
should be part of a company’s financial statements, and that it should be measured through an index that looks at (among other things) corporate strategy,
financial strength and viability, organizational culture, ethics and integrity,
governance processes and leadership and products and services.
Measurement
According to Miller (1999) a survey commissioned by Hill and Knowlton
revealed that 96 percent of CEOs believed that reputation was a vital component of business success but less than 20 percent had instituted a method for
measuring their reputation.
With no agreement as to what reputation actually is, it is not surprising
that there is scant agreement on measurement methodology.
One of the best-known measures of reputation is the Fortune “Most Admired” list. Annually 15,000 top executives, directors and financial analysts
are asked to rate companies overall and relative to peer organizations on
nine attributes of reputation: innovation, people management, use of corporate assets, social responsibility, quality of management, financial soundness,
long-term investment, quality of products/services and global competitiveness (Hay, 2012). Candidate companies include the FORTUNE 1000, Global
500 and top non-US companies. Critics of the Fortune ranking (Davies, Chun,
da Silva & Roper, 2001) point out that the list is heavily finance-based and is
essentially a peer ranking system that does not reflect the customer voice – a
critical component of reputation, they argue.
Another measurement methodology is based on Fombrun and Riel’s reputational quotient: six dimensions and 20 attributes they believe help make up
a company’s reputation (Fombrun & van Riel, 2004). Their approach is based
on the concept that an organization’s reputation is based on its stakeholder’s perceptions. The dimensions they measure include emotional appeal, the
quality of the products or services, financial performance, vision and leadership, workplace environment and social responsibility.
Davies, Chun, da Silva and Roper (2001) acknowledged that there is no
universally accepted methodology for measurement, and proposed a tool
based on personification. Their measurement methodology rates companies
on 42 human personality traits sorted into five factors: sincerity, excitement,
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competence, sophistication and ruggedness.
Helm (2005) developed a set of reputation indicators based on a study
involving a literature review, focus group interviews and personal interviews.
She started with a list of 25 company characteristics and through the study
narrowed this list down to ten: quality of products, commitment to the environment, corporate success, treatment of employees, customer orientation,
charitable endeavors, value for money of products, financial performance,
management skill and credibility of advertising claims.
What all of these measurement methodologies have in common is a
strong emotional element. They are frequently based on observer’s feelings
and perceptions, rather than demonstrable, measurable results.
Reputation and hospitals
While hospital executives and writers seem to agree that reputation is
important to a hospital, there is a lack of foundational research to support that
assertion, especially in a Canadian context.
The reputation a hospital enjoys is no accident and the reputation of
a hospital matters – to the people it serves and to the hospital itself…
A hospital’s reputation affects its occupancy rate, the cost of borrowed
money, its differentiated position… and performance. (Rynne, 1983, p 57,
66)
A similar opinion is expressed by Rodak (2012), who asserts that a hospital’s reputation is critical in attracting physicians, patients and potential
partnering organizations. Neither writer, however, presents any empirical
evidence to support those assertions.
How is a hospital’s reputation formed? In the limited material that
touches on this question, writers and researchers point to the importance of
first-hand experience (Andreassen, 1994; Manning 2004). In an article written
about his father’s experience in a hospital, author Tim O’Brien (2006) asserts
that a hospital’s reputation is entirely based on the first-hand experiences of
patients and family members with little or no opportunity for public relations
or other business functions to impact said reputation.
“Family members live with memories of hospital stays like this for the
rest of their lives. These memories are indelible… and they are the foundation
of perception that cannot be reversed by a big-budget PR program” (O’Brien,
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2006, p. 10).
If O’Brien is correct, his theory supports the notion that a single organization may have many reputations, and, in the case of hospitals, reputations
based solely on first-hand care experiences. O’Brien’s article also calls into
question the role of public relations in reputation management. Should his
theory prove correct, hospital-based public relations professionals may want
to focus their efforts on the in-hospital experience rather than concentrating
on external messaging.
In a study of 300 hospital patients in Turkey, Cigdem Satir concluded that
trust and service quality were the most important components of a hospital’s
reputation (Satir, 2006).
In a UK study that examined how professional intermediaries were purchasing hospital services on behalf of doctors’ offices and their patients, Laing
and Cotton (1996) underscored the importance of relationships and reputation
in the evaluative process, as opposed to clinical outcomes:
Professional services such as healthcare are dominated by experience
and credence qualities, with the result that the evaluation of such services, for both consumer and organizational purchasers, is based primarily
on experience and perception….outcomes, particularity in health care,
frequently cannot be evaluated for a considerable length of time, and
indeed in certain instances it may ultimately not be possible to evaluate
the outcome…In the majority of instances it is not the service outcome
which is actually evaluated, but rather the processual aspects of service
delivery. (Laing & Cotton, 1996, p 731-32)
Methodology
A deductive method of social research is at the heart of this paper. Based
on the literature review, there are many factors that influence corporate reputation; however, for the purposes of this research, the focus is on the six dimensions and 20 attributes developed by Fombrun and van Riel that they
have synthesized into what they call “the reputation quotient” (Fombrun &
van Riel, 2004). These are summarized as follows:

1. Social responsibility: supports good causes, environmental responsibility, community responsibility;
2. Emotional appeal: feel good about, admire and respect, trust;
3. Products and services: high quality, innovative, value for money,
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   stands behind;
4. Workplace environment: good place to work, good employees, rewards employees fairly;
5. Financial performance: record of profitability, low risk investments,
   growth prospects, outperforms competitors;
6. Vision and leadership: market opportunities, excellent leadership,
   clear vision for the future;
7. Social responsibility: supports good causes, environmental responsibility, community responsibility.
   This paper explores the theory that many of the commonly cited dimensions, attributes and drivers of corporate reputation that appear in the work
   of Fombrun and others, such as vision and leadership and financial performance, are not strongly applicable to publicly funded hospitals. Instead, the
   theory that a hospital’s reputation is based primarily on quality of service, as
   evaluated through the first-hand experience of patients and hospital visitors,
   and, when no such experience exists, word of mouth and physician influence
   are used as a proxy, is tested.
   A mixed methods approach to the research has been undertaken including interviews, focus groups and a quantitative on-line survey.
   Research participants
   1) In-depth interviews with six Ontario hospital CEOs regarding the key
   aspects of reputation such as the impact on operations and how reputation is created.
   2) Two focus groups with Scarborough Hospital patients and community members exploring reputational issues as they relate to their personal
   experiences as patients and what they hear in the community and/or
   from their family doctors.
   3) A link to an on-line survey was distributed to the 3,481 subscribers to
   The Scarborough Hospital’s community newsletter. Fluid Survey was
   used to collect and help analyze the data. The link was distributed on
   two separate occasions – December 20, 2012 and January 22, 2013.
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   Results/Analysis
   The information from the interviews and the focus groups was analyzed
   for general themes. In the hospital executive interviews, consensus around the
   impact of reputation and how reputation might be formed was sought. In the
   patient/community focus groups, similar commonality around how reputation is formed and sources of information was sought. The impact of word-ofmouth, media and other sources of information was explored.
   Fluid Survey was used to collect and help analyze the data from the online survey. This data was compared to the themes from the focus groups and
   interviews.
   CEO interviews
   The executives selected represented a variety of hospital types (urban,
   rural, general community and specialized) and embody a wealth of experience in hospital administration.
   Despite their varied backgrounds and experiences, the CEOs interviewed
   in this project held remarkably similar views regarding hospital reputation.
   Three broad themes that emerged from these interviews are explored here:
8. The growing importance of reputation;
9. How reputation is created; and
10. In a hospital setting who is responsible for reputation?
    The growing importance of reputation
    All the CEOs agreed that reputation was already important to Ontario
    hospitals, and that its importance was growing rapidly.
    “Reputation is a huge issue… it impacts a hospital’s ability to recruit,
    raise funds, compete for patients, be seen as a reasonable partner – it impacts
    your relationship with the province” (Hospital CEO C, May 23, 2012).
    In the next five years, you’re going to see a fundamental shift. Patient satisfaction and reputation will be part of the funding formula, and hospitals will need to redefine themselves and compete. Ten years ago no one
    paid any attention to this; you didn’t have to. But that’s already changed
    dramatically (Hospital CEO D, personal communication, May 1, 2012).
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    We don’t talk about reputation very much, because the public isn’t yet
    at the point where they view healthcare as a business. But that’s starting to shift. Soon, you’re going to see increased emphasis on individual
    outcomes and how those relate to reputation (Hospital CEO F, April 30,
    2012).
    The CEOs unanimously agreed that reputation had the greatest and
    most direct impact on fundraising:
    Fundraising is a very tight barometer of reputation. If you have a good
    reputation, you attract donors. If you don’t people won’t donate, and
    they’ll tell you that’s why. Donors want to back a winner and know that
    their money will be well used (Hospital CEO E, personal communication, May 17, 2012).
    The ability to attract and recruit skilled medical staff was also cited as
    something strongly impacted by reputation. Patient volumes, they agreed,
    were still strongly tied to geography and existing referral patterns rather than
    reputation, but all agreed that this too was likely to change in future.
    How reputation is created
    All of the CEOs agreed that reputation was created by a myriad of factors that include quality of care, patient satisfaction/experience, staff word of
    mouth, the media, transparency and involvement in the community.
    Only two CEOs were willing or able to identify one factor or source of information as the most important to the reputation building process; one cited
    quality of care, and a second cited traditional media.
    While the other CEOs might not have identified the media as the most
    important factor, all agreed that it was an important influence.
    Transparency and its role in creating reputation was mentioned specifically by four of the CEOs unaided, with one (who leads hospitals in small
    communities) citing it as a key factor.
    “The perception of transparency really affects reputation. Transparency
    engenders confidence. The more guarded you are, the more people question
    what you’re up to. As the CEO I have a huge role to play in creating an atmosphere of transparency” (Hospital CEO F, personal communication, April 30,
    2012).
    When asked specifically about patient satisfaction and its role in creating
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    reputation, all the CEOs agreed that patient satisfaction was part of the reputational picture, but it isn’t the whole picture.
    Most of the CEOs identified word of mouth as a strong contributor to
    reputation, and many identified staff as having an important role in that.
    Who is responsible for reputation?
    All of the CEOs agreed that they themselves were ultimately accountable
    for their hospital’s reputation as they are for all aspects of the business; but
    they were clear that everyone had a role to play, especially hospital employees.
    “Without engaged staff, your reputation doesn’t stand a chance. Your
    staff have to believe that ‘yes, we have our challenges but I’m part of the solution’. Everyone impacts reputation by what they do and what they say”
    (Hospital CEO D, personal communication, May 1, 2012).
    All of the CEOs were in agreement that public relations/corporate communications staff can, should and do play a strong role in reputation management, and all (with the exception of one who does not have dedicated communications support but is planning on hiring in the near future) stated that
    public relations was at the table when strategy is being developed.
    Focus group findings
    Two focus groups were held – one on December 7, 2012 with nine participants, and a second on January 16, 2013 with five participants.
    When asked why they believed a particular hospital had a good reputation, the majority of participants cited positive personal experience, the experience of close friends or family members or word of mouth. Only one of the
    14 cited things they had read in the paper or online as contributing to reputation in that context.
    Participants were asked to recall a personal experience with a hospital
    (either as a patient or visitor/family member) that was positive and explain
    exactly what made it positive. Factors most often mentioned as contribution to
    a positive experience were caring nurses/doctors/staff, communications (was
    told what would happen next, procedure carefully explained) and short wait
    times. As one patient explained:
    When I went for the surgery, they addressed me by my name – that made
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    me feel good. Then, when I was in the O.R. – they’re really cold in there,
    you know – they brought me a warm blanket. It’s things like that that
    make you feel cared about (Focus group participant A1, personal communication, December 7, 2012).
    Similar answers were received when asked what a hospital could do to
    improve its reputation – shorten wait times and work on staff behavior/customer service.
    Interestingly, not one participant mentioned outcomes (cured, surgery
    went well) as a reason why their experience was positive; and two of the participants told stories that they self-identified as positive in which the patient
    involved ultimately died.
    When asked about a negative experience, lack of caring on the part of
    staff/physicians and long wait times were frequently cited. Here, negative
    outcomes were mentioned by four of the participants, but usually after mentioning one or more of the other factors first, implying and some cases stating
    that these participants believed that uncaring staff and long wait times contributed to the negative outcomes.
    It was evident from the stories told by the participants that hospital experiences have an enduring impact. One participant told a story about taking
    her child to Toronto’s Sick Kids Hospital that happened 46 years ago; several
    other participants had stories that were 10 or more years old. In each case, the
    positive or negative experience that they described directly correlated with
    their description of that hospital’s reputation today.
    Participants were sharply divided on the question of whether or not you
    would go to a hospital with a negative reputation if sent by your family doctor:
    “If you trust your family doctor, you should listen to them. They probably have a good reason for sending you there. And if you don’t trust your
    family doctor, you should look for another one” (Focus group participant B2,
    personal communication, January 16, 2013).
    “I would do my research before I made up my mind. I would hear what
    he had to say and then look into it” (Focus group participant E2, personal
    communication, January 16, 2013).
    When the issue of research was brought up in the second group, participants were asked how they would research a particular hospital. Here, word
    of mouth (would ask friends), the internet and media were mentioned.
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    On-line study findings
    A total of 92 participants completed all or part of the survey. Because
    participants could skip parts of the survey depending on their circumstances,
    the denominator varied from section to section.
    Like the focus group participants, the online survey participants were
    divided on whether or not they would go to a hospital with a poor reputation if their family doctor sent them. After subtracting the participants who
    said they did not have a family doctor, 56% of the remaining respondents said
    they would or probably would go, while 44% said they probably or definitely
    would not.
    When asked to score five sources of information about a hospital’s reputation (newspapers, radio/television, personal experience, the experiences of
    close friends or family and word of mouth) on a Likert scale personal experience was rated as the most important source of information, followed by the
    experiences of close friends and family and then word of mouth. Traditional
    media was ranked as a distant fourth (newspapers) and fifth (radio and television).
    Other key survey findings:
    • 90% agreed or strongly agreed that if they had a good experience at a
    hospital, they would tell people.
    • 66% of respondents characterized their most recent experience with
    any hospital as positive, with 26 % characterizing it as neutral/mixed,
    and just nine percent saying it was negative.
    • 74% of respondents agreed or strongly agreed that they didn’t care
    about reputation, they would base their opinions on their own experience.
    • Respondents did not seem to feel it was important to know the leadership at their local hospital – 49% neither agreed nor disagreed that it was
    important, while 30% disagreed or strongly disagreed. Similar results
    were seen when presented with the statement “the board of directors is
    critically important to the success of a hospital” with just 19% agreeing or
    strongly agreeing.
    • Respondents seemed unsure about the concept of innovation as it applies to community hospitals. Thirty percent agreed or strongly agreed
    that it was important, while 35% neither agreed nor disagreed and 13%
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    didn’t know.
    • 87% of respondents indicated that they generally use the hospital closest to their home.
    • Word of mouth emerged as an important source of information, with
    78% of respondents agreeing or strongly agreeing that they listen carefully to what friends and family members say about their local hospital.
    In comparing the results of this research with Fombrun’s dimensions of
    reputation, three dimensions do not appear to have a large impact on hospital
    reputation: vision and leadership; financial performance and social responsibility.
    While the CEOs highlight the importance of leadership, vision and transparency in forming a community hospital’s reputation, this factor was never
    mentioned in focus group discussion. In the electronic survey, only 18% of
    patient and community respondents agreed that it was important to know the
    leadership at their local hospital, and only 19% thought the board of directors
    was critically important to the success of a hospital.
    Financial performance was only mentioned by one CEO who thought
    it might impact reputation specifically as it applies to recruiting new staff and
    physicians. Focus group participants did not mention this aspect and when
    survey respondents were presented with the statement “if a hospital balances
    its budget, it’s probably a good hospital” only ten percent agreed or strongly
    agreed.
    Fombrun’s dimension “workplace environment” figured largely in both
    the CEO and focus group discussions. Several CEOs suggested that staff were
    a big part of reputation, particularly through word of mouth. Focus group participants were clear that staff had to be happy and engaged to provide good
    service, which then leads to reputation. In the electronic survey, 64 percent of
    respondents agreed or strongly agreed that a good hospital treats its staff well.
    “Emotional appeal” and “quality products and services” both figured
    prominently in all three data sets. Patients and community members seemed
    to inextricably link emotional appeal and high quality products and services
    suggesting strongly that in order for a healthcare service to be considered high
    quality it must contain emotional appeal. Almost all focus group participants
    mentioned the concept of feeling cared about by staff and physicians as an
    important component of quality care. Conversely, not feeling cared about was
    consistently mentioned when discussing an experience that was not positive.
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    Table 1: Summary of Online Survey Results
    Statement Strongly
    disagree
    Disagree Neither
    agree
    nor
    disagree
    Agree Strongly
    agree
    Don’t
    know/
    not
    sure /
    NA
    A good hospital ensure that it
    treats its staff well
    0% 3% 30% 43% 21% 3%
    If I had a good experience at a
    hospital, I would tell people
    0% 2% 5% 67% 23% 3%
    I don’t care about the reputation of a hospital; I base my
    opinion on my own personal
    experience
    3% 12% 11% 48% 26% 0%
    It’s important for me to know
    the leadership at my local
    hospital
    5% 25% 49% 15% 3% 3%
    Community hospitals need to
    be innovative
    3% 20% 35% 8% 22% 13%
    The healthcare system in Ontario is better than it used to be
    28% 38% 20% 11% 2% 2%
    I trust The Scarborough Hospital to provide the best care
    possible
    7% 5% 22% 47% 22% 0%
    If a hospital balances its budget,
    it’s probably a good hospital
    7% 18% 56% 7% 3% 10%
    The board of directors is critically important to the success of
    a hospital
    5% 17% 49% 14% 5% 12%
    I need to feel good about a hospital before I would go there
    2% 12% 25% 33% 28% 0%
    I generally use the hospital that
    is closest to my home
    2% 8% 5% 62% 25% 0%
    My family doctor is a trusted
    source of information regarding
    hospitals
    2% 5% 11% 39% 41% 2%
    I listen carefully to what my
    friends and neighbours tell me
    about our local hospital
    0% 3% 20% 59% 18% 0%
    Note: n=74 for this set of data
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    Analysis by research question
    RQ1: How does reputation impact a hospital’s operations?
    The CEOs believe that reputation impacts funding, fundraising, and staff
    recruitment. While there was some suggestion that it could impact patient
    volumes, most believed that this was still strongly driven by geography and
    physician referral.
    The online survey supports this belief, with 87% of respondents agreeing or strongly agreeing that they generally use the hospital closest to home.
    Eighty percent agreed or strongly agreed that their family physician was a
    trusted source of information regarding hospital and fifty-six percent would
    or probably would go to a hospital they believed had a poor reputation if sent
    by their family physician.
    RQ2: What creates a hospital’s reputation and how important is personal experience
    and word of mouth in that process?
    The CEOs saw a strong link between personal experience and hospital
    reputation, but did not identify them as the same thing. They saw reputation
    as a more complicated construct with other factors contributing.
    Focus group participants strongly linked personal experience and hospital reputation. When asked to identify a hospital with a positive reputation
    and discuss why, most participants started with a personal experience (their
    own or that of a family member or friend) and then linked what they heard
    through word of mouth back to that experience.
    When asked specifically whether their experience and the reputation of a
    hospital were the same thing or different, focus group participants identified
    these as separate concepts. Some related stories of a hospital that they knew
    had a poor reputation but where they had a good experience, suggesting (or,
    in two cases actually stating) that the reputation was somehow “wrong.”
    When presented with the scenario of a friend or family member having a
    bad experience when they had a good one in similar circumstances, no participants indicated that they would change their opinion. Instead, they suggested
    that their friend/family member was somehow wrong or at fault or that their
    negative experience was an isolated incident, highlighting the value of personal experience in people’s minds.
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    RQ3: What are the sources of information used by patients and members of the community in creating reputation? Are these the same ones cited by hospital administrators?
    The CEOs were aware of the power of word of mouth in the formation
    of hospital reputation. Word of mouth, many of them felt, was the result of a
    myriad of factors, but patient experience and what staff members and physicians say in the community were usually cited as the most important. None
    mentioned family physicians as contributing to reputation specifically.
    Most of the CEOs felt that media coverage has a role to play in the formation of reputation, however, survey and focus group participants did not give
    it the same weight.
    Patients and community members seemed to value personal experience
    above all else when discussing hospital reputation, however, the relationship
    between that experience and the reputation is not entirely clear. Some focus
    group participants were able to identify hospitals with a bad reputation where
    they themselves had a good experience. Another two participants identified
    hospitals with a good reputation where they had negative experiences and
    suggested that the reputation was not accurate.
    A patient’s individual experience of care seems to influence his or her
    perception of the reputation of the healthcare system in general. Sixty-seven percent of survey respondents who described their last hospital experience as negative disagreed or strongly disagreed with the statement that the
    healthcare system in Ontario is getting better. None agreed or strongly agreed.
    However, 18 % of respondents who described their last hospital experience as
    positive agreed that the healthcare system was getting better, suggesting that
    a single episode in a single institution can colour the perception of the system
    as a whole.
    Limitations
    As there is scant research that examines reputation from a community
    hospital perspective, this study is limited by not having a body of work to
    build on. This study used a corporate reputation model as its foundation and
    as this research strongly suggests, doing so may not be applicable to a community hospital setting.
    As the focus group participants and survey participants were drawn
    from a limited geographical area and a single hospital, some of the findings
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    may not be applicable province-wide or to other hospitals. Additionally, this
    research could benefit from a larger sample size as only 92 people completed
    all or part of the on-line survey.
    Conclusions
11. Corporate reputation models, such as that proposed by Fombrun (2004) are
    not directly applicable to hospitals. Most corporate reputation models include
    reference to dimensions such as financial performance and strong leadership.
    The results of this study strongly suggest that these factors are not important
    to patients and members of the community when they evaluate a hospital’s
    ability to deliver the outcomes they value and thus contribute to its reputation. While the CEOs highlighted the importance of leadership and their role
    in the formation of reputation, the results of the focus groups and online survey strongly suggest that leadership, including that of the board of directors,
    is not as important to patients and members of the community in this context.
    Additionally, financial performance (balancing the budget) does not seem
    strongly linked to the concept of a good hospital.
12. Hospital reputation is a collective concept, based primarily on past experience and word of mouth. The data in this study supports both Vendelo’s (1998)
    and Bromley’s (1993) definitions of reputation where it is attributed to an organization by constituents based on their experience with the organization.
    Bromley points to an estimation of an organization’s nature and value, which
    seem to be at play in the formation of a hospital reputation. The nature and
    value of hospitals that patients/community members appear to be evaluating
    is whether or not the staff and physicians demonstrate caring.
13. Reputation is not strongly linked to clinical outcomes. As Laing and Cotton
    (1996) suggested, this data supports the theory that the evaluation of healthcare services is based on experience and perception, not clinical outcomes.
    Patients and family members highlighted whether or not they felt “cared for”
    by staff; few mentioned clinical outcomes. Several of the focus group participants told stories that they identified as positive in which the outcomes were
    not positive in that the patient ultimately died. The data in this study strongly
    suggests that patients and community members equate high quality products
    and services – in this case, delivery of healthcare services – with emotional
    aspects such as feeling cared about, regardless of the clinical outcomes.
14. Personal experience is paramount in terms of information gathering, but
    how that translates into reputation is not entirely clear. Patients and community
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    members considered personal experience as the most important source of information. If, as Grunig (2012) suggests, reputation is what people say about
    you, stories of these personal experiences presumably contribute to reputation
    depending on whether or not they are passed on to others. Since 92% of survey participants agreed or strongly agreed that they would tell people about
    a positive experience, this aspect of reputation formation is clearly important.
    Additionally, survey participants clearly identified personal experience as the
    most important source of information, followed by word of mouth. Media
    sources were ranked significantly lower.
15. Word of mouth is powerful. Seventy-eight percent of survey participants
    agreed or strongly agreed that they listen carefully to what friends and neighbours say about their local hospital, supporting Silverman’s (2001) assertion
    that word of mouth is the most powerful force in the marketplace. When it
    comes to hospitals, community members seem to use word of mouth in the
    manner Silverman suggests – as an experience delivery mechanism, allowing
    them to experience care indirectly without risk.
16. Hospital experiences and therefore reputation, is enduring. Many of the focus group participants related stories of hospital care that were very dated – in
    one case, the care episode occurred 46 years previous. These stories, and what
    the teller thought of the hospital involved, were very well remembered, and it
    appeared that the participants continued to seek information over the years to
    confirm their original conclusion.
17. Family physicians are powerful information brokers. The opinions of family physicians are given great importance by their patients. It can be assumed
    that they, therefore, contribute to reputation, but how that relationship works
    is not clear from this study.
    Future Research
    The findings in this study are far from conclusive; however they offer
    some tantalizing clues as to the nature of hospital reputation and strongly suggest some avenues for future research.
    One avenue of future research is an examination of the relationship
    between patient satisfaction and reputation. As most hospitals use some kind
    of survey tool to gauge patient satisfaction, the relationship between these
    two could be explored. Are reputation and patient satisfaction the same thing,
    closely related or only loosely related? Understanding this relationship is critical to understanding hospital reputation.
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    More work also has to be done to better understand what creates a positive patient experience. Research in the healthcare field is helping to answer
    this question, however, how this translates (or does not translate) into reputation needs further exploration. If emotional appeal/feeling cared about is the
    most important factor, as suggested by this study, how can hospitals create
    environments that better support this aspect of the care?
    The critical role played by family physicians as information brokers, as
    suggested by this study, should be explored.
    Finally, research needs to be done to develop and refine a new model of
    reputation that is applicable to hospitals. A larger-scale study could create an
    expanded database that allows for regression analysis to the drivers, confirming some of the ways that reputation is created that are only suggested by this
    study.
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    Appendix A – Questions used in hospital executive
    interviews
    RQ1: How does reputation impact a hospital’s operations?
    • Do you think patients choose a hospital based on reputation or geography?
    • How does reputation impact staff and physician recruiting?
    • How does reputation impact fundraising?
    • Do you think a hospital’s reputation impacts decisions around funding or
    capital?
    • What importance does your board place on your hospital’s reputation?
    • How is reputation measured and tracked at your organization?
    RQ2: What creates a hospital’s reputation?
    • What do you see as the single biggest driver of your hospital’s reputation?
    • How big an impact does the media play?
    • Are patient satisfaction and reputation the same thing or do they differ?
    • Has social media impacted your hospital’s reputation?
    • What contribution can your hospital’s public relations or communications department make to your hospital’s reputation?
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    Appendix B – Focus group question guide
    Guiding questions:
    • I notice a number of you put a dot beside hospital X. Can someone tell me
    why this hospital has an excellent reputation?
    • How do you know? How did you hear about X’s reputation?
    • We’ve been talking about good reputations, now lets turn out thoughts to bad
    reputation. Without naming any specific organizations, can someone explain
    how a hospital might get a poor reputation? How would you know a hospital
    had a bad reputation?
    • If your family doctor wanted you to go to a hospital that you believed had a
    poor reputation would you go?
    • Now let’s talk about The Scarborough Hospital specifically. Before you came
    to The Scarborough Hospital, you must have heard something about this hospital’s reputation. Can anyone share what that was?
    • Did your experience here match the reputation you heard about? Why or why
    not?
    • Can you describe a positive experience you had at any hospital, and tell me
    why it was positive?
    • For those of you who had a positive experience – if your spouse or best friend
    came to the hospital for the same problem or procedure and had a terrible time,
    would that change what you thought?
    • How many people have you told about your experience?
    • Can any of you recall anything you might have read in the newspapers or
    watched on television about The Scarborough Hospital? (Look for specific examples.)
    • What are some of the things that we could do at The Scarborough Hospital to
    improve our reputation?
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    Appendix C – On-line survey questions
    Where do you live? (Scarborough, Markham, East GTA, Toronto, Other)
    Are you a current or past Scarborough Hospital staff member or physician? (Yes, No)
    Please describe yourself (you may choose more than one answer if more than one applies).
    • I am a recent Scarborough hospital patient (within the last year)
    • I was a patient in the past (more than a year ago)
    • I am involved in the hospital in some other way (volunteer, donor)
    • I am interested in what happens in my community
    • I recently visited a friend or family member in the hospital
    • Other
    If your family doctor asked you to go to a hospital you believed had a poor reputation,
    would you go? (Yes, Probably, Probably not, No, I don’t have a family doctor)
    Before you visited The Scarborough Hospital as a patient OR a visitor, you probably
    heard things about the hospital. Did your experience match the reputation you had
    heard about?
    • The experience was better than the reputation
    • The experience and the reputation were the same
    • The experience was worse that the reputation
    • Don’t know/didn’t hear anything
    If you visited The Scarborough Hospital as a patient, which of the following scenarios
    best describes how you came to Scarborough for care?
    • I chose to come to The Scarborough Hospital myself
    • I was sent to The Scarborough Hospital by a doctor or other healthcare professional
    • I came to The Scarborough Hospital by ambulance or other means
    • A friend or family member decided I should go to The Scarborough Hospital
    • I have never been a patient at The Scarborough Hospital
    • Other
    People will often gather information about their local hospital from a variety of sources. On a scale of 0 to 10, with zero being unimportant or a source you would not use
    and 10 being very important, please indicate how important each of the following
    -155- jpc.mcmaster.ca
    Males, A., Journal of Professional Communication 3(1):125-155, 2013
    sources is to you when determining what you think about The Scarborough Hospital.
    • Newspapers
    • Radio/television
    • Personal experience
    • The experiences of close friends or family members
    • Word of mouth/things you hear in the community
    Please read the following statements and indicate whether you agree or disagree using the scale indicated. (Strongly disagree, disagree, neither agree nor disagree, agree,
    strongly agree, don’t know/not applicable.)
    • The Scarborough Hospital has really improved in the last five years.
    • A good hospital ensures that it treats its staff well.
    • If I had a good experience at a hospital, I would tell people.
    • I think it’s important to support my local hospital through donations.
    • I don’t care about the reputation of a hospital; I base my opinion on my own
    personal experience.
    • I feel good about coming to The Scarborough Hospital.
    • It’s important for me to know the leadership at my local hospital.
    • Hospitals should work on their customer service.
    • Community hospitals need to be innovative.
    • The healthcare system in Ontario is better than it used to be.
    • I trust The Scarborough Hospital to provide the best care possible.
    • If a hospital balances its budget, it’s probably a good hospital.
    • The board of directors is critically important to the success of a hospital.
    • I need to feel good about a hospital before I would go there.
    • I generally use the hospital that is closest to my home.
    • My family doctor is a trusted source of information regarding hospitals.
    • I listen carefully to what my friends and neighbours tell me about our local
    hospital.
    How would you characterize your most recent experience (as a patient or a visitor)
    with any hospital? (Positive, negative, neutral/mixed, not applicable)
    When thinking about your last hospital experience, can you tell us the most important
    factor that is causing you to describe it as positive, negative or neutral? (Please skip
    this question if you have no experience.)
    Is there anything else you would like to tell us about reputation or The Scarborough
    Hospital?