|  Scott Regan

Despite having rankings for everything imaginable in healthcare — patient satisfaction, core measures, best hospitals, best places to work, and more — the industry still hasn’t figured out how to measure and rank hospital brands. So, pending an accepted standard, we decided to tackle this on our own.

With all of the data that hospitals have at their disposal, it’s not too difficult to measure your brand. If you subscribe to the notion that a hospital’s brand is largely experientially based, then there are many metrics that can help you illuminate the power of your brand.

Here is our list of brand indicators that deserve a watchful eye:

• Physician Satisfaction: If I had to select a single metric to correlate with brand power, I would choose physician satisfaction. If the physicians don’t like your hospital, they won’t refer or admit patients to your facility, and worse, they will tell patients who actually want to use your hospital exactly why they shouldn’t. What’s more, with so many hospital ranking surveys based, to some degree, on physician preferences, not having this group tightly aligned with you can spell brand disaster. Metric to watch: Overall physician satisfaction.
• Patient satisfaction: Ultimately, your brand hinges on patient satisfaction. The word-of-mouth advertising that results from a patient’s experience is more powerful than any TV spot, billboard, print ad, or direct mail piece that you can produce. Metric to watch: Overall patient satisfaction.
• CMS Likelihood to Recommend: This is the ultimate question in the CMS HCAHPS survey. More than likely, patients who are not willing to recommend your hospital are telling their friends and neighbors why they shouldn’t use your hospital. Metric to watch: Likelihood to recommend.
• Employee Satisfaction: The ability to turn your employees into brand ambassadors is a powerful strategy that has not been leveraged by many healthcare organizations. For a mid-sized hospital with 2,000 employees, their potential market reach is dramatic. And because they work for you, what they tell people about your hospital is taken as gospel. Unhappy employees who are bad-mouthing you away from the hospital can destroy brands faster than a couple of ill-advised Tiger Woods text messages. Metric to watch: Overall employee satisfaction.

So, if you take the four factors above (overall physician satisfaction, overall patient satisfaction, CMS likelihood to recommend, and overall employee satisfaction), all of which are on a 100-point scale, and multiply them together, you will get an indication of your brand strength.

For example, Hospital A has the following metrics: 72.6 overall physician satisfaction, 81.5 overall patient satisfaction, 67% likelihood to recommend, and 56.9 overall employee satisfaction. Multiply all four scores and divide the product by 1,000,000 (to convert the score back to a 100-point scale), and you discover that Hospital A’s brand strength is 22.6.

Comparatively, a hospital that scores 90 in each of the four categories would have a brand strength of 65.6, and one that scores 80 in each of the four categories would have a brand strength of 41.0.

While this might not be the perfect solution to rating and ranking hospital brands, it’s not a bad place to start.

If you don’t think hospital advertising will ever be banned, think again. In Vermont, State Representative Steve Maier has proposed legislation that would prohibit hospitals from using money for advertising and marketing. Does it have any chance of passing? Doubtful, as the State would have to prove that such expenditures actually add to healthcare costs, and most economists would argue that advertising spurs competition, which actually leads to cost reductions instead.

But let’s play through on this one and assume Vermont passes legislation banning hospital advertising and the other 49 states follow suit. I, for one, relish such a scenario, as we will quickly see which hospital brands are built from a house of cards and which are built from brick.

No more smoke-and-mirror branding that lures in patients and physicians alike with false promises. No more hollow adjectives claiming to be the biggest, best, lovingest, most advanced, newest, most specialized, smartest, top-rated, and preferred hospital around. No more five stars this, Leapfrog that, JD Power here, Press Ganey there, Magnet praise, and Thomson Reuters accolades.

The brand for every hospital in America would rest solely, entirely, and 100 percent on the patient experience.

But that’s where the brand has been all along.

Savvy hospital communications executives have known for quite some time that what happens inside the walls of the institution is infinitely more important than what is communicated externally. Sure, a good brand communications campaign gives the organization a strong brand voice, but the voice can never be stronger than the brand experience itself.

And in the end, an organization that spends zero dollars on advertising, but has a great brand experience, will trump a poor-performing organization that funnels hundreds of thousands of dollars into marketing. Certainly, the most powerful brands do both – they invest in creating and maintaining a strong brand experience, and they also invest in communicating that brand to their stakeholders.

Still, I relish the day when we strip away all the gloss and let hospitals battle it out on brand experience alone. Only then will the truly brilliant marketers in healthcare get their due.

Does your hospital’s brand have defined values — brand attributes — that drive your brand promise? Are brand values even necessary? Do they make a difference?

The short answer to both questions: Yes and yes.

Consider two hospitals, each anchoring itself to a brand platform of customer service. The first hospital identifies its brand values as excellence, compassion, and respect. The second hospital, meanwhile, defines its customer service experience around the values of responsiveness, accountability, and accessibility.

If each hospital operationalizes a brand experience and articulates a brand promise based on their respective brand values, then each will offer a unique experience that is distinctly different from the other — even though both hospitals are building their brands around a customer service theme.

The benefits of knowing your brand values are multi-fold.

First, it richly defines your brand promise, allowing your organization to inculcate those values into the organization — from back-office processes such as recruitment and retention to front-line process such as patient care.

Second, it provides your organization with a touchstone for making decisions. By asking the question, does this decision erode our brand values or strengthen them, you are assured of charting a much truer course.

And third, it gives you something to measure against. You want to “own” your brand values in the marketplace, and if your values are clearly defined, then it is relatively easy to determine if you do. For the hospital whose brand values are excellence, compassion, and respect, questions regarding these values can be included on patient, employee, and physician satisfaction surveys. Consumer preference surveys can ask, “When I say the word compassion, what is the first hospital that comes to mind?” Through these methods, you can actually quantify the strength of your brand.

And knowing the strength of your brand allows you to make it even stronger. After all, you can’t manage what you can’t measure. Having defined brand values allows you to do both.

The Achilles heal for most hospital brands these days is the fact that they are built upon statistics. The two most common brand platforms – customer service and clinical outcomes – are often reliant on patient satisfaction scores, core measure data, Healthgrades rankings, and the like. And why not? Objective, third-party data is always better than hollow claims of superiority.

But what happens when the market shifts? What is the impact to your brand when patient satisfaction falls, or the competition’s scores surpass your own? Where do you turn when your brand – based on clinical outcomes and medical staff performance – is suddenly under attack because of a headline-raising event?

These are issues faced by every company that built its brand around celebrity endorsements. Pepsi-Cola with Michael Jackson. Hertz with OJ. Kmart with Martha Stewart. And, most recently, Accenture, Nike, Gillette, and Gatorade with Tiger.

And they will eventually be issues faced by every hospital built around market data. At some point, the market changes, and your brand has to high-tail it out of town.

So how do you prevent this likely brand demise?

Simple. Build a brand that transcends market forces.

Sounds mystical, doesn’t it? But it is relatively quite easy. If the brand is built upon the organization’s personality, values, operational philosophy, or some other organizational attribute, it can make itself immune to market conditions.

Take, for instance, a hospital brand not build on clinical superiority, but on the experience and commitment of its people. This was a strategy deployed by Avis, which built a brand on its “we try harder” mantra. It didn’t matter whether Avis was No. 1 or No. 2 in the market, nor did it matter if it was ever awarded a single J.D. Power customer satisfaction trophy. Avis was laying claim to an organizational value that was elevated to a brand position. Only Avis could sabotage its brand, and it never has. The “we try harder” brand was launched in 1962 and will soon celebrate its 50th birthday. How’s that for market transcendence?

Now, imagine your own hospital brand being wrapped around the experience and commitment of your staff. No one – and no organization – can strip you of these attributes. Commitment and experience are yours to own or give away. They do not rely on market superiority to succeed, or volume supremacy, Magnet hospital status, nationally leading patient satisfaction statistics, or any other measure that the competition might claim.

Certainly, you have to deliver on the brand. But if you do, yours will be a brand that really does elevate itself out of reach of market forces.

I struggled with whether I wanted to venture into these waters, but there are so many brand lessons in the Tiger Woods saga that I finally decided to jump in feet first.

Tiger Woods is, arguably, the world’s biggest brand. On any level. In any country. In any industry. Period. Even if you want to debate that point, it’s hard not to agree with the premise that his brand is sizeable and robust.

And infallible. Or so we thought.

As the first athlete to earn $1 billion, his brand was once sterling. He was a Golden Boy. And now, his brand is fast approaching rubbish. Accenture has already severed ties with Woods. As the scandal continues to unfold, there will certainly be others. So what can you learn from this debacle that might save your own brand? Plenty. Here’s five lessons that will serve you well.

1. Brands are often tied to people, as organizations take great strides to personify their brands. Your hospital’s brand is inexplicably intertwined with the CEO, the physicians on your medical staff, and your employees. Woods only needed to manage himself. You have to manage 500 to 50,000 individuals, depending on the size of your brand. And any one of them can destroy your brand as quickly as Woods destroyed his. If you are going to manage your hospital’s brand, you have to also manage the reputation of your team — because they are a critical component of your brand.
2. Hubris almost always sinks a brand. It certainly sunk Woods. Because of his own arrogance and overbearing presumptions, he believed that he could behave badly without retribution. When hospital CEOs begin believing their own press releases, trouble is on the horizon. And when those same CEOs believe they are bigger than the organizations they serve, trouble is just around the corner. Hubris has killed many an executive — as well as the brands they were charged to protect and oversee.
3. It takes five to 10 years to build a brand. It takes five to 10 minutes to destroy it. We need brands. They serve as a trust mark, a sorting device. We make conscious and subconscious decisions all day long based on brand trust. Ever purchase Advil for $9.99, when the generic next to it sold for $3.49 and had identical ingredients? Maybe it wasn’t Advil. Perhaps it was Philadelphia Cream Cheese versus the generic. Or maybe it was the physician who was the recent subject of a Medicare fraud investigation that you passed by in favor of a doctor a mile further away. My point is this: The next time Tiger Woods talks about the values that was inculcated in him as a child (although I can’t believe this will happen anytime in the near future), how much of his rhetoric will you actually believe? Now take your answer and apply it to your collective community next time your hospital is trying to defend its brand and the values associated with it.
4. Even in times of utter and total brand turmoil, brands can survive. However, pulling this off takes skill. And speed. Tiger Woods displayed neither as he cocooned in his home, forgoing an appearance at his own charity golf tournament and hiding behind the “private matters should stay private” comment. Had Woods stepped forward into the white hot spot light and bared his soul, showing remorse for what he had done, and pledging to take steps to rectify his sins, many would have raised his pedestal even higher. We all fall at some point. Individuals and institutions. It’s not the fall that is unforgiveable. It is not rising up after the fall and soaring even higher.
5. It’s better to take all of your medicine in one dose, that have it administered to you over several weeks or several months. Woods is learning this lesson the hard way, as new stories emerge nearly every day. With each new story, the Woods brand continually erodes, and Woods has more to answer for. When your brand is in trouble, it is better to assume that the things you are hiding will eventually emerge, rather than hope they are never uncovered. Step forward, put it all on the table, and be done with it. Not only is this brave, it shows that you have taken responsibility for your actions — even those that have yet to be disclosed. It’s easy to forgive someone who tells the whole truth, shows remorse, and pledges to do better. It’ hard to forgive someone who does otherwise.

You’ve worked hard to develop a strong hospital brand. Take a minute to think about how fast it can come tumbling down, should your hospital accidentally kill a patient, the Justice Department launches an investigation into billing fraud, your purchasing manager is accused of taking bribes, or your CEO is charged with sexual harassment. Now think about what you will do to save your brand from ruin. The time you spend planning now could save your brand in the future.

Last week, we conducted a poll on the eight most common brand platforms for hospitals, and 135 of you responded. The results: 60% of respondents listed “customer service” as their hospital’s primary brand platform, followed by medical staff reputation (13%), clinical outcomes (13%), teaching and research (7%), and facilities (7%).

Those categories without a single mention: Technology (surprise!), physician relationships, and financial stewardship. So maybe the Big Eight is really the Big Five, although every category with the exception of teaching and research was considered to be a secondary brand platform by at least six hospitals.

Quite a few hospitals also provided their own secondary brand platforms that were not on the list of eight. Among those that were included were compassion, affordability, accessibility, trust, and world-class. The question is, are these really brand platforms? Or are they brand values?

Dictionary.com lists the sociological definition of values as is “the ideals, customs, institutions, etc., of a society toward which the people of the group have an affective regard. These values may be positive, as cleanliness, freedom, or education, or negative, as cruelty, crime, or blasphemy.”

If you are searching for a home, the home itself has a certain brand platform: wealthy, poor, urban, rural, etc., depending on where the home is. And depending on the location of the home and how it is constructed, it can also carry specific values: clean, cost-efficient, warm, drafty, and secure, to name just a few. But these are attributes of the home that help convey the home’s brand. They are not the brand platform itself.

You can purchase a home in a down-trodden neighborhood whose brand platform is under-class by virtue of the neighborhood that surrounds it, and elevate the brand platform by adding a Florida room, re-landscaping the yard, and adding exterior lights. By focusing on the brand’s values, you can strengthen, weaken, or even change the brand platform.

A hospital I worked with a few years back focused on clinical outcomes as its primary brand platform and customer service as its secondary brand platform. It had a single brand value it wanted to own in the marketplace, that value being “trust.” The hospital felt that unless the community really trusted the hospital, it would never fully develop their brand platforms.

That single value of “trust” was imbedded in every internal and external communication. Hospital executives obsessed on this value. The external marketing communications conveyed images of trust and had the word unobstrusively included in every message that was released into the marketplace. Within five years, the percent of people who mentioned this hospital by name when asked what hospital they trusted the most went from 32% to 74%.

And market share went from from 37% to 51% during this same time.

All by understanding their brand platforms, brand values, and interweaving them together.

Take our three-question survey on brand platforms by clicking here.

When was the last time you gave any thought to the platform your hospital’s brand was anchored to? Was the brand platform a deliberate choice, or did it “just happen”? Even more important, do you know what your brand platform is and whether that platform is effective?

After conducting extensive research over the past 10 years, I have found that 95% of all hospitals anchor themselves to one or more of the following eight brand platforms.

1. Customer Service
2. Clinical Outcomes
3. Teaching and Research
4. Technology
5. Medical Staff Reputation
6. Physician Relationships
7. Financial Stewardship
8. Facilities

The two that dominate hospital marketing is customer service and clinical outcomes. Hospitals usually make up their minds to win the war for patients either by providing excellent personalized attention and creature comforts or by leading the marketplace in clinical indicators. It’s a fight between “we’ll love you” and “we’ll save you.”

The second tier of brand platforms includes teaching and research, technology, and medical staff reputation. Often, two of these are naturally coupled together. Teaching and research hospitals tend to migrate toward their strength, laying claim to the belief that because of their status, they are simply better and more sophisticated. But it’s not uncommon in markets where there is a major teaching institution to see a community hospital build a brand around technology and medical staff reputation. Consistent messaging is the key.

Finally, the third tier consists of physician relationships, financial stewardship, and facilities. While not as likely brand platforms as the first five on the list, they are still common, and are often a secondary brand platform for hospitals. The difference between medical staff reputation and physician relationships is that the latter is grounded in the collective pedigree of the medical staff (board certifications, fellowships, specialized training, awards and recognition, etc.) while the latter uses the medical staff to provide professional references for the hospital (physician testimonials, physician practice patterns, where physicians receive their own care, etc).

Financial stewardship is — and will probably always be — a stronghold of sorts for safety net hospitals, which must maintain a public dialogue about the need foir public funding. Integrated delivery systems, on the other hand, have given rise to the facilities brand platform, as they try to win market share by having a hospital, physician’s office, urgent care center, and/or imaging facility on every corner in town.

Any one of these brand platforms can be successful, if executed correctly. Where hospitals get into trouble is moving from platform to platform, creating diffusion as well as confusion. To create a strong, sustainable brand, define your platform — whether it’s on the above list or not — and use it to create a strong foundation for everything that you do, from operations to communications.

This blog may generate a lot of criticism. I know it going in.

So, which are the most powerful hospital brands in America?

Mayo? Cleveland Clinic?

No and no.

If a measure of a brand is volume and market share, then neither of these brands — or any other hospital brand, for that matter — makes the cut.

Of the two brands mentioned above, neither of them are even among the 20 largest hospitals in America.

If volume is a measure of brand strength, then the Big Two would be Florida Hospital and New York-Presbyterian Hospital, which have national market shares of 0.29% and 0.25%, respectively.* So, you say, it isn’t fair that I measure brand performance at a national level. Okay, then, let’s look at it regionally. In Orlando, which is essentially a two-hospital town, Florida Hospital is battling Orlando Regional with 53.2% market share. And in New York City, New York-Presbyterian — the largest hospital in America with 2,207 staffed beds — has but 19.8% market share.

I know what many of you are thinking right now. A brand cannot be measured solely on market share.

And I agree with you.

But my point is this: Whatever market you are in, you are not trying to position your brand against Mayo or the Cleveland Clinic (unless, of course, you happen to be in Rochester or Cleveland). Hospitals are local in nature and, for the most part, the vast majority of patients travel less than 50 miles to seek a hospital provider. This is not Nike vs. Reebok for world domination. This is Community Hospital vs. Memorial Medical Center for local market position.

The fact is, there are no powerful hospital brands in the U.S. (This is where the criticism begins.)

Even in Cleveland, the renowned Cleveland Clinic has but 33.8% market share and is battling Fairview Hospital, MetroHealth Medical Center, and University Hospitals for quality bragging rights, as all four have been named a top 100 hospital in recent years. (Check out the CMS Hospital Compare website and see which of these hospitals is the leader in core measure performance. Hint: It isn’t the Cleveland Clinic.)

Which is why branding is becoming increasingly important — not at the national level, but at the local level. More and more hospitals are figuring out they can create a brand that can be more dominant in their market than Mayo or the Cleveland Clinic is in theirs. The smart ones are even tearing a page from the Mayo/Cleveland Clinic playbooks by creating a customer experience built around quality and service.

After all, there is a reason that Mayo and the Cleveland Clinic are held in such high regard, even if their brands don’t translate into king-of-the-hill kind of market share numbers. They are both intensely focused on what their brands mean and work hard to deliver on their reputations. And they have been doing it for years.

The lesson here is that brands are not built overnight, and healthcare brands are not even built nationally. Which means that the most powerful hospital brand in America is, in actuality, the most powerful hospital brand in your own market.

The question is, is it yours?

*Market share is based on 2007 data

We are dealing with a paradox of sorts. At a time when most hospital emergency departments are dealing with issues of overcrowding and wait times in excess of an hour, we are simultaneously trying to cram more and more patients through the E.D. The idea actually makes sense to me. After all, the emergency department is the front door to the hospital; some of our clients report that as much as 60 percent of their inpatient admissions come through the E.D.

It’s the strategy that is often lacking.

The very survival of many hospitals resides in the emergency department. Drive E.D. volume, and you also drive inpatient admissions, surgical procedures, average daily census, contribution margin, and net revenue. It’s pretty simple, right?

Yes, if you have an E.D. sized and staffed for 60,000 visits per year, but currently only have half that number. That’s probably not you, is it?

Hopefully, you are not the type of organization that thinks you can simply launch a slick E.D. campaign, despite 60-minute wait times and a left-without-being-seen rate of 6%, and all your problems will be solved. To the contrary, such an approach will make matters worse, as initially more patients crowd into your already overcrowded waiting room, more patients walk out, and more patients tell their family, friends, and neighbors about their horrific experience in your emergency room.

If you want to own emergency medicine in your market, there is only one way to do it: Reduce door-to-doc time to less than 10 minutes, eliminate LWBS, and then — and only then — communicate a brand promise that cannot be matched by your competitors.

This is brand-building from the inside-out — at its best. Create a brand-busting experience first. Commuincate a brand-busting promise second.

I know what many of you are thinking right now. Door-to-doc in less than 10 minutes? Hah!

If you think this can’t be done, think again. New models of emergency care are being implemented that are completely overhauling the E.D. experience. One client, with a door-to-doc time of 47 minutes and a LWBS rate of 4%, decided on a Thursday to implement a new model the following Monday. The results were astounding: On the very first day, the door-to-doc time was eight minutes and not a single person left the E.D. without being seen. The hospital has sustained this improvement for the last two months, during which time their E.D. patient satisfaction scores have shot up from the 9th percentile nationally to the 75th percentile nationally.

At the same time, their point-of-service collections have improved, E.D. volume is on the rise, and E.D. admissions are up — and they still have yet to launch any type of E.D. campaign; this is all through word of mouth.

They are not alone. Hospitals in New Jersey, Pennsylvania, Ohio, and Florida have all recently reported similar results. So what are they all doing that is yielding these kinds of results? Eliminating nurse triage, eliminating fast-track, and moving to an immediate-bedding system that includes a rapid decision unit.

If you want to learn how to execute this kind of a brand-busting E.D. strategy, drop me a line. We also have a great little Excel app that does a thorough cost-benefit analysis of your E.D. opportunity. And it’s free for the asking.

If you toss and turn at night wondering about the strength of your brand, well, you probably should. There are a handful of organizations shaping your brand, whether you know it or not. And if you pretend that the big four reporting organizations – CMS, HealthGrades, The Joint Commission, and Leapfrog – aren’t having a public impact, then your brand gets what it deserves.

Our research over the past three years has identified eight primary brand platforms that the vast majority of hospitals anchor themselves to. Currently occupying the top spot on that list is “clinical outcomes,” as hospitals in every major market fight to claim the title of “quality leader.” (The other seven brand platforms? Customer service, medical staff reputation, physician relationships, technology, teaching and research status, financial stewardship, and facilities.)

If you haven’t poked around CMS’s Hospital Compare website lately, then you are already in a dangerous place. The site(www.hospitalcompare.hhs.gov) provides a plethora of comparative information covering all the core measures and then some (such as, likelihood to recommend the hospital – how is that for a brand maker or breaker?) So, if you were selecting a hospital for you elective knee replacement surgery, would you select the hospital that provides the right antiobiotic at the right time for the right duration 72% of the time, or the hospital that got it all right 98% of the time?

No billboard, no matter how good the location or how great the visuals, will overcome a deficiency such as that.

Experience = Brand.

Brand = Experience.

There is no getting around it. Data reporting has matured to the point that hospitals MUST monitor its publicly reported data and focus intensive resources on improving its scores. What makes data reporting even more tenuous is the length of time it sometimes takes to improve your scores. HealthGrades, for instance, uses a rolling three years of data. Thus, if your most recent year had some clinical anomolies that might be negatively impacting your brand, you have to live with those anomolies for three years.

All of this means that the marketing function in hospitals has to take on a bigger role than it currently has. Marketing professionals have to move beyond communications strategies and be involved in operational improvement strategies. They have to data mine various web sites to understand the true implication of publicy reported data, and then craft strategies to integrate that data into their organization’s brand.

This is not easy work. But for those who decide to manage their brand, despite what public data shows, they will certainly be better off for it. Let CMS manage your brand for you, however, and you put your entire organization at risk.