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Public relations in the healthcare industry

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IN SEARCH OF BEST PRACTICES Health Care Industry

51
Public Relations in the
Health Care Industry

LAUREL TRAYNOWICZ HETHERINGTON

DARADIREK EKACHAI

MICHAEL G. PARKINSON

Frankly, it’s hard for me to tell you where health care PR

[public relations] is going because I can’t see where health
care organizations are going.

—Anonymous public relations professional

(quoted in Lewton, 1995, p. 1)

䊑 Health care is changing at unprecedented other service industries (Zeithaml, Parasura-

levels. Former models of care that feature the
physician providing medical treatment have
been largely replaced by health care team models
promoting prevention and wellness (Dziabis &
Lant, 1998; Marino & Ganser, 1997). Further-
more, current intricacies based on changes in re-
imbursement, clinical and operational practices,
the management of health care processes and in-
formation, and the very structure of health care
organizations combine to challenge even the
most astute public relations practitioner.
In this chapter, the theory and practice of
public relations in the health care industry are
examined. The practice of health care public re-
lations, formerly described as similar to that of
man, & Berry, 1992), has changed along with the
dramatic transformation of health care itself. In
a sense, public relations in health care might be
no different than that in any other service indus-
try given that the overall aim of public relations
still is one of “harmonizing long-term relation-
ships” (Seitel, 1995) and “reputation manage-
ment” (Newsom, Turk, & Kruckeberg, 1996). In
the current health care environment, traditional
public relations practitioners who are skilled in
writing, research methods, and analysis remain
invaluable.
Yet, health care is a unique industry. Starr
(1982) claimed that medicine is different from
any other industry because of the product (life,

571
572 IN SEARCH OF BEST PRACTICES
death, and healing), the rapid and profound
changes in the health care system (from physi-
cian as solo practitioner to multiconglomerates
of layered health care processes and reimburse-
ment scenarios), and the interaction of client
(patient) with suppliers (health care providers
within a defined system). Furthermore, the mo-
tivation to improve the health care industry is
not fixed on cost reduction—a universally cited
rationale in other service industries. Rather, the
desire to improve health care processes is moti-
vated by providers who seek to provide a higher
quality of care in a coordinated manner (Beed,
1994). Thus, public relations practitioners who
are responsible for promoting and conveying
improvements and systemwide transformation
within the health care industry must walk the
tenuous line between motivation for purposes of
profit and care.
The stance we take is that health care is, first
and foremost, an industry. It has products, pro-
cesses, suppliers, vendors, customers, and out-
comes. It is unique, as are other industries, and
its suppliers (physicians, other health care pro-
viders, and internal agents such as hospital work-
ers) view themselves as unique (Oddo, 1992).
During this era of transition to managed care
within the health care industry, public relations
represents a series of processes by which the vari-
ous health care publics adapt to and cooperate
with each other. Yet, the common and funda-
mental public relations principles remain.
CHANGING NATURE OF HEALTH
CARE AND ITS PUBLIC RELATIONS
Lewton (1995), in a history of health care public
relations, indicated that the “good times” of
health care public relations spanned the 1950s
and 1960s. During that time, health care public
relations practitioners “felt little need to create
awareness or preference because health care or-
ganizations had always received public support
and favor” (p. 2). Public relations did not need to
be proactive to “maintain and build on public
confidence” (p. 2). Rather, public relations roles
were prescribed and limited to the communica-
tion of information and positive image.
During the 1970s, however, noticeable shifts
emerged in health care delivery, reimbursement,
and the public’s insistence on high-quality care
at lower costs (James, 1989). The modern deliv-
ery of health care was being examined by critics
who questioned the high cost of getting and stay-
ing well. “In short, payers were beginning to ask
questions” (Lewton, 1995, p. 3). Marketing de-
partments in health care organizations took on
greater responsibilities thanks to a new emphasis
on generating health care revenues from sources
different from traditional sources—individual
patients. Some within the health care industry
have called the dramatic change in health care
provision over the past 20 years a “paradigm
shift,” consistent with Kuhn’s (1970) discussion
of what happens when foundations of knowing
transform. The traditional public relations tasks
of promoting positive image and placing appro-
priate news items expanded to include conduct-
ing administrative briefings on how to manage
new levels of consumer criticism and training in-
ternal publics on the team-centered nature of in-
ternally derived communication about the orga-
nization.
The 1970s and 1980s marked a time of finan-
cial difficulties for traditional health care provid-
ers as employers strove to reduce their health
care costs. Increasingly, physicians were slowly
losing control of the health care system in favor
of reimbursers and third-party payers (Pearson,
1996). Out of necessity, those hospital adminis-
trators who had not already done so began to
seek out public relations and communication
professionals so as to maintain a two-way rela-
tionship between the hospital or health care or-
ganization and its publics (Lewton, 1995).
Currently, at the turn of the 21st century,
health care public relations is continuing to be
influenced significantly and irrevocably by four
major business changes: the arrival of managed
care, the transition from a medical model to a
wellness model, the emergence of continuous
quality improvement initiatives, and the genesis
of health care networks and systems.

Managed Care
Managed care, the health care reimburse-
ment system that has restructured health care
delivery and payment processes, is fast becoming
the norm in the United States (Pearson, 1996).
Managed care is perhaps the most dramatic
change experienced within the health care in-
dustry within the past two decades. Through
managed care plans, patients are encouraged to
stay well, and providers are financially motivated
to avoid costly medical tests. Managed care bases
reimbursement on capitation, which means that
providers receive a certain amount of money
each month based on number of health plan sub-
scribers (patients per capita) rather than money
for each test and procedure (also known as a fee-
for-service plan).
The Wellness Model
The health care industry formerly relied on
what is known as a medical model. A patient be-
came sick and sought the medical attention of a
health care provider—usually a physician. The
doctor’s office and the hospital were places
where people went for treatment, diagnoses, sur-
gery, and other medical procedures. Patients also
saw physicians for “well checks” such as immu-
nizations and annual physician examinations,
but the emphasis remained one of treatment.
With the advent of managed care, the health care
industry moved from the medical model, which
emphasized solving health problems, to a
wellness model emphasizing prevention of ill-
ness and injury.
Continuous Quality
Improvement
The genesis of health care public relations
has moved hand-in-glove with the changing fab-
ric of American health care practices. The one-
way public relations models of the 1950s and
1960s have dissolved in favor of more aggressive
two-way models attuned to the needs of the vari-
Health Care Industry 573
ous health care delivery system publics. Current
emphases on values-based and values-driven
management (Thomsen, 1997) are consistent
with continuous quality improvement (CQI)
methods that are emerging in health care systems
across the world.
Of greatest concern for health care systems is
the emphasis on the patient in a CQI environ-
ment (Carleton, 1997; Luciano, 1997; Winter-
steen, 1997). This patient-centered focus usually
shows up formally in health care organizations’
vision and/or mission statements. In addition,
research and quantification of clinical and oper-
ational results, a hallmark of CQI initiatives,
continue to take center stage for those responsi-
ble for communicating within the industry
(Spath, 1989). Furthermore, emphasis is increas-
ingly being placed on patient-centered solutions
to managed care challenges (Joint Commission
on Accreditation of Healthcare Organizations
[JCAHO], 1992). Addressing routine and acute
patient problems in a medically responsible
but cost-effective manner always has been a con-
cern of the medical community, but now
reimbursers, third-party payers, and accrediting
agencies are adding to the challenge in ways not
seen previously.
Health Care Networks
and Systems
DeMuro (1994) discussed the advent of the
health care delivery system, which has replaced
or is quickly replacing the hospital-based or hos-
pital-centered model of health care delivery. In-
tegrated delivery systems include medical
groups, physician-hospital organizations, and
medical services organizations. Their aim almost
always is related to the desire to coordinate the
provision of care (McCarthy, 1997). A fully inte-
grated delivery system, according to DeMuro
(1994), is “an organization or group of affiliated
organizations that provides physician and hospi-
tal services to patients” (p. 30). Systems may in-
clude standard services as well as mental health
care, long-term care, home health care, and reha-
bilitation.
574 IN SEARCH OF BEST PRACTICES
THE RESPONSE OF PUBLIC
RELATIONS TO HEALTH CARE
INDUSTRY CHALLENGES
The transformation in health care delivery has
significant effects on all who enter and sustain
health care systems, and it includes patients, pro-
viders, reimbursers, and vendors. As the health
care field evolves, so do the public relations theo-
ries, models, strategies, and tactics that surround
and define it. Past work in health care public rela-
tions has focused on strategies and tactics en-
gaged by health care organizations, with an ar-
cher-target stance prevailing (Smith & Schaaf,
1995). Previously, public relations was consid-
ered as something to “use” rather than as a pro-
cess through which an organization could meet
many goals as well as its aim of building a loyal
and satisfied customer base (see, e.g., Giordano,
1997; Johnston, 1997). This perspective pro-
motes an asymmetrical one-way view of the role
of public relations in health care.
Although public relations professionals rec-
ognize that changes occurring in the health care
field call for public relations transitions (Bardin,
1994; Green, 1994; Greenberg, 1994), subse-
quent working models of health care public rela-
tions practice are scarce. Health care’s future—
focused on patient-centeredness, prevention,
and systems based on capitation rather than on
fees for services—calls for new ways in which to
manage and address public opinion. Published
case studies (Comrie, 1997) provide evidence of
the dynamic nature of public relations practitio-
ners and constituencies. Yet, two-way symmetri-
cal models proposed and advocated by J. Grunig
and his colleagues (J. Grunig, 1992a) are not
found in substantial numbers in actual practice
situations.
Traditional approaches to health care public
relations have not vanished but rather have
transformed as changes continue to occur within
health care systems. Public relations practitio-
ners continue to perform the mainstay activities
of the profession—writing, research, and plan-
ning. With the continually increasing emphasis
on health care relationships and systems, the
center of public relations practice in the 21st cen-
tury is relationship building and maintenance.
The communication principles that describe
and predict healthy long-term relationships are
no less relevant in health care public relations
than they are in everyday dyadic relationships.
Thus, principles of reciprocity, equality, respect,
and trust take on renewed meaning in the con-
text of health care business relationships. With
the patient at the center, vendors and providers
such as physicians, pharmaceutical companies,
managed care companies, and third-party payers
find themselves in a unique public relations co-
nundrum.
Lewton (1998) suggested that the role of
public relations in health care systems is increas-
ingly one of requiring listening rather than one
of emphasizing sending messages. Proactive as-
sertive methods of promoting and communicat-
ing health care images, such as through educa-
tional initiatives, are in line with the new health
care emphasis on preventing problems instead of
waiting to fix them when they occur.
The state of health care reform, and the ever
present possibility of national health care, raises
additional issues for health care and public rela-
tions practitioners who seek to predict the future
of this industry. New technologies such as
telemedicine are making an entrance into rou-
tine health care delivery, and third-party payers
are holding the verdict on reimbursement pend-
ing additional clinical trials. Capitation systems,
in which insurance companies pay providers
based on the number of enrolled patients rather
than using a fee-for-service system, currently are
incapable of absorbing the costs of some of the
health care innovations on the horizon.
LESSONS FOR AND FROM PUBLIC
RELATIONS PRACTITIONERS
Case Studies
Recently published case studies convey the
tenor of change within health care public rela-
tions. Four themes predominate: the value of co-

operation during this era of health care systems
and managed care, the success that systems expe-
rience when communication is timely and lavish,
the importance of education during change, and
the role of involvement in establishing enduring
improvements.
Several case studies converged on a popular
contemporary public relations lesson: A strug-
gling organization can become competitive
through cooperation. Laurel Health System in
Tioga County, Pennsylvania, did just this. The
system formed a partnership with community
groups (including churches, lending institu-
tions, governments, and schools) as one method
by which to analyze customer needs and meet
health care demands (Sandrick, 1995). By relin-
quishing some degree of control over system fea-
tures and having other groups provide resources
for the assessment that the health system desired,
Laurel Health System now is one partner in a
community-wide system that has community
health as its aim.
The lessons of communication and educa-
tion resonated in the case study of the Nebraska
Health System. Warneke (1998) provided a case
study of the involvement of public relations in
the merger of two health care organizations,
Clarkson Regional Health Services and the Uni-
versity of Nebraska Medical Center, into the Ne-
braska Health System. The role of public rela-
tions in this case was both internal and external,
and it focused equally on communication and
education. Internally, employees required infor-
mation due to the uncertainty involved in any
potential merger. Building a base of mutual em-
ployee support across the two organizations
proved to be a complicated task for human re-
sources and public relations officers. Externally,
customers and suppliers required information
about the merger and its effects. Employees from
both organizations formed cross-disciplinary
teams with the greater good of the ultimate ex-
ternal customer (the patient) at the heart of the
transition.
Additional case studies revolve around large
health care systems that underwent major CQI
initiatives. Oddo (1992) provided detailed sum-
maries of the clinical and operational changes
that took place when two large medical centers,
Health Care Industry 575
the University of Michigan Medical Center
(Ann Arbor, Michigan) and Intermountain
Health Care (Salt Lake City, Utah), adopted
CQI initiatives as a way in which to improve
quality and lessen health care costs. Although the
organizational details differed across these
two corporations, the basic public relations pre-
mises remained the same: Communicate changes
thoroughly and quickly to internal and exter-
nal audiences, provide ample education and
training during the change initiative, and in-
volve as many individuals as possible during the
process.
A Model of Health
Care Relationships
A model relevant to the concerns of health
care public relations practitioners follows is de-
picted in Figure 51.1. This model illuminates the
changing relationships between the patient and
health care providers, as buffered by the influ-
ence of the managed care environment (the
health maintenance organization), and is com-
patible with a two-way symmetrical view of pub-
lic relations.
The model centers on public relations in the
current patient-focused environment. As dis-
cussed previously, a body of recent research indi-
cates that the patient-centered health care net-
work constitutes the new way of doing business
in the 21st century. Unlike the medical model,
which places the physician at the center of busi-
ness, the wellness model places the patient at the
center.
Clearly, there is an interdependence between
the public relations practiced within a specific
health care organization and its constituencies
including what previously were considered
“competitors” such as local health care systems.
The notion of cooperation where there once ex-
isted competition among health care systems
will be discussed as a critical feature of the public
relations models taking center stage in the 21st
century of health care transformation. Various
power control theories (L. Grunig, 1992b) ex-
plain former views rather than current and fu-
ture views of health care public relations.
576

Figure 51.1. Public Relations’ Concerns in the Health Care Industry

NOTE: HMO = health maintenance organization; PA = physician’s assistant.

Best Practices for Public Relations
Practitioners
Several public relations lessons are pertinent
to the health care public relations practitioner.
These best practices are gleaned from a historical
and critical reading of health care management
and public relations literature; from experiences
of public relations professionals; and from the
future forecasting being done now by financial
analysts, health care providers, public relations
practitioners, and managed care experts.
1. Two-way public relations models work.
One-way models and power control theories
will not work in a managed care CQI systems en-
vironment. The nature of patient-centered care,
by definition, negates the utility of one-sided
models. Two-way models, such as those pro-
posed by J. Grunig (1992a), continue as the pub-
lic relations practitioner’s prototype, with mini-
mally a two-way asymmetrical model employed
in health care settings. Symmetry remains a goal,
although it is difficult to attain based on con-
straints such as patient privacy, confidentiality,
and risk management issues.
2. Cooperation is needed among former
competitors.
Public relations practitioners must take a
leadership role in encouraging cooperation be-
tween and among health care entities that now
must work together in an integrated delivery sys-
tem. As boundary agents who cross department
and organizational lines, public relations per-
sons will find this quest for cooperation a com-
mon thread in their work during the early years
of the 21st century.
3. Public relations must take a leadership
role with CQI initiatives.
CQI is accepted by health care, management,
and accrediting principals as a necessary part of
health care organizations’ future. Current busi-
ness trends are reinforced by requirements of ex-
ternal accrediting agencies such as JCAHO and
Health Care Industry 577
the Health Care Financing Administration. Pub-
lic relations will continue to play a prominent
role in the internal and external rollout of CQI
initiatives.
4. Internally, public relations must con-
tinue to work with education, commu-
nication, and recognition components
of health care system reform.
Public relations also must remain or become
integrally involved with organizational and stra-
tegic planning as well as with the relations be-
tween the health care system and accrediting
bodies. This is an important point to stress be-
cause normally health care accreditation is seen
by health care administrators as a function tak-
ing place between the accrediting agency and
medical staff (including quality management
and physicians).
5. Continue with the accepted tenets of
“good public relations.”
The roles of writing, research, planning,
community and media relations, internal and
external relations, and other such public rela-
tions functions remain invaluable even in a rap-
idly changing health care environment. These
traditional public relations functions vary little
in essence from their roles in other service indus-
tries, but the context in which they are engaged
(e.g., managed care, CQI) has changed. Specific
knowledge of the health care and managed care
context is critical to accomplish traditional pub-
lic relations tasks.
6. In practice, health care public relations
can and must continue to operate in a
complementary fashion with marketing
and integrated marketing communica-
tions.
The theory of public relations is conceptual-
ized differently from the various practices and
components of integrated marketing communi-
cations. This point was made by L. Grunig
(1992b) and continues to be advocated today in
modern public relations textbooks (McElreath,
 578 IN SEARCH OF BEST PRACTICES
1996). Yet, as we put on our “downsized reality of
21st-century health care public relations” hats,
there is no room for public relations specialists
who do not do marketing or integrated market-
ing communications. Wearing more than one
hat will remain an important facet of how the
health care public relations practitioner accom-
plishes his or her work. The actual configuration
of public relations in health care system compo-
nents, such as in medical centers and hospitals,
must change from separate departments labeled
communication, marketing, staff development,
and community relations to interdependent de-
partments stemming from a larger communica-
tion and public relations base.
7. New public relations hires must be con-
tinually educated in health care manage-
ment principles.
The best way in which to use new hires will be
in traditional roles—writing, research, and com-
munity relations. But new hires and other mem-
bers of the public relations staff must be edu-
cated regularly in the business of health care
change to keep the public relations function
ahead of the curve in a demanding environment.
8. The patient-centered focus of the health
care system must be prominent in pro-
motion efforts.
Any type of promotion or communicative
efforts of the health care system will be best if
they speak about an innovative, quality-con-
scious, reasonably priced, continuously improv-
ing system that values external and internal cus-
tomers. Not doing so jeopardizes the future of
the organization in terms of the marketplace
(patients) but also in terms of accrediting bodies.
Such promotion must, of course, come from se-
View publication stats
nior management decisions and be voiced
through the uppermost layer of the system.
9. Public relations models must change
continuously.
Within the realm of two-way public relations
models, change will occur regularly. This is an
important mind-set for the public relations
practitioner, who is responsible for leadership
and communication efforts that respond to new
demands and practices in the industry.
10. Public relations practitioners must re-
tain a sensitivity to, and an awareness of,
where we have been and where we are
going.
Similar to any other industry in which public
relations is practiced, the health care practitioner
must remain committed to continuous educa-
tion in health care industry changes. To maintain
credibility with internal and external customers,
a sensitivity to health care’s past will prove im-
portant.
Health care often is described as a complex
business with an uncertain future (Lewton,
1995). Public relations professionals responsible
for the planning, implementation, and promo-
tion of health care business strategy are sure to
continue the wild ride begun during the latter
part of the 20th century. As the paradigm shift
continues in health care provision and reim-
bursement, the public relations practitioners
who will survive are those who continually edu-
cate themselves and their colleagues in the busi-
ness of health care provision and who become
integrated with the systems thinking so founda-
tional to modern health care practices.