1. INTRODUCTION

The professional management of corporate communication constitutes a true challenge for Spanish public hospitals: lack of experience, limited budgets, constantly changing market, etc. Nevertheless, it also represents an opportunity to build a strong brand in a collective way along with their stakeholders: employees, patients, suppliers, public authorities, and media companies. That is why many Spanish public hospitals have resorted to social media platforms as a corporate communication tool: thanks to these platforms, they dynamize their branding initiatives and reinforce their strategic positionings in the health market. Even if using these platforms involves several risks related to patients’ privacy, health professionals’ participation, and hospitals’ brand reputation, social media contribute to improve hospitals’ corporate communication strategies. Thanks to these platforms, hospitals can focus their communication initiatives on creative techniques such as branded content, online communities, or health education. This paper aims to analyze how Spanish public hospitals managed their corporate websites as well as social media platforms to promote their brands. In other words, we try to answer the question: Which branding initiatives do Spanish public hospitals implement on Facebook, Twitter, Youtube and on their corporate website to reinforce their brand reputation? To do that, we conducted a literature review about social media as a corporate communication tool, patients’ and doctors’ involvement in this area, and the impact of these platforms on hospitals’ communication strategies. Then, we analyzed how the 100 best Spanish public hospitals managed their social media platforms (Facebook, Twitter, and Youtube) as well as their corporate websites to promote their brands. Finally, we propose three conclusions as well as three managerial implications that will allow these organizations to improve their efficiency when implementing branding initiatives based on social media.

2. HOSPITALS’ REPUTATION MANAGEMENT THROUGH SOCIAL MEDIA

Social media platforms have revolutionized hospitals’ corporate communication strategies by allowing these organizations to engage with patients in a more efficient way, collect data and develop supportive networks (^{Prochaska et al, 2017}). According to ^{Taken (2017)}, in the United States 95% of hospitals managed social media as a corporate communication tool. Some hospitals, such as Mayo Clinic, also use these platforms to reinforce their internal protocols: relationships with patients, research projects protocols, health professionals’ evaluation, and health education initiatives (^{Kotsenas et al., 2018}). From a scientific perspective, using social media represents a public health constraint: information accuracy, interactions with different patients, etc. (^{Costa-Sánchez & Míguez-González, 2018}). Nevertheless, from a branding standpoint, these platforms allow hospitals to improve patients’ experiences: social groups, conversations with doctors, health education initiatives, etc. (^{Falisi et al., 2017}). Many private and public hospitals use these platforms to implement health communities where patients and doctors share medical experiences and knowledge (^{De Las Heras-Pedrosa et al., 2020}). These communities positively impact on hospitals’ reputation and patients’ perceptions about the organization (^{Kotsenas et al., 2018}).

In this framework, health professionals are becoming brand ambassadors (^{Medina Aguerrebere, 2019}). Some hospitals propose workshops and other learning initiatives to train doctors on how to use these platforms when interacting with patients (^{Salmon & Bridget, 2017}). In some medical schools, students can enroll in courses focused on interpersonal communication skills when using social media (^{Epstein et al., 2017}) as well as other domains such as how to communicate bad news, or how to adapt to different kinds of patients: elderly people, children, aggressive patients, etc. (^{Moore et al., 2018}). These initiatives are based on a main idea scientifically proved by many authors: when health professionals communicate efficiently, they provide patients with a better medical service (^{Brown, 2008}). That is why, more and more hospitals implement combined learning initiatives including to help doctors and patients improve their skills in interpersonal communication (^{Epstein et al., 2017}). Indeed, once both enhance their communication skills, they can implement a true dialogue on social media based on mutual respect and empathy (^{Brand et al., 2017}). Moreover, thanks to these skills, they can also implement collective decision-making processes, which positively impacts on patients’ perceptions about the hospital (^{Peterson et al., 2016}).

Health professionals play a key role in health communication; however, the main protagonist remains the patient. Most of them use social media as a source of information about treatments or diseases (^{McCarroll et al., 2014}). Nevertheless, more and more patients also resort to social media to develop a supportive network allowing them to interact with patients facing similar problems (^{Myrick et al., 2016}). Thanks to social media, patients establish a more symmetric conversation with health professionals (^{Smailhodzic et al., 2016}). These new relationships determine patients’ behaviors and attitudes (^{Namkoong et al., 2017}). That is why more and more hospitals recruit social media managers whose main responsibility consists of redesigning the hospital’s social media presence and establish a true dialogue with patients (^{Visser et al., 2016}). Communicating efficiently with doctors through social media allows patients to improve their interpersonal communication skills when they meet doctors in the hospital (^{Jiang & Street, 2016}). Moreover, social media directly influence patients’ adherence to medical treatments (^{Badr, 2017}).

According to different authors, such as ^{Johnson (2014)}, there is a direct relationship between patients’ experiences with health professionals through social media and the hospital’s reputation. Building a reputed brand constitutes a priority for hospitals: to do that, public hospitals associate their image with the principles followed by public administration, while private hospitals try to create a unique brand (^{Ruiz Granja, 2015}). Nevertheless, both of them always prioritize the same value: patients’ trust (^{Kemp et al., 2014}). This value is essential to build a reputed brand that helps the hospital to survive in a constantly changing context (^{Mira et al., 2014}). To do that, many hospitals focus on two social media platforms: Twitter and Facebook (^{Triemstra et al., 2018}). Hospitals use Twitter to disseminate corporate information about health-related topics (research, treatments, trends) and in this way establish a dialogue with stakeholders (^{Park et al., 2016}). Concerning Facebook, many hospitals manage this platform to implement health education campaigns whose main objective is to change people’s behaviors and reinforce the hospital’s brand (^{Glover et al., 2015}). Besides these two platforms, hospitals also use other social media platforms, such as Instagram or Youtube, which are especially useful to better understand patients’ perceptions about the hospital, its services, and its employees (^{Balasooriya-Smeekens et al., 2015}).

In Spain, 87% of people aged 16-65 years use social media platforms, which represents more than 25 million people (^{IAB, 2019}). According to the same source, this percentage increases when it comes to women (89%) or people aged 16-24 years (93%). The main social media platforms Spanish citizens use are WhatsApp and Facebook: on average, they spend 105 minutes per day on WhatsApp, and 67 minutes every day on Facebook (^{Statistica, 2020}). Concerning health organizations, 81,6% of health professionals manage social media to communicate with patients and doctors: the main platforms managed by health professionals are Facebook (53,7%), Instagram (30,3%), Twitter (25,3%) and Linkedin (18,3%) (^{Consejo General de Colegios Oficiales de Médicos, Confederación Estatal de Sindicatos Médicos, 2020}). Many health professionals and patients also use “Conectando Pacientes”, a social media platform specialized in health-related issues.¹ On the other hand, some hospitals and schools of medicine in Spain propose workshops to help doctors and future doctors to understand how to use social media in a professional and respectful way (^{Aroca & López, 2017}). In this country, social media have become a public health tool that improve patients’ experiences and hospitals’ reputation (^{Matarín Jiménez, 2015}).

3. METHODOLOGY

In order to analyze how Spanish public hospitals promote their brands through social media platforms and their corporate websites, we focused on the Merco Monitor de Reputacion Sanitaria Espana, a national reputation ranking specialized in public hospitals and published in 2019. To do so, Merco conducted 6.149 interviews to health professionals working in different Spanish public hospitals, and evaluated 2.525 medical services based on 2.853 key performance indicators.² This ranking identifies the 100 best public hospitals in Spain according to their reputation (see Appendix 1, List of hospitals analyzed).

For each hospital, we analyzed how they implemented branding initiatives on four platforms: a) their corporate website, b) Facebook, c) Twitter and d) Youtube.³ Corporate websites centralize hospitals’ online communication strategies (^{Lee et al., 2015}); nevertheless, these organizations also manage other platforms such as Facebook, the most important social media in the world with more than 2.603 million users⁴; Twitter, a platform that helps organizations make their branding initiatives more dynamic (^{Park et al., 2016}); and Youtube, the best platform to share videos and disseminate scientific content in a visual way (^{Kotsenas et al., 2018}).

In order to analyze how Spanish public hospitals managed their brands in these four platforms, we defined 48 key performance indicators covering three main categories: a) identity, b) communication activities, and c) patients’ engagement (see Table 1, Key Performance Indicators). Most of these indicators focused on how hospitals disseminated brand-related content: values, mission, vision, etc. We tried to homogenize these indicators in all platforms; nevertheless, we also considered the different metrics proposed by each social media platform. For each indicator, we only considered inputs that we could immediately retrieve (Homepage, About Us section): in other words, we did not evaluate inputs for which we needed to do more than one click and browser on different menus. We only analyzed hospitals’ corporate profiles, and hence disregarded secondary profiles (departments, events, etc.).

To summarize, we focused on 100 units of analysis (hospitals), four variables (corporate website, Facebook, Twitter and Youtube) and three main categories (identity, communication activities and patient’s engagement). All these indicators were analyzed according to the binary system, except seven of them that were evaluated as absolute numbers: Facebook (11, 12), Twitter (9,11,12) and Youtube (11,12).

4. RESULTS

Most Spanish public hospitals resorted to their corporate websites and to different social media platforms to reinforce their corporate reputation. Nevertheless, according to our results, many of them were not really performant. We grouped our results in four main categories: a) corporate website, b) Facebook, c) Twitter and d) Youtube.

5. DISCUSSION

Most Spanish public hospitals did not manage online corporate communication in a professional way: 32% of them did not even have a corporate website, 53% did not manage Twitter, 59% did not have a corporate profile on Facebook, and 68% did not use Youtube. Moreover, some of them did not integrate their corporate websites with their social media platforms: in other words, they had a profile on Facebook, Twitter or Youtube, but they did not have a link on their corporate website to direct patients to these platforms. Other hospitals did not develop their own platforms: they preferred to use the official profiles of their regional health authorities. This lack of professionalism can negatively impact on these hospitals’ corporate communication strategies: communication objectives, targets, and brand positioning.

Communication objectives. Social media allow hospitals to improve collective decision-making processes among doctors and patients, as well as health services quality (^{Lim, 2016}). These platforms reinforce the dialogue among doctors and patients, enhance health education initiatives and improve the knowledge sharing (^{Visser et al., 2016}). However, to do that, hospitals need to recruit experts in social media and assign a budget for these activities (^{Rando Cueto & de las Heras Pedrosa, 2016}). According to our results, most Spanish public hospitals did not employ experts in online corporate communication, that is why 85% of them did not use videos on their corporate website; no hospital explained on Facebook or Youtube anything about their awards, brand values, mission and vision (brand architecture); 85,11% these organizations did not even use hashtags on their corporate description on Twitter; and 78,12% of them did not use channels on Youtube.

Targets. Even if hospitals interact with many different stakeholders such as media companies, public authorities or unions, the most important targets remain patients and employees (^{Medina Aguerrebere, 2019}). Patients are true opinion leaders who influence hospitals’ public image (^{Becerra et al., 2015}); and employees play a key role as hospitals’ brand ambassadors (^{Blackstone & Pressman, 2016}; ^{Jahromi et al., 2016}). However, most Spanish public hospitals did not make enough efforts on social media to focus on these two targets. In fact, on their corporate website, only 9% of hospitals proposed mobile apps for patients, and only 26% of them showcased a patient platform; on Facebook, 59% of hospitals did not even showcase an event section to explain to patients the hospital’s corporate events; and on Youtube, 62,50% of hospitals did not propose links to their corporate websites or to other social media platforms. Finally, concerning employees, only 6% of hospitals included on their corporate websites a search engine to find doctors; and, on Youtube, only 53% of hospitals had playlists to showcase videos about their doctors and nurses.

Brand positioning. Brands refer to intangible and tangible elements that companies use to create an added value (^{Esposito, 2017}). Hospitals need to integrate their brands into internal and external processes to build a consistent reputation (^{Nelson et al., 2014}) and in this way reinforce their strategic positionings in the health market (^{Kemp et al., 2014}). Unfortunately, most Spanish public hospitals did not use social media to build a reputed brand in a professional way. For example, most hospitals did not do an effort to publish a corporate description allowing stakeholders to understand the organization’s brand: Facebook (56,10%), Twitter (53,19%), Youtube (25%). Concerning milestones, most hospitals did not even have a section for that: Facebook (95,2%) and Youtube (96,87%). Finally, on Youtube, a platform that has become a reference to build brands, 56,25% of hospitals only respected between 1-2 key performance indicators.

6. CONCLUSION

Using social media as a corporate communication tool constitutes a true challenge for many hospitals. This paper aimed to identify the main initiatives implemented by Spanish public hospitals on Facebook, Twitter, Youtube as well as on their corporate websites to reinforce their reputation. According to our results, as well as our literature review, we can identify three main branding initiatives. First, on their corporate websites, most hospitals implement a journalistic approach based on disseminating content related to the hospital: links to medical departments, links to research and education sections, links to the Communication Department, as well as publication of press releases. Second, Facebook and Twitter are mainly used to share visual information about the hospital’s brand: logo, corporate videos, and pictures of health professionals. And third, on Youtube, most hospitals published videos about medical treatments or internal protocols to explain to stakeholders the organization’s corporate culture and create an added value.

Even if some Spanish public hospitals developed their communication strategies on social media in professional way, most of them should urgently improve in this area. To do that, we propose three main managerial recommendations. First, hospitals need to recruit experts in social media, create a Social Media Unit with the hospital’s Corporate Communication Department, assign a budget, and implement an annual communication plan based on protocols and key performance indicators. Second, experts in social media need to focus on strategies (communication objectives, main and secondary targets, brand positioning) rather than final products (posts, videos, etc.), otherwise they will never be able to build a meaningful brand. And third, hospitals must integrate social media into some internal protocols to accelerate the organization’s digital transformation, and this way promote the value of health communication.

This study has allowed us to better understand how Spanish public hospitals used social media to promote their brands. However, we must highlight three main limitations affecting this article: we did not contact hospitals’ corporate communication departments to understand why they managed social media in this way; we did not contact these hospitals’ stakeholders to evaluate their perceptions about how these organizations use social media for branding purposes; and finally we did not find similar papers about Spanish public hospitals, which did not allow us to compare our results. We recommend researchers interested in developing this area in the next years to focus on how to train doctors and nurses to become brand ambassadors able to use social media in a professional way; how to use these platforms to reinforce the hospital’s brand architecture (identity, values, mission, vision and culture); and how to evaluate stakeholders’ perceptions about the hospitals’ branding effort on social media.