Introduction

The professional management of corporate communication has become a strategic priority for hospitals that want to establish satisfactory relationships with their different stakeholders (employees, patients, health authorities, etc.), as well as improve their own brand reputation. However, several factors force these organizations to rethink their communication strategies: new patients’ demands, an increasing competition between public and private hospitals, development of new business models based on technology, etc. In this context, social media platforms, such as Facebook, Twitter or LinkedIn, have become useful tools to help hospitals manage their corporate communication in a professional way and achieve several communication goals (patients’ engagement, relationships with media companies, etc.). This paper aims to analyse the role of Twitter as a corporate communication tool used by hospitals to promote their brand. We have defined three main objectives: 1) better understand how hospitals use Twitter for doing branding initiatives, 2) identify some trends related to online corporate communication in health organizations, and

3) define some recommendations for helping hospitals use Twitter in an efficient way. To do that, we carried

out a literature review about corporate communication, branding, reputation and social media; and, then, we analysed the branding actions on Twitter implemented by the best US hospitals specialized in the treatment of cancer diseases.

From corporate communication to hospital branding through social media

Many researchers in Schools of Medicine and Schools of Communication around the world focus their research in health communication as a strategic issue for hospitals (^{Hannawa et al. 2015}). In some countries, public health organizations and Schools of Medicine have integrated corporate communication as a strategic element in their business structures and study plans (^{Gonzalez-Pacanowski, Medina Aguerrebere, 2018}). According to ^{Blackstone and Pressman (2016}), helping public health professionals develop communication skills constitutes a priority, especially for those who directly interact with patients, such as health professionals, nurses or other assistants. Public health organizations collaborate with experts in knowledge management in order to better satisfy all stakeholders’ needs and expectations (^{Nazione et al. 2013}). Public health and communication have merged and have resulted in a strategic field called “health communication”, which represents a challenge as well as a priority for all organizations dealing with health-related issues - hospitals, clinics, patients’ associations, public authorities, etc.- (^{Penafiel Saiz, Pastor Gonzalez, Camacho Markina, 2014}). On the other hand, this new field has also influenced some academic institutions which focus now their research and teaching activities on global studies about health communication in order to better understand how to use this professional activity to improve their internal and external functioning (^{Weberling McKeever, 2014}). Thanks to health communication, public health professionals can improve their relationships with some social groups, especially elderly people, children and patients suffering from chronicle diseases (^{Smailhodzic et al., 2016}). Health professionals collaborate with experts in corporate communication working in these organizations in order to influence people’ attitudes and behaviors concerning health-related issues (^{So et al., 2016}). According to ^{Rupert et al. (2014}), during next years, public health organizations should recruit more communication experts in order to optimize their public health communication campaigns. Public health professionals as well as experts in communication should work together for implementing a new health communication paradigm based on health education, social influence and responsible behavior (^{Jones et al. 2015}).

In hospitals, the professional management of corporate communication is a recent issue: in other words, during these last years, only some hospitals have fully implemented this activity in a professional way (^{Medina Aguerrebere, Buil Gazol and Heath, 2015}). In these organizations, we can identify three main communication activities: interpersonal, internal and external communications (Medina Aguerrebere, 2017). Professional skills in interpersonal communication allow health professionals to improve their relationships with patients (^{Weech-Maldonado et al. 2012}). When doctors interact with them at hospital, they must allow patients to play an active role, ask questions and share information (^{Salamonsen, 2013}). Moreover, they also should base their communication on human values allowing patients to accept the diagnostic and follow the set treatment (^{Brent, 2016}). In hospitals, internal communication activities include all initiatives focused on improving the organization’s internal functioning as well as its relationships with employees and patients (Medina Aguerrebere, 2017). Thanks to internal communication, organizations can promote employees’ engagement, their sense of belonging to the company and their commitment with corporate objectives (^{Welch and Jackson, 2007}). Finally, external communication refers to all initiatives implemented by hospitals to enhance their relationships with external stakeholders such as providers, media companies, policy makers or pharmaceutical companies (^{Martini, 2010}). In order to reinforce these relationships, hospitals analyse all stakeholders’ attitudes towards the organization, its products and employees (^{Moser, Greeman, 2014}); and disseminate public health related content that lead stakeholders to better understand diseases and treatments (^{Fischer, 2014}).

The corporate brand represents tangible and intangible inputs which influences stakeholders’ attitudes and behaviours (^{Esposito, 2017}). The hospital’s brand includes not only names and logos, but also patients’ experiences at hospital as well as their relationships with health professionals (^{Wang et al., 2011}). Before implementing branding initiatives, hospitals define their brand architecture: identity, values, mission, vision and culture. Identity is an external element which allows hospital to differentiate from other public or private companies (^{Medina Aguerrebere, 2017}). Identity determines organizations’ strategies: in fact, there is an interdependent, reciprocal and dynamic relationship between both concepts (^{He and Balmer, 2013}). Corporate values are a powerful tool to influence employees’ behaviours and attitudes, and help them work in an efficient way to achieve the company’s organizational objectives (^{Sheehan and Isaac, 2014}). Thanks to these values, organizations can create an emotional link with their stakeholders (^{Ortega and Sastre, 2013}). Concerning the mission, it’s a corporate element describing all mid-term objectives pursued by the company (He and Balmer, 2013). The vision describes the company’s long-term objectives and defines all initiatives implemented to meet them (^{Singal and Jain, 2013}). Finally, culture refers to the specific way in which all organization’s employees work every day; culture should be consistent with the mission and values in order to create an unambiguous brand in all stakeholders’ mind (^{Nelson, Taylor and Walsh, 2014}). The professional management of identity, values, mission, vison and culture allows hospital to establish a corporate communication strategy consistent with the organization’s priorities (Medina Aguerrebere, 2017). Social media are already a strategic tool for hospitals interested in reinforcing their relationships with stakeholders (^{Bermudez-Tamayo et al. 2013}). Using social media in professional way involves respecting ten communication principles: a) implementing social media rules related to how to engage stakeholders and disseminate pedagogical information without commercial interests (^{Campbell and Craig, 2014}); b) respecting medicine principles such as integrity, ethics, humanism and trust (^{Chretien and Terry, 2013}); c) analysing main competitors’ communication strategies as well as communication trends in the health market (^{Blomgren, Hedmo and Waks, 2016}); d) developing a corporate framework which helps organization’s employees communicate in a coherent way and disseminate an unique brand image (^{Linke and Zerfass, 2013}); e) publishing professional contents useful to better understand health related contents (^{McCarroll et al. 2014}); f) promoting a dialogue between health professionals and patients for developing an hospital community (^{Greysen, Kind and Chretien, 2010}); g) monitoring conversations between them in the hospital’s corporate social media platforms in order to make sure all health information disseminated is accurate from a scientific point of view (^{Abramson, Keefe and Chou, 2015}); h) implementing innovative strategies useful to communicate differently and establish an emotional connexion with stakeholders (^{Hackworth and Kunz, 2011}); h) using visual information (videos, images, information graphics, etc.) to better disseminate scientific content (^{Gabarron et al., 2013}); and i) defining quantitative indicators to measure the hospital’s reputation as well as its stakeholders’ perceptions (^{McCaughey et al. 2014}).

Twitter is a strategic social media platform allowing hospitals to achieve several communication objectives such as reinforcing their brand, disseminating health information, or improving their health professionals’ skills in interpersonal communication (^{Rando Cueto and De las Heras Pedrosa, 2016}). Hospitals carry out different initiatives to promote their brand through Twitter: a) dissemination of corporate information related to health, treatments and pathologies (^{Park, Reber and Chon, 2016}); b) establishment of a corporate dialogue between the organization and its stakeholders to explain the hospital’s corporate identity (Rando Cueto and De las Heras Pedrosa, 2016); c) dissemination of scientific information which helps patients better understand their treatments and communicate in a more efficient way with health professionals (^{Terry, 2009}); d) implementation of platforms letting patients to communicate with health professionals about

treatments, pathologies or other health preoccupations (^{Antheunis, Tates and Nieboer, 2013}); e) training health professionals to effectively communicate with patients during the whole year, and not only during their medical consultation at hospital (^{Alpert and Womble, 2016}); f) publication of corporate information about health professionals’ activities such as papers published in scientific journals or participation in international conferences (^{Lee and Dundar, 2013}); g) collaboration with international organizations and public authorities for launching public health campaigns (^{Chung, 2016}); h) reinforcing the emotional relationships established with stakeholders (^{Kim et al., 2016}); i) developing a convergence between social media platforms and corporate websites in order to promote patients’ engagement and reinforce the participative medicine approach (^{Gallant et al., 2011}); and j) implementation of different Twitter’s applications -videos, statistics, etc- to build an unique brand image (^{Huang and Dunbar, 2013}).

Methodology

In order to analyse the role of social media platforms in branding initiatives carried out by hospitals, we have analysed the Twitter’s profile of main US hospitals specialised in the treatment of oncological diseases. We have focused on American hospitals because United States was the first country to develop corporate communication in health organizations in a professional way, that is why they have now some of the most reputed hospital brands such as Mayo Clinic, Cleveland Clinic or MD Anderson. To analyse the American hospital market, we have resorted to the Best Hospitals US News World Report, a reference report published by the US News. This organization compares more than 4.500 medical centres around the country in 25 medical specialities, procedures and conditions. For elaborating this ranking, they analyse several indicators like risk-adjusted survival and readmission rates, volume, patient experience, patient safety and quality of nursing.¹ They propose several rankings by specialities (cardiology, diabetes, geriatrics, gynaecology, etc.). Among these different rankings, we have chosen the 2017 best US hospitals in oncology, since cancer patients require a lot of monitoring by health professionals, as well as an emotional support from other patients (^{Gilligan et al. 2018}). And, for both functions, Twitter turn out to be a very appropriate tool (^{Rando Cueto and De las Heras Pedrosa, 2016}).

From 2nd April to 28th May 2019, we have analysed the Twitter’s profile of the 100 best US hospitals in oncology². To do that, we have searched each hospital’s corporate profile on Twitter, and we have checked whether this profile is active or not, and whether it belongs only to a department or is the true hospital’s corporate profile. Second, we have analysed each profile according to ten indicators concerning branding actions - 1) corporate elements in the main profile image, like the hospital’s buildings, health professionals, etc.-, 2) logo in the main profile image, 3) hospital’s description, 4) links to the hospital’s corporate website and 5) inscription date-; communication activities - 6) number of tweets, 7) number of subscriptions and 8) number of lists-; and patients’ engagement - 9) number of followers and 10) number of likes-. Using images directly related to the company’s identity (health professionals, hospital’s buildings, logo etc.) allows these organizations to develop their brand because, on the one hand, health professionals are also considered as “brands”; and on the other hand, buildings and logos represent the hospital in a tangible way. Explaining clearly the hospital’s structure (description) and recommend patients to refer to the corporate website involves an effort to disseminate complete information about the company in order to build an unambiguous brand. The inscription date shows how experienced hospitals are using this social media platform, as well as their true interest in using Twitter to dynamize their brand. As to communication activities, we analyse the number of tweets, subscriptions and lists to check if hospitals are active on Twitter and use it as a true communication tool for establishing a constant dialogue with stakeholders. And finally, concerning the patient’s engagement, we consider the number of followers and likes because these data prove how patients participate in this corporate dialogue established with hospitals. Followers’ activities on Twitter (number of likes, sharing content, etc.) show their engagement with the organization (^{Chen and Pirolli, 2012}) as well as their level of activity in the corporate relationships established with companies (^{Bhattacharya, Srinivasan and Polgreen, 2014}).

For doing this analysis, we have used a binary code for the first four criteria; and a quantitative record for the other ones. We have fulfilled a database with all this information in order to analyse results and obtain clear conclusions. Once we have finished this database, we have checked again all hospitals’ corporate profile on Twitter, and this way we have validated the whole analysis.

Results

After analysing the corporate communication initiatives carried out on Twitter by the 100 best US hospitals specialised in oncological diseases, we propose four main results.

First, 96% of hospitals have an active profile on Twitter. The only four hospitals not having a profile on this social media platform are Mayo Clinic Phoenix, Mayo Clinic Jacksonville, Sinai Hospital of Baltimore and Cleveland Clinic Fairview. Mayo Clinic has a corporate profile, but not a profile for its local branches in Jacksonville and Phoenix. Cleveland Clinic has a corporate profile, another one for Cleveland Clinic Florida, but none for Cleveland Clinic Fairview. Below, we analyse how these 96 hospitals use Twitter as a corporate communication tool.

Second, branding actions. Concerning the inscription’s date, most hospitals have a Twitter profile since 2008 (20 hospitals), 2009 (43 hospitals) or 2010 (17 hospitals). Nine hospitals launched their Twitter profile in 2011; two, in 2012; three, in 2014; one, in 2015; and another one in 2016. As to four other indicators about branding actions (corporate elements in the main profile image, logo in the main profile image, hospital description and link to the corporate website), we must highlight that 75% of hospitals respect all these indicators; 18,75%, 3 indicators; and 6,25%, 2 indicators. Regarding the main profile image, 84,38% of American cancer hospitals use a corporate image (patients and doctors, buildings and facilities, etc.); and 98,96% also add the corporate logo as a complement. On the other hand, 85,42% of hospitals propose a brief description that helps users understand the structure and corporate objectives pursued by the hospital. Finally, all hospitals have a link to their corporate website in order to let users to contact health professionals and better know the organization.

Third, communication activities. We identified several differences regarding the number of tweets subscriptions and lists. Cleveland Clinic, Mayo Clinic and Dana Farber Brigham and Women's Cancer Center are the three more active hospitals on Twitter (see Table 1. Number of Tweets). As to the number of subscriptions, USC Norris Cancer Hospital-Keck Medical Center has 171.135 subscriptions; in other words, it’s the best hospital in this domain (see Table 2. Number of subscriptions). And, finally, concerning the number of lists, the three more active hospitals are University of Michigan Hospitals and Health Centers, UMass Memorial Medical Center and Dartmouth-Hitchcock Medical Center (see Table 3. Number of lists).

Fourth, Patients’ engagement. Mayo Clinic, Cleveland Clinic and John Hopkins Medicine are the three best hospitals concerning the number of followers (see Table 4. Number of followers); however, the three hospitals having more “likes” are Dana-Farber/Brigham and Women’s Cancer Center, Advocate Lutheran General Hospital and Memorial Sloan Kettering Cancer Center (see table 5. Number of likes).

We want to highlight the case of four hospitals that are especially active on Twitter (number of tweets and subscriptions) and whose patients are really engaged (number of followers): Cleveland Clinic, Mayo Clinic, Dana Farber Brigham and Women's Cancer Center and Vanderbilt University Medical Center. These four health organizations use efficiently Twitter as a corporate communication tool for building their brand in a collective way along with stakeholders.

Discussion

Hospital should create a corporate communication department to manage in a professional way all communication activities taking place on social media; otherwise, they cannot protect their own corporate reputation (^{Ruiz-Granja, 2015}). This department analyses all the information disseminated on social media and make sure this information is reliable and respects patients’ privacy (^{Moorhead et al. 2013}). The Corporate Communication Director trains health professionals to use social media in a strategic way; in other words, they help them integrate some principles in their daily professional logic: a) be authentic and only share interesting information, b) ask for help to the Corporate Communication Department in case of questions, and c) prioritize information which can help the hospital boost patients’ engagement (^{Grajales et al., 2014}). According to the results obtained in this paper, 75% of US hospitals respect, at least, four indicators concerning branding actions, which means that they are committed to the professional management of social media like a corporate communication tool. In other words, it seems that most hospitals analysed have already integrated an in-house corporate communication department.

Social media have become a useful tool for hospitals to disseminate health information and improve their professional relationships established with patients (^{Matarin Jiménez, 2015}). Thanks to these platforms, hospitals can improve their collective decision-making processes established between health professionals and patients (^{Lim, 2016}). Social media let hospitals to better understand patients’ expectations and needs, what is really useful to improve the hospital’s health services (^{Bubien, 2015}). Hospitals implement knowledge management programs for correctly using all information disseminated on Twitter and help health professionals improve their performance (^{Rozenblum and Bates, 2013}). According to results obtained in this paper, we wanted to highlight the case of Mayo Clinic (1.906.623 followers), Cleveland Clinic (1.753.138 followers) and Dana Farber/Brigham Women’s Cancer Center (18.904 likes): these hospitals manage efficiently to engage theirs patients in an active way, what allows them to access many information about these patients.

Patients use several indicators to evaluate hospitals’ quality, such as their presence on social media platforms, the information disseminated in these platforms and the kind of interaction that these organizations establish with stakeholders (^{Huesch, Currid-Halkett & Doctor, 2014}). Several studies found that suggestions and opinions disseminated by stakeholders through social media influence patients’ perceptions and their satisfaction with the hospital’s health services (^{Bardach et al., 2013}). In order to improve patients’ perceptions, hospitals can implement a strategic approach for using social media as a true corporate communication tool (^{Park, Rodger and Stemmle, 2013}). Thanks to these platforms, hospitals can improve their reputation; however, to do that, they must disseminate accurate information useful for all stakeholders (^{Gurau, 2013}). Although these organizations can use social media to communicate with stakeholders, the real goal is to promote their reputation and influence their perceptions (^{Tsimonis and Dimitriadis, 2014}). Hospitals’ reputation is an extension of the organization’s legitimacy to carry out its professional activities: research, medical assistance, event, health education, etc. (^{Blomgren, Hedmo and Waks, 2016}). Increasing the number of subscriptions, lists and tweets could help hospitals influence stakeholders’ perceptions and improve their own reputation; that is why is interesting to show the case of US Norris Cancer Hospital - Keck Medical Center USC (171.375 subscriptions), Universtiy of Michigan Hospitals and Health Centers (56 lists) and Cleveland Clinic (43 632 tweets).

Despite the interesting results provided by this paper, we can point out several limitations, such as the lack of information about hospitals’ online communication strategies (Facebook, Instagram, etc.); the impossibility to analyse how each hospital organises its Corporate Communication Department (employees, budget, processes, etc.); or even the difficulty to access similar scientific studies in other countries. However, this paper raises future avenues of research such as the training of health professionals in online communication skills, the use of Twitter as a strategic tool to promote hospitals’ brand reputation, or the impact of this social media platform on patients’ attitudes during their medical consultation at hospital. The main contribution of this paper is to highlight that Twitter is a corporate communication tool able to help hospitals dynamize their online strategies and build their brand in a collective way along with their stakeholders.

Conclusion

In the hospital context, social media have become one of the main corporate communication tools. Thanks to these platforms, hospital can improve patients’ commitment, dynamize their online communication strategies and reinforce their own corporate reputation. Twitter allows hospitals to promote their brand to different internal and external stakeholders and build an unambiguous, credible company. To do that, these organizations implement some trendy initiatives such as integrating social media platforms and corporate websites or using health professional’s image to promote the hospital’s corporate brand.

In order to conclude this paper, we propose three recommendations or managerial implications. First, hospitals need to carry out a strategic reflection before implementing any initiative on Twitter: they must define key aspects such as their communication objectives, main and secondary targets, brand positionings, or key performance indicators. This strategic reflection is led by the Corporate Communication Director, but all the hospital’s employees should take part to that. Second, as shown by results obtained in this study, Twitter has become a corporate communication tool used by the most important US cancer hospitals. However, these hospitals must still improve several aspects such as the integration of Twitter with other social media platforms, their own corporate website and their mobile applications. Moreover, they should promote videos as a communication support for explaining pathologies and treatments, and increase health professionals’ participation on this platform. And third, the collaboration between health professionals and experts in communication is essential to help hospitals monitor all conversations on Twitter in order to make sure all information disseminated is accurate from a scientific point of view. Nevertheless, hospitals should apply codes of ethics in order to respect patients and health professionals’ privacy.