Ongoing treatment

One often overlooked aspect of America's ongoing health care crisis is the disappearance of the nation's rural hospitals. Rising health care costs, shrinking small town populations, a long-slumping agrarian economy--all have taken their toll on hospitals in outlying areas. According to American Hospital Association figures, 330 rural hospitals closed between 1980 and 1990, trimming the number of rural facilities by over 14 percent.


One facility in west central Arizona is aiming to stem that tide, and marketing research is part of its plan.

Located in Prescott, about 100 miles north of Phoenix, Yavapai Regional Medical Center (YRMC) is a full service community hospital staffed for 87 beds. The hospital draws patients from a population base of 65,000. (Prescott's population is about 25,000.) Its proximity to Phoenix makes the region a convenient weekend destination for that city's residents. The Prescott area is also a popular choice for retirees, who, along with other newcomers, contribute to the area's steady growth.

Though YRMC is the only health care facility in its area (with the exception of a nearby veteran's hospital) it must compete, in a sense, with health care providers in Phoenix. Some residents choose to drive there either for specialized services that Yavapai doesn't offer or because they don't have a local physician.

Because of this competitive situation, the hospital uses a regular cycle of surveys to gauge community awareness and perceptions of the hospital. These help determine what kinds of marketing efforts to undertake, says Robbie Nicol, YRMC's director of development and community relations.

"In a smaller community, it's easier to make assumptions about our market and those assumptions are not always accurate. That's why it's important to stay in touch with all the publics, not only the patients but the family members, the employees, and the people who haven't had any recent contact with the hospital. We're not just listening to one segment. We're trying to listen to everybody."

Survey of voters

The importance of listening to the market was made clear in 1986, when YRMC used a survey of local voters to help pass a bond election that would ensure funding for completion of a renovation of the hospital.

Though the hospital receives no tax support from area residents, the hospital district operates as a public body, hence voter approval was needed to pass the bond measure. The hospital commissioned a telephone study with voters that Nicol says was critical to the development of a campaign for bond passage that would convince voters.

"I knew I had to have some information about the community's perceptions and attitudes before I could begin to design any kind of campaign. I genuinely do not think that it would have been successful without the information that the research was able to provide," Nicol says.

Chris Herbert, now president of The Insight Group, a Phoenix -based research and consulting firm, designed the bond issue survey for Yavapai while employed by another firm. He says that the survey was designed to find out how people reacted to the bond issue and to determine the arguments that were most likely to sway people to vote yes. "The initial survey data was encouraging but nothing near a slam dunk. Just over half of the respondents were in support of the bond, 20% said they'd vote no, and 25% were undecided, so the vote shift could go either way. The hospital had to find out what messages the voters needed to hear about the bond issue to assure passage."

Tax support

From the survey process, the hospital learned that residents had a number of misperceptions about the amount of tax support YRMC received. "We still struggle with the misperception that we're tax supported, even though we've never received any tax revenue since the district was formed in 1960," Nicol says.

In addition, the hospital found that it had some misperceptions of its own. For example, YRMC was proud that its rates were much lower than the statewide average and in comparison to other rural facilities, but this wasn't important to residents. "I think that's because health care is expensive and it's not relative in the minds of the consumer. Although some do shop around for health care, when it's a friend or a loved one, people want the best care they can get," Nicol says.

"That's when I first realized that the community does not think like we in hospital administration think. We were so proud that we had kept our rates low and in fact that probably ended up hurting us in the long run because in the last few years we've spent a lot of time playing catch-up with our rate increases."

New study

The bond issue passed, and the new section of the hospital has been open since late 1989. Earlier this year, YRMC commissioned The Insight Group to conduct a more marketing-related survey to examine resident impressions of the hospital and determine if the renovation has had a positive impact on community perceptions of the hospital.

"The main goal for the newest study was to find out how the image of the hospital had changed. At the beginning of this year we launched a vision for the hospital. We've done a lot of work internally with the employees and the department managers and we were interested in knowing if that work has had an impact on how we're perceived by the patients and the community at large," Nicol says.

For the latest survey, 400 heads of household were interviewed by telephone. Because of the likelihood that hospital employees or their family members might be interviewed, the hospital provided The Insight Group with a list of telephone numbers of employees, hospital board members, and doctors to eliminate them from the sample.

The survey was presented to respondents as a survey of current issues in Yavapai county, including public attitudes towards health care in the area.

Respondents gave their opinions on:

  • overall quality of hospital care in the area
  • perceptions of the physicians
  • changes in their impression of the hospital over the past three years
  • reasons for deciding to use one hospital over another

A number of questions dealt with where the respondents went for their own health care or where they would go if they needed it. "It's only 90 minutes to Phoenix, so some people go there," Herbert says. "They feel that the hospital in Prescott can't meet their needs. In some cases that's true but YRMC is certainly equipped to do a number of different procedures and tests and they have the ability to provide a more personal level of care in a more caring atmosphere closer to the patient’s home."

During the survey, respondents were given a hypothetical situation: If you or a family member faced a hospital stay of a week or so, which hospital in Arizona would you choose? "We specifically tried to understand why people made the choice to go to the hospital in Prescott versus a hospital in the Phoenix area. And we found in many cases that it was a result of personal experience or some sort of reputation that the hospital had. People were saying, 'I had good care there' or, 'They treated a family member of mine well.' Conversely, individuals who chose motto go to the hospital tended to do so on the basis of the perceived quality of care, either from personal experience or from hearsay," Herbert says.

Findings favorable

In general, the findings were favorable toward the hospital. Respondents who had been hospitalized at YRMC tended to rate the hospital and its staff highly. The hospital received somewhat lower marks from people whose friends or family members had been treated at YRMC.

"Some of those reactions might be caused by the fact that people feel helpless and anxious when they see a friend or loved one hospitalized," Nicol says. "That may lead to a propensity to be more critical, but I think there are things we can do to help people feel less anxious and more comfortable with the care their loved ones are receiving. The research gave us very good information and we plan to pursue that with focus groups so we can get more information to find out what we can do to improve things in the eyes of the family members."

Herbert says that these visitor reactions to the hospital's care concur with information he has obtained from prior research about patient expectations in a hospital stay. "Often it seems that the patient is more satisfied with the experience than is the person who's watching the patient. There's a lot of empathy on the part of the individual who is watching the patient. They tend to be much more critical of any little thing that happens.

"These findings show YRMC that they have a good opportunity to help to manage those expectations and that whatever they can do to make those family members and household members feel positive about the hospital experience helps their general impression in the community. Those people are liable to go out and speak well of the hospital."

Reservoir of goodwill

The hospital appears to have a reservoir of goodwill in the community, because even respondents who offered criticism said they maintained a positive view of YRMC. "They would tell us they had a favorable impression of the hospital and they would also tell us some negative things," Herbert says. "I interpreted that to mean that they were trying of give constructive criticism. They said the hospital is good, but it could be better, and here are some areas where it needs to improve. That information will help the hospital go out into the community both by mail and in person to educate the public about the facilities and what they're doing to improve them."

About ten percent of the respondents had no impression of the hospital, which may be because new residents are always moving into the area, Nicol says. "We're a fast growing community, and that means there's a challenge for me in getting information about the hospital out there." This includes mailing a newsletter to 35,000 households, and working with local banks, realtors and even the Welcome Wagon to promote the hospital.

The most common response of people who had a better impression toward the hospital was that it looks better. "People felt better about the hospital because of the facade, but many didn't know what was behind that. They didn't know about the improved quality of the surgical suites, the new equipment, the rooms. So I think there's an opportunity there for the hospital to get the word out: it not only looks better, it is better," Herbert says.

"We found that no matter what the facility, equipment or other amenities, it really comes down to the staff and the perception of the quality of care overall. People want high-tech, but, as the saying goes, they also want high-touch."

Patient satisfaction surveys

Along with embarking on a regular schedule of research on community perceptions and awareness of the hospital, YRMC also began distributing patient satisfaction surveys over a year ago. Positive comments are shared throughout the facility and included in the employee newsletter. For negative comments, the departments are consulted individually, Nicol says.

"We know that we're far from perfect. We have patient complaints just like everybody else does. It can be easy to feel threatened by the things that come back from the research but I think instead we should try to look at them as areas that we can improve on."

YRMC appears to have a large enough population base to draw patients from and its research shows that the community values its presence. Fund-raising efforts are also going well. So the threat of closure doesn't seem likely. But Nicol says the hospital will keep working to stay in touch with the community. "Rural hospitals have to operate on a tight budget, so sometimes we feel like we can't afford to do market research. But I maintain that we can't afford not to."