Reputations Work from the Inside Out: Lessons Learned from a Father's Final Hospital Stay

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Perhaps it is common knowledge in our business that the reputations our organizations have earned more than likely are justified. In simplest terms, either the organization has done something or has not done something to deserve the reputation it gets. Often, when clients hire PR consultants, the assumption is the one thing the organization has not done is communicate effectively and that improved communications to key external audiences is the solution.

Oddly enough, this was on my mind as I sat alongside my dying father earlier this year. It's impossible for many of us to entirely separate ourselves from our professions when we aren't at work, and I'm no different.

So, I sat in hospital rooms, waiting rooms and offices, intensive care units and emergency rooms, assisted-care facilities, and more hospital rooms. I interacted with everyone from the janitorial staff to nurses, nurses' aids, cardiologists, social workers, and general practitioners. My family rallied around my father, and each of us had his or her own observations, which shaped our perceptions of the healthcare providers, the institutions, and the system that was charged with my dad's outcome.

If this experience served any benefit to my work, it reminded me that reputations, both good and bad, are earned from the inside out, and no amount of public relations targeting external audiences can compensate for this.

Sparing you all of the details, my father's story may serve as a good illustration of how one industry — healthcare — and one hospital have contributed to their reputation problems.

Systemically, perhaps the root of the larger problem is how accountabilities are widely fragmented and shared. With no one being ultimately responsible for the outcome of the individual patient (reducing legal liability exposure), the assembly-line system for care seems designed to serve the business and fiscal needs of the system rather than the patient. At the ground level, however, pointing to systemic problems provides no solace.

My Father's Final Stay

My father was admitted to the hospital because of a fracture to one of his vertebrae. Two days later, he went through a series of tests and was put on oxygen. Apparently, his lungs were failing him as well. No one suspected this, including his regular doctors, even though he had kept regular appointments with them every few months.

Diagnosis: pulmonary fibrosis, a terminal lung disease he probably had for years. Being laid up because of his back injury only complicated his condition.

During his month-long deterioration, I learned why people hate going to hospitals. It's not just that people don't like being sick; it's also because we hear anecdotes of people coming out sicker than they were when they went in. There's a perception that the healthcare system plays a role in this process. After what I saw firsthand, I admit I wonder about it myself.

I watched nurses and other hospital staffers ignore and not document my dad's lack of appetite as required. I watched them serve him meals with high sugar content, even after his blood levels showed a spike in a diabetic condition he never had before being admitted to their hospital.

Routinely, I saw doctors and nurses come and go without having checked his chart yet issuing change orders to medication, removing and replacing medicine that caused further complications. Each doctor or nurse looked at his or her own piece of my dad's case, but no one took responsibility for the whole. Later in the year, it was my mother's turn at another hospital. Eventually, she recovered, but the pattern was the same.

Most disturbingly in my dad's case, I saw how staff members routinely ignored him when his family — his group of advocates — wasn't around. The cynic in me suspected that in the event my 82-year-old father developed an acute crisis, it would have been easier for the system to allow things to run their course than to try to interfere and save his life. In the end, the justification would have been "He was old, and when we last checked on him he was doing fine. We had no idea, but the obvious cause of death was his age and various health conditions" (i.e., "Not our fault").

After one such acute incident, our whole family had a wake-up call. We realized if we left it to the healthcare professionals, our father would die more quickly. He would have no understanding of what was happening to him and would be scared, confused, and hopeless.

We determined that our dad would need a family member, an advocate, to be in his room as much as possible. We realized that there would be a need for a good cop (my sister) to schmooze the hospital staff to ensure my dad received the kind of attention we thought all patients deserved. She regularly delivered homemade cookies to the nurses' station. And we realized there would be a need for a bad cop (me) to crack the whip if we felt a sense of urgency was required, and it was required.

The hospital staff responded to this approach, and during the last two weeks of his life, my father received the best possible care. Ultimately his death was unavoidable, but the process of his dying could be influenced. What we were able to accomplish was to give him a final two weeks that were not without hope, comfort, or clarity. He knew what was happening. He had time to make peace, but he was able to do so in spite of the hospital where he spent those last days, not because of it.

Bedside manner is something we may envision as a soft tone and comforting style doctors should use with patients literally at their bedsides. What I saw, however, was that bedside manner extends to the hallways and doorways of hospital rooms, to how hospital staff members talk amongst themselves within earshot of patients and family and how they handle direct communication with family and patients. Timing is critical.

In one instance, I — a family member — watched a doctor who knew my dad had only days to live condescendingly lecture him on his casual use of the term "nursing home" as opposed to the politically correct term "assisted-care facility." While standing in the doorway to my dad's room, another doctor briefed a colleague frankly, saying, "This one isn't doing too well," and immediately went to my dad, paper in hand, and asked him in a patronizing tone to sign a "code status form," which was her euphemistic way of saying, "When you start to die, do you want us to bother trying to resuscitate you?" He heard everything and got the message loud and clear.

The Lasting Effects for This Hospital

Family members live with memories of hospital stays like this for the rest of their lives. These memories are indelible, to say the least, and they are the foundation of perceptions that cannot be reversed by a big-budget PR program.

Taking a cursory view, as the healthcare system does in situations like this, my dad's case was typical for an elderly patient. Medically speaking, his obituary was as common as most of those you find in the daily newspaper. But his immediate survivors, those who witnessed what was described here, number roughly 20. These are 20 individuals who came away with their own negative perceptions of the care of their loved one. They will share this story with friends and families for years to come.

Imagine the long-term reputation-related consequences for hospitals like this one as other families endure similar experiences. Opinion surveys, news releases, websites, and community outreach programs cannot compensate for this. Pointing fingers to a system comprised of insurance companies or "other" hospitals or painting a few doctors or nurses as the exception rather than the rule is no excuse.

If this hospital is to correct its fundamental reputation problem, it has to start with me, the family member. It has to prove it is making fundamental changes to ensure that the doctors get it, that the nurses get it, and that no matter how old the patient is or what his health condition and prospects for the future are, in every instance, every day, he will be treated like a valuable person, a life worth saving, even if it's for a few extra days or weeks.

In the world of communications, acts are priceless, and that is where reputation begins. It starts from the inside out, and it must be consistent. Firsthand experience makes the strongest impression, one person at a time.

Copyright PRSA. Reprinted with permission by the Public Relations Society of America (

About the Author

Tim O'Brien is principal at Pittsburgh-based O'Brien Communications and can be reached at
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