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Best Practices in Public Reporting No. 3

How to Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies

The purpose of the Best Practices in Public Reporting series is to provide practical approaches to designing public reports that make health care performance information clear, meaningful, and usable by consumers. Report 3 applies social marketing and other principles to explore how to target reports to specific audiences, develop messages to promote the report with key audiences, engage consumer advocacy and community groups in promoting reports and helping people use them, disseminate reports through trusted channels, and ensure that consumers see and use comparative quality reports.

Select for Report 1 (on presentation of comparative health care performance data) or Report 2 (on effective use of explanatory information).

Select for print version (PDF File, 135 KB; Plugin Software Help).

Prepared by Judith Hibbard, Dr.P.H., and Shoshanna Sofaer, Dr.P.H., Center for Health Improvement.

Prepared for the Agency for Healthcare Research and Quality, Contract No: HHSA290200710022T.

Purpose

The purpose of this guide is to help report sponsors promote and disseminate comparative quality reports to the public. The guide contains 10 evidence-based recommendations. Intended audiences include Chartered Value Exchanges (CVEs) and other community collaborative. The guide also may be of interest to States, health plans, and purchaser and consumer groups involved in the design, production, promotion, and dissemination of comparative health care quality and cost information for consumers.

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Value of Effective Public Reports

According to a recent poll from the Kaiser Family Foundation, 30 percent of Americans say they have seen information comparing the quality of different insurance plans, hospitals, or doctors, while only 14 percent have used such information.¹ These figures are slightly higher than in surveys conducted in previous years. For example, a 2007 survey by Harris Interactive on behalf of the California HealthCare Foundation revealed that 23 percent of respondents had seen hospital comparative quality reports.²

Consumer use of reports can influence quality in at least four ways:

Increase consumer understanding of dimensions of quality that are relevant to their needs. Consumers can use their expanding understanding to obtain high-quality health care for themselves and their family members, not only when they choose providers but also when they use health care.
Stimulate quality improvement among providers (in more competitive markets) if they perceive that performance data may affect consumer choice and, thus, their market shares.
Encourage purchasers and health plans to use higher quality providers in their networks.
Affect the public image of clinicians and facilities, by clearly identifying their performance compared to their peers. This has been demonstrated to encourage them to improve the quality of care they provide, to protect or enhance their reputations.^3,4

As a result, gaining broad awareness of public reports on quality through effective promotion and dissemination is part of an overall strategy to improve health care. This report, which is organized around 10 recommendations, is intended to help report sponsors, including CVEs, achieve this goal.

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Why Promotion and Dissemination Are Critical to Effective Public Reporting

It is essential that sponsors enhance public awareness of comparative quality reports and the benefits consumers can derive from using them. Report sponsors invest substantial time and valuable resources in designing and producing comparative quality reports. In the first two reports in this Best Practices series, we shared insights into how to produce a report that people can understand and use. But if consumers do not know about public reports, they will never see them. If they never see them, they cannot use them. And if they do not use them, there is no return on those investments.

Few, if any, sponsors have been fully successful in expanding access to and awareness and use of quality reports whether they use a print or Web format. There are several reasons for this problem: poor promotion and dissemination of reports; flagging awareness among consumers who heard an initial announcement about a report and then forgot about it; lack of consumer interest in the providers measured or the measures reported; and poor report design.

Little research exists on how to promote and disseminate quality reports; however, there is much to learn from social marketing and Web marketing. In this report, we will apply key insights and strategies from those fields to the challenges of getting comparative quality reports seen and used by the public. This is a tough job, but there are steps sponsors can take to reach more of the people who need to see and use reports.

In the following sections, we offer 10 recommendations for handling specific challenges:

Plan from the outset for promotion and dissemination.
Identify your audience as early as possible.
Engage those who can help you learn about and reach your audience.
Use the insights of social marketing.
Be strategic about timing.
Be strategic about positioning.
Actively work with media to promote the report.
Use advertising to promote the report.
Use outreach to promote the report and facilitate its use.
Gather and analyze feedback on the report and its promotion.

We also encourage report sponsors to share what they learn with each other as they take on this task.

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Recommendation No. 1: Plan from the outset for promotion and dissemination

It is critical to address how to promote and disseminate your comparative quality report in the beginning stages of the planning process. Time and resources must be budgeted at the outset as part of the entire public reporting process. In addition, it is best to pursue partnerships that will be important for the end tasks of promotion and dissemination before making major decisions.

Some of the most important resources to help with promotion are people. It will be critical to create a team with expertise in media relations and marketing, especially social marketing; advertising and promotion; and Web-based promotion and analytics. Some CVEs, such as the Puget Sound Health Alliance, have found it useful to create a multistakeholder communication committee that includes representatives from consumer groups, physicians, hospitals, employers, unions, and government agencies.

Many potential partners may have deep experience in these areas that can be applied to promoting comparative quality reports to consumers. For example, private sector purchasers have staff or other resources with marketing, advertising, and Web expertise. The Cincinnati CVE, Health Improvement Collaborative of Greater Cincinnati and HealthBridge, is fortunate to include Proctor & Gamble, a major consumer products firm with extraordinary expertise in marketing. Proctor & Gamble assigned one member of its staff to work with the CVE for 18 months on promotion and dissemination issues. In addition, the company helped the CVE develop its Web site. Public and nonprofit organizations also have expertise in media relations and social marketing, as well as skill at marketing with limited budgets.

In putting together a multistakeholder partnership, it is also imperative to include those who serve, can reach, and are trusted by your audience, in particular consumer and patient organizations. Involve them early and ensure that they have a clear voice in decisions. These organizations are not likely to participate as productively and completely as you would like unless they believe they are viewed as essential to the process, rather than an afterthought.

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Recommendation No. 2: Identify your audience as early as possible

Sponsors must identify, and get to know, their audiences as soon as possible to ensure effective promotion and dissemination of comparative quality reports or cost information.

Whom do you want to reach? Often, sponsors say they want to reach everyone in the community. While this is admirable, it may be self-defeating, at least in the short term. Marketing professionals know that "audience segmentation" is essential for effective promotion of any product or service.

We are a highly diverse society. People's needs and interests differ. A message that reaches older rural Americans, for example, will not necessarily work with the urbanized Facebook generation. Women respond differently than men. People from different ethnic groups have different beliefs and values about health care that will significantly influence both what to emphasize and where to place your messages.

The nature of the information provided also points to the audience. Information about primary care physicians implies a broad audience. Data that relates to nursing home quality suggests a narrower audience: those likely to be admitted to a nursing home, plus those who help them make decisions.

So, while planning, sponsors should think carefully about priorities in terms of audience. A CVE's mandate is important, but within the context of a mandate for a public report, there are options. Report sponsors may choose to target audiences who:

Need the information the most.
Will be easiest to motivate to look at and use the information.

These groups are unlikely to overlap completely, so tradeoffs will be necessary.

Reach those who need your information the most

Our first instinct in health care is to help those whose need is greatest. Sponsors may want to target reports to people whose health problems are most pressing and serious. Comparative quality information is likely to be of high interest and significant value for them. They use a disproportionate amount of health care services, so influencing them also has a high potential impact.

People with chronic conditions may be a very important audience, but reaching them is not without challenges. People who are extremely ill may not have the energy and focus to examine comparative quality reports, even those that contain data specific to their condition. This suggests the need for a broad reach to include the people in your audience who help those who are very ill, frail, cognitively impaired, or otherwise unable to use your report.

An ideal audience for public reports on comparative quality is one that contains people who are not seriously ill but who know they will be using health care in the next few months or year. Here are three examples: (1) women who are pregnant or planning to become pregnant very soon; (2) people who are planning to have elective surgery, such as joint replacement, as soon as they absolutely have to but not right away; and (3) people who recently moved to a community and need to find a primary care provider. Even in these cases, you may need to extend the audience to include family members and close friends who can help fragile consumers deal with their health problems.

Target those who are easy to reach and motivate

Evidence indicates that people can be divided into two basic groups, sometimes called "monitors" and "blunters," with respect to their use and processing of information about health.^5,6 Monitors generally want all the information they can get; blunters, if they want to know anything, only want the basics, and may actively want to avoid things that are frightening. Especially at the outset of your reporting efforts, focus on the monitors, while also including information on the "basics" for the blunters. Even information-hungry monitors will look only at information that is of immediate relevance to their concerns. They will search for your reports, but they must be easy to find. (Recommendations 7 and 8 discuss strategies to enhance visibility.)

There are fewer monitors than blunters in the world, and monitors are more likely than blunters to be literate, health literate, and skilled at using the Internet. The idea of narrowing the initial focus to monitors can be disturbing to those who believe it is essential to reach the less literate groups in their communities. The reality is that less literate consumers not only have difficulty using print or Web-based reports but also are unlikely to consider looking at quality reports in gathering information. This does not mean that blunters are not motivated to get good health care for themselves and their families, just that the pathways to reaching them are different than for monitors.

It is important to make reports as easy to understand as possible for people with lower levels of education. Still, people in this group are most likely to seek information from media that do not require them to read and understand text and graphs. Such media include radio, TV, and perhaps most important, other people. To reach less literate groups, or groups that are more comfortable speaking a language other than English, the strategies presented in Recommendations 3 and 7 are essential.

Promotion and dissemination efforts also should target those who can influence others because they are trusted sources of information. People ask friends and family for health care recommendations, and they can extend a report's influence. People who are highly engaged in health issues and are natural helpers are likely "early adopters" of new health information.

Heightening awareness of your reporting among this group through community organization newsletters, health-related blogs, or other media can provide an avenue into hard-to-reach groups. Keep in mind that a "trusted source" can vary by topic. For example, consumers may trust physicians for reports on clinical issues and look to health plans for information on medical groups.

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Recommendation No. 3: Engage those who can help you learn about and reach your audience

Multistakeholder sponsors, such as CVEs, must strategize from the outset about how to include organizations that are knowledgeable about and trusted by their report's intended audiences. Many groups can help: Employers can help reach their employees and their families; health plans can spread the word to their members; and providers can contribute to getting out the word out to patients. However, the stakeholders that are especially important to help you learn about and reach your audience are consumer and patient advocacy groups⁷:

Consumer advocacy organizations that serve women, children, older adults, members of minority groups, and labor members, such as:
- AARP.
- AFL-CIO.
- NAACP.
Organizations that serve these populations, such as:
- The Arc (the world's largest community-based organization of and for people with intellectual and developmental disabilities).
- Area Agencies on Aging and others in the "aging network."
- Easter Seals and other disease-specific groups.
- YWCA and YMCA.
Faith-based organizations, such as:
- Churches.
- Mosques.
- Synagogues.
Broad-based or policy-focused organizations, such as:
- Citizen Action.
- Consumer's Union.
- Kiwanis Club.
- League of Women Voters.
- Lion's Club.
- Literacy Council.
- Neighborhood associations.

In addition to their other considerable contributions to reporting efforts, consumer-oriented organizations can be a key resource for ensuring effective report promotion and dissemination. Community groups that advocate or provide support for people with the kinds of conditions measured in specific quality reports could make a substantial contribution. Partners with special access to groups you want to reach, such as minorities, older adults, parents of young children, people who prefer speaking a language other than English, women, or consumers in rural areas, can become critical "information intermediaries" who do hands-on promotion and dissemination of reports and, in some cases, help people use and understand them. The following list of "Roles of Information Intermediaries" was adapted from a report on the subject for people on Medicare.⁸

Roles of Information Intermediaries

Promote and Disseminate Information

Promote the availability of information, assistance, and decision support.
Disseminate information "broadcast" through one or more channels.
Disseminate information to particular groups of people in a more tailored and customized manner.
Legitimate the trustworthiness and usefulness of information materials and sources of information and decision support.

Connect Specific Individuals With Information When Needed

Identify specific individuals who need information and decision support.
Refer people to appropriate sources of information and decision support.

Provide, Explain, and Apply Information to Specific Individuals

Educate and inform people through person-to-person interactions.
Help people understand and interpret comparative information.
Help people apply information to their own circumstances.

Provide Decision Support

Help people identify what is most important to them in choosing a health plan or provider and the constraints they face in making a choice.
Help people on Medicare narrow the number or range of options, consistent with what is most important to them and the constraints they face.
Recommend more desirable options, there in general or based on the individual's characteristics and preferences.

These organizations also can help conduct formal and informal audience research to identify the kind of report to use to attract those you want to reach. Reports will be more likely to resonate with the public if they address the providers people are most interested in learning about and include measures that are important and make sense to them. Clearly, these are "up front" questions. In addition, audience research can help identify modes of dissemination most likely to reach people, benefits to highlight in promoting the report, and barriers to overcome in raising awareness and achieving access, as well as what will make consumers most likely to trust the report.

When seeking to involve those with special access to your audience, you cannot start too early, especially if your intended audience is vulnerable or often ignored. If people think they are being included only after many of the important decisions have been made, they are less likely to support the efforts. They are not interested in being a rubber stamp and may be quick to think they are being used.

Also consider reasons these organizations might be persuaded to work with you. Identify the benefits for them, including but not limited to serving their constituencies well. Many have limited resources and may need some type of compensation for the time they contribute.

Finally, treat community-based, consumer-oriented organizations with respect. Value and recognize their opinions and recommendations equally to the input from stakeholders that may bring more technical expertise to the table. These organizations' expertise is different, but just as necessary for successful reporting. They know and understand the people you want to reach.

Do not forget about secondary audiences

Keep in mind that in addition to your primary consumer audience, you may have important secondary audiences. One important secondary audience is made up of those being rated, and they should receive the report before it goes public. There are two ways to share the report. In both cases, providers receive their own data and information about how they compare to other nonidentified providers and to whatever you are using as a comparator (the average, the top fifth of the score distribution, etc.) before the report goes public.

In one scenario, a hiatus, perhaps 6 months, follows provision of the initial data to providers. Then, a second round of data collection is completed, and these are the data reported to the public. This approach is particularly appropriate the first time a set of measures is presented. The hiatus allows providers to work on performance problems they are made aware of from the first round of data collection before the second round begins. Evidence indicates that this approach drives a significant focus on quality.⁹

In the second scenario, after providers receive their own data and the deidentified data of other providers, they are given an opportunity to correct any problems in the information before it is reported publicly. As noted in Best Practices in Public Reporting No. 2, some sponsors permit providers in these circumstances to publish their comments within the report.

Secondary audiences also exist in areas where elements of health care delivery interact. For hospital ratings, physicians constitute an important audience, since they admit patients to hospitals and refer patients to specialists who have privileges at one or a very small number of hospitals. It is not likely that physicians will change referral patterns overnight, but if some facilities perform poorly and do not improve, they may reconsider their relationships and referrals. PacifiCare Health Systems has some experience providing incentives to physicians in their network for referring to hospitals that provide higher quality care.¹⁰

It is also important to include physicians because patients may ask them about ratings. From interviews with physicians, we know they are interested in being informed about public reports of hospital quality prior to their release. They do not want to be blindsided if a patient asks about a recently issued report. While hospitals may be the most appropriate group to provide that prior notice to physicians, a multistakeholder collaborative could also be the source.¹¹

Consult with the provider members of your venture to devise the best way to get this information out in your community. A communication committee as mentioned in Recommendation No. 1 is an ideal context for this kind of discussion. In their communications, for example, the Puget Sound Health Alliance CVE creates model materials for hospitals and physicians to use in communicating about reports to their medical staff, patients, media, and others. Your reporting efforts might provide similar support to these groups with tools, such as Frequently Asked Questions, key messages, model newsletter articles, and Web site text.

Currently, most physician reports focus on primary care doctors. In the future, however, reports on specialists may become available. Since many referrals to specialists come from other physicians, a report on specialists also should consider primary care physicians as an important secondary audience.

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Recommendation No. 4: Use the insights of social marketing

Social marketing is the application of business marketing principles and strategies to promote ideas, behaviors, and services that have high societal value. In contrast to commercial endeavors, which direct marketing at convincing consumers to buy a particular product or service, social marketing has been used in health care settings to promote healthy behaviors. Examples include using seatbelts, quitting smoking, and putting babies to sleep on their backs.

The purpose of publishing comparative quality reports is not to encourage consumers to choose a particular provider or plan. Rather, it is to influence consumer behaviors in accessing reports, looking at them long enough to make meaningful comparisons, and using the information to make a decision, or in some other related way. Keep these desired consumer behaviors in mind as you develop your social marketing strategy. This may be a different kind of objective than you are used to.

Good social marketing involves:

Identifying the audiences you want to reach.
Identifying the benefits of a product or service that will be important to your audience.
Identifying when your audience may benefit most from your report.
Identifying the barriers your audience might perceive or experience in taking the action you desire.
Motivating your audience to take the action you desire.
Placing or distributing your product/service/message where your audience can find it quickly and easily and in a location that reinforces their trust in its benefits.

More information on social marketing can be found on the TalkingQuality Web site, supported by the Agency for Healthcare Research and Quality (http://www.talkingquality.gov).

Another central element of social marketing is developing key messages to use in promoting your report. As discussed in Recommendation No. 5, these key messages need to be repeated over and over again if you are to reach your audience. Messages should emphasize the benefits your audience will value most and effectively counter the barriers they are likely to perceive or experience.

As noted in Best Practices in Public Reporting No. 2, the public generally does not recognize that quality varies and that much health care is not of high quality. We recommend that this key message be incorporated into reports, right at the beginning. Evidence indicates that people respond better to messages that show them how to protect themselves from risks than to messages that show them how to "find the best."

Very often, however, stakeholder groups, especially those being rated, object to risk-oriented framing of promotional messages. In addition, some stakeholders want to emphasize transparency and the fact that new information is available as benefits of producing a quality report. They might want the report to be promoted as a way of learning how much better the providers in "x" community are compared to everyone else in the State or Nation. That approach may make sponsors and stakeholders feel good but is not likely to attract much attention in the short term.

The Puget Sound Health Alliance CVE found another approach to address this dilemma. They framed the CVE's Community Checkup report with the message that everyone in the region needs to improve. Even among those with the best reputations, no one did everything right. All providers had room to improve, and all community members bear some responsibility for problems in quality. Providers must recommend the right care; patients have to follow through. Before that happens, employers need to purchase benefits from health plans that provide coverage for the recommended service. Puget Sound found that this framing of the issue reduces the extent to which providers feel blamed for things they do not control.

Developing a well-known and trusted brand identity is another important aspect of marketing. No one can create a brand overnight. If your organization sponsors reports as one of its major activities, you may want to use your organization's established brand to promote the report rather than creating an entirely new brand. As we discuss in Recommendation No. 5, until your brand is established in the minds of the public, you may need to make creative use of the brand identity of other organizations with whom you partner. Choose to go with a partner whose brand identity gives them credibility with your audience around health care issues.

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Recommendation No. 5: Be strategic about timing

A major challenge of promoting reports is the difficulty in knowing who will be making what kinds of health care decisions at what point in time. This is particularly true of decisions about selecting clinicians and facilities. Obvious times to promote reports are when they are launched or when important information is either added or updated. Unfortunately, only a very small percentage of your audience will be making a decision at exactly those points in time. It is important to remind audiences frequently about the availability of the report and how to access it. That way, when consumers find they need the information, your report will be closer to top of mind.

Public reports on quality are new to most people and require them to enact a new behavior. Other efforts to change health-related behaviors and social norms tell us that one message, delivered in one format and through one channel, is never enough. Your audience needs to get the message multiple times in different formats, from different sources, over extended periods of time before it even begins to sink in that the report is a resource available on demand.

Effective tobacco control efforts, for example, required persistent and inescapable cues and messages in a wide variety of trusted venues and contexts over a long period of time. Strong antismoking messages were delivered by laws that restricted tobacco purchases to those older than 18 and that banned smoking in workplaces and public venues, as well as through extensive mass media campaigns. The goal of the antismoking social marketing campaign was to change social norms around smoking.

The goal of effective public reporting is to change social norms about how proactive consumers should be in making health care decisions.

This kind of all-encompassing marketing approach requires that promotion be a coordinated effort over time to reinforce key messages. Multistakeholder sponsors have an advantage since each partner may contribute to presenting key messages in different ways and venues to different groups.

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Recommendation No. 6: Be strategic about positioning

Whether you are developing a print or Web-based report, or doing a mix, it is critical to consider your audience in determining where to place your report. Your initial audience research should identify all the places people go for health information, the kind of site or location they will most likely access, and the sites they are most likely to trust.

Consider placement and links when using Web-based reports

If you are publishing a Web-based report, it is important to decide if you will create a new site for it or if you will place it on another site that is already widely trusted and used by the audience you want to reach. As mentioned above, if another organization has the right brand identity and will be viewed as trustworthy and objective by your audience, why not use their site?

A multistakeholder sponsor may also need to consider whether to locate its report on one of the major stakeholder's Web sites (and under its brand) or create a Web site for the collaborative effort. Before taking the latter approach, consider if one of the collaborative's partners is already known, trusted, and used by the audience. Consider also if it will cause problems within the partnership if one member is chosen to be "home" to the quality reports. Since most sponsors have created new Web sites for their reports, there has been little research to test the relative effectiveness of these strategies.

There is no doubt that it is useful to place links to your report's Web site on as many trustworthy and appropriate sites as possible. Pick sites consumers visit when dealing with a health problem or trying to make a decision. All kinds of organizations can serve this purpose, including consumer and patient advocacy groups, providers, employers, public agencies, and health plans; indeed, the full range of partners in the typical CVE and beyond. It is especially important to go back to the consumer and patient groups you engaged to learn about your audience and give them the opportunity to host a link to your report.

Whether or place links to your report on the Web sites of the organizations being rated is an issue that needs special consideration. For example, is it a good idea to link from a rated hospital's site to your report? Again, there is no clear evidence. Ideally, you would do this when all the hospitals rated are willing to allow the links, as you do not want to be perceived as being more influenced by some hospitals than by others.

It is best to get Web posting agreements before the ratings are out to ensure that organizations do not back out if they have relatively poor performance. In some cases, however, particularly when reports are first being made public, you may have to settle for a situation in which only some providers are willing to offer links to the report. The same approach can be taken in getting agreement from hospitals, physicians, or others to place print versions of your report, or a take-away announcement about your Web site, in their offices and waiting areas. Like so much else in quality reporting, this requires a robust relationship with providers.

Even more fundamental, it is important to design your report so that it can be found easily by consumers searching the Web for information related to health care and health care providers. This means making sure your report includes prominent use of common search terms that your audience is likely to use. So-called "search optimization" techniques, in which Web site designers use specific terms to maximize the chances that a site will come up in a search, are an important step in the report design process.

We recommend that you optimize your Web site, testing a variety of search terms prior to rollout, to see whether your report comes up and where it appears in the list of search results. If potential users have to know the name of your organization or your report to find it, you have a problem. Ideally, your Web site should appear on the first page of results from a search, as close to the top as possible. Keep in mind that this requires use of terms that might be used by people who do not know your report exists.

In addition to reaching consumers who are looking for information about quality, you want to attract those who are seeking health information but are not necessarily thinking about quality. Embedding links on related sites will help bring users to your Web site. For example, placing links to your report on Web sites that consumers visit for health information is an effective tactic for reminding them to consider comparative quality information when they are, for example, deciding on a hospital for their surgery. Consumers seek health information more often than quality information. Some will be interested in learning about comparative quality if prompted to do so.

Be aware of multiple quality reports in a single community

One of the greatest challenges a sponsor faces is dueling quality reports; the situation can undermine the credibility of all the reports. The likelihood of this occurring is on the rise, as more organizations at all levels, including some commercial ventures, get involved with quality measurement, reporting, and improvement. To effectively promote your report in this context requires that consumers understand the comparative benefits of using and believing your report. You should provide evidence that shows how your report is more complete, more relevant, and more trustworthy, as well as easier to use.

Sometimes reports may have different scores on similar measures, perhaps because of variations in specification of the measure, scoring methodology, or time period covered. This is especially confusing to the public and irksome to those rated. Before releasing a report, make sure to examine existing reports and compare findings. You will have to make an extra effort to explain the reasons for any variation both within the report and in your interactions with the community.

Other times, reports cover different measures, e.g., one reports on one aspect of quality, such as patient safety, while another reports on patient experience for an identical or similar set of providers. The best strategy in this circumstance is to work toward a collaboration in which, at least as a first step, each report references the other, perhaps links to the other, and explains that the user would be wise to look at both reports. This is not a perfect solution, as many people will be unwilling to work at integrating information from two reports. Ultimately, a fully integrated approach to quality reporting is the best solution, but this will take time, skillful negotiation, and trust among the sponsors involved.

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Recommendation No. 7: Actively work with media to promote the report

Begin early to plan how you will work with the media—both print and electronic—to promote your comparative quality report. Most sponsors typically issue a press release and hold a news conference. These steps are necessary but clearly not sufficient to yield the breadth, depth, and quality of coverage needed to raise awareness about your report.

As with other partners, start building relationships with the media as soon as possible. Identify the reporters who cover health care in the most widely trusted media in your market. Identify the radio and TV programs—particularly local programs—that address health issues. Seek out bloggers who write about health care. You need to let them know what you are doing ahead of time and give them opportunities to watch events unfold. When your data are available, you can also arrange a meeting with media representatives, individually or as a group, to preview the results and, more important, make sure they really understand what they mean.

The media want stories that will help them sell papers or get audience share and, thus, advertising revenues. The electronic media, in particular, need stories that work as "9-second sound bites." Just as it is necessary to grab the attention of consumers immediately in a report on comparative quality, it is also imperative to get to the point of your story quickly. This means you need to shape your pitch to the media as "new news."

But what is news? It has been said that "victims, villains, and simple solutions" are what make news. A horror story about a patient's terrible experience with a particular hospital is more likely to be reported than a story about the release of a report on hospital quality. It is necessary to explain the "quality story" to members of the media and entice them to cover it. In this way, you may complement social marketing efforts with what is called media advocacy or earned media by turning your messages into news. This gets them on air or in print without your having to pay advertising fees.

This approach has served key health behavior efforts extremely well. Your goal is to place periodic stories—;news and features—about your quality report. Some people think the public will respond better to your story as earned media than as paid advertising because when you advertise, it is clear you are shaping your message.

The challenge is to identify interesting and surprising findings in your report as "teasers" to interest the media without "victimizing" or "villainizing" anyone. Focusing on your data, pitch stories to the media that:

Compare your community to others.
Reveal trends as your reports are updated.
Report on improvements in quality over time and how they were achieved.

In addition to talking about report content, you also might interest the media and the public in stories about how disparate health care stakeholders reached decisions on tough issues, how individual patients and consumers benefited from using your reports, or how someone fared who wished they had used your report. A personal story will always be of greater interest than something that is abstract and general.

Craft policies to ensure consistent messaging

It is important to develop guidelines for interactions with the media, particularly for multistakeholder groups. Everyone must be on the same page and use the same key messages. Identify who the primary media contacts will be and make sure they coordinate efforts, not only at the outset but also on an ongoing basis. Keep in mind our earlier suggestions to create a communication committee and take advantage of the expertise that lives within your partner organizations. Expertise in media relations, while growing in public and nonprofit organizations, may be more established in private sector organizations, such as employers.

Consider also whether rated entities may be allowed to use selected extracts of the report in their advertising. In one of the early CAHPS® (Consumer Assessment of Healthcare Providers and Systems) demonstrations in Oregon, rated health plans signed agreements that prohibited this. They were not permitted to publish their own ratings without the comparisons; they also could not advertise the measures on which they did well and leave out those on which they did poorly.

A current example of one approach to this issue comes from the National Committee for Quality Assurance (NCQA). NCQA has issued policy guidelines that must be followed by any organization (health plan, hospital, physician practice) it accredits or recognizes in one of its programs. For example, organizations may use only the most recent results and cannot claim to be accredited or recognized unless the process is complete.¹²

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Recommendation No. 8: Use advertising to promote the report

Although we have noted the advantages of using earned media to promote reports, do not ignore paid advertising. Those who doubt their ability to interest the news media will need to depend heavily on ads. Advertising can reach broad populations, as well as target specific populations by focusing on channels and media different segments use and trust. Reach distinct cultural, regional, or age-specific audiences through newspapers, free magazines, radio spots, and TV stations.

With Web-based reports, consider advertising on the Internet to get your message out. It is possible to purchase the rights for your site to appear at the top of the list on searches involving specified key terms. Consider also buying ads on popular commercial sites (in addition to links on your partners' Web sites). Little is known about the effectiveness of Web advertising techniques for comparative quality reports. Consult Web advertising experts to define strategies that might work best given your circumstances and budget. However, here is a summary of one effort to study the impact of different kinds of advertising and promotion for a report on hospitals.

Promoting CalHospitalCompare.org

The California HealthCare Foundation (CHCF) has spent years supporting efforts to provide hospital quality information to Californians. In 2008, CHCF reported on its study of how consumers use the Internet to manage their health care.^2,13 CHCF found that in 2007, 23 percent of those surveyed had seen hospital rating information, but only 4 percent of those had considered a change in hospital choice, and only 1 percent made a change based on the ratings.

CHCF's analysis of usage statistics from its CalHospitalCompare Web site revealed a substantial number of visits. But because about half of the traffic came from visitors who had "bookmarked" the site on their Internet browsers, it was believed that industry insiders were responsible for as much traffic as consumers. In response, CHCF launched a campaign to increase consumer awareness of its Web site, hoping to drive more consumers to the site and increase their use of the data in hospital choice decisions. (Note that hospital participation in this initiative was voluntary; CHCF demonstrated the benefits of their participation by showing them that consumers visited the hospitals' Web sites as well as CalHospitalCompare.org.)

Most report sponsors do not have the resources that CHCF had to launch its awareness campaign and track the cost-effectiveness of different promotion and advertising strategies. The campaign focused on maternity care—a "shoppable" condition—targeting expectant mothers in the San Francisco Bay Area as a distinct media market. The aim was to tap into mothers' desires for information and to reassure them that CalHospitalCompare's ratings were unbiased and independent. It was primarily an online campaign, which used a strategy of placing display and text ads on local news Web sites, community participation sites, and online networks such as Google and Yahoo. CHCF purchased keywords from search engines, including the names of Bay Area hospitals, the term "hospital reviews," and terms relevant to maternity and pregnancy, such as "C-Section" and "NICU." The campaign also employed branded E-mail messages and event sponsorships.

What worked? What didn't? What was cost-effective? The campaign's display ads led to more than 14 million "impressions," or page views by individuals, and 12,000-plus new "clicks," or visits, to the CalHospitalCompare Web site. Selected search terms resulted in fewer impressions, only 1.3 million, but to more clicks, more than 13,000. Branded E-mails were not nearly as effective, resulting in 10,000 impressions and only 100 clicks. The awareness campaign succeeded in driving traffic at the Web sites of Bay Area hospitals. Indeed, page views during the campaign were six times higher than average page views of major hospitals elsewhere in the State.

Placement mattered also. Costs for online ads are based on "per million impressions" or the number of "clicks" that result from the ads. The cost for both of these actions was lowest for ads placed on search engine sites and much higher for ads on the Web sites of local newspapers. The ads most successful in generating traffic at CalHospitalCompare focused on C-Section rates at different hospitals and on "finding the hospital that is best for you." Ads that were less direct—such as those that spoke about how one typically gets more help choosing baby names than in picking a hospital—were less successful.

CHCF's campaign provides rare evidence of how to successfully build an audience for a comparative quality report, and how to encourage hospitals to collaborate in the reporting effort, as well as which promotional methods are most effective.

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Recommendation No. 9: Use outreach to promote the report and facilitate its use

Outreach in this context refers to working with and through other organizations who have an ongoing relationship with one or more of your target audiences to help deliver your message. Outreach is an essential complement to media coverage and advertising in any promotion and dissemination strategy. As noted earlier, it is critical to build and sustain relationships with those who, in the natural course of daily life, interact with your audience. There are dozens of such organizations, large and small, public and private, nonprofit, and affiliated with churches and other religious organizations. Recommendation 3 has an illustrative list of such organizations.

For multistakeholder groups, partners are key. Employers can help reach workers and their families; labor unions can help reach their members; and providers (hospitals, physicians, community health clinics) can help reach their patients. Public agencies can help reach those they serve, whether these are people with Medicaid coverage or people who use public health services; condition-specific advocacy groups can help reach specific groups of patients and their caregivers; and so on.

Tap existing networks

It is likely that you will need to reach beyond your partners to gain the widest possible awareness of your report. To reach seniors, for example, take advantage of State AARP chapters along with what is called the "aging network," the vast array of primarily small- or medium-size agencies that serve the social and health needs of elders. In many communities—especially those of color—faith-based organizations can be of great assistance. Social clubs and service clubs exist for all kinds of cultural groups in your community. This is where people congregate, where they chat, and where they expect to get information that is in their best interest.

Educational institutions are natural partners; this does not just mean elementary and high schools, but also community colleges, adult education programs (including those who provide classes in English as a Second Language), daycare centers, and after school programs. Programs directed toward children provide a great way to reach out to parents, especially if your report includes measures of health care for children.

The impact that effective outreach can have is exemplified by the outreach efforts made when the State Children's Health Insurance Program (SCHIP) began more than 10 years ago. States eager to enroll as many eligible children as possible used the full range of organizations discussed above and more to get out the word about the then-new program. Those who did more outreach enrolled more children.^14,15

When reaching out to these groups, it is critical to demonstrate that you have no "ax to grind" and that your report is not a form of advertising for any particular insurance company or medical provider. Similarly, you must show how the organizations and their members will benefit from working with you. Work collaboratively with these organizations to identify the best tools for reaching their constituencies. And do not be surprised if they propose face-to-face contact instead of, or in addition to, the use of pamphlets, brochures, posters, and other written materials. They also will want materials that are user friendly. Indeed, staff of community-based organizations may be an excellent source of feedback on your report; if they do not find it compelling, relevant, and easy to understand and navigate, chances are their constituencies will not either.

Do not forget libraries

Last, but by no means least, public libraries offer important promotion and dissemination opportunities. Libraries are all about access to information, and most libraries today realize that a significant part of their service to the public is to help those caught in the digital divide gain access to both print and Web-based information. At least two CVEs have experience working with libraries for this purpose: Puget Sound Health Alliance and Pittsburgh Regional Health Initiative.

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Recommendation No. 10: Gather and analyze feedback on the report and its promotion

Given the investment of time and effort in a public report, sponsors should have a mechanism to assess its impact. Knowing how many people a report reaches, whom it reaches, and how it is received and used will be helpful in refining future versions. Simply tracking online "hits" offers a rough gauge of use of Web-based reports. It also is possible to track more detailed information, such as pages viewed, time spent per page, and links that produce the most traffic. Many sponsors of Web-based reports take advantage of the extensive free tracking and analysis services available. However, to understand how people respond to and use the Web site, other methods are needed.

A survey built into the Web site is one possible feedback mechanism. Focus groups with key audiences will provide information about how well the report meets the needs of those subgroups. Community partners, such as employers, payers, and community organizations, may help by recruiting their members to participate in focus groups. Conducting two to four focus groups involving five to 12 participants each can yield a great deal of useful information.

Similarly, some community partners, such as employers or unions, want indepth information about their employees or members. In surveying their employees or members, they may be willing to include questions about awareness, use, and perceived value of the comparative quality report. These kinds of efforts may contribute to your overall assessment and provide insights for improvement.

Sponsors may seek to learn how easy or difficult it is to use their Web site, as well as inquire about what consumers find useful or not useful and what kind of additional information they would be interested in seeing in future reports. Information about how users heard about the report will help sponsors refine efforts to attract new users to the Web site. Similarly, quotes from users in focus groups and interviews may be useful to include in the promotion materials for future releases of the report. Finally, tracking media coverage of the report will indicate the level of public awareness, as well as help sponsors understand how the report is being portrayed to the public.

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Purpose of Report Series

The purpose of this three-part series of reports is to provide practical approaches to designing public reports that make health care performance information clear, meaningful, and usable by consumers. The goal is to help sponsors present information so that a wide variety of people can understand and apply it easily to key decisions, even if they do not want to spend a lot of time on details and have limited technical knowledge of the subject.

Together the three reports cover the wide range of issues and challenges faced by report sponsors:

Best Practices in Public Reporting No. 1: How To Effectively Present Health Care Performance Data to Consumers focuses on the challenges involved in designing a public report card so that the performance information is easily understood by consumers and on strategies to make it easier for consumers to understand and use comparative health care quality reports.
Best Practices in Public Reporting No. 2: Maximizing Consumer Understanding of Public Comparative Quality Reports: Effective Use of Explanatory Information focuses on the explanatory information in public reports, beyond the performance data itself, that helps to accurately communicate quality ratings to consumers and motivate them to use the ratings in making informed health care decisions.
Best Practices in Public Reporting No. 3: How To Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies applies social marketing and other principles to explore how to target reports to specific audiences, develop messages to promote the report with key audiences, engage consumer advocacy and community groups in promoting reports and helping people use them, disseminate reports through trusted channels, and ensure that consumers see and use comparative quality reports.

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References

2008 Update on consumers' views of patient safety and quality information. Menlo Park, CA: Kaiser Family Foundation; October 15, 2008.
Harris Interactive. Just looking: consumer use of the Internet to manage care. Oakland: California HealthCare Foundation; May 2008.
Hibbard JH, Stockard J, Tusler M. The long-term effect of public performance reporting on hospital quality improvement, market share, and reputation: evidence from a controlled experiment. Health Aff 2005 Jul/Aug;24(4):1150-60.
Hibbard JH, Stockard J, Tusler M. It isn't just about choice: the potential of a public performance report to affect the public image of hospitals. Med Care Res Rev 2005 Jun;62(3):358-71.
Miller SM. Monitoring and blunting: validation of a questionnaire to assess styles of information-seeking under threat. J Pers Soc Psychol 1987 Feb;52:345-53.
Miller SM. Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease. Implications for cancer screening and management. Cancer 1995 Jul 15;76:167-77.
Sweeney, J. The Community Quality Collaborative leader's guide to engaging consumers. Rockville, MD: Agency for Healthcare Research and Quality; November 2008. Available at: http://www.ahrq.gov/qual/value/caguide.htm.
Sofaer S. A classification scheme of individuals and agencies who serve as information intermediaries for people on Medicare. Report to the Center for Beneficiary Services. Baltimore, MD: Health Care Financing Administration; May 2000.
Barr JK, Boni CE, Kochurcka KA, et al. Public reporting of hospital patient satisfaction: the Rhode Island experience. Health Care Financ Rev 2002;23(4):51-70.
Rosenthal MB, Frank RG, Li Z, et al. Early experience With pay-for-performance: from concept to practice. JAMA 2005;294:1788-93.
Barr J, Bernard SL, Sofaer S, et al. Physicians' views on public reporting of hospital quality data. Med Care Res Rev 2008;65(6):655-73.
Guidelines for marketing and advertising: NCQA 2008 physician and hospital quality certification. Washington, DC: National Committee for Quality Assurance; October 2008. Available at: http://www.ncqa.org/Portals/0/Marketing/AdGuidelines/PHQCertification_12_23_08.pdf. [Plugin Software Help]
Shannon M. CalHospitalCompare.org San Francisco maternity campaign. CAHPS®-SOPS User Group Meeting, Joint CAHPS® Session on Public Reporting: "Engaging Consumers in Using Quality Reports: What it Takes To Capture Eyeballs; 2008 Dec; Scottsdale, Arizona.
Felland L, Benoit AM. Communities play key role in extending public health insurance to children. Issue Brief Cent Stud Health Syst Change 2001 Oct;(44):1-4.
Kincheloe J, Frates J, Brown ER. Determinants of children's participation in California's Medicaid and SCHIP programs. Health Serv Res 2006 Aug 17;42(2):847-66.

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Acknowledgments

The authors wish to thank the following people for reviewing this document: Cindy Brach, MPP, Agency for Healthcare Research and Quality; Kathy Crosson, M.P.H., Agency for Healthcare Research and Quality; Jan De La Mare, M.P.Aff., Agency for Healthcare Research and Quality; Janice Genevro, Ph.D., M.S.W., Agency for Healthcare Research and Quality; Diane Giese, M.P.P., Puget Sound Health Alliance; Al Lazar, M.B.A., Agency for Healthcare Research and Quality; Donna Marshall, M.B.A., Colorado Business Group on Health; Peggy McNamara, M.S.P.H., Agency for Healthcare Research and Quality; Dale Shaller, M.P.A., Shaller Consulting; Karen Shore, Ph.D., Center for Health Improvement; Jennifer Sweeney, M.A., National Partnership for Women & Families; and Nancy Brands Ward, Center for Health Improvement.

We consider our Learning Network tools to be works in progress and always welcome your comments. Please forward suggestions to Peggy McNamara at peggy.mcnamara@ahrq.hhs.gov.

AHRQ Publication No. 10-0082-1-EF
Current as of May 2010

Internet Citation:

Hibbard J, Sofaer S. Best Practices in Public Reporting No. 3: How to Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies. AHRQ Publication No. 10-0082-EF, May 2010, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pubrptguide3.htm