In search of a credible and cost-effective way to promote Mount Sinai Hospital (Mount Sinai) and educate a broad public, Mount Sinai opened its doors wide to The Globe and Mail (The Globe). The result was a three-part national feature series that told Mount Sinai's compelling story, provided third-party credibility and confirmed the value of proactive media relations. The series engaged our staff, energized our volunteers and reached both stakeholders and the general public on an emotional level. It also generated the more than $6 million worth of equivalent advertising space it would have required for Mount Sinai to reach this national audience.

The Challenge

In the spring of 2005, differentiating and promoting Mount Sinai was an ambitious goal for the new leadership of the Communications and Marketing Department.  

Anecdotal evidence indicated that Mount Sinai was suffering from both "media chill" and internal timidity. While Mount Sinai had a strong reputation for providing infection-control spokespersons to the media during SARS, reporters felt that in non-crisis times, it was difficult to secure comment, and that Mount Sinai was not eager to accommodate requests for interviews.  

During meetings with hospital leaders, the Vice-President, Communications and Marketing, Judith John and Director, Public Affairs, Rob McCartney, heard common themes emerge. Physicians and administrators were reluctant to speak with reporters for a variety of reasons, including previous bad experiences and fear of jeopardizing important stakeholder relationships.

Ironically, some of this reticence could be attributed to Mount Sinai's strict adherence to provincial health privacy legislation, known as PHIPA (Personal Health Information Protection Act). PHIPA makes it illegal to use or disclose personal health information about individuals without their express or implied consent. Like its peer hospitals, Mount Sinai ensures all staff sign confidentiality agreements and protects the rights of its patients.

But reticence was only part of Mount Sinai's public relations dilemma. Differentiation in a competitive marketplace was also a factor. Mount Sinai is a mid-sized general hospital with established areas of excellence, but not dedicated to a single cause. Larger hospitals generally enjoy greater resources; smaller ones can market themselves as the underdogs, build emotional attachments and relationships with geographically local stakeholders such as donors, patients, business leaders and politicians, and appeal directly to specific target audiences in terms of fundraising; single-focus hospitals, such as SickKids, have an immediate emotional and recognizable appeal.  

Without a budget to address these significant communications challenges, Mount Sinai needed to find a way to tell its story to a broad audience, at a low cost, through a credible third party, in a way that conveyed relevance to all stakeholders.  

Intervention

Communications is about storytelling, and Judith John knew there were stories galore within the big brain/big heart personality of Mount Sinai. In the spring of 2005, a few months after John joined Mount Sinai, she began an informal e-mail dialogue with The Globe's Editor-in-Chief, Edward Greenspon. John knew Greenspon from her days at the United Way of Greater Toronto, and was sharing her enthusiasm for her new position. She wrote:  

"I am mesmerized and stimulated by the healthcare issues, present and future, now that I'm at Mount Sinai, and would love to sit down with you, your editorial board, and bring Joseph Mapa, our terrific President and CEO" (J. John, personal communication, June 20, 2005).

Greenspon would later reflect to his readers on how John's ingenuous approach ultimately led to the emergence of the series, writing in his introductory column:  

"It started with a casual e-mail exchange…her cup running over with enthusiasm. And then one day Judith John channelled this cauldron of mental energy into a simple proposition: if she could guarantee unlimited access, would The Globe and Mailbe interested in retracing her process of discovery? We could walk the floors of the hospital, all 832,498 square feet of them, see what we wanted to see, ask what we wanted to ask, judge what we wanted to judge - and tell our readers about the daily triumphs and tragedies of this particular temple of medicine" (Greenspon 2005).

Greenspon was curious and agreed to an editorial board meeting.  

The Methodology

Negotiating an Agreement Based on Trust

On August 22, 2005, a team of Mount Sinai administrators and physicians headed to The Globe's   headquarters. One physician, running late and still clad in green surgical scrubs, came directly from performing surgery and unintentionally brought an air of hospital authenticity into the editorial board meeting room. All spokespeople were briefed beforehand simply to talk about their work at Mount Sinai, and not to cramp any editorial style by trying to influence story directions.¹

Greenspon and his team (editorial staff, a photography editor, an advertising representative, graphics and production people) were clearly interested in the notion of open access to the inner workings of a downtown teaching hospital.  

"The conversation was fascinating, refreshingly devoid of the deep pessimism that so often suffuses discussions of health care," Greenspon later recalled. "These people were on a mission. They repeated their promise of free access. We emphasized that they had to be prepared for outcomes they might not like; that we retained full editorial control. They seemed confident that a fair examination would yield reasonable results. We all agreed that the only limitation we would impose was to respect patient confidentiality where a waiver could not be obtained" (Greenspon 2005).

John assured Greenspon that innovative solutions would be found to ensure proper consents from patients without jeopardizing the spontaneity that would breathe life into Mount Sinai's human stories.

  The Globe committed Ian Brown - an investigative feature writer rather than a medical reporter - to spend up to five weeks at Mount Sinai. Brown, staff photographer, Kevin Van Paassen and graphics editor, Richard Johnson, would research, fact-find, interview, sketch and snap countless photographs of the people who come to Mount Sinai for care - and those who care for them. In return, Mount Sinai agreed it would not interfere with the journalists by determining individual stories or angles, but rather suggest and facilitate access.

The series would start in the Saturday Focus section in November - the newspaper's highest readership period - and would run for five consecutive business days, with 3,500-4,000 words each day. It would end with another front-page Focusfeature the following weekend, for a total 25,000-30,000 word count. It was a PR dream come true.

Next Steps - Privacy, Primacy of Care, Trust and Transparency

In late August, the Communications and Marketing Department still faced several hurdles it would need to leap if it was to keep its promise to - and credibility with - The Globe.  

First, there was the "kid-in-the-candy-shop" issue. How do you ensure that a zealous roving reporter, let loose to do his job with complete autonomy (and without a pesky public affairs person breathing down his neck 24/7) would not ask questions first and get patient consent later?

Second, how would the 4,000 staff, physicians and volunteers feel if a reporter with a notepad were to suddenly show up at the bedside, or if a photographer's camera were to flash at a newborn's isolette?

In addition to the protection of patients, staff privacy was also a concern. As Mount Sinai's Legal Counsel and Corporate Privacy Officer, Jodi Butts, noted, the hospital's own media policy protected the private business of staff, and no details of their employment could be disclosed prior to consent.  

Clearly, openness and trust were important, but best practices were also required.  

John and McCartney called a meeting with Butts in early September. While concerned about the concept, Butts agreed that if express and implied consent were obtained from patients (or their substitute decision-maker) prior to their being identified, interviewed or photographed in any way, PHIPA legislation would be satisfied.  

Likewise, a mechanism was required to provide staff throughout Mount Sinai an opportunity to talk or be silent - without censure - or choose to hide behind a curtain when the camera filmed their daily routine.  

Rather than create complex legal contracts, Ian Brown and Kevin Van Paassen were asked to meet with John, Butts and McCartney in September, specifically to discuss privacy concerns. Butts explained that, while Mount Sinai's administration understood the desire to openly roam patient units, unconditional access would be outweighed by implied and express consent. This was followed up with a letter outlining the rules of engagement from John to Brown, ensuring that ground rules were clearly understood.

• PHIPA applies to patients and all nurses, allied health professionals, doctors enjoying privileges, residents completing educational requirements and everyone else affiliated with Mount Sinai.  
  
• PHIPA demands that patient consent is obtained in advance to feature individual patients in the media through an interview, photograph or other means.  
  
• Patient consent (or that of the patient's substitute decision-maker) is required to learn about an identifiable patient's story, even if The Globe had no intention of publishing the patient's name.  

Primacy of care was a condition that didn't take much negotiation. Everybody agreed that Mount Sinai was in the patient-care business, and patients must remain priority one. If a caregiver felt uncomfortable for clinical or ethical reasons with media interaction - even with the patient's consent - the health provider had the final say.  

(At one point in the process, Brown was piggybacking on rounds, scribbling notes and gathering vivid details for his features. In this case, the event was Psychosocial Rounds, where clinical team members speak intimately about highly personal and confidential matters with patients and family members. Brown was innocent enough, though an alert caregiver red-flagged his presence. Mount Sinai's bioethicist, Dr. Kerry Bowman, sat down with Brown to explain that this was inappropriate and Brown, without hesitation or protest, agreed.)

Customized letters were distributed to patients on units prior to visits by The Globe, indicating that if patients were not comfortable participating, it would in no way impact on the quality of their care. Likewise, clinical staff received letters indicating there was no pressure to participate, but if they chose to, they were to feel free to speak their minds. Signed consent forms were then returned and filed in the Communications and Marketing Department.  

In reality, the team did influence and guide the journalists to get them going. However, after a few weeks, comfort and trust grew on both sides, interviews evolved naturally and the rest of Mount Sinai became more comfortable with its house guests. Eventually, the healthcare professionals - the knowledge base - steered Brown and team in the right directions, towards the proper people and true stories.  

The partnership was confirmed by issuing The Globe's team official Mount Sinai employee identification badges. This proved to be a best-practice solution to ensure them access without barriers, while also reassuring staff these were not wandering strangers. And, for the journalists, this access helped them document - as Brown later wrote - the "endless human dramas, unfolding everywhere you turn."

Communications

Putting out the welcome mat meant letting the residents know company was coming.  

Mount Sinai Hospital President and CEO, Joseph Mapa, informed the organization of the visiting journalists through a blanket e-mail message - one tool in his two-way communications program known as "Connecting with Joseph." Letters were also sent to Mount Sinai's and the Mount Sinai Hospital Foundation's Boards of Directors. Anyone with questions, concerns or complaints was invited to contact John or McCartney.  

Occasionally, e-mail correspondences were distributed to provide staff updates, and to clarify and reinforce instructions concerning confidentiality, privacy and ethical procedures.  

Media Relations

Communications and Marketing remained facilitators, setting the context by arranging Brown's first meetings with President Mapa and other senior leaders. As the process moved forward, everyone in the organization put on a media relations hat, while the Communications and Marketing team managed calls, e-mails and visits to its office by concerned or curious staff and physicians. Though nobody complained about the presence of the reporters, the department was consulted by people anxious about upcoming interviews.  

On approximately 10 occasions, media training was provided, though not in the traditional sense. Instead of providing briefing notes full of scripted key messages, John and McCartney met with individuals or clinical teams to help shape their thoughts, and to reassure them the journalists wouldn't bite (despite their loose leash). Creating a comfort level and intimacy with the media would pay big dividends in terms of aligning the organization for future media efforts.  

Results

In the end, five weeks turned into eight weeks, as Brown toiled to tidy up loose ends, complete last-minute interviews and write Mount Sinai's compelling story. Brown was so captivated by the Sinai experience - finding it "both exhilarating and exhausting" - and so eager to keep discovering and talking with people, that his editor called John in late October and asked her to lock him out of the hospital so he could do no more interviews and begin the task of writing.  

Almost taking up residence, Brown and Van Paassen spent day and night speaking to nurses making shift changes or watching patients in need of immediate care come through the Emergency doors. They attended classes with medical students in the University of Toronto Surgical Skills Centre, saw the "real thing" with surgeons in the operating room and joined residents on rounds in the Intensive Care Unit. Van Paassen waited - often around the clock - for that once-in-a-lifetime opportunity to photograph a premature newborn opening his eyes for the first time. They became great friends with a brave patient and his family - a mechanic from Prince Edward Island who had a tumour the size of a fist in his upper arm. (Months later, when that patient died from the cancer that spread through his body despite having surgery at Mount Sinai, Brown and Van Paassen travelled to Prince Edward Island and did a moving follow-up story) (Brown 2006a).  

Together, The Globe's articles and photographs provide an intimate and meaningful look inside Mount Sinai, sharing its human side. Another in-depth story followed a fragile "preemie" born at just 24 weeks, and the complex care and critical decision-making that marked his entry into the world. Brown's inside look into Mount Sinai's pandemic planning gave perspective to the work and difficult, humane decision-making that goes into preparing for the worst.

Saturday, November 17, 2005 exceeded expectations. Rather than being launched in the Focus section as was originally planned, the series hit the front page, immediately blanketing the country with a riveting colour photo and the title "Mount Hope." The article dominated the Focus section, with beautifully designed pages of eloquent text and memorable photographs. This exposure alone held more intrinsic marketing value than any paid advertisement ever could.  

Leger Marketing graciously provided a pro bono analysis of the first story in the series, estimating that the overwhelmingly positive tone and worth of the coverage - not just the equivalent $1,125,000 to $1,800,000 value of the space it filled - was assessed at a remarkably high 90% quality index.

The series continued on the next two Saturdays, November 26 and December 3. Six days later, Veritas Communications gave Mount Sinai's Communications team a "triple touchdown" in the pages of the company's weekly e-newsletter, Touchdowns and Fumbles, which portrays the good and the bad of media relations best practices. About the Mount Hope series, Veritas wrote:  

"We're talking here about millions of dollars worth of paid media, if you could buy it, and you simply cannot. Nor can you buy the credibility for Mount Sinai that these journalists lent through their unbiased and unfiltered reporting. Medical schools are already asking the hospital about using the series of articles in curriculum. So here's a Triple Touchdown to Mount Sinai - one for each of the stories" (Walker 2005).  

During the months of October and November, members of the Communications and Marketing team often worried that Brown might drop a bomb in the pages of the series. What if their continued assurances to senior management - that Brown and team could be trusted, and that the situation could be controlled by developing open and transparent media relationships - proved to be naïve? Despite some sleepless nights herself, John repeatedly told President Mapa and Board Chair Lawrence Bloomberg that while this project was a great opportunity, it also wasn't a guarantee.  

But nothing negative happened.

Brown told the Sinai story accurately and fairly - and gave as good as he got. In spring 2006, Brown voluntarily wrote a reflection piece about his experiences at Mount Sinai for its consumer health magazine, Your Health Report.  

"The opportunity to spend weeks on end with brilliant men and women, all of whom are at the top of their profession and utterly committed to their work, was one of the most inspiring experiences I've had… My biggest worry, however, was that the unprecedented access you granted me would backfire. I worried that, having been invited into the hospital, to see and hear things no reporter had ever seen before, I would feel compelled to go easy on you, in return for the access, and not report the bad stuff that went on.

"You were brave enough to show me the full human range of what goes on in a hospital - the light and the dark of your work, its ups and downs, your certainties and triumphs as well as your doubts and disappointments, even your grief - all of which made for a moving story about dedicated people doing their best at an impossible job" (Brown 2006b).

What about the media chill? Staff warmed up to The Globe and adopted them as family. They sought out consent forms, arranged interviews and juggled their schedules to talk openly about why they came to work every day. The only disappointment was that, as an apologetic Brown would say in casual conversation, "writers need to make decisions."  

That meant everybody's story could not be told in the limited space, for, as Brown would later write, "…my editors were only giving me 20 pages in the newspaper. I could have filled 20 more, with ease" (Brown 2006b).  

That said, staff members were extremely proud of the recognition the series created. Mapa, Bloomberg, John and McCartney received hundreds of calls, e-mails and letters of congratulations from across the country. Compliments ranged from the positive exposure for Mount Sinai itself to a broader understanding about the issues and choices in healthcare, from the passion for the place and those who make it what it is to the overall tribute to the community that is Mount Sinai.  

Two days after the first feature appeared, Ontario Minister of Health and Long-Term Care, the Honourable George Smitherman, addressed a group of healthcare leaders at Mount Sinai. With a good-humoured glint in his eye, he accepted his introduction from Joseph Mapa, calling him "creamy smooth," quoting words from Ian Brown's description, and complimenting him on courage and conviction at "Mount Hope."

Mount Sinai posted electronic versions of the series on its Intranet and Web pages, and visits to its website doubled. Meanwhile, The Globe was running photo/audio slide shows online, with commentary by Van Paassen and various Mount Sinai clinicians and researchers describing experiences that accompanied photos interactively on the newspaper's Web page.  

Overall, Brown and Van Paassen interviewed or photographed hundreds of physicians, staff, leaders, volunteers - and all of them became intimate with the press through a transparent media relations initiative involving the entire hospital community.  

Conclusions

On April 22, 2005, Mount Sinai's Communications and Marketing Department gathered in a conference room and chiselled out its collective vision: "To be a proactive, responsive media-savvy department that uses best practices and strong relationships to foster earned media and build a strong and respected public brand and image."

Five months later, patients, staff, researchers, students, volunteers and visitors quietly strolled through Mount Sinai's main lobby, viewing about 50 enlarged images taken by Kevin Van Paassen. Hospital News, a Canadian newspaper published for healthcare professionals, ran a story about the exhibit and the special event where Van Paassen and Ken Meats, Mount Sinai's Manager, Graphics and New Media, lectured side-by-side on medical and Mount Hope photography.

Van Paassen and The Globe's editorial team earned an Award of Excellence from the Society of News Design in the Multiple Photos Series.² The photography was used in a Mount Sinai Hospital Foundation gift appeal, which ran in The Globe on December 9, 2005, and Mount Sinai later reproduced the entire series in a booklet. By June, pull-out quotes from The Globe series were sprinkled through the combined annual report of Mount Sinai, its Foundation and its Samuel Lunenfeld Research Institute.

Recently, a senior manager joined Mount Sinai Hospital, confessing he was drawn to work here after reading The Globe series, word-for-word, image by image - and knowing this was where he wanted to be.  

By exercising best practices in media relations, the Communications and Marketing Department demonstrated that public relations does have a role in a hospital setting in terms of promoting the brand, earning trust and credibility with the public and creating a sense of pride in the people who work within its walls.

Total budget? Zero dollars.  

Providing unlimited access, with some conditions around privacy laws, proved to be a best practice in itself in terms of building media bridges.  

"Mount Sinai granted me an unprecedented degree of access - access, in a hospital, to a reporter!" Brown would write later. "And a non-medical reporter at that! Needless to say, I didn't want to blow the opportunity, and I didn't want to discourage you from trying it again with someone else in the future" (Brown 2006b).

President Mapa celebrated, too, sending out two Connecting with Joseph memos to Mount Sinai's global address list, recognizing the success of best media practices.  

"We allowed Ian and Kevin complete access to the Hospital, after setting some important ground rules about privacy, confidentiality, and ethics," Mapa wrote to staff on November 18, 2005. "This was a departure from our normal practice, but we wanted to 'walk the talk' about being transparent and open, and it was essential for the integrity of the story that they find their own voice here. The feedback from our team is that they were cooperative and demonstrated the utmost professionalism, respecting privacy and confidentiality of patients and employees, and recognized that the safety and care of patients was always our first priority" (Mapa 2005).

All at "Mount Hope."

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