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Calculating and Understanding the Drivers of a Net Promoter Score in Health Care

Posted By Andrew S. Gallan, PhD, Monday, May 15, 2017
Updated: Thursday, May 11, 2017

In 2016, Advocate Health Care, the largest health system in the Chicagoland area, integrated into its performance measures a Net Promoter-like score, which they call a Patient Loyalty Score (PLS). Net Promoter Score (NPS) is a valuable metric, and it has been adopted by many companies in almost every industry. NPS is a simple, easy to use, and easily calculated metric that is intuitively associated with business health by assessing a respondent’s likelihood to recommend an organization to a friend or colleague.[1] Health care organizations are beginning to see its value, and are exploring how it is best calculated and used.

For Advocate Health Care, PLS is constructed using data from CAHPS and vendor surveys, and utilizes the likelihood to recommend question. Only a top-box score is defined as a promoter, and varying bottom scores are defined as representing a detractor. That is, for a five-point scale (ED vendor survey) the bottom three responses are categorized as detractors; for a four-point scale (HCAHPS) the bottom two are detractors; and, for a three point scale (CG-CAHPS) only the bottom score is a detractor.

Some issues with the measure include the referent (CG-CAHPS asks about likelihood to recommend the provider’s office, ED refers to the department, and HCAHPS asks about the hospital), and the limited scale width (the original NPS scale is 11 points). However, for me, having a patient-provided measure outweighs the issues, and I commend the organization for holding people accountable for patient perceptions of care. The strength of this metric is to create system-wide responsibility for a patient-provided measure, thereby ensuring that the patient’s voice is heard.

Like most organizations, Advocate Health Care is interested in earning increased rates of positive word-of-mouth recommendations. As a result, I recently engaged with Advocate as an Academic-in-Residence. In this role, championed by EVP & COO Bill Santulli, SVP & CNO Susan K. Campbell, and VP Information and Technology Innovation Tina Esposito, I performed analytics to identify drivers of PLS. The two important research questions that drove this project were:

  1. Which variables are the most important drivers of PLS?
  2. What can we learn from patient comments about potential drivers of PLS?

In order to investigate these questions, I was provided with almost two years of HCAHPS, CG-CAHPS, and ED survey data and patient comments. Top line results included the following:

Inpatient (HCAHPS): Nurses and personal issues (privacy, pain, and emotional issues) had by far the most impact on patients. Positive comments centered on comfort, communication, and care. Negative comments focused on food.

Outpatient (CG-CAHPS): The face-to-face interaction between a patient and physician is the “moment of truth,” and as such is what the patient apparently will use to evaluate the entire experience. Positive comments centered on comfort and communication. Negative comments focused on waiting and rude treatment. 

Emergency Department (Vendor Data): When patients are in the ED, taking care of personal issues will have the greatest impact on PLS. These issues include keeping patients informed about delays, caring about patients as people, pain control, and providing information about caring for yourself at home. Positive comments centered on comfort, communication, and care. Negative comments focused on feeling vulnerable and afraid in a busy and foreign environment.

As a result of this project, Advocate Health Care is now embarking on disseminating the results, integrating insights into daily practice, and evaluating additional questions that emerged from the analysis. I’d be interested in hearing more about what your organization thinks about NPS, how you use it, and what you have learned as a result!

[1] NPS was first proposed by Fredrick F. Reichheld, (2003), "The One Number You Need to Grow," Harvard Business Review, 81 (December), 46-54. For more on advantages and issues utilizing NPS in health care, see

Andrew S. Gallan PhD is an assistant professor at DePaul University in Chicago, a member of the Editorial Review Board of Patient Experience Journal, and principal of Dignity in Action, Inc., a PX analytics and advisory company ( Andrew can be contacted via email:

Tags:  CAHPS  CG-CAHPS  data  drivers  HCAHPS  net promoter score  NPS  patient loyalty  patient loyalty score  survey 

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SPOUSE-CAHPS – For Better or for Worse (Happy Valentine’s Day)

Posted By Don Prisby, Tuesday, February 2, 2016
Updated: Monday, February 1, 2016

SPOUSE-CAHPS. What a great idea! Hilarious. Actually… when you really, really think about it, it’s a terrifying prospect. Imagine sitting on the couch together with your spouse or significant other, filling out THAT survey,

"Let’s see:
The rooms are clean.
You’re a good communicator.
It’s quiet at night.
And the food is good.”

Ninety days later, you tear open the snail-mail envelope that finally arrives. And the results: Congratulations you’re in the 95th percentile! "Whew, another good quarter!” As healthcare professionals, since it seems that we evaluate just about everything else, why not take a peek at our personal relationships? Well, maybe not.

H-CAHPS, CG-CAHPS, PEDS-CAHPS, ED-CAHPS... Now those can also be terrifying. With the move from fee-for-service compensation to outcomes-based quality, the full force of Value Based Purchasing and the oversight of the Centers of Medicare and Medicaid Services in place, it seems we’re all in for evaluation and scrutiny. Like a happy couple. Forever and ever and ever. These post-discharge scores are helpful as benchmarking tools to guide organizational change. Just like in a healthy relationship, how much improvement we make is dependent upon the approach and methodology we employ to transform our behaviors and impact change.

With the myriad approaches to performance improvement advocated by multiple authors in contemporary business literature, a wide array of styles can be observed. In addressing behavior change, insights like Quint Studer’s, "Hardwiring,” are quite prescriptive. Employing a different tone, Fred Lee’s, "If Disney Ran Your Hospital, 9-1/2 things You Would Do Differently,” is informative and insightful. In his New York Times best seller, "Unaccountable,” Atul Gawande is instructive, advocating the responsibility of healthcare providers to get "better” based on a commitment to "diligence, doing right and ingenuity.” Marty Markary, surgeon and professor of health policy at Johns Hopkins Hospital and School of Public Health, illustrates the dangers of unchecked health care service in his work, "Unaccountable.” For those who want a great weekend read, Sanjay Gupta’s, "Monday Mornings” is a revealing story about the trials of healthcare that is captivating throughout and concludes with a heartbreaking finale.

While there are a variety of perspectives available, organizations also have various approaches toward people and process change. Some are paralyzed in the face of poor or falling CAHPS scores. Others lack two precious commodities: time and budget. Some over-analyze and are locked in the metrics, unable to translate data to insight and actionable plans. And some are punitive, holding measurement over the heads of their offenders.

Reviewing some of the more successful healthcare systems in my day-to-day work, I find the following: One leading hospital is presenting a Kudos report of same-day patient satisfaction every afternoon championed by the care area leader. Others are escalating such reports to the executive level where upon administrative rounding, recognition can be provided to top performers. Another hospital is engaging all of their non-clinical office workers in assessing the patients’ experience, thus connecting all employees to the mission of the hospital. Still another is informing their providers with the previous day’s assessment of care reports right on their smart phones at 5:30 every morning.

There are as many models about patient experience improvement as there are wedding planners in May. The key combination for success, it seems, is using CAHPS data with a combination of real-time insight and leadership coaching to drive change. Looking forward, this writer sees organizations that are combining CAHPS benchmark and real-time input to create immediate and sustained change.

In closing, one could only hope never to be the subject of a SPOUSE-CAHPS survey. I’m not sure I’d want to see the wide swings or downward-turned trends on my relationship behavior. And I don’t know about you, but I cringe at the thought of how I would be rated for, "Willingness to Recommend.” However, it is exciting to be part of an industry that is getting more and more committed to the intrinsic value of providing extraordinary care. With an internal drive to "do no harm” and extrinsic assistance through benchmarking, real-time insight and rapid-cycle improvement, healthcare systems are transforming their cultures and developing gradual and sustained improvement.

So, SPOUSE-CAHPS? Um, not this guy. CAHPS data, complemented with real time point-of-care insight? It’s time to say "I do… for better or for worse, for richer or for poorer, in good times and in bad, in sickness and in health……care.”


Don Prisby is a business development executive with Minneapolis-based TruthPoint, a technology enabled performance improvement firm focused on delivering patient insight and performance improvement services to healthcare systems nationwide.

Tags:  HCAHPS  improvement  pay-for-performance  survey  value-based purchasing 

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Patient Experience Builds Brand Equity

Posted By Jim Lahren, Monday, March 9, 2015
Updated: Monday, March 9, 2015

Healthcare in the US continues its radical transformation with the rollout and rapid adoption of high-deductible insurance plans. More than even value-based purchasing, this has the potential to reshape the healthcare landscape because it has awakened the healthcare consumer. In its 2014 Employer Health Benefits Survey, The Kaiser Family Foundation reported that 41% of all firms (32% of large employers, 61% of small firms) have rolled out high-deductible insurance plans.

With the patient now responsible for large deductibles at insurance company negotiated rates, households are forced to become smarter consumers of healthcare services. New businesses and services have been introduced to meet market needs. Witness the rapid expansion of urgent care facilities, the availability of vaccinations at pharmacies, and most recently, staffed clinics within retailers. These all serve one purpose: providing consumers more expedient, cost effective access to care on their terms.

This ever-increasing trend in consumer activism necessitates that healthcare providers start to view their patients as healthcare consumers. In a January 2015 article titled "Improve patient satisfaction from the eyes of the consumer,” this author advocated that providers improve patient satisfaction in order to build their brands. With a stronger brand, they can better compete, and be among the winners as the industry consolidates. Overwhelming feedback to the article questioned the appropriateness and relevancy of patient satisfaction as a stated goal. Instead, reviewers advocated that patient outcome should be the sole focus. Notably, the article’s premise: "How will hospitals compete given the structural changes facing their industry?” was not addressed.

Why did this happen? Simply, the phrase "Patient Satisfaction” has become polarizing. CMS measures hospital patient satisfaction and ties reimbursements through standardized patient surveys called HCAHPS. Many clinicians believe that the HCAHPS survey is misguided, inaccurate and leads to excessive costs in an effort to please the patient. And as one nurse said, "And you can’t make everyone happy!”

An expert on patient experience development and cultural transformation, Jake Poore of Integrated Loyalty Systems, says: "Many providers today feel like they are set up to fail. With the pressures of new requirements, tools and processes for documentation (EMRs) and having to see 10-30% more patients than last year just to make the same productivity or revenue, they feel like they are literally running ‘on the daily gerbil wheel.’ When you add the fact that most patient clinic appointments are in 15 minute windows, you have a perfect storm: The last thing on a provider’s mind is patient satisfaction or survey results.” What is the root cause? Poore suggests a misalignment of priorities between what healthcare organizations measure, reward and hold accountable and the priorities patients expect from their caregivers. When Poore and his team ask healthcare leaders, providers and staff to identify the top 4 most important operational priorities and prioritize them in order, they say: #1. productivity, #2. competency, #3. safety, and #4, courtesy.

On the other hand, when you ask patients (which Poore and his team have done with nearly all of their clients around the country) what they want most from the front desk to their physicians and nurses, patients rate their priorities as: #1. courtesy/compassion, #2. competency, #3. productivity, and #4. is safety. In explaining the patient priority order, Poore says that it rarely even occurs to patients that a hospital or the caregiver is not safe. As one patient said it, "safety only becomes my concern when safety has been jeopardized.” Overwhelmingly, what patients say they want FIRST is a care team member (clinical and non) who is "warm, welcoming and listens” and talks with them, not to them: "… as an individual, with dignity and respect. As patients, we assume you are smart and an expert of your trade, but we want you to start the conversation on the human side first, do your exam second.”

As consumers, we purchase products and services we like. We are most loyal to brands where we have an emotional connection and where the people behind those brands seem to share our priorities and values. But when managing our own healthcare, we have traditionally been the "Patient.” The patient has now become the consumer who expects the healthcare provider to treat them as such. But how should providers adapt to this new paradigm? They need to focus on their client, the patient, and improve the patient experience. More than ever before, healthcare consumers have many choices for their care. Providing a poor patient experience will damage an institution or provider’s brand, resulting in lost loyalty, lost patients, and above all, lost revenue. By improving the patient experience, providers will not only enhance their patients’ well being, they are better equipped to prevail in the new healthcare marketplace.

Jim Lahren is the Principal of Lahren Consulting. A former Chief Marketing Officer, he has worked in highly competitive consumer categories where he developed a comprehensive understanding of consumer behavior. His retail experience spans big box, department store, specialty, and online. He believes that patient experience will become the driver in building the institution's brand and is excited to attend The Beryl Institute’s Patient Experience Conference 2015.

Tags:  branding  HCAHPS  healthcare  patient experience  survey 

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Survey Finds that A.C.A. and Triple Aim Creating Re-Think that Enhances Value of Integrative Medicine

Posted By John Weeks, Thursday, February 19, 2015
Updated: Thursday, February 19, 2015

The Center for Optimal Integration: Creating Health has announced results of a survey found that integrative health and medicine is increasingly viewed by involved health systems as integral to advancing the values of the "Triple Aim."

The term "integrative health and medicine” typically applies to such therapies as mind-body and yoga and practitioners like acupuncturists, massage therapists, chiropractors and naturopathic doctors.

The area of most significant engagement of integrative medicine leaders by their parent systems was found to be in initiatives to enhance patient experience. Nearly 9 in 10 (87%) agreed that, under the new incentives of the Affordable Care Act, their parent systems are increasingly interested in how integrative health and medicine can help meet patient experience targets.

The survey, through the Center's Project for Integrative Health and the Triple Aim (PIHTA), found other positive alignments. These leaders of health system-based integrative centers perceive they are increasingly valued as part of their system’s efforts to "reduce hospital re-admissions" (72%) and "lower costs"(75%). Many report new outreach from system specialty groups to explore partnerships. A subset are finding increased financial investment.

When the exploration of complementary and integrative medicine originated in the mid-1990s, the relationship with conventional delivery systems was quickly hampered by misalignment. The prevailing "perverse incentives” from a payment and delivery focus on procedures proved an inhospitable environment for these typically high-touch, time-intensive and human-centric integrative services.

I served on the PIHTA team that developed the survey. The questions we asked essentially tested an assertion of Allina Health’s CEO Ken Paulus as the A.C.A. was coming into being in 2011. Allina’s integrative health and medicine program, is the most significant in the United States. At that time, the in-patient and outpatient integrative initiative at Allina had been nurtured for a dozen years via substantial philanthropic investment from the George Family Foundation started by Penny George and her spouse, Bill George. The latter is the former Medtronic chair and present author-professor at Harvard Business School.

Paulus told a New York City audience of integrative medicine leaders that when he took the job at Allina in 2006, he judged integrative medicine to be "a cost center.” But as now the A.C.A. "is paying us to keep people healthy,” Paulus sees integrative medicine as an ally. He believes that as the A.C.A.’s payment structure "kicks in that supports keeping people healthy, integrative medicine will be an asset."

The data in this survey suggest that Paulus’ assertion is correct. Surveyed were leaders of 28 integrative medicine clinics most of which are part of academic health centers. The set of participants was the same as those in the widely reported Integrative Medicine in America (2012) project engaged by the Bravewell Collaborative of philanthropists in integrative medicine. Seventy-five percent (21/28) took part in the PIHTA survey.

Many of these health system-based integrative medicine centers were originally developed for marketing purposes. The core interest was to gain competitive advantage by showing responsiveness to patient interest in complementary and alternative therapies and practitioners.

These data make abundantly clear that interest is deepening from these early adopters. Integrative approaches and practitioners are edging into core business models of hospitals and other delivery organizations. Data charts on the all survey outcomes are available here.

The PIHTA survey team also included Jeffrey Dusek, PhD, the research director at the Penny George Institute (PGI) to Allina, Melinda Ring, MD who directs the Osher Center for Integrative Medicine at Northwestern and Jennifer Olejownik, PhD, PIHTA’s manager.

Some outcomes on integrative care that are shaping system interest are contained in the PGI reports at this link. In addition, the PIHTA initiative that engaged the survey has posted what we hope are useful links to resources on lowering costs and others on enhancing patient experience.

Both existing data from pioneers and the timing in health system maturation suggest that integrative practices will continuously be woven more tightly into strategies to provide accountable, values-based care.

John Weeks is the director of the Center for Optimal Integration: Creating Health where he is actively involved in the Center’s Project for Integrative Health and the Triple Aim (PIHTA). He is a 30-year veteran as writer, organizer, speaker and executive in the integrative care movement.

Tags:  integrative health  medicine  survey  triple aim 

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Understanding the Gap Between Patient Expectations and Reality

Posted By Barbara Lewis, Friday, June 21, 2013

Some events change our lives. They may be small actions that have a substantial impact or they may be traumatic events that forever alter our life. For me that event began to unfold when my younger sister, Joan, called me from the Intensive Care Unit where she had been hospitalized for an unknown infection. She expected to be released within a few days. Nonetheless, as soon as I hung up the phone, I booked a flight across the country to be with her. I spent 15 to 18 hours a day in her room recording and monitoring medications, test results and procedures. During the next few days as she improved, I put on my marketing hat and observed the hospital environment with both awe and surprise. After spending nearly three decades in marketing, much of that around customer or client satisfaction, I was fascinated with how the hospital functioned.

I decided to jot down my observations, which I planned to discuss with the head of the ICU on the day of my sister’s release. Unfortunately, Joan took a turn for the worse and died at the end of the second week. When I returned home, I found my notes. As a looked over the pages, deciding what to do, I thought that the head of the ICU might like to know my thoughts. I set to work on a document I called Joan’s Family Bill of Rights. I marveled at a group of unbelievable people who have dedicated their lives to healing the sick and comforting the dying. Yet, as a family member I felt invisible most of the time – a nuisance in the hospital room, who asked too many questions.

I emailed the document to the head of the ICU, who sent it to the head of the hospital and he, in turn, emailed it to the heads of the health care system. They contacted me to talk and within three months flew me to their facilities to make three presentations, which they videotaped for their training program.  I didn’t feel invisible any longer. Here was a health system that truly listened.

What surprised me was the number of people after each presentation who told me their stories. I realized that my experience was not unique and that patients and family members everywhere shared my own narrative. Joan’s Family Bill of Rights wasn’t just my story; it was universal. As the document was passed around in meetings and on the internet, an increasing number of nurses contacted me.

I asked myself, "How can I help?” I spent over a year researching my observations, such as compassion fatigue, situational awareness and the relationship between quiet and healing. I found that the Healthcare Consumer Awareness Hospital Process and Systems (HCAHPS) surveys were tracking patient satisfaction in hospitals across the country. I was surprised to learn that money was tied to the scores, which reflected certain patterns. For example, the well educated and younger generally score the survey lower, while the poor and less educated score the survey higher. I studied the questions and devised scenarios of high scoring or low scoring.

In my opinion, the discharged patients score the HCAHPS surveys based on the difference between expectation and reality. Patients come into hospitals with certain expectations. Every person has different expectations; however, in many cases those expectations can be generalized. For example, the more educated probably want more information about their condition. (HCAPHPS survey question: Patients Who Reported that Their Doctors {or Nurses} Always Communicated Well.) The gap between the expectation and the reality is where the survey scores reside.

There are at least five HCAHPS survey questions that are directly related to the patient’s journey through the hospital system. Low HCAHPS scores not only affect Medicare payment, but insurance reimbursements; future patients, who opt for other facilities; and donor defections, as well.


As businesses have been doing for years, it’s time hospitals understand the patients’ expectations, manage those expectations and shut the gap between the hope that patients have when they come into the hospital and the realization they are stuck with when they leave. Closing that gap means redesigning systems and altering behaviors.  It’s time to exceed patients’ expectations, which will not only boost HCAHPS scores, but have a substantial impact downstream as well.


Barbara Lewis has been a marketing consultant for over two decades. She began her career as a journalist writing for national publications from The Wall Street Journal to Ladies Home Journal. She has an MBA from the UCLA Anderson School of Management where she currently lectures. You can reach her at: 

Tags:  Expectations  HCAHPS  ICU  Patient Experience  reality  survey 

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