Net Promoter Score: Are Your Patients Promoters, Passives, or Detractors?

July 5, 2016

// By Jane Weber Brubaker //

Memorial HermannNet Promoter Score is a mechanism that collects consumer feedback by asking the question: How likely is it that you would recommend [brand] to a friend or colleague? Memorial Hermann uses Net Promoter Score to measure consumer sentiment across a range of online experiences. “We can get a gauge whether or not patients are satisfied with their experience with a metric that is comparable across industries, and across competitors inside our industry,” said Kelly McCormick, Director of Web Strategy and Digital Marketing at Memorial Hermann, in a recent eHST article.

Patients are consumers. They want convenience—especially online. They expect it, and when they don’t get it, they don’t like it. When they don’t like it, they may tell other people. If they’re really upset, they may use the large megaphone known as the Internet to tell the world. Wouldn’t it be great if they told you, their health system, so you could fix the problem?

Net Promoter Score, introduced by Bain & Company in 2003, is one way to listen to the voice of the customer. Major health systems have used it as a way to cultivate a patient-first culture and improve clinical care. Others, like Memorial Hermann, use it to drill down to specific aspects of customer experience online. Here, we’ll look at some examples, and suggest some ways health systems could improve overall brand perception by improving specific aspects of their websites.

Promoters Minus Detractors = Net Promoter Score

Net Promoter Score is calculated by subtracting the percentage of “detractors” (not likely to recommend) from the percentage of “promoters” (likely to recommend). Detractors are those who rate the experience 0 to 6, and promoters rate the experience 9 or 10; a rating of 7 or 8 is “passive.” The range of scores is -100 to 100.

Net promoter score


Below are actual Net Promoter Scores for Memorial Hermann, from three different digital touchpoints. The top result is for the health system’s billing process. The graph shows that 61 percent of consumers were promoters, rating their experience 9 or 10, and 19 percent were detractors, rating their experience 0 to 6, for a positive score of 41.

Net promoter score

Source: HCIC 2015 presentation, “Why Billing is Key to the Patient Experience”

A Tool to Predict Growth

Net Promoter Score was developed in 2003 by Fred Reichheld, a partner at Bain & Company. Working with data supplied by Satmetrix, a customer experience management software and consulting firm, Reichheld tested different questions to see which one was the best predictor of customer behavior, and found that one question correlated with repurchases, referrals, and other actions that contribute to a company’s growth. Customers who are promoters buy more, stay longer, refer friends, and provide feedback and ideas, according to research from Bain & Company.

Intervening at Pivotal Moments to Turn Detractors into Promoters

Ascension Health was the first major health system to use Net Promoter Score as a framework for transforming patient experience. Beginning in 2006, Ascension used the tool to survey 1,800 patients, and found that patients’ hospital experience centered on three aspects of care: clinical, environmental, and emotional. “NPS results showed the emotional realm is where hospitals can truly distinguish themselves and create real promoters,” say the authors of a 2007 Bain & Company report, “Would you recommend this hospital to a friend?” In one example, a patient’s rating of his experience went from 5 to 10 between admission and discharge. The patient was initially upset about a new diagnosis of diabetes and wasn’t sure what he could eat. He gave a 5 rating to his experience upon admission. Noting the score, a nurse followed up and connected him with a dietician. At discharge, he rated his hospital experience a 10. The authors note that “empowering the frontline employees to experiment, and equipping them to solve problems on an ongoing basis is a critical part of the equation.”

One Hospital, Two Bills

Outsourcing emergency services is a growing trend, but from a patient perspective, it’s still one hospital. Emergency Medicine Associates is a physician staffing company providing emergency medicine staffing as well as hospitalists, pediatrics, critical care, and urgent care. “For us, patient satisfaction is a religion,” says Dr. Alex Mohseni, Partner and Chief Innovation Officer. “It is something that is deeply embedded in our culture and in our planning and thinking about everything that we do.” The company was founded in the 1970s, serves approximately 750,000 patients, and according to Mohseni, has never lost a contract.

“We looked at the patient experience for the billing portion,” says Mohseni. “The first thing is typically confusion. Why am I getting two bills? And who is Emergency Medicine Associates? I thought I had insurance. Why do I have to pay this much?” To solve the confusion, Mohseni piloted Simplee’s billing solution, and based on positive results, has now moved the entire system to Simplee. “One of the key things I really love about it is they have patient satisfaction embedded as part of the payment process,” he says. “And the scores that we are getting are absolutely phenomenal. People are saying that they would come back to our hospital and our ER simply because the payment process was so simple and easy and convenient.”

What Consumers Demand

As we saw in our recent article about captive website visitors, one bad experience on a website can taint a patient’s or a consumer’s overall perception of the health system’s brand. Patients demand the convenience of online access and the ease of self-service functionality they’ve grown to expect from digital experiences.

As we’ve seen with Memorial Hermann, Net Promoter Score can be used to gauge patient satisfaction for a variety of digital experiences on hospital websites. The NPS question becomes more specific: “How likely are you to recommend Memorial Hermann to a friend/colleague due to your recent payment experience?”

Embedding a Net Promoter Question into key transactional experiences can shed light on issues with real-time feedback, helping health systems better understand issues and work to resolve them. Some of the ways the question could be phrased to get at other transactional experiences on websites might include:

How likely are you to recommend [hospital/health system] to a friend/colleague due to your recent:

  • Payment experience
  • Online scheduling experience
  • Event registration experience
  • Find A Doctor experience
  • Patient portal experience
  • App experience
  • Secure messaging experience

What Matters to Consumers

The chart below illustrates the things that matter to consumers about their care. Many are not measured through Hospital Consumer Assessment of Healthcare Providers and Systems, among them:

  • Ease of understanding bill
  • Access to medical records
  • Ease of scheduling appointments
  • Online tools and resources


Source: McKinsey on Healthcare, “Measuring the Patient Experience: Lessons from Other Industries”

A Growing Need for the Skill Set?

Expertise in Net Promoter Score is becoming more visible in job specifications, with 850 listings on LinkedIn containing the keyword “Net Promoter Score” as of this writing in June. Adding the word “hospital” to the search yields just 13 results, and only one is an actual hospital. Boston Children’s Hospital is looking for a Senior Manager, Market Research and Customer Insights, and one of the responsibilities listed is: “Applying Voice of Customer methodology and measuring and tracking Net Promoter Score to drive brand preference and intent to purchase.”

Net Promoter Score is one way digital marketers in health systems can zero in on specific pain points. Emergency Medicine Associates, for example, uses its own discharge survey and a “caring callback” program in addition to Net Promoter Score; its hospital clients survey patients through HCAHPS, providing more insight.

Tipping the Scale in the Right Direction

Regardless of the methodology used, specific, real-time feedback is a valuable tool in understanding and resolving issues. Customer experience can tip the scales either way; patients will either become promoters or detractors, and the pivot point, as we have seen, could be one isolated experience. Dave Weineke, Digital Strategy Practice Director at ConnectiveDX, commenting at the Cleveland Clinic Empathy + Innovation Summit in 2014, said, “Whether it’s measured in Net Promoter Score or HCAHPS, what patients say about their care becomes the brand of the caregiver.”

Jane Weber Brubaker is the Editor of eHealthcare Strategy & Trends. Contact her at