Loyalty also pays dividends beyond influencing patient choice:
individual physicians will also benefit from getting more in tune
with patients' feedback, as loyal patients become repeat patients
and help improve physicians' practice economics.
How can hospitals transform themselves into consumer-oriented
operations? The key is to understand clearly which parts of the
patient experience are the real "moments of truth" and how to
ensure that they can become "wow moments." Too often, though,
hospitals lack reliable information to take the full measure of the
patient experience.
A new measure for hospitals
Hospitals usually rely on traditional customer satisfaction
surveys to determine the wants, needs and disappointments of
healthcare consumers. However, these surveys frequently fall short.
They are samples, not a true census of the full patient population
about how to improve the patient experience. The questionnaires
aren't always timely and they therefore rely on patients' memories,
which can compromise the accuracy of the feedback. Finally,
hospitals must sort through an enormous amount of data from lengthy
questionnaires to find key insights, and even when they do find
them, there is no closed loop with the people who need to learn and
change.
Some hospitals have adopted a different approach, which is
rooted in the principle that the key to success is customer loyalty
and advocacy, not merely satisfaction. In other industries,
profitable growth comes from finding and delighting a core group of
customers who will do your marketing for you. These loyal customers
not only return to purchase goods or services again and again, but
also provide enthusiastic referrals for the business to their
friends, relatives and colleagues.
One of the most effective approaches to creating a culture
focused on customer loyalty has Net Promoter® Score (NPSSM) at
its heart. It's a radically simple approach. NPS is based on a
single question: How likely are you to recommend this company or
product/service to a friend or colleague? This is not the exact
question for all industries, but it does work particularly well in
healthcare given the high level of emotion surrounding how to best
take care of yourself. Customers score their responses on a 0-to-10
scale: Loyal promoters score 9s and 10s; passive customers rank as
7s and 8s, while those who respond with a 6 or below are
detractors. Subtracting the percentage of detractors from the
percentage of promoters yields a single figure-the company's Net
Promoter Score. Typically, customers are asked only one or two
open-ended follow-up questions to provide information about why
they rated the company that way.
The NPS approach has helped loyalty leaders such as Apple, Four
Seasons Hotels, American Express, General Electric and Philips to
identify and target high-value customers, design the right product
or service at the lowest cost, and develop the capabilities to keep
turning customers into promoters. Companies with loyal followings
grow revenues at more than twice the rate that their competitors
do.
Some hospitals have adapted the lessons learned by these loyalty
leaders to design patient-focused organizations. In healthcare,
perhaps even more than in other industries, loyalty has two
dimensions-the head and the heart. Getting a fix on these two
dimensions requires considering a patient's practical
concerns-quality of care, facilities and price-as well as emotional
issues; how well do they treat me, do they respect me, and do they
keep me informed and listen to me? It also is important to
gain an understanding of which parts of a patient's experience are
most crucial to a patient's overall perspective on the hospital
stay, and then be able to zoom in on the behaviors and
circumstances that most influence those "moments of truth."
Improving the patient experience in these key moments is very
motivational for caregivers and staff, and in fact is far more
inspirational than cost-or even quality.
NPS is an invaluable tool in reshaping an entire hospital
culture because it probes both dimensions of loyalty-the head and
the heart. And because it can be done in real time, it enables
employees to act quickly on what they can learn from patients.
To see how it works in practice, we'll consider the experiences
of three healthcare providers that have used NPS as a starting
point for building patient loyalty. The three organizations span a
broad range of healthcare providers-not-for-profit institutions,
for-profit hospitals and ambulatory centers. Each hospital is at a
different stage in the process of turning patients into promoters,
and each highlights a different aspect of how NPS can be
effectively deployed to create real patient advocates.
Ascension Health: The power of compassion
The first step in turning detractors into vocal promoters is to
understand what matters most to patients. Ascension Health, the
nation's largest Catholic healthcare system, is working to pinpoint
the drivers of an exceptional patient experience. In 2006,
Ascension Health adopted NPS as the metric of choice for evaluating
the patient experience, using NPS as the central element of a
long-term plan that aims to transform Ascension Health by creating
cultures that support the delivery of a consistent, exceptional
patient experience. Ascension Health turned to NPS after using
customer satisfaction surveys with inconsistent improvement in
customer loyalty.
To learn what patients value, Ascension Health conducted
extensive research and interviewed more than 1,800 patients, using
NPS to help gauge customer loyalty. The information revealed that
patients have specific expectations and needs around the clinical,
environmental and emotional aspects of their hospital experience.
Further, the NPS results showed the emotional realm is where
hospitals can truly distinguish themselves and create real
promoters. Specifically, both responsive care and compassionate
care turn patients into promoters, while the perception of
disrespectful or unresponsive treatment will create detractors. On
the compassion dimension, however, Ascension Health discovered that
expectations typically are so low that a lack of compassion rarely
creates detractors, but does mean that an opportunity to create
more patient promoters has been missed.
That approach transformed the experience one patient diagnosed
with adult-onset diabetes had at an Ascension Health facility. As
part of the hospital's new focus on experience delivery, shortly
after being admitted he was given a brief survey and asked to rate
his experience. The score was a lukewarm 5 on the NPS scale. A
nurse manager immediately followed up and learned that the patient,
distraught over the diagnosis, was unsure about what he could eat,
both at the hospital and once he went home. She arranged for a
dietitian to start working with him. At discharge, when patients
once again are asked to complete a survey, the man's NPS jumped to
a 10.
A dietary consultation is just one of many touch-points during a
hospital stay. Wait times, scheduling, testing, billing, insurance
issues, communications with doctors all shape a patient's
experience. The challenge is to understand which touch-points are
most critical to different types of hospital consumers. For
example, Ascension Health found that respect was especially
important to less educated, lower-income patients and those who had
frequent stays; a higher percentage of men and the elderly ranked
compassion as highly important, while more educated and younger
patients said being informed was a crucial loyalty test.
Identifying the critical touch-points and creating a group of
loyal promoters requires a tightly focused organization. Loyalty
leaders understand that the NPS metric itself is only one part of
the overall Net Promoter system. Organizations need the right tools
and management processes to create more promoters and fewer
detractors. For example, having aligned people practices which
enable the company to recruit, train and reward based on behaviors
that will lead to better customer experiences is a key element of
this system. And, empowering the front-line employees to experiment
and equipping them to solve problems on an ongoing basis is also a
critical part of the equation.
Ascension Health relies on these capabilities coupled with NPS
to deliver a consistent, exceptional patient experience. This
approach has been refined at St. Joseph Hospital, a midsize
facility in Kokomo, Indiana that already had a high NPS but desired
to move from good to great performance through its "Patients First"
program. Patients were asked to complete short surveys immediately
after two important transition points-admissions and discharge.
That allowed staff to quickly respond to concerns. In tandem, St.
Joseph employees were taught "soft skills" such as how to provide
emotional and spiritual support. They attend formal workshops to
help them identify and meet patients' emotional and social needs.
In addition, frontline employees are empowered to put patients'
needs first and solve problems-a critical step in the "Patient
First" program.
Within about six months, early results show that patients have
taken note of the difference: the hospital's NPS improved by more
than 15 percent and other Ascension Health facilities are
considering rolling out versions of the program.
Cancer Treatment Centers of America: Patient-empowered
medicine
Cancer Treatment Centers of America (CTCA) offers another
example that an improved consumer experience translates into
sustainable growth. Since CTCA opened its doors in 1988, the
midwestern specialty hospital chain has been a trailblazer in what
it calls "Patient-empowered medicine." Long considered
non-traditional, some of CTCA's approaches now are being adopted by
mainstream hospitals. At CTCA, patients have personalized treatment
plans, lab turnaround times that are some of the fastest in the
industry, doctors who are required to quickly return calls, and a
travel planner who arranges transportation to chemotherapy
appointments, even laughter therapy, massages, and organic
food.
Loyal patients have fueled growth that's the envy of mainstream
competitors: five consecutive years of double-digit increases in a
mature industry. CTCA recently incorporated NPS questions on its
internal surveys and now achieves scores that range from the high
80s to the low 90s. In contrast, the average hospital NPS is
approximately 55. By employing NPS to track customer satisfaction,
CTCA hopes to maintain its double-digit growth as it expands the
number of its holistic treatment centers.
Cancer Treatment Centers of America follows four principles to
put NPS findings into action and keep the organization focused on
patients:
1. Gather real-time consumer feedback.
Just as companies don't measure profits only at the
corporate level, customer relationship data should be clear enough
so that front-line work teams can make better decisions and deliver
an improved customer experience. In addition to having patients
complete satisfaction surveys that include NPS ratings at
discharge, CTCA has weekly patient focus groups, run by guest
services and attended by staff members at various levels across
departments.
2. Make the right people accountable for following
up.
Even the best consumer feedback is useless unless an
organization addresses the problems that the process uncovers. CTCA
has systems in place to ensure that issues raised by patients
aren't ignored or fall through bureaucratic cracks. Every patient
receives a follow-up call after his or her stay, further inquiring
about their experience. After those weekly patient focus groups,
staff members are contacted to resolve issues raised by patients.
In addition, clinicians meet three times a week to discuss and act
on patient concerns. Finally, CTCA's board members also review
patient issues. According to CTCA officials, each board meeting
begins with the "Voice of the Patient," a presentation to the Board
by each patient that recounts a specific patient experience. If the
presentation raises an issue or concern, the meeting doesn't
continue until it's been resolved.
3. Train employees to deliver patient-oriented
care.
At every step of the hiring and training process, CTCA
keeps the focus on creating a workforce that knows how to deliver
patient-empowered medicine. This means giving employees the skills
and tools they need. All candidates are screened to make sure they
have the attitude needed to fit into CTCA's culture. Job interviews
are conducted by a team of representatives from within and across
departments. Once hired, all employees undergo a two-day
orientation. The training process employs an innovative
cross-departmental curriculum to improve employees' understanding
of the different and vital roles that they'll play in creating a
hospital experience, which turns patients into loyal promoters.
4. Measure often.
Sprinkle surveys throughout the patient experience with survey
activity conducted each day throughout the year. If you measure
only once a year or once a quarter, nobody will pay attention
except when the results come out. Also, the more often reports come
out, the more chances there are to try out new approaches to see if
they improve results. CTCA constantly seeks feedback in a variety
of ways and acts on it. Repeat patients are surveyed every 60 days.
In addition, CTCA recognizes the critical link between employee
loyalty and patient loyalty; therefore once a year, employees
complete NPS surveys. Each hospital's senior leadership reviews the
employee surveys during three- to four-hour town-hall-style
meetings to be sure they have understood all relevant feedback. And
board members see the employee results and also regularly sit in on
patient focus groups and make unannounced patient visits to get a
firsthand view of the patient's feedback.
The goal is to track NPS at every step of the way. To learn if
problems have been effectively resolved, managers follow up with
patients and ask: "If you previously reported any concerns,
were you satisfied with the resolution?" This allows managers to
identify which department and staffers are doing the best job of
turning customers into promoters and reward stellar employees, a
challenging process in hospitals where small teams form around each
patient.
CTCA wrestled with this and devised a clever solution-the
patient-care tracking system has been reworked to register which
departments and which employees from each department touch each
patient. This allows CTCA to figure out which staff oncologists,
for example, are generating the most enthusiastic patients and
promoters. Since referrals are critical to the hospital group's
success, outstanding staffers merit careful observation so that
their practices can be used to train other CTCA physicians.
Evanston Northwestern Healthcare: NPS in doctors'
offices
Just as NPS has helped hospitals transform their organizations
into more patient-oriented cultures, physicians are finding it an
invaluable tool for diagnosing customer loyalty ills in their
practices and implementing remedies. Evanston Northwestern
Healthcare (ENH) has been using a precursor to the NPS system since
1999 to measure patient experiences with individual doctors, as
well as at its clinics and hospitals.
When ENH started collecting this feedback, patients commonly
cited two primary reasons for being less than thrilled with their
doctor visits: physicians who didn't "look me in the eye," or
physicians who did not "know my name." Broader concerns emerged
from the survey as well, such as difficulty in getting appointments
with specialists.
ENH responded with an aggressive "service value" program, which
monitors the patient experience for 350 doctors across 50 offices.
The program asks patients for feedback, applies fixes, and then
checks back with patients again. To win acceptance, ENH used
incentives to promote the new program and tied 33 percent of all
annual raises to ratings of doctors based on patient feedback.
Each quarter, ENH conducts about 20,000 short surveys with seven
to eight questions. All detractors who provide their names receive
a follow-up call from the practice manager or a member of the
staff, as do a sampling of the promoters. The payoff: in the last
three years, more than 80 percent of patients have become true
promoters.
After working with this patient feedback system for eight years,
ENH has also found a close correlation between a high NPS score and
increased physician productivity: an 11 percent increase in loyalty
at primary care offices has translated into a 24 percent increase
in physician productivity and a similar increase in physician
compensation. This relationship has been instrumental in helping
physicians get excited about the patient feedback system and
creating ownership for the full clinic staff around being truly
patient-focused.
With the rise of consumerism in healthcare, caregivers cannot
afford to continue to do business as usual. Instead, healthcare
providers must increase their focus on creating real patient
promoters. NPS can be an essential tool in that endeavor, as the
link between the emotional and clinical experience is a powerful
one that determines patients' ultimate choices. Those providers who
deploy a closed-loop, real-time patient feedback mechanism and
provide the front-line caregivers with the necessary tools and
training to deliver an "excellent patient experience" will be best
positioned for growth and success in the coming years.
Julie Coffman is a partner with Bain & Company in
Chicago. Phyllis Yale is a Bain partner in Boston. Both are senior
members of Bain's Global Healthcare Practice.
Copyright © 2007 Bain & Company, Inc. All rights
reserved.
Editorial team: Paul Judge, Elaine Cummings
