AskMariaTodd: How can physicians calculate their Net Promoter Score (NPS)?

Recently, I've walked into consults where the marketing savvy doctor beams while telling me their most recent Net Promoter Score (NPS) like it is a badge of honor.

What is a Net Promoter Score anyway and why should you care?

The whole purpose of the NPS system is culture change and continuous improvement.  

If you are a physician in private practice (whether you own the practice or another entity or hospital owns it), you are now measured on patient delight and brand awareness.  In case that memo slipped by you, it is also a revenue impact issue as bad scores equal decreased revenues, lost contracting leverage, lower payment rates, potential network deselection and loss of key staff to practices where the mood and reputation are more positive.

The NPS system is meant to go beyond testing how satisfied a customer is with a company; it’s designed to test if someone likes your professional brand so much that they want to tell the world how pleased they are. So while you have CG-CAHPS and HCAHPS this is different.   The NPS isn’t a yes/no question. Participants are asked to grade their responses on a scale from 0 to 10, with low scores indicating a complete lack of willingness to promote your practice and your reputation but a 10 score gives a very high likelihood that your patient and their family will promote you and your business as a brand ambassador. That ties in social media, word of mouth (WoM) and referrals that are earned on merit, not paid advertising.

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The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) survey is a standardized tool to measure patients' perception of care provided by physicians in an office setting. Another way to think of CG CAHPS is like a "sister" survey to the more well-known HCAHPS survey. The rating scale is still 0-10 where 9's and 10's will be evaluated in terms of a top score.

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One practice we worked with between 2013 and mid-2015 did a great job of Monday morning quarterbacking and changing vendors frequently.  In that time, they changed out their EMR - twice. They changed their billing company - three times.

They had nothing but complaints on social media, high staff turnover, and face-to-face complaints while people were still in the office. Nobody took charge, nobody (especially not the doctor or his wife/practice manager) took the complaints seriously. They ranged from running late to lack of follow through, to billing errors, to slow answers on the phone, not enough managed care contract participation, really high prices, and other fixable problems.  The more complaints they got,  the more they pushed for social media feedback on Facebook, Twitter, FourSquare and Google Local -- as if to intentionally expose their shortcomings to the world.

They had an advertising agency that was expensive and encouraged them to by radio spots, cable TV ads, newspaper ads, billboards, bus ads, yellow pages ads, and anything print related or media related. Why? Because that's what the agency knew about and what it got paid glorious commissions to sell.  At the end of the advertising agency's run, they were billing out close to $450,000 a year for a small private physician practice. What were the returns? Nobody knows because there was no ROMI data.  Eventually, they canceled the contract with the ad agency as well.

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ROMI (Return on Marketing Investment)

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Meanwhile, the practice did not pay attention to or take seriously that which it could impact without spending an additional media buying dime.  It was as if they expected to be able to pull down a high Net Promoter Score from patients without earning it.

At one point, we had to enlist their $550 per hour health law attorney to emphasize our admonitions that they could not create a tabletop ad that solicited good feedback on social media platforms like Google, Yelp, HealthGrades, Vitals, Angie's List, etc.,  in exchange for a $15 gift card.

At the same time, they also had every excuse to not measure patient satisfaction formally. We provided the CG-CAHPS tool, Survey Monkey, paper templates and more and the excuse was always some other urgency, no time.  It spoke volumes to me: either they were afraid to face reality, lazy, or just didn't care.

The Tortoise and the Hare - Revisited

They also noticed that their two nearest and toughest competitors had started to use social media tools effectively, had enhanced and updated the effectiveness of their website, the doctors blogged on topics that patients wanted to read about, a newsletter was published monthly, and the competitors began hosting local public relations activities to get the doctors out in the community engaging with patient prospects in a feeding frenzy from this practice's patients as well as other doctor's addressable and potential market.

When the penetrated market is small and the addressable and potential market is being won over by competitors, it is time to step up one's game and find out what it will take to retain the penetrated market and grow it.  

Instead, the doctor and wife management team chose not to do anything internal to boost ratings and satisfaction to a level of delight. Even worse, they did something that caused me and my team of creatives and experts to simply walk away. The doctor and his wife started taking days off and telling the staff they had to take forced vacation time on those same days since the practice simply wasn't that busy anymore.  Can you spell d-e-a-t-h  s-p-i-r-a-l?  When I see this behavior, it is beyond my capabilities to rectify.  I can't help those who won't help themselves. I'd rather work with those who are ready to do the hard work to build a business.

The Net Promoter Score Scale

(NPS?, Net Promoter? & Net Promoter? Score are registered trademarks of Satmetrix Systems, Inc., Bain & Company and Fred Reichheld.)

To get started, customers are asked to rate their likelihood of recommending a company to a friend or colleague by using a 0-10 point scale. The number on the scale that a customer chooses is then classified into one of the categories: “Detractors,” “Passives,” and “Promoters.”

Score breakdowns:

0 – 6: Detractors

7 – 8: Passives

9-10: Promoters

You can think of the NPS system as similar to a four-star system on an online review, but the NPS scale gives you a broader way (and a more accurate method) to measure customer’s opinions. You can do this as a one button click response to an email.

Let's assume that out of a practice with 4500 active email addresses and patient followers, you get 100 responses. 

The NPS system gives you a percentage, based on the classification that respondents fall into—from Detractors to Promoters. So to calculate the percentage, follow these steps:

• Enter all of the survey responses into an Excel spreadsheet.
• Now, break down the responses by Detractors, Passives, and Promoters.
• Add up the total responses from each group.
• To get the percentage, take the group total and divide it by the total number of survey responses.
• Now, subtract the percentage total of Detractors from the percentage total of Promoters—this is your NPS score.

Let’s break it down:

(Number of Promoters — Number of Detractors) / (Number of Respondents) x 100

Example: If you received 100 responses to your survey:

10 responses were in the 0–6 range (Detractors)

20 responses were in the 7–8 range (Passives)

70 responses were in the 9–10 range (Promoters)

When you calculate the percentages for each group, you get 10%, 20%, and 70% respectively.

To finish up, subtract 10% (Detractors) from 70% (Promoters), which equals 60%. Since an example Net Promoter Score is always shown as just an integer and not a percentage, your NPS is simply 60. (And yes, you can have a negative NPS, as your score can range from -100 to +100. That's where people don't just say no, they say "hell no" -or worse!)

Do you need an expert's help to do this?

Probably not. The only reason why  you would need assistance to conduct a NPS survey would be if you simply don't have time but want it done for you. In that case, I have a competent virtual assistant based in Miami who will help you prepare and measure your NPS survey and manage the whole process for $25 per hour.  She's available as an independent contractor and willing to prepare and send out your monthly e-newsletter, manage professional copyediting and proofreading, testing for mobile, desktop and tablet versions, do all your editing, tally your responses and tell you the outcome of your NPS.  Or, she can do all the prep work and if you decide to use Survey Monkey, they will do the calculations for you. None of this requires big money to undertake.

The hard work is after your initial measurement. What can you do to improve? Will you toss money out the window on purchased media buys?  Will you try to cajole patients into giving social media feedback? Or will you embark on a crusade for service level improvement and practice growth?

Beyond asking if they would recommend your practice to friends and colleagues, you can ask two class organizational development (OD) questions:

• What changes could this practice or our doctors make to earn a higher rating?
• What does this this practice or our doctors do really well?

What if you end up with a lower score than expected?

It depends. It may not be the end of the world.  If your competitors have similar NPS numbers,  you’re doing just as fine as them. That's not saying much, is it?  If you are doing worse, you are at risk for the feeding frenzy I described above. 

Troubleshooting a lower than expected NPS score often elucidates that you:

1. Have no internal brand champions working for you
2. May be suffering from poor internal communication
3. Aren't maximizing all channels to be exceptional and welcoming

You can improve by creating opportunities for continual improvement, remeasuring, and measuring how your investment into customer service drives up revenues.

Where to look for low hanging fruit

1. Improve communication of company goals
2. Initiate strategic changes as a result of newfound knowledge about your NPS
3. Get management buy-in
4. Link NPS to staff retention and customer retention
5. Use promoters as social media influencers and spokespersons
6. Set internal bonuses to improvements in NPS

Across all industries, those who measure performance target a 7% improvement over 12 months, so don't expect huge leaps right away just because you did something. Unlike the school playground, there are no participation trophies in business.  That may sound easy, but it isn't. To pull it off, you must earn a 0.6% improvement each month.

What kinds of practices will benefit from a NPS benchmarking evaluation and improvement campaign?

• Primary Care
• Specialists
• Chiropractic
• Podiatric
• Psychotherapy
• Psychiatry
• Physical Therapy
• Telehealth (synchronous and asynchronous)
• Hospitals
• Home health agencies
• EMR
• Billing software systems
• Nurse Practitioners in private practice
• Pharmacies
• Rehab centers and hospitals
• Health insurance companies
• Employers offering a self-funded health benefit program with or without a medical tourism benefit feature.
• Employers who offer a worksite health center or occupational health clinic onsite.
• Medical Tourism facilitator
• Concierge medical practice
• Direct pay medical practice

The smaller your organization, the more you can do with NPS improvement campaigns because they are easier to manage. It seems that the larger the company, the lower the NPS score. This is most likely do to the challenge of managing so many people, systems and moving parts.

If you want to improve your business, your first goal should be market retention and referrals. Next it would be to improve the Customer Experience with your business (CX). People don't buy what you sell, they buy why you sell it and how your people act when selling it.  Next after that would be employee engagement and retention, followed by loyalty measurement and operational improvement -- in that order.

How often do most professionals measure NPS?

52% ask customer at least twice a year - often far more frequently. Some ask on a transactional basis while others act on a relational basis.  Some do it once a quarter, the worst performers do it once a year.

How do they do it?

• Email is the dominant survey tool (>70%)
• 22% (mostly in developing countries) survey NPS by phone
• 10% are now using SMS by permission.

Overall the response rate is 31% across all industries.  About 13% report response rates above 61%.  You may see articles that mention "coverage".   The lower your NPS score, the more likely your coverage is low. 14% is the average, low performers average about 9%.

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Coverage = Reach x Response

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About international comparisons of NPS

NPS also varies by country and culture so even if your hospital, clinic or private medical/dental practice does well in Spain or Thailand,  benchmarking a survey responded to by Thai patients or Spanish patients is not comparable to a same question, similar sample size of American patients at an American hospital. I added this for the benefit of my clients outside the USA involved in medical tourism or marketing locally.

How did Mercury stack up?

We did an NPS measurement not too long ago. Our coverage was about 23% across all segments, our method was email, our lookback was customers over the past 5 years. Our mailing list was 35,000 but we segmented by type of service.

• managed care contracting
• revenue cycle outsourced services
• concierge medical practice startup and transitions
• medical tourism patient coordination (2003-2013)
• medical tourism industry consulting
• training and development clients (NPS was 97.6%)

Our net promoter score was an average of 81%. I want it to be higher and I know that as CEO that falls to me to drive it up.  I can do better. We can do better as a team.

Well that about sums it up today. I am leaving for a few days to teach in Idaho at The Hospital Co-op. If you are located in or near Pocatello, give me a shout and let's have coffee. I'll be there until the evening of the 26th, and then head south to Provo to visit family.  

I'd love to hear or read your point of view on this article. 

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Do you have a question to AskMariaTodd? ?  

Get in touch with Maria Todd by calling +1.800.727.4160 or sending her an email at: mtodd(at)mercuryadvisorygroup(dot)com.

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About Maria Todd

 Denver-based consultant, award-winning speaker, trainer and author, Maria Todd, brings you her best insights and strategies and point of view from working on various healthcare, concierge medicine and international development projects in the USA, Europe, Asia, Latin America and Central America for over 30 years.

As part of her professional work as a consultant, speaker and author, Maria Todd travels a great deal all over the country . Wherever she is, she encounters the latest and greatest examples of private practice operations and management, exemplary clinics, healthcare practitioners, and meets with many government officials and investors.

She identifies rising trends and really amazing ideas as well as some things that are pretty bad, where an opportunity to do something great was missed. Maria writes, speaks, and consults internationally about her experiences and professional activities with the good and the bad in healthcare and health and wellness and provides insights regarding what stakeholders, investors and government authorities might learn from these examples.  

 Maria Todd consults to healthcare executives, physicians, dentists, and other practitioners, retailers, investors, and entrepreneurs through Mercury Advisory Group.  She also provides a fair amount of consultation for investment firms and market analysts through GIZ, GLG, PWC, Third Bridge, Maven, and other consulting firms.  

She is a member of the Society for Healthcare Strategy & Market Development (SHSMD).   SHSMD members represent healthcare-specific disciplines such as marketing, communications, public relations, strategic planning, business development, physician relations, sales, and government and public affairs.

Learn more about Maria's work as a strategist and innovator in the world of health and wellness tourism business development at her websites,

MariaTodd.com
Mercury Advisory Group

Center for Health Tourism Strategy

  and be sure to connect with her on LinkedIn and leading social media networks including, but not limited to: Twitter, Facebook, Quora, Google+, Tumblr,  LinkedIn and via her newsletters.