Innovations in Patient Satisfaction Measurement: Means and Methods

There is a growing emphasis on patient reported outcomes (PROs) within all rehabilitation venues of care. Many payers are starting to adopt policies and incentivize providers based on patient outcomes. Certainly nascent value-based approaches hold a great emphasis on such perspectives, as do capitated and case-rate payment models.

While most clinicians are trained and well versed in PROs, they may be less so in the measurements of patient satisfaction. Patient satisfaction, per se, is not an outcome measure as there is generally no “pretreatment baseline” level of satisfaction for care that has yet to have been provided. (This may be changing, however, as we’ll discuss below.)

Practice leaders can use survey data to not only better understand their patients’ experiences and opinions, but also to aid in staff management and development, augment clinical outcome findings from PROs, and for marketing and contracting purposes.

The Lingua Franca of Satisfaction

While there is a great variation of patient satisfaction surveys which can make meaningful comparisons and benchmarking difficult, there seems to be a move to use the Net Promoter Score (NPS®) approach.

What It Is

The NPS® concept was developed by Fred Reichheld and gained notoriety from his 2003 article “One Number You Need to Grow” published in the Harvard Business Review. The initial application was for use in business, but it is now migrating to healthcare in general, and rehabilitation in particular. Although not yet widespread, it is a hopeful harbinger that if more clinics employed it, there would be better opportunity to compare scores across clinics and practices.

How It’s Calculated

The “math” behind the concept makes gaining a high score a bit of a difficult task. Here’s how it works: a patient is asked to rank whether they would refer someone to the practice on a scale from 0 to 10. Their answers rank them as follows:

  • 9 or 10 is considered a “Promotor”
  • 7 or 8 are “Passives” and not counted
  • 0 to 6 is considered a “Detractor”

The Net Promotor Score equals the percentage of Promoters minus the percentage of Detractors. Thus, you can see how it differs from a traditional arithmetic average of a set of scores from 0 to 10, and therefore more difficult to score high marks.


A problem with having a one-stop-shopping-number is that one really does not know that the patient considered when ranking. Was it the great clinical experience, or the poor outcome, or the frustrating billing, or the great receptionist, or some other variable? One could conceivably have a NPS® for all aspects of the clinic experience—front office, billing, clinical, environment, etc., to remedy this. (The MedBridge NPS® tool takes all of these factors into account and allows clinicians to add an additional six attributes to the standard NPS survey in order to gauge the entirety of a patient’s experience.)

How to Mitigate Bias

Clinicians need to be wary of some common pitfalls associated with poor design of patient satisfaction metrics. For example, it’s ideal to provide patients with the opportunity to provide written comments to their scores in order to more clearly understand the thought process behind the numeric score given. Nothing is more frustrating than to get a strong score (either positive or negative) and have no idea why it was given.

There are also a number of biases to be aware of and guard against, such as selection bias, sampling biases, etc. They are noted below with methods to mitigate each as well:

Selection Bias

Problem/Risk: If clinical staff are responsible for administering the satisfaction survey there can be a risk of not asking a known disgruntled patient for their feedback as it may already be presumed to be negative, so why ask for trouble? Also, busy clinics miss surveying patients unintentionally.

Method to Mitigate: Have patient satisfaction surveys sent from and returned from the business office, bypassing the clinics entirely. Or use a digital solution with surveys being emailed or texted to patients following discharge. This means that any selectivity in regard to who takes the survey or data entry errors are avoided. Use of a third party vendor to administrate satisfaction survey process would also be a helpful solution.

Sampling Bias

Problem/Risk: The surveys are generally given to patients at the end of their care. However, patients who stop coming to appointments mid-treatment are never surveyed. These patients are oftentimes those who are most unhappy with their care and so it is important to obtain their responses to the satisfaction survey.

Method to Mitigate: It’s a good policy to provide any patient that has been seen for at least two or three visits to receive a patient satisfaction survey. This means that even patients who stop attending sessions mid-treatment are surveyed.

Pressure/Demand Bias

Problem/Risk: Patients are oftentimes required to take surveys within clinic walls. This puts pressure on the patients to either complete their survey in a hurried manner or to answer questions more positively.

Method to Mitigate: Patient satisfaction surveys can be mailed, emailed, or texted to patients so that they can complete the survey in their own surroundings at their convenience.

Technology Concerns

Problem/Risk: If clinics don’t have the resources to have computerized surveys, clinicians/staff have to input the data, which could lead to mistakes or fudging the numbers.

Method to Mitigate: Use of automated tools or third party vendors can aid with this.

Types of Questions/ Content Management

Problem/Risk: Some third party vendors do not allow for editing of questions or may be limited to asking quantitative questions. Quantitative data is good for analysis, but qualitative data is necessary for actionable information.

Method to Mitigate: Leaders should strive to have the ability to customize question sets to include both qualitative and quantitative questions. This allows leaders to have good analysis of clinics and clinicians, but also to obtain actionable information in order to make practical, concrete steps to improve.

What the Future May Hold

Practices that address the issue of patient satisfaction will always have room for development, that’s the nature of continuous quality improvement. For example, a practice could use the data acquired through patient satisfaction surveys to perform predictive analytics and take preemptive or preventive measures. The wisdom gained through data and experience can be converted into improved policies and procedures.

It is felt that one of the next notable advances in quality improvement in healthcare will be the result of the application of predictive analytical tools to data mining of information gathered via both quantitative and qualitative surveying. This will be resultant from nascent programs that actually are able to convert qualitative data into quantitative analysis. The use of digital and mobile tools to collect NPS® and other satisfaction data before the end of care will also be a boon to quality management and good clinic leadership.

The future looks bright for the creative and innovative blending of quality management perspectives powered by mindful approaches that mitigate bias and optimize sampling in improving the patient experience of healthcare. Such has always been important, but in these turbulent times of healthcare reform, increasing penetration of accountable care organizations, and ever-shrinking healthcare spending, it is incumbent upon today’s innovative clinical leaders to develop and share new concepts in ensuring quality patient experience in addition to optimal patient outcome.