Should patient satisfaction be our goal?

A revolution is ongoing in healthcare, and it is a good one for patients, so for all of us. Indeed, after decades, even centuries, of medicine being provided like charity, there is now a growing realization that healthcare needs patients as partners, not subjects. In most other industries, the concept as the customer as True North has been established already for years, but medicine, for various reasons not to be discussed here, was lagging behind. Thus, great news for healthcare customers, great news for patients.

The key challenge of this new approach is: how do you measure the value created for the patient, the ultimate costumer? Within this broad question I want to focus on customer satisfaction. Where does this fit in when it comes to healthcare? What can we learn from other industries? What should we use from other industries, and what not?

From personal experience we all know that customer satisfaction seems to be key in many industries. We book or buy something online and immediately a survey is sent our way. We call for a service, and are asked if we agree to answer a few questions after the call. We have the four smiley buttons popping up in many places, including after airport security and in our town halls.  Our Apps ask us to rate them, over and over. We receive evening calls on our home and mobile phone to survey us. It seems that all those who offer us goods or service want to know how satisfied we are. In many countries you can now even enrol in services that will stop the phone calls and surveys in your post box.

So, why all this interest in customer satisfaction? The answer is relatively simple: ample research has shown that, in most all of those goods and service industries, customer satisfaction is the best predictor for future (read more) business. And this works in two ways: a satisfied customer will come back, and a satisfied customer will refer others. It is generally much cheaper to keep a customer than to get a new one. Thus, in marketing terms, customer satisfaction drives both repeat and referred business. So, as a business, you really must focus on customer satisfaction, which actually means to measure it and to then improve it. Different instruments are used; the most widely adopted (because it has been so well studied and validated) is the Net Promotor Score (NPS), which we have all completed. There is one question: “How likely are you to recommend XXX to others?”, and we rate our likelihood from 0 (no chance whatsoever) to 10 (already done it and will do more for sure). The NPS itself is than a single score, calculated by taking the % of people who score 9 or 10 (called Promotors) and subtracting the % of those with a score of 0-6 (called Detractors). The middle scores 7 and 8 (called Passives) are not used. So the NPS can be any number between -100 and +100. A simple, standardized score, easy to use, compare and track; no wonder NPS is used so broadly.

Logically, therefore, there is great interest in applying NPS also to measure (and of course improve) patient satisfaction with the goods and services delivered to them. I think that this is a great idea and I also think that care is needed in doing so. What are some of the key considerations to be made?

Firstly, and most obviously, there is the name of the score. Indeed, the “P” stands for “Promotor” and that word itself used in the context of patients is enough to cause sheer panic in many legal departments. Indeed, any form of promotion to patients is strictly and strongly prohibited in Europe, and in the US such promotion is also subject to strict conditions and close scrutiny. Here, I think it is important that it is not the name that should be looked at, but the activity itself. Asking someone for feedback is not promoting. Asking someone if they are likely to recommend something is not promoting. Asking someone to recommend, that is promoting. So, in spite of its name, which is a description of what is being measured, not done or asked, the NPS itself is not promotional. And the fact that it is used as such across many industries should provide further reassurance.

So, I do not think that the name NPS is a real issue. There are in my view a few other and more important issues to consider. For starters, satisfaction may not be the right metric for value creation. Indeed, in medicine as in education, satisfaction is not the overriding priority that should guide decisions. If pupil satisfaction would be the only goal, schools may start later (or not at all), there would be no tests or homework, and so forth. Thus, while as parents we do not want our children to feel unhappy or abused at school, we will prioritise educational value (both academic and non-academic) above their satisfaction, or at least find the best possible balance. As parents we take this accountability serious, and that is also what is expected of us. We see the broader picture, we have the experience, and we know that without some degree of discomfort and effort our children cannot receive the maximum educational value. The same is true in medicine: physicians train long and hard, and they also draw on years of individual and collective professional experience, to diagnose and treat. And, like parents, they really do have the best of intentions. While indeed it is both possible and desirable that many physicians, and indeed the whole healthcare system, deliver a more satisfying patient experience, the primary purpose remains to protect and improve health. And this is why measuring patient satisfaction must always be done in a much broader and well-balanced assessment. The risk is that it is so much easier and faster to measure satisfaction (e.g. with NPS) that more attention is given to this metric that is actually healthy (literally and figuratively speaking). A clinic could provide free transportation, a warm welcome, a coffee service, 2 hours per patient, smiling and gentle staff, but if the diagnostic and/or therapeutic service delivered is substandard then patients should go elsewhere. Similarly, a cheap drug may be nice to have, but that does not automatically make it better.

There is another reason to be careful with focusing too much on patient satisfaction, and this is particularly relevant for pharma. Indeed, from experience we know that if customer satisfaction becomes the primary focus, then this will drive behaviours in a way that may become risky. Indeed, for years prescriber satisfaction was somehow thought to be related to and predict prescribing behaviour. Thus, prescriber satisfaction became the goal and this was the reason behind historical practices like wining and dining, gifts and even trips, all of which today we consider to be unethical on top of being illegal. We are happy that these commercial practices targeting prescribers are now well behind us; let us not head down that same slippery slope with patients.

To be clear, my plea is not against the importance of patient satisfaction or against measuring it. As a patient I also highly appreciate a positive customer experience when I visit my physician or the hospital. My point is that my satisfaction is only a small, and sometimes secondary, element in what patient value means to me. Thus, rather than ignore patient satisfaction, which we should not, we should work together to develop equally validated and predictive standard measures of the other elements of patient value. Indeed, the True North is patient value, which is best achieved by understanding first what is of value to a patient through engagement, and then leads to better system decision making that includes their perspectives as well as other stakeholders'. Now that is really satisfying.

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