Friends & Family Test: the NPS system in commercial operation…

NPS (Net Promoter Score) is all the rage in hospitals these days. The essence of the question posed to about-to-be-discharged patients is: based on your experience would you recommend us to your friends and family?

Developed as a measure of ‘customer loyalty’, initially by Fred Reicheld in 2003, it’s intended to be an effective way of knowing, not only whether existing customers will stand by you, but also whether they will – or will not – tell their loved ones and buddies to spend their money at your store too. (Not a million miles then from the old retail nostrum: “If you liked us, tell others. If you didn’t, tell us.”)

Whether or not the NPS works as a lead indicator of future success, as well as a lag indicator of past performance, is moot in the commercial sector, with its place, purpose and value in health care services distinctly unclear if not downright controversial. (Would you want to be the nurse who hands such a questionnaire to someone about to be discharged after a RTA in which they were seriously injured but also their child killed? No of course not, you wouldn’t dream of being so crass. But how then do you capture such an important *patient experience*, or is it simply not to be included in the aggregated feedback about whether your hospital in total is a star or a dog?)

An example in NPS practice from the commercial sector with some reflections:

This morning one had a necessary falling out with one’s mobile telephone provider, vis the length of their contract and its baleful effect. The call-centre worker was charm personified, but utterly unable to help: rules being rules, rules is all she has to go by. Customer, though, is not a happy bunny and says so: not about her, no not at all, but the bloody system and its wretched inflexibility.

Half an hour later the NPS kicks in. Texts start to arrive asking whether – let us call them Vodaphone – would be a company I would now recommend to others. First off – how has this come into being? Did the machine kick in because of key words I used (‘F*** that for a game of soldiers’), because she pressed the ‘Customer down!’ button, or by some other means? Is there also an equivalent for happy bunnies, or do they only pounce on the grouches? Are they even interested in improving their service, or is this just another means by which they monitor and control their front-line staff? That last is crucial to the hospital case.

So Text One is the standard opener: “Based on this experience, how likely would you be to recommend Vodaphone, from 10 (definitely would) to 0 (definitely wouldn’t)?” Truth, of course, is I neither would nor wouldn’t. If Vodaphone want to pay me to advertise their wares then let them. Otherwise I’m keeping stum. Everyone round these parts knows already which is the only mobile with a decent signal, and it isn’t Vodaphone; so the conversation would never, in any case, occur.


Comes to mind, though, that Text One was in fact the second, not the first, received on the matter; it being preceded by an invitation to participate in the process to which the only available  response was a silent ‘Yes please’. “Hello [bit informal, but let that pass]. We’d like to ask you 4 questions about your most recent contact with Vodaphone. All texts are free and the 1st question will follow shortly.” Not “We’d like to ask you, is that all right with you?”, but “We’re going to bother you whether it suits or no”. Backs. Up. Put.

Then comes: “Did we resolve your issue on this occasion. Please reply with either Yes or No.” What does that say? It says most clearly that Vodaphone expects all its contact to be ‘failure demand’ calls. That is, something has gone wrong and the customer wants it sorted. See John Seddon passim for why that is entirely the about-face way to proceed with any organisational learning or management of performance.


Then the killer: “How satisfied were you with the adviser who handled your query, from 10 (very satisfied) to 0 (very dissatisfied).”

Please note – the only moral reply to such a question is a resounding ’10’. Nothing else will do. The worker may have been rude, impossible to understand let alone do business with. It’s not their fault OK? Call centres are a latter-day vision of a Dante-esque Hell and all within the tormented souls. You can also be pretty damn sure that a low score here will cost the individual their wage (in fines) or even their job. They didn’t create whatever your problem is: chances are either you did or the company’s systems did. And if you can’t acknowledge the one, don’t let the company systems blame the hapless front-line worker for the other.


Next: “Thanks. Finally [it isn’t] please could you tell us the reasons for your ratings?” Pay me and I’ll fix your systems for you. Haven’t time or the intention to bash out some text that will simply scanned for key words – profane or other – and then entered into the database.

“That’s for me to know and you to work out.”

Finally: “Thanks for the sarcasm buddy!” No, sadly not. At least that would be a human-to-human moment. Instead the inevitable “We really appreciate your help. Your feedback will be used to help us continually improve our service to customers.”

Well hang on! I, frankly, couldn’t give a fig about *customers* plural. This customer is displeased. How about improving your service to me?! How about rewarding my feedback efforts with a bit more flexibility in your contract duration?

Now the absolute lulu, the avalanche of icing on this cake – 30 seconds after completing this discourse a spam text arrives “We sue for you!” One of those shyster companies wanting to know if you’ve just had a bum deal and are chasing a bit of compo. Call me the most barking of cynics, but I bet there’s a deliberate leak in their algorithm that routes the seriously discontented to the shysters. Easily done, and if it can happen it just did.

So where does that leave us with a hospital point-of-discharge NPS survey?

1. Would you want to be bothered by and with it anyway; or are you simply thrilled/relieved at going home, wanting to concentrate on packing, on checking you’ve got your meds, on remembering post-discharge instructions, on working out what you now need to do to catch up on all the things left undone while stuck in a hospital bed?

Crucially, would you want even to think of your loved ones in the same situation? You’re going home with a cancer diagnosis, you’re probably desperate to know whether your faulty gene has been passed on to your children (been there, felt that guilt and shame); you want to be forced to think about that right now – your sprog having the same ghastly chemo you’ve just endured – and to give that terrible feeling a proxy score on a bit of bloody paper?

2. Would you want any feedback you give geared towards whether or not you would ‘recommend’ the hospital to others. Aren’t you more interested in having your own, personal experience recorded? What does it mean anyway, and how often do conversations in the ‘Dog and Ferret’ begin: “Anyone know where’s good for gallstones?”; or “I’m thinking of crashing the car next week. Their A&E any use?”

3. The whole NPS thing is predicated on whether or not there is any choice in the matter. If not Vodaphone then who? In that case the answer is simple and it is ready. There are other mobile providers – hundreds – but only one that works around here. So if I could get out of my Vodaphone contract I would and head straight to O2. That I can’t is my beef. As for hospitals – what do I know? Very little in truth. What I want is assurance that my local gaff is the best it can be; that it is safe, clean and knows its trade. If somewhere in Birmingham is better on all counts, what earthly use is that to me? Local hospitals for local people. That is that ticket.

4. If I do sound off about the place, who’s going to catch it in the neck? You can bet it won’t be the CEO, it’ll be the Ward Sister who may well be doing everything she possibly can to keep the place going as best it can, with insufficient staffing numbers and junior doctors who are still at the “Is it an arse or an elbow?” stage of their medical learning. What if I just say ‘No ta, can’t be arsed’? Does Sister catch in the same neck if her respondent rate is below target? Probably, but this is my worry? It is, again, but why should this guilt trip be laid on me when I just want out?

5. Does my ‘happiness quotient’ really tell them anything useful? Will there be any depth analysis of the data, any looking for root causes, or will the forms simply drop into a performance management box for counting towards scores on the door? Isn’t this all a bit post hoc anyway? Never mind about any future trade I might put their way, have they bothered to ask me whether I’ve been happy with my stay? That may be but the dreaded lag indicator – but it’s what matters to this and to every patient.

Maybe though hospitals could learn from that spam text. Perhaps they should allow – decent and legitimate – compo claiming firms space in their front lobby in case anyone does leave spitting feathers and forceps. That would be the risk management equivalent of the ultimate car safety device: take out all of the seat-belts, the air-bags, the anti-lock brakes and the SIPS; replace them all with a just dagger mounted on the middle of the steering wheel with its point towards the driver. The perfect way to reduce ‘failure demand’, not bits of NPS paper.


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