Inherent biases and limitations of the NPS approach are uncovered, leading to the development of a novel feedback technique – Patient Smile®
In this UX research project, I delved into the nuances of healthcare feedback systems, specifically the Net Promoter Score (NPS®) survey, and its impact on patient experiences. Through extensive research and data analysis, I uncovered the inherent biases and limitations of the NPS approach, leading to the development of a novel feedback technique – Patient Smile®. This innovative solution aims to capture genuine, emotion-rich patient stories, fostering a patient-centric culture and driving positive transformations within healthcare organizations.
This is a research project where I wore the following hats:
Qualitative Research | User interviews, contextual inquiry, observation studies
Data Analysis | Excel, R
Visualization + Wireframing | Figma
Duration | 3 months
Team | Collaboration with 2 researchers from Forum Business Research
Despite consistent efforts to improve the patient experience (PX), multiple hospitals across India were failing to increase a trusting patient base that would recommend their business.
Well-established, multi-speciality hospitals in various major cities in India faced the same challenge with improving Patient Experience.
Happy patients make for promoters of the hospital by recommending the hospital to friends and family. Thus hospitals focused significant resources on keeping their patients happy. However, despite relying on traditional and credible methods like the Healthcare Net Promoter Score (NPS®), something was amiss. Google reviews kept dipping. Patients were not giving referrals. Patient Experience management was failing.
To understand the problem we first looked at the correlation between the NPS analytics and the Google reviews of two hospitals.
We noticed a steep decline in scores in public forums like Google reviews when compared to the scores reflected by in-house feedback systems (Net Promoter Score).
Numbers in a spreadsheet reveal valuable insights no doubt, but that story is always incomplete. And that's why we investigated the patient feedback systems in-person at both hospitals.
We employ three different research methods to gain meaningful insights that together complete the story.
Conducting semi-structured interviews with patients, hospital staff, and healthcare professionals to gather their perspectives, experiences, and feedback on the existing NPS survey process.
Observing patients in their natural environments, such as hospital waiting rooms and during their interactions with healthcare providers, to gain insights into their behavior, emotions, and pain points.
Examining relevant literature from cognitive psychology, user experience, and healthcare domains to understand the theoretical foundations and best practices related to patient feedback and experience.
Our multi-pronged research approach uncovered inherent qualities of the NPS survey design that shed light on the PX trends we see across both hospitals.
The classic NPS survey is short in order to serve the purpose of brevity. The reasoning: patients don’t have much time to spare for feedback.
After all, patients are not here to make hospitals better, they are here to get the right treatment. This is an assumption. We have evidence to show that in some cases, this assumption about patients’ is detrimentally wrong.
Questions that are designed in a quantitative form automatically activate the rational reasoning in patients.
Patients, when presented with a 0 - 10 scale to rate on, start with the default of 10 being perfect, impeccable service. They then try to reason their way to score lower. Patients thus try and recall reasons to justify scoring lower, following the faulty prompting by the survey design.
The NPS survey is designed to draw the patients’ focus to issues they faced.
Questions are crafted such that patients remember their negative experiences at the hospital.While a part of the feedback is intended to shed light on the hospital’s problem areas, it is only a part.
Feedback obtained through the NPS survey reflects a distorted ratio of +ve and -ve experiences. While the surveys might bring attention to the weak points in the patients’ journey, they do not report on the good moments of their journey.
Cognitive biases are deviations in rational judgment when our brain takes mental shortcuts.
We are more likely to remember negative experiences over positive experiences. Negative emotions generally involve more thinking, and the information is more thoroughly processed than positive ones.
This has to do with the additional recruitment of sensory processes during the encoding of negative items that allow negative items to be vividly remembered.
And hence, -ve events are stored in memory for longer durations with easier, faster retrieval on cue.
The framing effect is when our decisions are influenced by the way information is presented.
Because of the way NPS questions are typically worded, they have an automatic framing effect that restricts the scope of patients’ feedback to areas of improvements. This causes them to focus information retrieval on moments of disappointment intheir journey at the hospital.
Our choices are impacted by the way options are framed through different wordings, reference points, and emphasis.
Our user interviews with both the healthcare staff and the patients revealed a two-fold detrimental effect.
Higher likelihood of remembering negative experiences and a framing effect that encourages retrieval of negative experiences from memory together produce biased representation of patient experience at the hospital skewed toward negative experiences.
This adversely impacts the way caregivers view the quality of their service. The lack of incentive ultimately lowers their morale and results in subpar service.
A biased and restricted recollection of negative experiences reinforces an overall negative impression of the hospital i.e, how the hospital made them feel.
Meanwhile the positive experiences and moments of satisfaction and joy are discounted during recollection, eventually leading to disremembering or forgetting.
-ve impressions are reinforced and +ve impressions are gradually lost from memory.
We begin by collating and analyzing the insights picked up from various stakeholders and research methods. Next, we craft our How Might We's which forms a framework for our Behavioral Science team to design a novel feedback solution using.
This work ultimately results in Patient Smile®.
We employ three different research methods to gain meaningful insights that together complete the story.
Patient Smile® employs a novel feedback technique that leverages qualitative methods to elicit metaphors and emotional constructs, resulting in rich, honest feedback from patients.
This approach circumvents the framing effect and potential priming inherent in NPS surveys, leading to unbiased reports that capture both positive and negative experiences, as opposed to the dry or dissociated feedback often obtained through traditional methods.
The solution recognizes that the feedback design not only reports on patient satisfaction but plays a significant role in influencing the patient experience journey for better or worse.
Patient Smile employs a novel feedback technique that corrects the bias caused by the NPS design.
The feedback technique is designed to first elicit in the patients the emotions associated with the patient experience journey, followed by a rationalization of evoked emotional impressions by using metaphors as a crutch.
This is done to circumvent the framing effect and the possibility of priming the patient.
We recognize that patients are not like any other customers. They are vulnerable, often scared and helpless.
Our novel feedback technique is designed to make the patients feel heard. The approach is designed to actually hear their stories, map their emotions at multiple touch points during their journey in the hospital, and address their concerns, if any, before they leave the hospital. Not a single patient leaves the hospital feeling ignored, overlooked, or unseen.
The technique is designed to evoke emotions associated with the patient's journey first, followed by a rationalization of these impressions using metaphors as a guide.
We analyzed the output that Patient Smile generated in the two hospitals 3 and then 6 months later. We compared this data with data that NPS generated.
The new approach collected more positive stories + impressions in 3 months than the NPS survey did in 3 years at multiple hospitals in India.
This finding is evidence for the NPS-bias correction. Hearing positive stories is pivotal to:
a) understanding which PX practices are working at the management and caregiver levels, and
b) showcasing the patients’ responses to caregivers to boost their morale and more importantly, re-establish to them that patients are people who are impacted by their every action.
# of words spoken per patient increased four-fold with the new approach.
This suggests not only did we collect more valuable information about the patient’s experience, but also that we gained their trust through the process.
The latter is the mark of achievement that patient-centric culture strives for. The former shows that while the NPS survey included open-ended questions that encouraged patients to share their experiences, these questions often yielded half-hearted answers that provided little to no information on what practices work and which don’t. This changed for the better with Patient Smile.
