Part 1 of a 3-Part Series on Loyalty
The Next Era in
Patient Satisfaction
Excellence Provides
a Springboard
to Loyalty
PRC’s 3-Part Series on Loyalty
Read about why response scales are important
when measuring and improving patient loyalty.
Follow-up articles will take a deeper look at the
subject of satisfaction and loyalty.
Telephone Surveys
Provide a Springboard to Loyalty
Learn how mail surveys are appropriate for
patient satisfaction but deficient for patient
loyalty.
Seeking Guidance in Developing
a Springboard to Loyalty
Understand how employees, physicians
and the care they provide affect loyalty.
IS SATISFACTION ENOUGH ANYMORE?
Historically, organizations have been content to merely satisfy their customers and were pleased as long as they
responded with at least a satisfied rating (good, very good or excellent). A level of approval somewhere below
complete or total satisfaction was acceptable. Simply meeting the needs of patients used to be enough.
Today hospitals know the key is to gain more loyal patients — those patients who will return to the hospital for
care, enthusiastically promote the hospital to others, and even override their physicians’ hospital
recommendations to receive care at their preferred hospital. Merely satisfying patients doesn’t cut it anymore.
PRC’s President & CEO, Dr. Joe Inguanzo, elaborates, “There are many different aspects that come into play
when the goal is to increase patient loyalty. First and foremost, how is the hospital measuring patient loyalty?
Does the measurement system clearly tie satisfaction to loyalty? Are all of the hospital’s patients evenly
represented? What is the hospital’s action plan and does it encompass all aspects of loyalty as well as all
touchpoints?”
REGARDLESS OF RESPONSE SCALE, VAST MAJORITY OF PATIENTS RATE CARE POSITIVELY
In August 2007, PRC conducted a study of 1,000 U.S. adult healthcare decision-makers and, as in the past,
found that the vast majority are satisfied with the health care they receive. For the first time this study included
variables using different rating scales.
Half of the respondents were presented an
Excellent Top-Box Scale from which to choose a
response (Excellent, Very Good, Good, Fair or
Poor). The other half of the respondents were
presented a Very Good Top-Box Scale (Very Good,
Good, Fair, Poor or Very Poor). Each respondent
was randomly selected to rate the overall quality
of care at their preferred hospital using one of
two scales. Regardless of the scale used, more
than 94% of the respondents rated the overall
quality of care as positive (2007 PRC National
Consumer Perception Study).
This data shows what healthcare professionals
have known all along: an overwhelming number
of patients are satisfied with the care they receive. The challenge is distinguishing between those patients who
are merely satisfied and those patients who are truly loyal.
DISCONNECT BETWEEN SATISFACTION & LOYALTY
Dr. Inguanzo alludes to the frightening disconnect between patient satisfaction and patient loyalty.
“Unfortunately, some research organizations have been masking their survey’s effectiveness by referring to
their highest positive rating as the ‘Top Box’ and not by its response name (e.g. Excellent or Very Good).
Research proves that the name given to the top-box matters. Excellent isn’t the same as Very Good. Patients
2
How Patients Rate Quality of Care:
Positive vs. Negative Responses

2.7%
94.6%
5.4%
0%
20%
40%
60%
80%
100%
% Responses
Excellent Top-Box Scale Very Good Top-Box Scale
Posit ive Responses (Excellent, Very Good, Good) Negat ive Respones (Fair, Poor, Very Poor)
who feel the care they received was excellent are much more likely to be loyal patients. That’s the icing on the
cake.”
PRC isn’t the only organization researching the difference in satisfaction levels and loyal customers. Research
published in Harvard Business Review also discusses the tremendous difference between the loyalty of merely
satisfied and completed satisfied customers, “Any drop from total satisfaction results in a major drop in
loyalty…the company that will survive and flourish over the long term is the one that continually works to
understand the relationship between satisfaction and loyalty.”(Jones & Sasser).
SURVEY RESPONSE SCALES ARE IMPORTANT WHEN SEEKING LOYALTY
When researching satisfaction levels and loyalty, PRC also found that patients are much more discriminating in
rating their care when presented the Excellent Top-Box Scale. Nationally, only 42.6% of patients chose the
Top-Box (Excellent) when rating their care using this scale. However, when presented with the Very Good TopBox Scale, patients are much more likely to singularly
choose the Top-Box (Very Good) response when rating
their care.
The differences in these two response scales become
even more apparent when comparing patient care topbox ratings against patient loyalty. Of the patients who
were presented “Excellent” as a Top-Box choice, 70.4%
also stated that their overall loyalty to that hospital was
excellent. PRC has found the Excellent loyalty rating to
be the true measure of a loyal patient. In comparison,
of the patients who were presented with “Very Good”
as a top-box choice, merely 41% of them also said their
loyalty to the hospital was Excellent (2007 PRC National Consumer Perception Study).
By using the Excellent Top-Box Scale, hospitals can
easily distinguish between those patients who merely
like them and those who love them.
WORD–OF-MOUTH IS LOYALTY IN ACTION
The quality-loyalty connection is so strong in healthcare
that four out of five patients who rate the overall
quality of their care as Excellent would also definitely
recommend the organization to their family and friends. At a Very Good ranking, only one out of five rate their
Top-Box Responses For Two Popular Scales:
Overall Quality of Care Ratings

100%

Very Good
37.1%
Good
17.6% Fair
2.7%
Poor 0.5%
Good 7.8%
Very Good 21.3%
Excellent 70.4%
Ev aluations of
Ov erall Quality of Care
of Preferred Hospital
Excellent Top-Box Scale
Evaluations of Overall Quality of
Care at Preferred Hospital
Evaluations of Loyalty at
Preferred Hospital

Good 31.9%
Fair 3.0%
Poor/Very Poor 2.2% Fair 0.2%
Good 11.2%
Very Good 47.6%
Excellent 41.0%
Ev aluations of
Ov erall Quality of Care
of Preferred Hospital
Very Good Top-Box Scale
Evaluations of Overall Quality of
Care at Preferred Hospital
Evaluations of Loyalty at
Preferred Hospital
3
likelihood to recommend the organization as Excellent. In other words, only one out of five will actually
recommend the organization to others (PRC’s 2007 Inpatient Normative Database).
Jones and Sasser also found the quality-loyalty connection when researching why satisfied customers take their
business elsewhere. “The levels of satisfaction among targeted customers are a good indicator of the level of
quality of the products or services
they are receiving.”
Loyalty expert Frederick F.
Reichheld explains how
customers’ likelihood to
recommend the organization is an
important facet of loyalty.
“Customer loyalty is about much
more than repeat purchases…a
loyal customer may not make
frequent repeat purchases
because of a reduced need for a
product or service. Loyalty is also
about customers’ willingness to recommend a product or service to someone else” (Reichheld).
USE LOYALTY TO GAIN A COMPETITIVE ADVANTAGE
Healthcare organizations committed to providing excellent quality of care while increasing patient loyalty must
use research tools that are the most effective measurements of these areas. These organizations will gain a
competitive advantage only when they can identify, measure, track and improve loyalty of patients in each of
their specific service lines.
“There is a tremendous difference between the loyalty of merely satisfied and completely satisfied customers.
The company that will survive and flourish over the long term is the one that continually works to understand the
relationship between satisfaction and loyalty for each of its customers, for each of its business units (service lines)
and for each of the industries in which it competes.” (Jones & Sasser)
WORKS CITED
1 2007 PRC Inpatient Normative Database, Professional Research Consultants, Inc. 2007.
2 2007 PRC National Consumer Perception Study, Professional Research Consultants, Inc. 2007.
3 Jones, Thomas O., and W. Earl Sasser, Jr., “Why Satisfied Customers Defect.” Harvard Business Review. Nov-Dec 1995: p89-90, 99.
4 Reichheld, Frederick F., “The One Number You Need to Grow.” Harvard Business Review. Dec 2003: p48.
Research compiled and authored by Joe M. Inguanzo, Ph.D. & Janna L. Binder, MBA
© 2007 Professional Research Consultants, Inc.
87.0

0
20
40
60
80
100
Excellent Very Good Good Fair Poor
Patients’ Perception of Overall Quality of Care
Likelihood to Recommend
(% Excellent)
Inpatients’ Likelihood to Recommend the Hospital
Based on Overall Quality of Care Rating