How to Improve Patient Experience in a Hospital: The One Question That Predicts Loyalty Better Than HCAHPS

You know the patient. Came in through the ED, got solid clinical care, left with a clean discharge summary and a follow-up appointment on the calendar. Textbook.

But then they drove 40 minutes to the other hospital, the next time something came up.

Not because of a misdiagnosis or a complication. Because nobody on your care team made them feel like anything other than a room number with insurance.

NRC Health studied this across more than 300,000 healthcare consumers and found one question that predicts loyalty, reputation, and revenue better than any question on any survey in American healthcare: “Did everyone treat you as a unique person?”

Patients who say yes are 12 times more likely to be Promoters on the Net Promoter Score. They’re 295% more likely to rate the organization’s reputation as “excellent.” And 86% confirm their loyalty to that hospital, the kind of loyalty that means they come back, and they tell their friends.

That’s the operating model for patient experience. It’s the infrastructure your whole organization runs on. And improving it starts with that one question.

Here’s how to integrate this into improving your patient experience.

One question predicts patient loyalty better than anything on your HCAHPS, and the hospitals asking it are seeing 12x more Promoters. Discover how to build your patient experience strategy around it.

Key takeaways

• One question outperforms your entire survey. In our study conducted with over 300,000 customers, we discovered that “Were all people treating you as an individual?” was a better predictor of loyalty, reputation, and revenue than HCAHPS, where people who answered ‘yes’ were 12 times more likely to be Promoters.
• Survey timing is silently distorting your scores. Scores will decrease by about 9 points from day 40 after discharge due to the phenomenon called “sentiment drift”. Hospitals adopting real-time feedback systems are getting more surveys back than they did before (one hospital saw an improvement of 169%).
• Meaningful human connection takes 29 seconds, not 29 minutes. When doctors make a brief personal connection before diving into the chief complaint, patients rate them as knowing them significantly better.
• Accountability works when the goal is controllable. Stop grading managers on year-end NPS (which no individual can move) and start measuring how fast they close the loop on real-time service alerts.
• Fix one thing well before you try to fix everything.  Focused exclusively on one area and standardize a teachable process. The hospitals that spread effort across every composite at once saw little movement. Depth beats breadth.

You have sat in this meeting. Maybe even recently in the current quarter. The presentation of the HCAHPS review is done, and scores are not changing. CNO makes some comments regarding “communication focus.” Heads nod. Then everyone resumes their activities from before.

The problem isn’t that your team doesn’t care. It’s that caring doesn’t produce results without the right organizational scaffolding underneath it.

AHRQ’s improvement guide lays out the characteristics that separate hospitals where patient experience  improves from those that stay flat: governance with a vision, patient and family partnerships, engaged employees, and systematic feedback connected to specific goals. Most hospitals have one of those working on a good day. Maybe two if there’s a new CXO with political capital.

United Regional Health Care System is a 296-bed nonprofit in Wichita Falls, Texas. Rural, medically underserved, and dealing with the same staffing pressures as everyone else. Their Director of Patient Experience, Ryan Graves, described the situation before they changed their approach: “Our managers were frustrated. They were being held accountable for metrics that felt outside of their control.”

If that sounds familiar, it’s because that’s the lived reality of nurse managers at about 80% of hospitals right now.

United Regional rewired one thing. They stopped grading managers on year-end NPS numbers, a metric no individual manager can control, and started grading them on how fast they responded to real-time service alerts from NRC Health’s platform. Not “improve your score by Q4.” Instead, when a patient flags a problem, how fast did you close the loop?

Kim Stringfellow, their CNO, put it in a way I keep coming back to: “We gave them a goal they could control, and that made all the difference.”

What changed on the ground wasn’t dramatic. Nurse managers started calling patients back when something went wrong, and I mean the manager who’d been on that unit.

They also let bedside nurses change things.

The hospital set up governance councils, and a nurse on one unit used hers to flag a handoff process between shifts that she’d been watching create gaps for months. She didn’t fill out a form and wait. She walked out of that meeting with the go-ahead to fix it herself.

Meanwhile, leadership started putting every manager’s service alert response time on the screen during monthly meetings.

That last part sounds small, but it wasn’t. When people know their peers can see how fast they’re closing the loop, they close it faster. United Regional watched it happen in real time.

1. Your survey timing is changing your data more than your care team is

This one stings. NRC Health published research on feedback timing that every patient experience leader should read and probably won’t enjoy: the biggest variable in your scores might not be anything happening at the bedside. It might be when you mailed the survey.

William England, NRC Health’s strategic research advisor, coined a term for this: “sentiment drift.” In the traditional HCAHPS mail process, about 80% of responses don’t come back until around day 40 after discharge. By then, Overall Rating scores have slid to roughly 71% positive, compared to around 80% among patients who responded early. Same hospital, same staff, different week, different score.

By week five, the memory of the nurse who checked on the patient at 2:00pm has faded. The parking garage hasn’t. The bill definitely hasn’t. And some patients are filling in details from the experience that didn’t occur, because that’s what brains do when they’re reconstructing something from over a month ago.

But collecting feedback faster doesn’t help much if you’re still asking the wrong questions. Most hospitals put one open-ended box at the bottom of the survey, “Tell us about your experience,” and treat that as listening.

AHRQ tested something better: structured narrative item sets with prompts, such as “What did the doctors and nurses do that was important to you?”

A study in Hospital Pediatrics found parents wrote nearly six times as many words with the structured set, and 69% of those comments were actionable for quality improvement, compared to 39% from the open-ended afterthought.

A five-hospital system in eastern Virginia switched to NRC Health’s real-time feedback and went from 7,342 patient responses a year to 19,755, a 169% increase. But what showed up in the responses, once they had enough of them to see patterns, is what really matters.

One patient scored the entire visit with excellent marks across the board. Then added at the bottom: “PS, beds were awful.”

That postscript would have been invisible in a composite score. Instead, staff pulled the data, looked at bed age and capital spend on that unit, and moved up the replacement purchase.

On another campus, someone reported waiting five hours for lab results.

However, the lab had turned the results around in 45 minutes. So why the wait time? Because nobody told the patient. It was a communication gap dressed up as a wait-time problem. And the only reason anyone figured that out is because the patient described what happened in their own words.

A quarterly mail survey would have captured neither of those.

2. The behavior that predicts loyalty takes less time than you think

Dr. Gregory Makoul, NRC Health’s Chief Transformation Officer, studied first-time encounters between doctors and patients who’d never met. When the doctor made a brief personal connection, about work, family, anything that isn’t the chief complaint, patients rated that doctor as knowing them significantly better. That connection took 29 seconds on average.

Most patient experience programs never translate that finding into something valuable. It’s in the board report. There’s a target for next quarter. But has anyone sat with a resident or a charge nurse and said: Before you open the chart, ask the person in the bed one question about their life?

NRC Health’s research breaks the human understanding metric into three coachable behaviors: connect with me, listen to me, and partner with me.

And published research from Makoul and Dr. Carma Bylund found that when patients create an opportunity for empathy, they’re looking for three things: acknowledgment, openness to hearing more, and confirmation that it’s OK to feel what they’re feeling.

Makoul described the tool on a Becker’s Healthcare podcast with Wellstar’s Dana Caviness. Before a visit, patients use a digital questionnaire to share what’s going on in their lives. What they’re worried about, what goals they’ve set, what’s keeping them up at night. NRC Health compresses that into a summary that a provider can read in about 15 seconds before walking into the room.

Makoul said something interesting about what happened next: primary care doctors with long-standing patients (physicians who thought they already knew everything they needed to know) started seeing information that changed how they delivered care. Patients will type things they’d never say out loud, sitting across from a doctor.

A randomized controlled trial found double-digit increases in patients saying their care team treated them with respect and showed genuine interest. Caviness, who’s rolling this out across Wellstar, explained they are moving from “you’re a patient, I diagnose you” to something closer to a conversation between two people who each know things the other doesn’t.

The providers didn’t spend more time. As Makoul said, “Nobody goes into healthcare to have faster transactions.”

3. Burned-out staff can’t deliver what you’re measuring them on

We need to talk about this one because it’s the elephant in every patient experience strategy meeting, and nobody wants to acknowledge that the elephant is also updating its LinkedIn profile.

You can roll out communication training, rounding scripts, and real-time dashboards. If the people executing those things are exhausted and demoralized, none of it is going to hold.

A study of pediatric nurses found 27% reported burnout. But the finding that should reshape how you approach this: the nurses who were not burned out had something in common. They felt confident that patient experience measurement actually meant something. They were included in quality improvement work. And they experienced QI as part of patient care.

Think about what that implies. The antidote wasn’t higher pay or lighter assignments. (Those help. Obviously. But that’s not what the data showed.) It was believing the data mattered and having a voice in what happened with it.

AHRQ found that the effects on job satisfaction were positive when staff read patient stories related to their unit instead of numerical ratings.

And let’s be real, no one should find this shocking after witnessing how little a charge nurse cares about seeing “responsiveness: 78.4” on his or her dashboard.

Just compare this to an experience reported by one of the NRC Health partners; there was a comment left by the patient regarding being scared out of his mind after the procedure, alone at 3 AM, with an unnamed nurse sitting with him until he fell asleep again.

There are strategies for workforce well-being. You can’t build a patient experience program on top of a workforce that turns over every 18 months and expect it to survive.

4. Rounding works. But only when it’s not theater.

Everyone agrees rounding is a best practice. It’s been a best practice for decades. And most hospitals still do it like a compliance exercise: get in, check the boxes, get out, log it.

NRC Health analyzed 36,981 patient responses across eleven partner organizations and found that patients who recall being rounded on are 34% more likely to give a top-box “would recommend” score. The overall loyalty lift lands in the 15–20% range for most organizations, though one saw a gap as wide as 43%.

The interesting part is where the lift comes from.

The biggest gaps between rounded and non-rounded patients show up in operational domains — quietness (38% gap), responsiveness (37%), cleanliness and food (both 23%). But those aren’t the domains most strongly tied to loyalty. Trust is (RR = 2.68), followed by clear explanations (2.34), listening (2.24), and courtesy and respect (2.21). Rounding improves both sides; it makes the operational stuff better, and it makes the interpersonal stuff more likely to happen, but communication and trust together explain about 40% of the 20-point LTR gap. The other 60% is a mix of issue resolution, environmental conditions, and aspects of the experience that traditional survey measures don’t fully capture.

Ashley Nelson, a nursing strategic advisor at NRC Health and a nurse herself, shared her insight on rounding “Purposeful rounding is about doing what matters most while limiting disruptions and saving team time.”

Published research supports the claim that call-light use drops by about 21% with purposeful rounding, and one medical-surgical unit cut the number of falls from 2 per 1,000 patient days to zero for two consecutive months after implementing hourly rounds.

Separately, NRC Health’s research on how NPS and HCAHPS work together found that patients who experienced nurse leader rounding saw a 79% improvement in HCAHPS scores, compared to 46% among those who didn’t. That’s the gap between a rounding program that exists on paper and one where a leader walks into the room.

That’s what happens when a leader actually walks the floor. NRC Health’s rounding platform helps prioritize which patients are at higher risk for negative experiences, so the limited time leaders have goes where it counts. But the technology only works if the intent behind it is real.

5. Stop trying to fix everything. Fix one composite and standardize it.

Most hospitals spread improvement efforts across every HCAHPS composite at once, communication, discharge, pain, and responsiveness, and none of them get the focus or process redesign they actually need.

Kaiser Permanente went in the opposite direction. Stephanie Fishkin Dark, a principal consultant at Kaiser Permanente’s Center for Healthcare Analytics, chose one area to focus on: talking about medications. After that, she created a playbook that could be used repeatedly. Taught nurses how to use “Ask 3” so that patients know what the drug is for and why they are taking it. Added teach-back before discharge to make sure the information got through.

They went from 2 hospitals at the 4-star level to 10 at 4-stars and 1 at 5-stars. Fishkin credited the units where nurses understood why they were doing it. Some units internalized the change, and their numbers moved. Other units treated it like one more corporate mandate, and nothing happened.

McLeod Health took a similar focused approach, zeroing in on nurse communication and post-discharge connection, and saw a 5.4% HCAHPS improvement in the nurse communication domain and a 33.6% improvement in readmission outcomes.

PIH Health Good Samaritan Hospital improved nurse communication so effectively that they hit 100% on “Would you recommend this hospital?”

When reviewing AHRQ’s research on sustainability, one trend is consistent with successful programs: they have leaders committed beyond the implementation phase, staff ownership of the initiative, and meaningful feedback that reaches the unit where the care was delivered. The failed programs were those that had initial energy but lacked a follow-up plan to sustain it.

HCAHPS matters, and you shouldn’t want to opt out of it even if you could. Over 4,400 hospitals participate, close to 2 million patients fill it out each year, and the scores are publicly reported, tied to reimbursement, and compared nationally.

Sarah Fryda, NRC Health’s research team manager, put the financial stakes plainly: “Performance on the HCAHPS survey accounts for one-quarter of a hospital’s total performance score. Hospitals can lose or earn back up to 2% of Medicare inpatient payments.”

But HCAHPS has real structural limitations that anyone who works with the data already knows. About 63% of all HCAHPS respondents are 65 or older, and Jason Messerli has seen facilities where that number hits 80%. That’s a demographic skew that can mask issues experienced by younger, more diverse patients. And the survey arrives weeks after the care event, when the actionable moment has passed.

HCAHPS works best as a diagnostic tool. Kaiser Permanente proved that when they isolated one composite and moved 8 hospitals up in star ratings. But the hospitals pulling ahead aren’t relying on HCAHPS alone. As Fryda’s team showed, NRC Health customers improved across all 10 HCAHPS dimensions between 2022 and 2024 , and the reason was that real-time feedback reinforced the behaviors that eventually show up in HCAHPS. The two aren’t competing. They’re connected.

Jennifer Baron, NRC Health’s Chief Experience Officer, called trust “the most important predictor of likelihood to recommend scores.” We’ve seen that trust has to be built deliberately across every touchpoint, from the first ad a patient sees to the last interaction with a discharge nurse.

It fits right in line with everything else said in this paper. United Regional gained trust by completing the feedback loop on that very day. The Virginia health system gained trust by finding an error in the printing process and communication with the laboratory. Kaiser gained trust by standardizing one medication process so that it functioned properly. Ashley Nelson’s rounding model gained trust by showing patients someone will return.

None of these organizations did everything at once. They picked a specific problem, built a system around it, and made sure the people doing the work understood why it mattered.

The expectations hospitals set in the market are their experience commitment, and the experiences they deliver are the expression of their brand promise. When those two things match, trust grows. When they don’t, patients leave.

The question for your organization isn’t whether you care about patient experience. Everyone cares. The question is whether you’ve built the infrastructure to turn that caring into something patients can feel.

Start with one question. The data says it’s the right one.

“Did everyone treat you as a unique person?”

Ready to build your patient experience strategy around the question that moves the needle? See how NRC Health can help.