Is the Net Promoter Score the Best Way to Measure Loyalty? • Posts by EIM | Evidence In Motion Skip To Content

Is the Net Promoter Score the Best Way to Measure Loyalty?

October 6, 2017 • Practice Leadership

What is loyalty? When I think of loyalty, I think of Man’s Best Friend. A dog will love you no matter your mood and will always come running with a wagging tail when you come home. A dog will stay by your side whether you are happy, sad, frustrated, irritated, busy, hangry, or ill. A dog demonstrates little fear and stays by a policeman’s side or a soldier’s side. A dog does all that is asked. A dog never gives up on you. That’s loyalty.

Loyalty as strong as a dog’s loyalty isn’t easy to find.

Back in 2003, the net promoter score was introduced to the business world. It was created to measure the loyalty of customer relationships. The score is derived from the response to a single question: How likely is it that you would recommend our company/product/service to a friend or colleague? Seems simple enough. That’s probably why so many like this particular measurement.

I will challenge the net promoter score. Think of a dog’s loyalty. No matter how high the score or how many promoters you think you have, the net promoter score really doesn’t measure loyalty. Just because someone says they are highly likely to recommend you to a friend really doesn’t mean they will.

We have far better ways to measure loyalty. We already have an easy capability to use our business metrics to know we have loyal customers. We don’t have to ask our customers anything. Loyalty is the strength of a relationship. The higher the strength of the relationship, the higher the loyalty.

If I were to design a dashboard of information focused on loyalty, the dashboard would be based on behaviors.

If you have high loyalty, then your business metrics should indicate a low no show rate. Most metrics look at cancel and no show together. I don’t mind when someone cancels. When someone cancels that means something happened in their life. A cancel indicates being kind and valuing our relationship enough to reach out and communicate a cancellation. I view a no show completely differently. A no show, unless under extreme circumstances, indicates a complete disregard for our relationship.

Another behavior to measure is percent of returning patients. If you really have created a strong relationship, you really should see a high percentage of returning patients. These folks have chosen you to be their physical therapist. They trust you and think of you first when they think they need a physical therapist.

The next behavior to measure is the percent of your patients referred by previous patients. The highest compliment you can ever receive is having your previous patients refer their family, friends, and acquaintances.

The last measurement will be found in your business accounting records. This is a measurement of your behavior. What does your accounting system indicate on how much you have spent with the US Postal Service? You can laugh at this. Loyal relationships are meaningful. Loyalty works in both directions. If you want loyal patients, what are you doing to maintain relationships in a meaningful way. In a way where you have truly taken time to appreciate a relationship. Customer relationship management systems always seems so fake to me. I get more auto-generated crap in my email and snail mail than you can imagine. All it means to me is that someone is paying for a service to reach out to me, to stay in my face so I don’t forget them, to be there when I’m ready to spend. When you sit down and write a thank you note, a sympathy card, a congratulations card, a birthday note, when you send a gift, now that has meaning. I know it takes time, but real, loyal relationships require effort. Do you take the effort?

The dashboard has to be dynamic enough to note trends. A single snapshot is nice, while at the same time having the ability to compare years of data will be useful. From a company perspective, to be able to analyze by clinician would also be helpful. This also means that when a previous patient wants to see a particular physical therapist that the wish is accommodated. I’ve heard this is not always happening. A company desire to have patients scheduled within the first 48 hours of contact seems to take priority versus maintaining relationships.

I just changed primary care physicians because mine moved. His greeting to me, “you could run for mayor. You have the strongest following of patients and they love you.” This made me wonder why, it made me think about the net promoter score and delve into why I dislike it. It also made me want to figure out if I could capture loyalty in a different manner.

In looking at this year, I have less than 1% for a no show rate. My cancel rate tends to be higher than I like from a business perspective, but I also know that I had to cancel 2 of my business days due to illness and then about 2 days due to weather advisories and county alerts to stay off the roads. I also know that I have patients who actually walk in my doors who are ill and don’t want to miss their appointments and I turn them away. With about 60% of my patients 65+ in age, I have to accommodate illness, chemotherapy adverse reactions and transportation issues.


I honestly do not know what numbers would reflect a high patient loyalty. I can see from what I can track that I probably do have a decent patient loyalty. With about 75% of my business being previous patients and their recommendations, it seems I probably do create lasting relationships. (Or maybe it’s because I tease that when they leave they need to find someone to take their place. And that there will be a bill sent for the amount of time it takes to find a replacement. Of course, I’m joking.)


Here’s my challenge to you. Please don’t focus on the net promoter score. Saying and doing are two different things. Dig a little bit deeper and analyze behaviors. Behaviors mean more to me when it comes to loyalty.

What are your thoughts?

Until next time,


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Adrian Brown

Commented • October 24, 2017

Great blog Selena, a dog's loyalty is a truly sincere way to measure loyalty. I totally agree with you that online loyalty can be measured by building online relationship through effective communication. And effective communication is being positive even in the face of a negative situation. Always looking at the bright side, and the lesson you can take away out of any experience. It is when you create this type of relationship, that you will find visitors returning to your blog. And because they love what they are getting from you that they will tell their friends to come and see. Anyone who is serious about his or her online business will be willing to invest both time and financial resources. There is no way around that reality. There is no short cut, and anyone who tells you otherwise is either ignorant or insincere. You are doing a great job here, so keep up the good work!

Selena Horner

Commented • October 11, 2017

Thanks so much, Colleen.

Colleen Louw

Commented • October 11, 2017

I love your article, Selena. It is so spot on. Thank you.

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