Understanding Net Promoter Score (NPS): More Than Just a Number

The practice of surveying employees regarding their job satisfaction began in the 1920s, during a period sometimes called the Second Industrial Revolution. These employee attitude surveys became far more popular during World War II, when organizations in all sectors of the economy – ranging from manufacturing companies to the U.S. Army – sought to improve both morale and performance, and quickly realized, as the saying goes, you can’t manage what you don’t measure. The United States Army Research Branch, for example, conducted Soldier Surveys, which recorded the opinions of more than half a million soldiers on topics ranging from food quality to confidence in leadership.

In the next few days, the results of the Net Promoter Score (NPS) survey for the UCSF Department of Medicine will be disseminated, in what has become an annual event. It is worth reflecting on the history of NPS and the impact of measuring faculty satisfaction at UCSF.

Originally designed for assessing customer loyalty, the NPS has emerged as an effective metric for employee satisfaction. It involves a single, straightforward question: "On a scale of 0 to 10, how likely are you to recommend UCSF as a place to work, place for clinical work, or place to come for care?" Employees are categorized into promoters (scores of 9-10), passives (scores of 7-8), or detractors (scores of 0-6). UCSF Health has measured NPS among faculty since 2015; ZSFG began doing so in 2021, and the VA this year. Over time, these surveys have become increasingly enriched with new data and analyses, including the addition of burnout assessment in 2019; and in 2021, an exploration of factors influencing well-being, such as leadership effectiveness, family-friendly policies, and after-hours EHR usage.

At UCSF Health, the scores have catalyzed significant improvements in faculty workspaces, leave policies, lactation accommodations, meeting practices (most prominently starting meetings at 10 past the hour), fertility treatment coverage, salary equity, leadership training, and organizational communication and the flow of information. (A full list of improvements at UCSF Health aimed at the physician experience can be found here.) The comments collected through the NPS surveys continue to serve as a crucial source of data, providing invaluable insights into the day-to-day experiences of our faculty members, and shedding light on the obstacles they face in finding fulfillment and joy in their work. The comments have highlighted the most pressing issues at UCSF Health, including concerns related to patient access, EHR in-basket messages, and salaries. Sometimes the surveys point to areas of satisfaction or improvement.

At UCSF Health, this year’s Department of Medicine scores rose as a place to work (+1 in FY22 to +5 in FY23) and fell as a place to do clinical work (-3 in FY22 to -9 in FY23). As always, the responses point to specific improvement opportunities in staffing in both the ambulatory and inpatient settings, as well as ongoing efforts to support physicians in managing in-basket messages. In addition, this year’s survey highlighted an area in which the DOM is doing particularly well: the high level of trust the faculty have in their medical directors and service chiefs. When asked about the value of their local clinical leadership, an impressive 83% of DOM faculty members agreed that their leaders actively supported their work-life balance, the highest percentage among all departments. Similarly, 79% of faculty reported that their immediate local work/clinical leadership sought broad input for important decisions that impacted their work – again, the highest percentage among all departments.

At ZSFG, DOM scores declined both as a place to work overall and specifically for clinical work compared to last year, with the score for overall work falling from +18 in FY22 to -3 in FY23. Respondents raised concerns related to clinical staffing across multiple areas, including lack of appropriate physician staffing, unexpected coverage gaps in inpatient care, and lack of clinical and nonclinical support staff in ambulatory care. Our DOM leaders continue to advocate with our Department of Public Health (DPH) partners. The issue of pay parity with UCSF Health was also raised and has sparked further leadership-level discussions as well as a recent town hall. Our faculty at ZSFG continue to highlight the strong team dynamics and a deep commitment to the mission. Fewer faculty state an intention to leave or cut down clinical hours than faculty at our other sites. Burnout, while significant, remained stable compared with last year.

At SFVA, both the scores and the comments underscore the strength of the community, the alignment with the VA's mission, and the high level of trust in local leaders. It its first year, the VA scored +22 as a place to work and +28 as a place to do clinical work. Faculty members express satisfaction with the availability of remote work options, while also expressing a desire for in-person events to further foster community. Moving forward, efforts at the VA will be centered on enhancing support staff to address the rising administrative demands faced by MDs and to optimize their clinical efficiency, recognizing the challenges posed by current budgetary constraints. In addition, physicians feel it is important for senior hospital executives to spend time observing or participating in the outpatient clinics and the hospital wards to gain a better understanding of the challenges faced by front line providers.

Division- and service-specific scores and breakdowns by seniority, gender, and other categories will be available soon. Our department remains fully committed to learning from these scores, along with many other avenues for feedback, to improve the work experience of our people.

Michelle Mourad
Professor and Vice Chair of Clinical Affairs and Value
Urmimala Sarkar
Professor and Associate Chair for Faculty Experience
Kenneth McQuaid
Professor and Vice Chair of Medicine, SFVAHCS
Bob Wachter
Professor and Chair