World Class PX Pulse

World Class PX Pulse

Developing a patient experience auditing system




March 10, 2024

Assoc. Prof Dr. Maxwell Winchester
Keith Yates
Pam Poranan (Prae)

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Patient experience (PX) has been of interest in health care for many years, with the National Health Service (NHS) commencing its national patient satisfaction survey in 2001 and the USA introducing the Hospital Consumer Assessment of Healthcare Provider and Systems survey (CAHPS) soon after (Ahmed, Burt & Roland, 2014).  The US CAHPS Clinician & Group Survey launched in 2010, however was ceased a few years later (AHRQ, 2024).

Data on its own will not improve patient experience, there has to actionable information available and there needs to be a commitment to take action (Ahmed, Burt & Roland, 2014).

In fact, Coulter et al (2014) raised concern that despite the NHS implementing a thorough programme of PX measurement in 2013, there was no system in place to ensure the data improved performance.  This concern was confirmed in a study of all 153 NHS trusts which showed the results of the NHS patient satisfaction studies in various constructs did not lead to improvements in performance (Locock et al, 2020).  Below is the summary of patient experience dimensions included in different studies.  

The standard ‘customer satisfaction (CX)  measurement systems’ in healthcare or to be precise  - ‘patient experience (PX) measurements’ do not provide actionable feedback on what or how things need to be improved, which has been highlighted as most desirable by healthcare facility managers(Barry et al, 2015; Coulter et al 2014). PX measures also do not provide the much-needed ability to benchmark against other health care providers (Barry et al, 2016). Patients are not experts on health care service delivery (Ahmed et al, 2014; Barry et al, 2016), many have different expectations, which biases the results (Ahmet et al 2014)and most will have few comparison points to make a judgement on patient experiences.

Customer Experience (CX)/Patient Experience (PX) measures also assume that measuring customer attitudes of service provision is a valid measure of the service provision on offer(rather than actually measuring the service provision) (Sharp, Page &Dawes, 2000).

Objective measures of service quality by industry professionals are rare in practice, with the exception of mystery shopping, which is considered a marketing research-based variant of participant observation (Sharp, Page & Dawes, 2000). Across industries, mystery shopping has been demonstrated to be reliable and valid as a measure of customer experience(Dawes, Sharp & Adelaide, 2000) and the dimensions that emerge from mystery shopping generally resemble SERVQUAL dimensions. More specifically, simulated patient studies, known as ‘pseudo-patients’ (Lazarus, 2009) have demonstrated robustness over other patient satisfaction measures that include reduced recall bias, social desirability bias and elimination of bias from demographic factors (Campbell et al, 2013; Goodrich & Lazenby, 2022) and should be part of a health facility’s PX improvement programme (Lazarus, 2009).  

Mystery shopping more broadly has been used extensively in health care scenarios (Jacob et al, 2018) and has been demonstrated in one clinical setting to increase net margins by over 14 percent within 18 months of implementation (O’Neill et al, 2012) and in others, it contributed to significant improvements in PX, along with improvements in employee satisfaction and engagement (Garantino et al, 2013; Daouk-Öyry, 2018).

As much as positive impact of simulated patient studies created, there are still gaps in this measurement tool.

Firstly, mystery shopping is normally conducted using a tailor-made script or focus point based on existing standard of the medical facilities (e.g. Jacob et al, 2018). This leads to difficulties to benchmark regionally, nationally or globally. The absence of the opportunity to benchmark with the best in its category, leaves little room for the hospitals to improve to the best practice standard.

Second, most of mystery shopper providers do not offer actionable feedback by industry processionals, as they are “tick a box” exercises. Detailed qualitative feedback is required to aid the healthcare facilities improve their PX (Barryet al, 2015; Coulter et al 2014).

Lastly, it is questionable as to what is being measured. Most data collected on patient satisfaction including simulated patient studies are KPI-based. Based on the practice of mystery shopping in healthcare, measuring KPIs is important. It is still not a measurement of the experience of the patient (Barry et al, 2015).

To address these issues, the World Class PX Pulse is being launched in 2024. It is a first of its kind, measuring tool focusing on what matters to the patient categorised in 6 constructs. This will offer a patient experience auditing system that uses healthcare/hospitality professionals to rate the key aspects of patient experience, but more importantly provide detailed, actionable, qualitative feedback to participating health care facilities, focussing on the areas that require improvement. This is critical as it has been identified as a needed addition to PX measurement in health care settings (Barry et al, 2016). It is this qualitative feedback, alongside the recommendations from world class experience experts that is key to offer actionable strategic advice to health care facilities.  The PX Pulse consultant will use the data to provide specific areas of improvement to the executive team by benchmarking against other participating healthcare facilities. This will allow them to focus on the actionable recommended actions that will directly improve patient experience.

To take this further and to learn how the lounge audit is processed.

¹ Cholkongka, N. (2019). Identification of service quality competency framework for the lounge attendants: a case of a privately-owned airline in Thailand. ABAC Journal 39(4) , 123-150.

² Nghiêm-Phú, B. (2017). An analysis of airline/airport lounge service using data gathered from Asia Pacfic Journal of Advanced Business and Social Studies, 4(1), 127-134

³ YATES+ have taken the decision to include sustainability and keeping guests safe as these are notable in the strategic plan of many airline, airport and lounge operators and have received a lot of attention in the wider media. A number of studies highlight the importance of cleanliness of lounges and lavatories which is an important part of the perception of “keeping me safe”.  The following studies also support the addition of “sustainability” as important in lounge and airport experiences:
• Abdel-Gayed, A. H., Hassan, T. H., Abdou, A. H., Abdelmoaty, M. A., Saleh, M. I., & Salem, A. E. (2023). Travelers’ Subjective Well-Being as an Environmental Practice: Do Airport Buildings’ Eco-Design, Brand Engagement, and Brand Experience Matter?. International Journal of Environmental Research and Public Health, 20(2), 938.
• Han, H., Lho, L. H., & Kim, H. C. (2019). Airport green environment and its influence on visitors’ psychological health and behaviors. Sustainability, 11(24), 7018

⁴ Cholkongka, N. (2019). Identification of service quality competency framework for the lounge attendants: a case of a privately-owned airline in Thailand. ABAC Journal, 39(4), 123-150.

⁵ Chua, B. L., Lee, S., Kim, H. C., & Han, H. (2017). Investigating the key drivers of traveler loyalty in the airport lounge setting. Asia Pacific Journal of Tourism Research, 22(6), 651-665.

⁶ Curkan, S. C., & Özkan, E. (2021). The effect of airline lounge services on the selection of airline. Journal of multidisciplinary academic tourism, 6(1), 17-26.

⁷ Han, S., Ham, S. S., Yang, I., & Baek, S. (2012). Passengers’ perceptions of airline lounges: Importance of attributes that determine usage and service quality measurement. Tourism Management, 33(5), 1103-1111.

⁸ Aditya Julio, S. E. Proposed service quality improvement using servqual method and importance performance analysis (ipa) of sultan executive lounge in sm badaruddin ii airport. Second International Conference on Theory and Practice (ICTP-2016), 28th and 29th, October, Melbourne, Australia
ISBN: 9780 9943 65613

⁹ Kim, Y. J., Ban, H. J., Kim, D. H., & Kim, H. S. (2020). Understanding customer experience of airline lounge using text mining of online review. Culinary Science & Hospitality Research, 26(2), 36-44.

¹⁰ Farris, P.W., Bendle, N., Pfeifer, P.E. & Reibstein, D.  (2010).  Marketing Metrics: The Definitive Guide to Measuring Marketing Performance.  Pearson: London

¹¹ Sharp, B., Page, N. and Dawes, J., 2000. A new approach to customer satisfaction, service quality and relationship quality research. Australian & NZ Marketing Academy Conference Proceedings, Griffith University.

¹²  See:
• Fisher, N. I., & Kordupleski, R. E. (2019). Good and bad market research: A critical review of Net Promoter Score. Applied Stochastic Models in Business and Industry, 35(1), 138-151.
• Keiningham, T. L., Cooil, B., Andreassen, T. W., & Aksoy, L. (2007). A longitudinal examination of net promoter and firm revenue growth. Journal of Marketing, 71(3), 39-51.);
• Kristensen, K., & Eskildsen, J. (2014). Is the NPS a trustworthy performance measure?. The TQM Journal, 26(2), 202-214.
• Mecredy, P., Wright, M. J., & Feetham, P. (2018). Are promoters valuable customers? An application of the net promoter scale to predict future customer spend. Australasian Marketing Journal, 26(1), 3-9.
• Romaniuk, J., Nguyen, C., & East, R. (2011). The accuracy of self-reported probabilities of giving recommendations. International Journal of Market Research, 53(4), 507-521.
• Pingitore, G., Morgan, N. A., Rego, L. L., Gigliotti, A., & Meyers, J. (2007). The Single-Question Trap. Marketing Research, 19(2).
• Sharp, B. (2006), “Net promoter score fails the test”, Marketing Research, Vol. 20No. 4, pp. 28-30.
Also see [] to see that according to this source Airlines such as Aeroflot, United Airlines and Thomas Cook score significantly higher than award winning airlines such as Singapore Airlines. Not surprisingly, this leads to industry experts to questioning the validity of the NPS.

¹³  Sharp, B., Page, N. and Dawes, J., 2000. A new approach to customer satisfaction, service quality and relationship quality research. Australian & NZ Marketing Academy Conference Proceedings, Griffith University.

¹⁴  Dawes, J., Sharp, B., & Adelaide, N. T. (2000). The reliability and validity of objective measures of customer service: Mystery Shopping. Australian Journal of Market Research, 8(1), 29-46.

¹⁵ Lowndes, M., & Dawes, J. (2001). Do distinct SERVQUAL dimensions emerge from mystery shopping data? A test of convergent validity. Canadian Journal of Program Evaluation, 16(2), 41-53.

¹⁶  Halvorsrud, R., Kvale, K., & Følstad, A. (2016). Improving service quality through customer journey analysis. Journal of service theory and practice, 26(6), 840-867.

The World Class PXPulse should not be seen as a replacement for patient satisfaction measures and Patient Retention Index (PRI).

Instead, it provides a complementary measure of patient experience that triangulates these other two measures and in addition, provides detailed qualitative feedback to the executive team for future improvements of patient experience.  We note LaVela and Gallan’s (2014) observation: “It is important to examine data collectively from multiple sources and evaluation approaches; in many cases using several different data collection approaches to produce a more informative, rounded picture is preferred (e.g., triangulation)” (p.31).  The PX Pulse will complete this triangulation for health care providers to complement patient satisfaction measures and PRI.


For more information about World Class PX Pulse, please email


Agency for Healthcare Research and Quality (2023). [available:]. Accessed 19th February 2024.

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Sharp, B., Page, N. and Dawes, J., 2000. A new approach to customer satisfaction, service quality and relationship quality research. Australian & NZ Marketing Academy Conference Proceedings, Griffith University.

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