Balanced Rating Scales: The Foundation of Meaningful Feedback
I visited a relative in hospital yesterday. They had a few grumbles about some aspects of the care they were receiving. Fortuitously, a patient survey was delivered moments later! Great, this is your chance to provide feedback, I said. But working through the survey together, we felt we were being manipulated into providing positive feedback only. For each aspect the care, the options were ‘Excellent’, ‘Very Good’, ‘Good’, or ‘Needs improvement’. Three positives and one negative that was euphemistic.
The design of feedback surveys—in any setting—carries profound implications for both data quality and organisational integrity. When hospitals or other organisations implement rating scales that appear skewed toward positive responses, they risk undermining the very purpose of collecting patient feedback and may inadvertently compromise their ability to deliver genuine improvements in care quality.
The rating scale we encountered exemplifies a common but problematic approach to survey design. This four-point scale allocates three categories to positive feedback (Excellent, Very Good, Good) while providing only one option for negative experiences. Such asymmetry creates what researchers call ‘response bias,’ where the survey instrument itself influences how respondents answer, regardless of their actual experiences.
The Problem with Positive Skewing
When rating scales heavily favour positive responses, several issues emerge. First, respondents who had genuinely poor experiences may feel their concerns aren’t adequately represented by the available options. A respondent who experienced significant problems might reluctantly select “Needs Improvement” when their experience actually warranted a more critical assessment like “Poor” or “Unacceptable.” This compression of negative experiences into a single category obscures the severity and variety of problems that respondents encounter.
Furthermore, positively skewed scales can create a false sense of institutional performance. Organisation administrators reviewing data from such surveys might interpret the predominance of positive ratings as evidence of excellent service or care, when in reality, the survey design has artificially inflated positive responses while masking genuine concerns.
Trust and Credibility Implications
Perhaps more importantly, unbalanced rating scales can damage the trust relationship between hospitals and their patients. When surveys appear designed to elicit positive feedback, patients may perceive this as institutional dishonesty or a lack of genuine interest in improvement. This perception can extend beyond the survey itself, potentially affecting how patients view the hospital’s overall commitment to transparency and patient-centered care.
Healthcare organisations that demonstrate genuine openness to criticism and negative feedback, conversely, often build stronger relationships with their communities. Patients recognise when institutions are truly committed to understanding and addressing problems, which paradoxically can enhance rather than damage the organisation’s reputation.
Best Practices for Balanced Survey Design
Effective feedback surveys should provide equal opportunity for both positive and negative responses. A truly balanced five-point scale might range from “Excellent” through “Very Good,” “Adequate, (a neutral middle point)“ “Fair,” to “Poor.” This symmetrical approach ensures that patients can accurately express both positive and negative experiences with appropriate granularity.
Moving Forward
The most successful organisations view feedback as an invaluable tool for continuous improvement rather than a public relations exercise. They design surveys that genuinely seek to understand user experiences in their full complexity, recognising that negative feedback, while sometimes uncomfortable to receive, provides the most actionable insights for meaningful change.
By implementing balanced rating scales and demonstrating genuine openness to criticism, hospitals and other organisations can build stronger patient/client relationships while gathering the honest feedback necessary to deliver truly excellent service and care. The goal should never be to generate positive survey results, but rather to understand and improve the actual patient experience.