• American Society of Clinical Oncology ASCO (www.asco.org)
• Association of Community Cancer Centers ACCC (http://accc-cancer.org)
• Commission on Cancer Quality of Care Measures (https://www.facs.org)
• Comprehensive Cancer Network NCCN (www.nccn.org)
• National Quality Forum NQF (www.qualityforum.org)
• National Consortium of Breast Centers, Inc. NCBC (www.breastcare.org)](https://image.slidesharecdn.com/navigatoram-metricsinnavigation-gentryapproved-161104174400/85/Metrics-in-Navigation-16-320.jpg)
Metrics in Navigation
- 1. 1 Metrics in Navigation Sharon Gentry, RN, MSN, AOCN, CBCN, CBEC Breast Nurse Navigator Novant Health Derrick L Davis Cancer Center Academy of Oncology Nurse & Patient Navigators + Standardized Metrics for Navigation Committee
- 2. 2 Metrics in Navigation Objectives: Define the role of metrics in navigation Define three metric outcomes Explore examples of navigation metrics
- 3. 3 Metrics in Navigation What is a metric? Standard for measuring or evaluating something, especially one that uses figures or statistics “To measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.” - Centers for Medicare & Medicaid Services (CMS)
- 4. 4 Metrics in Navigation What is navigation? “Navigation is individualized assistance offered to patients, their families, and caregivers to help overcome barriers to care, whether through the healthcare system or the environment, and facilitate timely access to quality medical and psychosocial care from before…diagnosis…through all phases of the cancer experience.” – Commission on Cancer Therefore in navigation – Metrics are methods used to evaluate the success of the navigator role (accurately measuring performance) in cancer programs to improve the care of patients by monitoring and measuring outcomes
- 5. 5 Metrics in Navigation The measurement goals need to be SMART • Specific - Objectives should be straightforward and emphasize what you want to happen • Measurable - If you cannot measure it, you cannot manage it. Establish objectives that are measureable and allow you to gauge progress. • Achievable - The objectives you set should be action-oriented and related to activities or tasks that you and your team can make progress toward. • Realistic - "do-able." It means that the learning curve is not extremely steep and that the skills needed to do the work are available. • Time-bound - Set a timeframe for the objectives. Putting an endpoint on your objectives gives you a clear target to work toward. Willis, A., Hoffler, E., Villalobos, A., Pratt-Chapman, M. (2016). Advancing the Field of Cancer Patient Navigation: A Toolkit for Comprehensive Cancer Control Professionals. The George Washington University Cancer Institute. Washington, DC.
- 6. 6 History of Metrics In Navigation Freeman - In oncology, navigation arose to improve cancer screening, early detection, and timely follow-up among low-income and disadvantaged populations Freeman, H. & Rodriguez, R. (2011). History and principles of patient navigation. Cancer, 117(15), 3539-3542. Shockney – “has extended beyond addressing the needs of underserved populations or facilitating screening and diagnosis; its goal is to navigate all patients throughout the cancer continuum.” We were challenged to compare various navigation models and measure their impact on: outcome indicators, …participation in cancer screening, adherence to diagnostic follow-up care, reductions in late-stage diagnoses, fewer delays initiating treatment, improvements in survivorship, and patient satisfaction with cancer care • Shockney L. (2010). Evolution of patient navigation. Clinical Journal of Oncology Nursing. 14(4):405-7
- 7. 7 Navigation improves… • Patient satisfaction • Decreases in barriers to care • Timely access to care • Continuity of care • Symptom management • Emotional support • Patient empowerment Espinosa, a. Gabel, M. & Vlahakis, P. (2012). Patient navigation: Defining metrics that support and justify the nurse navigator position. Journal of Navigation & Survivorship,3(5):16-20. Bellomo C. (2014). The effect of navigator intervention on the continuity of care and patient satisfaction of patients with cancer. Journal of Navigation & Survivorship,5(6):14-23.
- 8. 8 Where does one start? A system analysis or gap analysis is crucial to understanding the flow of care from the patient’s point of view. It is a flow chart depicting a timeline from access to care through delivery of care and should include follow-up and survivorship care. Questions to consider: Who does the care for the patient? Where the care is done? When it is achieved? How it is performed? Why it is implemented? What does the patient say? Hunnibell, L., Rose, M., Connery, D., Grens, C., Hampel, J., Rosa, M., & Vogel, D. (2012). Using nurse navigation to improve timeliness of lung cancer care at a veterans hospital. Clinical Journal of Oncology Nursing, 16(1), 29-36. doi.org/10.1188/12.CJON.29-36 Shockney, L. (2011). Becoming a breast cancer nurse navigator. (1st ed.). Sudbury, MA: Jones and Bartlett Publishers.
- 9. 9 Process Being Performed Average # Days to Next Step in 1997 Average # Days to Next Step in 2012 Before Navigation in 1997 After Navigation (current program, 2012) Screening Mammogr am 25 10 No recruitment, community education, or Navigator Caseworker arranges screening mammogram within 2 weeks. If patient has a breast abnormality symptom, mammogram done within 1 business day. Mammogr am Read by Radiologis t 3 0 Mammograms read in batch mode Same day read of screening mammogram Patient Informed of Abnormal Results 1 0 Technician called the patient for additional imaging Radiologist tells patient to inform her that additional imaging needed Diagnostic mammogr am/ultras ound 7 0 Patient informed of results by radiologist while the patient was there. Studies are done in real time and read immediately. Patient informed of results. Referring physician notified 0 0 Referring physician informed of findings and obtains approval if needed to perform a biopsy. The radiologist contacts referring physician with findings and obtains approval if needed to perform a biopsy the same day. Scheduled for biopsy 4 0 No education provided until patient arrived for the biopsy. Biopsy performed in real time. Nurse navigator meets with patient and survivor volunteer is introduced.
- 10. 10 “Cancer Navigation Metric Selection Picklist” • Improve care coordination • Enhance access to care • Provide multidisciplinary support • Attract and retain patients • Enhance patient education and engagement • Connect patients to support services 2016 Advisory Board Company Six steps to getting the most out of your patient navigation program. Retrieved from https://www.advisory.com/research/oncology-roundtable/resources/2016/patient-navigation
- 11. 11 Patient Navigation Metrics from Association of Community Cancer Center Publication Navigation metrics should evaluate across the continuum of care: • Patient experience • Clinical outcomes • Business performance (return on investment) Strusowski, T. & Stapp, J. (2016) Patient Navigation Metrics; Measuring the impact of your patient navigation services. Oncology Issues, Jan-Feb 62-69
- 12. 12 Academy of Oncology Nurse & Patient Navigators + Standardized Metrics for Navigation Develop standard metrics in the area of patient experience, clinical outcomes and return on investment (ROI) using the AONN+ DOMAINS for certification. These domains contain a comprehensive list of all areas navigators practice in order to provide quality patient care and financial stability for their organizations. Community Outreach & Prevention Coordination of Care/Care Transitions Patient Advocacy/Patient Empowerment Psychosocial Support Services/Assessment Survivorship/End of Life Professional Roles and Responsibilities Operations Management/Organizational Development/Healthcare Economics Research/Quality/Performance Improvement Academy of Oncology Nurse & Patient Navigators + (2016) Getting Metrics-Focused Navigation Practices in Place
- 13. 13 Patient experience Patient satisfaction with navigator (navigation process) *Internal benchmark/Consumer Assessment of Healthcare Providers & Systems for Cancer Care/ Satisfaction with Patient Navigation- Interpersonal scale * An open ended area is critical for feedback – “pearls” SMART = In 2017, 75% of the returned patient surveys will rate (Likert scale of 5) extremely satisfied with the patient navigation experience. Distress management * Decrease in distress related to navigation actions * # of referrals to address distress management SMART = In 2017, 90% of the patients will report a 3 point decrease in the distress scale after meeting with the navigator.
- 14. 14 Clinical outcomes Timeliness to Care from diagnosis to first consult (first treatment) *Internal benchmark (pre/post navigation)/Cancer site specific - Breast Cancer Care Quality Indicators/ Gilbert, J., Green, E., Lankshear, S., Hughes, E., Burkoski, V. & Sawka, C. (2011), Nurses as patient navigators in cancer diagnosis: review, consultation and model design. European Journal of Cancer Care, 20: 228–236. SMART = By March 2017, the time from patient diagnostic visit to first treatment consult will decrease by 2 days. Treatment = surgery, radiation, medical oncology, palliative care Guideline/pathway compliance * Internal benchmark/ NCCN Guidelines/Quality in Health Care Advisory Group/CoC Quality of Care Measures SMART = 75% of the stage 3 lung cancer patients in 2017 will follow NCCN guidelines for medical oncology care.
- 15. 15 Business performance Percentage of patients that are diagnosed and retained for care at your institution. *Internal benchmark/site specific/ Commission on Cancer SMART - Six months after the new navigation process starts (April 2017), outmigration will decrease by 50%. Number of ED admissions per 1000 chemotherapy visits. *Internal benchmark/ Quality in Healthcare Advisory Board SMART – After 1000 chemotherapy visits, the ED chemotherapy related admissions will be less than 500.
- 16. 16 Metrics in Navigation • Academy of Oncology Nurse & Patient Navigators AONN+ (www.aonnonline.org) • Academy of Oncology Nurse & Patient Navigators AONN+ Evidence Into Practice Committee Newsletter (www.aonnonline.org) • Advisory Board/Oncology Round Table (www.advisory.com) • American College of Surgeons [ACoS ](www.facs.org) • American Society of Clinical Oncology ASCO (www.asco.org) • Association of Community Cancer Centers ACCC (http://accc-cancer.org) • Commission on Cancer Quality of Care Measures (https://www.facs.org) • Comprehensive Cancer Network NCCN (www.nccn.org) • National Quality Forum NQF (www.qualityforum.org) • National Consortium of Breast Centers, Inc. NCBC (www.breastcare.org)
- 17. 17 Questions ?
- 18. 18 Metrics in Navigation Bibliography • Academy of Oncology Nurse & Patient Navigators + (2016) Getting Metrics-Focused Navigation Practices in Place. Retrieved from https://www.aonnonline.org/public/getting-metrics-focused-navigation-practices-in-place/ • 2016 Advisory Board Company Six steps to getting the most out of your patient navigation program. Retrieved from https://www.advisory.com/research/oncology-roundtable/resources/2016/patient-navigation • Bellomo C. (2014). The effect of navigator intervention on the continuity of care and patient satisfaction of patients with cancer. Journal of Navigation & Survivorship,5(6):14-23. • Centers for Medicare & Medicaid Services (2016) What are quality measures? Retrieved from https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-instruments/QualityMeasures/index.html?redirect=/QualityMeasures/ • Commission on Cancer (2016) STANDARD 3.1 Patient Navigation Process Retrieved from https://www.facs.org/~/media/files/quality%20programs/cancer/coc/2016%20coc%20standards%20manual_interactive%20pdf.ahx • Espinosa, a. Gabel, M. & Vlahakis, P. (2012) Patietn navigation: Defining metrics that support and justify the nurse navigator position. Journal of Navigation & Survivorship,3(5):16-20. • Freeman, H. & Rodriguez, R. (2011). History and principles of patient navigation. Cancer, 117(15), 3539-3542. • Hunnibell, L., Rose, M., Connery, D., Grens, C., Hampel, J., Rosa, M., & Vogel, D. (2012). Using nurse navigation to improve timeliness of lung cancer care at a veterans hospital. Clinical Journal of Oncology Nursing, 16(1), 29-36. doi.org/10.1188/12.CJON.29-36 • Shockney, L. (2011). Becoming a breast cancer nurse navigator. (1st ed.). Sudbury, MA: Jones and Bartlett Publishers. • Shockney L. (2010). Evolution of patient navigation. Clinical Journal of Oncology Nursing. 14(4):405-7 • Strusowski, T. & Stapp, J. (2016) Patient Navigation Metrics; Measuring the impact of your patient navigation services. Oncology Issues, Jan- Feb 62-69 • Willis, A., Hoffler, E., Villalobos, A., Pratt-Chapman, M. (2016). Advancing the Field of Cancer Patient Navigation: A Toolkit for Comprehensive Cancer Control Professionals. The George Washington University Cancer Institute. Washington, DC.
Editor's Notes
- #10: Flow Chart Depicts Previous and Current Patient Flow Process in the John Hopkins Breast Center