Metrics in Navigation

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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

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Metrics in Navigation
Objectives:
Define the role of metrics in navigation
Define three metric outcomes
Explore examples of navigation metrics

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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)

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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

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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.

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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

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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.

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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.

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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.

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“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

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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

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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

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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.

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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.

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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.

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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)

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Questions ?

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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.