Cancer survivors in the United States are living longer, and cancer is increasingly viewed as a chronic illness that requires systematic, coordinated care. But research and practice have not yet [ Read More ]
July 2017 VOL 8, NO 7
Developing a Universal Set of Metrics for Use in All Navigation Models
An Interview with Tricia Strusowski, RN, MS
The Academy of Oncology Nurse & Patient Navigators (AONN+) Standardized Metrics Task Force, an expert team of seasoned navigators, recently published their highly anticipated work of establishing a set of universal, research-supported metrics to prove the impact of navigation programs (see the May 2017 issue of JONS).
These metrics aim to measure the impact of navigation on patient experience, clinical outcome, and return on investment within 8 domains of navigation programs to include 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, and research/quality/performance improvement. The result? Thirty-five metrics that are designed for use in all navigation models and programs that enable an accurate evaluation of the program’s impact.
Today, we sit with the AONN+ Standardized Metrics Task Force program lead, Tricia Strusowski, RN, MS, to talk about her experience as an oncology nurse navigator, the need for national metrics, the process of metrics creation, and their intended use.
JONS Thank you so much for speaking with us today. To begin, we’d like to learn a little about your career path and how it led you to navigation.
Ms Strusowski I have been an oncology nurse for 34 years. I started on a hematology unit when I was a new graduate and eventually got involved in bone marrow transplantation. I’ve had many roles—assistant nurse manager, nurse manager, oncology home care—and ultimately headed up an oncology case management department.
My experience in case management was my introduction to the beginnings of navigation.
In that role, I learned how to follow patients across the entire continuum. Case managers worked with the physician in their office and developed the plan of care, after which we would meet with the patient and their family to ensure the plan of care was appropriate. We made sure that they had the appropriate level of care, meaning determining if their care was something they could handle at home versus requiring rehab or admission to a skilled nursing facility. We wanted to make sure that they were being heard and supported in regard to their needs and goals.
That was my introduction to talking with patients about their goals and trying to look at how we can help the patient as much as possible while trying to keep costs down.
From there I took a new position at the Helen F. Graham Cancer Center as the clinical director of the cancer care management department. In that role, I oversaw support services, including nurses, social workers, discharge planners, dietitians—all of the support services. But at that time we didn’t have clear direction on how to best navigate patients. There were no core competencies or guidelines. All I knew was that our goal was to follow these patients from time of diagnosis across the entire continuum.
During my 15 years at the Helen F. Graham Cancer Center I became involved with the Academy of Oncology Nurse Navigators (AONN). I was on the AONN Leadership Council in 2008 when our cancer center’s program started expanding. I became clinical director of the entire program. I still headed up the support services, but I also led 7 other departments. We also created multidisciplinary centers where the patient would come and see all their doctors and their treatment team.
For the past 3.5 years, I’ve been working for Oncology Solutions, consulting with cancer centers on their clinical programs, such as navigation and survivorship, creating and reassessing programs based on national standards and guidelines.
JONS Can you speak about the evolution of navigation as a distinct field within oncology?
Ms Strusowski Over the years, navigation has grown tremendously. The evolution of navigation started with utilization review, utilization management, and case management, which eventually led to patient navigation. It started as a way to eliminate barriers to screening. Now we have standards in place for navigation programs through accrediting bodies like the Commission on Cancer (CoC), as well as position statements from ONS [Oncology Nursing Society], AOSW [Association of Oncology Social Work], and NASW [National Association of Social Workers]. You’re starting to see that there are job descriptions specifically for navigators. You’re starting to see reports from the Institute of Medicine on how navigation fits into the goals of patient- and family-centered care.
These are our foundations in navigation. But there is still much work to be done. We still find that navigator positions are being filled by nurses or social workers who have been in oncology, whether they’ve worked the inpatient setting, the chemotherapy suite, or the radiation therapy department, and now they have to follow the patient from the earliest point of entry. They need to follow the patient across the entire continuum, from outreach screening through treatment, survivorship, and end of life. Although they are experienced in oncology, they need to be oriented on how to follow the patient successfully across the continuum.
In our program, we create tools to enhance the process and empower the patient. For example, we prepare patients before they go to surgery by letting them know what exercises to do prior to going to the hospital. We talk about what will happen in surgery. We give them their prescriptions and advise them to have them filled in advance, and how and when to take them for pain management after surgery. We’re working with the patients prior to any acute state of pain or during an episode of care.
I recently spoke with a patient and asked when she had met her navigator. She recounted that she met her navigator while she was in the hospital on a morphine drip and didn’t really remember what happened. That’s not good. We need to be one step ahead, and that needs to happen across the entire continuum.
We need to identify key points of contact for the navigator to enhance the process and empower the patient. Many times, this requires navigators to think differently even though they’ve been in oncology for decades.
JONS How do you feel navigation programs have been accepted nationally?
Ms Strusowski Overall, they have been very well accepted, and there is evidence in the literature to support the benefit of establishing navigation programs. Although navigation programs have been around for decades, many times the multidisciplinary team members, including physicians and administrators, aren’t entirely sure what navigators do.
As a consultant, I have created provider education fact sheets to educate the oncology team about the role of a navigator. This is extremely important because physicians and administrators must be the champions of navigators. You need your administrators and physicians to embrace how you complement the care in their office and for the entire cancer program.
A very basic understanding of navigation will tell us that navigators coordinate care across the continuum. Guess what? That can mean just about everything. You don’t necessarily want your navigator, social worker, or nurse navigator scheduling appointments. She turns into a very expensive clerk. So understanding roles is imperative. Based either on core competencies or the CoC standards, I include all support services in my assessment of a program, including the navigators, social workers, dietitians, genetic counselors, health psychologists—whatever resources they have—and create a fact sheet for them.
I also create fact sheets for the patients and their families so they understand what the navigator does versus the social worker or the nutritionist. Bottom line, cancer programs are very supportive in updating their processes to include a navigation component.
Bottom line, cancer programs are very supportive in updating their processes to include a navigation component.
JONS How was the idea born to create metrics to measure the impact of navigation programs?
Ms Strusowski I got involved with the AONN+ Evidence into Practice Committee where we first started discussing the need for metrics. At that time, we had already identified core competencies for navigators, we had identified standards, we had everything we needed to legitimize our role as navigators, but we didn’t have the metrics to prove it.
We talked to the leadership team at AONN+, and they were immediately on board and fully supportive. From there, we very quickly put our team together, created a proposal, and got to work creating the metrics. We’re extremely excited with this whole process.
JONS Can you speak to the core competencies and how they translated to metrics?
Ms Strusowski In my role as a consultant, I’ve had the opportunity to work with many cancer programs that need help in understanding core competencies and CoC standards. Reporting is extremely important in meeting CoC requirements. Along with reporting, I’ve always been an advocate for metrics to measure the success of your program.
It occurred to me through my experience consulting that we are not comparing apples to apples when it comes to assessing navigation programs. But, if we can create metrics that every program will be able to utilize no matter what model, collectively we’d be much more effective. There is also a tremendous need to create navigation benchmarks and conduct additional research in navigation; therefore, we need to be collecting the same information.
It became obvious that creating metrics was the logical next step.
JONS How was the Standardized Metrics Task Force created?
Ms Strusowski We knew we needed to create a team of experts; people who were known in the navigation field. We created an application for those who wanted to be part of this team. We started with the Evidence into Practice Committee, and we reached out to other well-known experts in navigation as well. Through that process, we came up with our team of 10 members.
JONS How did the Task Force approach this project?
Ms Strusowski My cochairs Elaine Sein, RN, BSN, CBCN, and Danelle Johnston, MSN, BSN, RN, ONN-CG, OCN, CBCN, and I standardized the tools that the team needs for collecting their supportive documents. We discussed the project and tools with our core team via webinars. We also assigned each team member to one of us for any questions or concerns. We began by collecting evidence-based source documents that represented the highest level of validation possible within our domains. The Task Force was trained to collect information the same way.
This process provided all the source documents; all the articles on which we could base our metrics. We obtained over 300 articles. With our initial research complete, the Task Force convened to write the metrics based on the AONN+ domains. We were sure to provide thorough definitions of each metric. And we ensured that each metric would be appropriate for every single navigation program no matter what model. So each metric is based on information that any program can collect. This approach ensures that we are creating a foundation for all navigation programs. We were careful not to create disease-specific metrics. And we are very pleased with the results.
JONS Can you provide an overview of what you’re measuring, and perhaps an example of an element of a navigation program to be measured?
Ms Strusowski So much work went into establishing the certification for the AONN+ domains, so those domains became the foundation for the metrics. We set a goal to create categories that measure patient experience, clinical outcome, and return on investment because those are powerful measurements that support value-based cancer care and the oncology care model.
By way of example, distress screening is an element of a navigation program that should be measured. It is a national standard, and there are validated tools out there to be utilized. It is part of the CoC standards, and the literature supports its need and the excellent outcomes when the tool is used properly. It’s an excellent metric.
In our metrics, we provide the definition of distress screening as well as the definition of the metric itself—meaning, the number of patients per month that receive the psychosocial distress screening with a validated tool. We provide a list of the tools that have been validated. In the simplest terms, we define the service to be measured and the tools with which to measure it.
JONS What is the long-term goal in collecting data from navigations programs?
Ms Strusowski We are currently developing an online database and repository where AONN+ members can submit their data, generate reports, view benchmarks, and show best practices. The site will also function as an avenue for assistance, giving members the ability to reach us as soon as possible with their questions about the metrics. It’s a way to support our peers and colleagues across the country in collecting their data.
Ultimately, we will use the repository for research, because for the first time we will finally be comparing apples to apples.
JONS In addition to the greater good of collecting data for research comparisons and articles, how do the metrics improve individual navigation programs?
Ms Strusowski Navigation has developed organically within individual institutions, and many oncology nurses or oncology social workers or lay navigators were put into a navigation role with no orientation, no explanation, and no job descriptions, and they’re expected to “go navigate.”
Our metrics ensure that we are providing necessary support to navigators to have them grow their programs so they can validate them and measure success and sustainability with their physicians and their administration.
JONS As the project lead for the AONN+ Metrics Task Force, do you have any advice for navigators regarding the use of these metrics?
Ms Strusowski There are 35 metrics. Do you have to use all of them? Absolutely not. I am a person who says keep things simple and start slow. Start with metrics you can easily capture, whether it’s through your EMR [electronic medical records] or through tumor registry. You can build some of these metrics in your tumor registry or your EMR. Maybe you’re only starting with the ones that are relevant to the CoC. I think it’s best to start with 3 to 5 metrics.
JONS Thank you for your time today, and continued success to you with the metrics program.
With over 30 years of experience in the oncology field, Ms Strusowski has worked in a variety of roles, including oncology nurse, nurse manager, case management, and most recently, clinical director overseeing a multitude of departments, including cancer care management. In conjunction with serving on multiple advisory boards, she has implemented 15 multidisciplinary cancer center teams, including breast, lung, head and neck, and pancreatic and various other tumor site–specific teams. She currently is a manager with Oncology Solutions, LLC, the nation’s largest, independent cancer consulting firm.