Utilizing Metrics to Advance Navigation Services
Deborah Christensen, RN, BSN, HNB-BC; Katie Wahler, RN, BSN, OCN
Intermountain Southwest Cancer
Background: Oncology navigation services continue to be seen as a valuable and needed component of person-centered care. Despite the differences in navigation programs from one institution to another, collecting clearly defined metrics and presenting the resulting data to program administrators can be useful in acquiring additional personnel. Human capital is not easily rationalized within the uncertainty of healthcare reform, especially if the position is not revenue-producing. Several tracking metrics were utilized within 1 institution to quantify the need for additional personnel and show how the additional hours would be utilized to expand and extend navigation services.
Objectives: (1) Identify current services being provided by 1 nurse navigator; (2) identify additional services that could be provided with additional personnel; (3) define current usage and additional hours needed to offer essential navigation services; and (4) demonstrate revenue-00generating potential and cost-reduction strategies through the expansion of navigation services.
Methods: Metrics, aligned with the above objectives, were developed and tracked for 9 months by the nurse navigator. A navigation flow chart, defining how navigation would be carried out utilizing additional personnel, was also developed and presented with the data to the director of the oncology program. The presentation was refined, and the nurse navigator and a medical oncologist presented the data to the hospital administrator.
Results: Discussion and presentation of navigation data resulted in the approval to hire 1 nurse navigator and 1 patient navigator to the oncology program.
Conclusion: Research verifies that oncology navigation programs improve patient care and elevate patient and provider satisfaction. Despite the evidence, oftentimes well-defined metrics, data, and program planning will be needed for continued development and success of oncology navigation programs.
Integrate Knowledge Gained from an Educational Event into Practice Using a Motivation Action Plan (MAP)
Deborah Christensen, RN, BSN, HNB-BC; Katie Wahler, RN, BSN, OCN
Intermountain Southwest Cancer
Background: Attending an educational event, such as a national conference, workshop, or in-service, can renew enthusiasm and produce ideas for personal and professional growth. Some type of strategy is needed to ensure that the motivation and knowledge gained from attending these types of events are brought home and integrated into practice. A Motivation Action Plan (MAP) is a simple planning tool that can be used during and at the conclusion of an educational event to map out strategic steps for transforming knowledge into attainable actions. The process is simple; the results can be profound.
Objectives: (1) Document and organize key points, questions, and ideas from an educational event; (2) formulate 1 to 4 action plan items; (3) assess motivation and self-efficacy using a 1 to 10 Likert scale; (4) prioritize intentions based on Likert scale scores; (5) detail MAP intention, action, and success; and (6) complete action plan items and report success.
Methods: Creating a MAP prior to returning home after an educational event must be easily accomplished yet structured in such a way that objectives can be reached and enthusiasm maintained. Therefore, MAP has a minimum of 1, but no more than 3, focused objectives/intentions per conference or educational event. There are 2 pages to a MAP; page 1 is designed to structure and document notes taken during the presentation, whereas page 2 is a more formalized planning document that details specific measurable actions and time frames. The MAP process is based on Albert Bandura’s self-efficacy theory. Simply stated, self-efficacy is a person’s belief in his or her ability to accomplish a task, goal, or life pursuit. This concept is integral when filtering the abundance of information and excitement generated from attending motivating educational events. High levels of self-efficacy and motivation lead to improved performance outcomes.
Results: A group of nurses from across the country volunteered to beta test a MAP during the Oncology Nursing Society 2014 Congress. One week following the conference, a survey was sent to each of the volunteers. Revisions made from suggestions by MAP beta testers included offering MAP in both printable and editable formats and providing preconference access. All respondents acknowledged that they were likely to use MAP in future educational events.
Conclusion: Participation in educational events is a fundamental part of continuing education. Attendees who use MAP can easily transform gained knowledge and personal enthusiasm into doable actions. The MAP project will continue to gather data on motivation, action planning, and outcomes through continued use of the tool by education event participants and planners.
Enhancing Survivorship Care Through a New Integrative Model of Navigation
Christine Stone, RN, MSN, OCN; Barbara McDonnell, RN, MSN, CBCN; Carrie Friedman, RN, BS
Inova Health System/Inova Life with Cancer
Background: Inova Health System (IHS) is a large multihospital, not-for-profit community health system. Each year, Inova diagnoses approximately 6000 new cancer cases. Within IHS is the Life with Cancer (LWC) program of nurses and social workers whose mission is to enhance the quality of life for those affected by cancer by providing information, education, support, and therapeutic services. LWC is a unique program, recently named “Best Practices” by the American College of Surgeons, that services not only Inova patients, but the larger community as well at no cost to patients and family members. Because a new diagnosis of cancer encompasses multiple physician visits and procedures, it produces overwhelming stress and emotion for all involved. Because of the complexity and growing number of cancer patients, LWC restructured their Nursing Team. They also created a centralized telephone number and e-mail address for entry into LWC. Through this access, callers are connected with the appropriate Oncology Nurse Navigator (ONN) or social worker as early as possible to gain diagnosis-specific support and education.
Objectives: To meet the psychosocial and educational needs of all cancer patients and their family members within the Inova community and beyond. (1) Restructure LWC nursing staff by merging nursing roles and functions into 1 job description; (2) create easy entry into LWC services through 1 phone number and e-mail supported by a triage team; and (3) establish ONNs as primary contacts once callers are triaged.
Methods: (1) Over a 6-month period, a team of LWC Nurse Educators and Inova Breast Care Institute Navigators reviewed, discussed, and developed a new role that encompassed ONN functions; (2) accessed the expertise of the process improvement department and collected the number of disease-specific cancer cases at all 5 facilities; (3) researched other oncology centers similar to our health system to see what job descriptions had been developed; (4) reviewed Oncology Nursing Society 2013 Nurse Navigator Core Competencies and assimilated those into the new ONN role.
Results: Changes resulted in a new framework and job description for navigation across IHS. The Oncology Nurse Educator and Breast Nurse Navigator roles were merged into 1 titled ONN. This led to a centralized phone number and e-mail for all cancer patients, families, and healthcare providers. The LWC staff triages the call and disseminates the information to the appropriate navigator across IHS. The next steps involve developing a New Cancer Diagnosis Orientation led by LWC social workers and ONNs. This will include healthcare team expectations, preparation for treatment, LWC programs and services, distress screening, and a survivorship care plan in addition to creating a postdiagnosis survivorship class to address such topics as side effects, late effects, fears of recurrence, coping skills, who to call, returning to work, sexuality and fertility, nutrition, survivors offering support, children support, etc. This will eventually become a formal survivorship clinic.
Conclusion: Through this change, there will be increased patient satisfaction and quality of life, decreased distress associated with a cancer diagnosis, physician satisfaction, and seamless care for patients and families.
Utilizing a Screening Tool to Measure Distress on the Initial Consultation of a Cancer Diagnosis andImplementing a Distress Protocol
Barbara R. McHale, RN, BS, OCN, CBCN; Sabrina Mosseau, RN, BS, OCN
Samaritan Hospital Cancer Treatment Center, St. Peter’s Health Partners
Background: Oncology nurses have observed patients struggling with both the physical and psychosocial effects of being diagnosed with cancer. With the knowledge that each individual develops different coping mechanisms during his or her lifetime, we realized each patient may react and deal differently with his or her diagnosis. Some of the patients may exhibit confusion, teariness, denial, anger, or become depressed and withdrawn. We struggled with the best way to address these issues and concerns. The decision was made to utilize an evidence-based tool to assess our patients’ distress level and to have a referral system established to remove barriers to care. Screening for distress is the first step in identifying factors that contribute to a poorer quality of life. By addressing these issues in the beginning of the cancer journey, we would be able to improve the patients’ quality of life and outcomes. The nurse navigator was involved with many of the patients, but we needed to have a protocol to initiate referrals to other services—counseling; pastoral care; nutrition; American Cancer Society navigator; physical, occupational, and speech therapy; and lymphedema rehabilitation.
Objectives: Initiate a distress protocol utilizing the National Comprehensive Cancer Network (NCCN) distress tool as our screening tool. (The tool was used with permission of NCCN. No content was altered.) Evaluate the impact of the distress tool screening on the initial consultation of a cancer diagnosis and referral to interventions established with the distress protocol.
Methods: (1) The distress tool was given to patients on their first consult at the cancer treatment center at Samaritan Hospital. Patients were able to rate their distress on a scale of 0 to 10 and identify any problems within the areas of practical, family, emotional, spiritual/religious, and physical they had experienced in the past week. Based on these results, referrals were to be initiated. If the score on the Distress Thermometer was <4 (lower level of distress), a physician and RN team intervention would occur. If the score was >4 (severe level of distress), the distress protocol would be implemented. The distress protocol consists of referrals for intervention to nurse navigator; counseling services; pastoral care; nutrition; American Cancer Society navigator; physical, occupational, and speech therapy; and lymphedema rehabilitation services. (2) Staff education was conducted prior to implementing the NCCN distress tool and the distress protocol. In the initial pilot, the distress tool was given to all new patients coming to the cancer treatment center and then readministered after completion of treatment, change in treatment, progression of disease, or a recurrence. Distress can occur at multiple points from a cancer diagnosis onward and may go unrecognized if screening is done only one time.
Results: The distress tool was implemented in December 2013. A chart audit was conducted on 81 new patients that started with the center in the first quarter of 2014. Chart audit revealed 71 charts had documented distress tools, 9 had no tools (they were inpatients at the hospital and were not given the distress tool), 1 had a blank tool, and 1 noted that the patient had refused to answer the questions. Utilizing the Distress Thermometer, 58% of patient scores were <4 and 42% of patient scores were >4. Patients who scored <4 on the thermometer were able to be assisted with direct education interventions by primary care physicians and the oncology nursing staff. Expandable folders with resources available by county were placed in the Medical Oncology and Radiation Oncology Clinic areas as a reference source. Distress Thermometer scores >4 had major areas of concern identified: (1) 80% of individuals indicated emotional problems: depression, nervousness, worry, and loss of interest in usual activity; (2) 73% of individuals indicated physical problems: fatigue, appearance, pain, sleep, eating, and getting around; (3) 33% of individuals indicated practical problems: insurance/financial, transportation, and work; (4) 13% experienced family problems: dealing with their partner; and (5) 3% indicated spiritual/religious concerns. Utilization of the distress protocol for referrals to interventions resulted in 100% referred to a nurse navigator; 27% referred to physical, occupational, speech, and lymphedema therapy; 10% referred to nutrition; 7% referred to counseling; 7% referred to American Cancer Society Navigation; and no referrals to pastoral care.
Conclusions: Review of data from the audit revealed that several areas need to be addressed for reeducation on the utilization of the distress tool and the distress protocol. Although the highest level of distress in patients who scored >4 on the Distress Thermometer was noted to be emotional problems (80% of the patients), only 7% of these patients were referred to counseling services. Physical problems were noted in 73% of the patients, but only 10% were referred to nutrition and 27% were referred to physical, occupational, speech, and lymphedema therapy. Practical problems were noted in 33% of the patients, and 100% were referred to the nurse navigator. Family problems were rated at 13%, with only 7% referred to counseling. The data showed that the oncology staff would benefit from further education and empowerment to initiate referrals to the various interventions. The nurse navigator was referred to 100% of the time, but to prove the effectiveness of the distress protocol, the other referrals needed to be initiated the day the distress tool was utilized. A second area of concern that was noted with the chart audit was there were no documented follow-up distress tool assessments after the initial one. To measure change in distress scores after referrals to various interventions, a second assessment needs to be done. NCCN included a standard that “all patients should be screened for distress at their initial visit, at appropriate intervals, and as clinically indicated, especially with changes in disease status.”1 “The role of the oncology nurse as a care provider is vital in distress management and includes a responsibility to understand the construct of distress and how to screen for it, educate patients and navigate patients to supportive care interventions as their assessments indicate.”2
1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): distress management. Version 1.2008. 2007: Dis-3. Accessed June 27, 2014.
2. Hammelef K, Friese C, Breslin TM, et al. Implementing distress management guidelines in ambulatory oncology: a quality improvement project. Clin J Oncol Nurs. 2014;18(suppl):31-36.
Advanced Cancer Patient Toolkit: Assisting Nurse Navigation in Assessing and Meeting Needs of the Advanced Cancer Patient
Lindsey Bowman, RN, BSN
Virtua Fox Chase Cancer Program
Background: There are numerous barriers that prevent patients from receiving quality end-of-life care, including lack of end-of-life education, patient/caregiver avoidance, and poor communication. These barriers can prevent patients from receiving many important resources and interventions at the end of life. Research shows that adequate end-of-life care both decreases costs and improves patient outcomes; therefore, it is imperative that healthcare workers use the many resources that are available to these patients. Nurse navigators are in an important position to ensure that this happens.
Objectives: Nurse navigators are tasked with helping cancer patients get to and through treatment, but there are times that treatment fails or no longer is an option for our patients. It is important for navigators to have the tools necessary to continue to support our patients through to the end of life. The objective of this project is the implementation of a developed toolkit to assist nurse navigators in starting conversations about end-of-life wishes and plans. The toolkit also contains all of the resources needed to ensure patients and families are as comfortable as possible.
Methods: An educational needs assessment was obtained through a short survey of the nurse navigators to determine their comfort level with end-of-life conversations and assessments. After the need was determined, a review of end-of-life care literature was performed to determine key points in end-of-life care. Based on the literature review, a toolkit was developed to assist nurse navigators in assessing the needs of the patient with advanced cancer. The toolkit also includes information on referrals that are often necessary and the contact information to streamline the referral process.
Evaluation: The toolkit was developed in March 2014. There is ongoing feedback regarding the use of the toolkit. The plan is to resurvey the navigators to determine the use of the toolkit and their satisfaction with the resource. Outcomes will be measured by the survey results and frequency of which the toolkit is being utilized. Goals moving forward would be to incorporate the checklist into our electronic databases for easier use, provide continued end-of-life education opportunities for navigators, and develop an end-of-life toolkit for patients and caregivers.
Conclusion: Part of our role as nurse navigators is to assist in removing barriers to ensure that patients with advanced cancer have their end-of-life wishes addressed and carried out. Increasing our own knowledge regarding end of life and staying current on the latest research surrounding the topic will ensure that we are providing the best care to the dying patient.
Improved Outcomes with Successful Intramuscular Injections of Octreotide Long-Acting Repeatable in Patients with Neuroendocrine Tumors: Training and Techniques
April Boyd, RN, BSN, OCN
MD Anderson Cancer Center
Background: Octreotide long-acting repeatable (OCT) is currently the only US Food and Drug Administration–approved therapy for symptoms associated with carcinoid syndrome (ie, diarrhea and flushing) and has been the mainstay of therapy for these symptoms in patients with neuroendocrine tumors (NET). OCT is administered monthly by gluteal intramuscular (IM) injections. However, IM injections can be inadvertently delivered subcutaneously (SC), with unknown effects on pharmacokinetics and efficacy.
Objectives: We investigated possible causes for unsuccessful injections and describe practical methods used by nurses at our institution to improve successful gluteal IM injections of OCT.
Methods: The project was conducted in 3 phases. In the retrospective baseline period, patient computed tomography (CT) scans underwent review to ascertain the ideal injection site, identify reasons for missed injections, and collect anthropomorphic data. In the awareness period, center nurses received informal communication about the project, including reasons for missed injections, but no specific training. Individual technique data were collected on 22 nurses. In the reassessment period, a skilled reference nurse demonstrated an ideal injection technique, and improvements in injection success and patient outcomes were assessed.
Results: The overall success rate improved from 52% (baseline) to 75% (reassessment period) (P <.001) after a skilled reference nurse shared a best practice method with the center nurses. Communication alone regarding injection issues led to significant improvement in overall injection success (P = .03) in the awareness period. Identification of the ideal injection site, confirmed by absence of opaque gluteal nodule on CT review, was the primary criterion for successful injection. Locating bony landmarks, specifically the posterior-superior iliac spine (PSIS) and greater trochanter, should be done first. The ideal injection site lies within 10 to 12 cm from the patient’s midline, approximately 4 to 6 cm inferior to the level of the PSIS and 7 to 9 cm above the level of the greater trochanter. Application of pressure to the injection site with the nurse’s free hand aided in placement of a successful IM injection (P <.001). Special care should be taken in females and patients with a high body mass index, because of the low rates of successful injections in these patients. Improvement in the rate of injection success was reflected in patient outcomes. The mean number of flushing episodes per day was reduced by two-thirds in patients receiving correctly placed OCT IM injections versus inadvertent delivery SC (0.22 vs 0.69; P = .005), while a trend toward improvement in the mean number of bowel movements per day (2.9 vs 3.3; P = .67) was observed.
Conclusions: Correct injection site choice and regular in-service training are pivotal for increased success of gluteal IM injections. These appear to have direct beneficial effects on symptom control in patients with NET and may have implications for other conditions in which the primary treatment is administered intramuscularly.
Treatment Patterns for Anemia Among Lung Cancer Patients Treated with Chemotherapy in 2000-2013
Hairong Xu, MD, PhD1; Langfang Xu, MSc2; John H. Page, MD, MSc, ScD1; Olivia Sattayapiwat, MSc2; Roberto Rodriguez, MD3; Chun Chao, PhD2
1Amgen Inc; 2Kaiser Permanente Southern California; 3Los Angeles Medical Center, Kaiser Permanente Southern California
Background: Anemia is a common complication of chemotherapy that can cause clinically important symptoms and reduced quality of life. It is unclear how management of chemotherapy-induced anemia (CIA) has evolved over time given the changes in US prescribing information (March 2007, July 2008), reimbursements (July 2007), and the implementation of a Risk Evaluation and Mitigation Strategy (REMS) (March 2010) for the use of erythropoiesis-stimulating agents (ESAs).
Objective: Describe treatment trends and current treatment patterns for CIA in 2000-2013.
Methods: Incident lung cancer patients (n = 1751) who developed CIA were identified from the Kaiser Permanente Southern California Health Plan. We estimated the proportions of anemia episodes with ESA use, prescription medication (ie, iron, folate, or B12), red blood cell (RBC) transfusion, and no anemia treatment in 3 calendar periods P1-P3: January 2000-December 2006 (P1), January 2007-March 2010 (P2), and March 2010-June 2013 (P3). We also estimated the hemoglobin (Hb) concentrations within 7 days preceding use of ESAs and transfusion. Differences between calendar periods were assessed for proportions treated and for Hb concentration prior to CIA treatment. Standard errors were estimated with generalized estimating equation models.
Results: The observed grade 2+ anemia episodes (Hb <10 g/dL) were 643 in P1, 257 in P2, and 262 in P3. The use of ESAs declined over time, with the proportion of grade 2+ anemia episodes treated with ESAs decreasing from 2006 to 2013 (36% in P1, 24% in P2, and 3% in P3; P <.01). This corresponded with an observed increased trend of transfusion use over time (10% in P1, 21% in P2, and 20% in P3; P <.01). The most evident increase in transfusion use was observed in grade 3-4 (Hb <8 g/dL) anemia episodes (23% in P1, 43% in P2, and 57% in P3; P <.01). A slight increased trend of use of prescription medication (ie, iron, folate, or B12) was observed over time in patients with any grade of anemia (2% in P1, 2% in P2, and 5% in P3; P = .01). The proportion of untreated grade 2+ anemia episodes increased significantly (58% in P1, 62% in P2, and 74% in P3; P <.01). We observed no significant difference in Hb levels (g/dL) at initiation of ESA use (mean [SD]: 9.5 [1.2] in P1; 9.3 [1.1] in P2; 9.1 [0.9] in P3; P = .26) or prior to transfusion use over time (mean [SD]: 8.4 [1.4] in P1; 8.3 [1.2] in P2; 8.2 [1.2] in P3; P = .66).
Conclusion: The study indicates that along with the decreased utilization of ESAs, utilization of RBC transfusion has increased significantly over time. Approximately 74% of patients with moderate-to-severe anemia (Hb <10 g/dL) remained untreated after the implementation of a REMS program for ESAs.
Development and Evolution of an Oncology Nurse Navigation Program: From Formation to Fruition
Peggy Malone, RN, BS, OCN; Lisa Bruno, RN, BSN, OCN; Beth Hayden, RN, BSN, MBA, OCN; Julie Carlson, RN, MSN, APN, AOCNS
OSF Saint Anthony Medical Center, Center for Cancer Care
Background: To better meet the holistic needs of our patients and the new program standards introduced in 2012 by the American College of Surgeons Commission on Cancer (CoC), the Center for Cancer Care at OSF Saint Anthony Medical Center clearly needed to develop a more comprehensive nurse navigation program. The concept of navigation was first introduced in 2006 with the addition of a part-time nurse navigator dedicated to the care of the breast cancer patient population. While anecdotal feedback regarding the navigation program was extremely positive, no concrete metrics were in place to measure outcomes. In addition, patients were not systematically screened, and survivorship care plans were not initiated.
Objectives: (1) Develop and implement an oncology nurse navigation program that achieves the following desired quality outcomes: improve referrals to ancillary support services, increase patient satisfaction, and ensure patients are seen by the oncologist within a week from the time of initial referral; and (2) meet CoC accreditation standards.
Methods: The existing navigation program was evaluated using the patient navigation preassessment tool and needs assessment checklist developed by the Association of Community Care Centers. A 10-step action plan was implemented to restructure the overall program, which included obtaining administrative and budgetary approval to hire 1.5 additional full-time employees (FTEs), resulting in a total of 2 FTEs for nurse navigation. The key to our success has been the use of the “care maps” based on National Comprehensive Cancer Network guidelines that were developed by a multidisciplinary team. These care maps expedite diagnostic testing, staging, and treatment for patients, but also assure integration of education, as well as supportive, palliative, and survivorship care into the patient care planning. The maps have been created and implemented for our top 4 analytic disease sites, which are breast, prostate, colon, and lung.
Results: For the first half of 2014, all new patients with a diagnosis of breast, prostate, lung, and colon cancer have been navigated–a total of 134 patients. Referrals have increased to ancillary services, including support groups, genetics, physical therapy, pulmonary rehabilitation, hospice, advanced directive services, social services, American Cancer Society, and financial services. Implementation of the oncology nurse navigation program has shown a marked increase in enrollment to the chemotherapy class offered in the department. The majority of patients are seen within 1 week of diagnosis.
Conclusions: Over the past 6 months, the navigation program at OSF Saint Anthony Medical Center has experienced tremendous growth in terms of volume and services offered to patients. Oncology nurse navigation is a valuable service that positively promotes referrals to ancillary and community services. Next steps include the following: (1) developing care maps and navigating additional disease sites, including head and neck and pancreatic cancers; (2) streamlining the survivorship care planning tool and process to ensure all patients navigated receive a survivorship care plan upon treatment completion; and (3) implementing a navigation-based patient satisfaction survey.
Aligning the Hematology Oncology Patient Navigator Program at Boston Medical Center with the Commission on Cancer Standards for 2015
Katie Finn, BA; Kathryn Ankner, BA; Mikaela Murphy, BA; Ina Petreli, BS; Robyn Souza, RN, MPH
Boston Medical Center
Boston Medical Center (BMC) is a private, not-for-profit academic medical center and the primary teaching affiliate for Boston University School of Medicine. The largest safety-net hospital in New England, BMC has approximately 73% of its patients coming from neighborhoods with the highest levels of mortality and health disparities. The hematology oncology (HemOnc) patient navigator (PN) program was developed in 2005 and now houses 5 full-time PNs to manage the multitude of barriers identified in our patient population. To remain an accredited medical center by the American College of Surgeons Commission on Cancer (CoC), we look to align our PN program with the 4 compliance criteria outlined in CoC Standard 3.1.
CoC Standard 3.1 for 2015, PN process, calls for a PN program to comply with 4 main criteria, including: (1) conducting a community needs assessment, (2) establishing navigation processes and resources for addressing barriers, (3) evaluating the PN program by the center’s cancer committee annually, and (4) modifying and enhancing the program yearly to address additional patient needs and barriers. The BMC PN program currently meets these standards through a variety of processes. These processes include measures such as reporting on and analyzing data from PN documentation, identifying additional resources uncovered by such reports, and presenting these data regularly to BMC’s Cancer Committee. Additionally, such reports demonstrated the increasing patient need, showing the number of unique patients served per month rising 3% from FY 2012 to FY 2013, as well as the number of PN contacts up 24%. Due to the continuous growth and successes of the PN program, a standardized training curriculum was established for developing the skills and knowledge required to become a fully competent PN. This became a “best practice” example, recognized by the BMC Patient Satisfaction Steering Committee in 2012. The annual community needs assessment also identified the city’s ever-growing need for assistance with transportation, despite Boston’s public transportation system, in order to access health facilities. BMC’s PN program responded to these findings, by establishing processes to address barriers, resulting in an average of approximately 160 rides scheduled per PN each month. By adhering to CoC standards, the BMC HemOnc PN program proves to be a successful, comprehensive, patient-focused program that is committed to excellence and quality improvement.
Noninfectious Pneumonitis with Mammalian Target of Rapamycin Inhibitors in Patients with Hormone Receptor–Positive, Human Epidermal Growth Factor Receptor 2–Negative Advanced Breast Cancer; Management Measures and Clinical Experiences
Nina Jinks, RN, OCN
Highlands Oncology Group
Background: Noninfectious pneumonitis (NIP) is a nonmalignant noninfectious infiltration of the lungs, a class effect of mammalian target of rapamycin (mTOR) inhibitors. Oncology nurse navigators, who are integral members of the healthcare team may find this condition among patients with breast cancer. In this analysis, NIP associated with mTOR inhibitors was evaluated from a nurse navigator perspective.
Objectives: To educate nurse navigators about NIP associated with mTOR inhibitors in patients with hormone receptor–positive (HR+), human epidermal growth factor receptor 2–negative (HER2–) advanced breast cancer. To provide information on various management techniques that can help nurse navigators in better patient management and to improve patient outcomes.
Methods: In Breast Cancer Trials of Oral Everolimus (BOLERO)-2, a phase 3 study, patients with HR+, HER2– advanced breast cancer, who recurred or progressed on previous letrozole and anastrozole, were randomized 2:1 to receive everolimus + exemestane or placebo + exemestane. NIP was reported among these patients, and this analysis will highlight the clinical data from BOLERO-2 and the measures used in the management of patients with NIP associated with everolimus. Best practices and additional experiences from a single clinical center will also be presented.
Results: In BOLERO-2, all-grade NIP was reported in 16% of patients in the everolimus arm, and most of the events were grade 1/2. Grade 3 NIP was observed in 3% of patients. No grade 4 events were observed. Among patients with grade 3 NIP and related events in the everolimus arm, 80% had improvement to grade ?1 within a median duration of 3.8 weeks. Patients should be evaluated for pulmonary history prior to initiation of everolimus therapy, educating them about the potential risk of NIP, and guiding them to approach nurse navigators if they have sudden cough or dyspnea or worsening of baseline symptoms. It is also important to rule out infection as the cause of symptoms. Grade 1 events (asymptomatic, with only radiologic changes) do not necessitate treatment discontinuation; however, patients have to be monitored closely for development of clinical symptoms. In patients with mild-to-moderate symptoms, treatment interruption until resolution of symptoms is a management option, and for management of respiratory distress, treatment with antibiotics and corticosteroids should be considered. Dose reductions and discontinuation of therapy may be necessary.
Conclusions: Evaluation of radiographic changes and clinical symptoms, early recognition, and early intervention are the important measures for proper management of NIP associated with mTOR inhibitors. Oncology nurse navigators must carefully monitor patients with NIP, as the symptoms are nonspecific in nature and can result in potentially serious consequences.
Developing a No-Cost, High-Impact Oncology Navigation Database
Anna Liza Rodriguez, MHA, MSN, RN, OCN; Stella Estrella, BSN, RN, OCN; Roxana Iacob, MSW; Tammy Kalinowski, RT (R)(M)
Presence Resurrection Medical Center
Background: Patient navigation is an integral component of a quality oncology program. While literature support the value of navigators in improving key metrics, such as timeliness and access to care, patient satisfaction, and coordination of care, oncology program administrators are challenged to demonstrate measurable navigation productivity and quality indicators to assess navigator full-time equivalent return on investment.
The current tracking system for Presence Resurrection Medical Center (PRMC) nurse navigation was an Excel document with multiple tabs. The spreadsheet was cumbersome to use; therefore, documentation of encounters was not entered consistently.
The oncology program director created a navigation database in Microsoft Office Access, which was further refined with input from the nurse navigator, breast navigator, and social worker. The new oncology navigation database was designed to enable the navigators to document in real time all navigation activities, including patient and family encounters.
Objective: Develop a no-cost oncology navigation tool for tracking operational and quality indicators.
Methods: The navigation team determined what indicators were relevant to track, and developed a password-protected Oncology Navigation Access database. The following access data forms were created that simplified the data entry during each encounter: intake, needs assessment, encounter, and outmigration/retention. Access reports were also created for ease of generating real-time productivity reports, including time spent, volume per navigator, new cancer patients navigated, number of encounters, referral sources, and tumor sites. Program indicator reports included reason for referral, barriers/concerns, and interventions, among others. The database was set up to group encounters by patient so that the navigator team could easily view all activities for each patient. The database is saved in a shared drive, allowing navigators to access the tool from various locations.
Results: The homegrown database simplified tracking of various navigation indicators. The number of encounters documented since database implementation significantly increased from a baseline of 61 documented encounters in 2012 to 1308 in calendar year 2013 and 771 year to date in 2014. The Access report functionality allowed quick generation of date- and time-stamped reports for cancer committee or department meetings. The database also has the capability to run customized patient-specific reports that can be scanned into the electronic health record.
Conclusion: Oncology program administrators can develop a no-cost patient navigation tool that can effectively track navigation outcomes and productivity without significant software investment. The PRMC homegrown navigator database validates navigator productivity.
Coordinating Care and Cutting Costs: Utilizing Navigation to Provide Pegfilgrastim and Rituximab Closer to Home
Chelsea Passwater, RN, BSN, OCN; Judy Koutlas, RN, MS, OCN; Evelina Kolychev, PharmD, BCOP; Andrea Faison, PharmD, BCPS; Janet Reimer, RN, BSN, OCN; Debra Mascarenhas, RN, BSN, CBCN; Teresa Parent, RN, BSN, OCN; Phyllis DeAntonio, RN, MSN, FAAMA
Vidant Medical Center
Background: Vidant Medical Center (VMC), the flagship hospital for Vidant Health System, serves approximately 1.4 million patients in 29 counties of eastern North Carolina. Oncology patients often live far distances from VMC, creating barriers to care. Transportation issues and inability to commute have caused prolonged hospital stays for administration of agents such as pegfilgrastim and rituximab. In January 2014, the nurse navigation program was restructured to enhance timely cancer care across the continuum, removing barriers, and reducing costs.
Objectives: (1) Describe the navigation process utilized to arrange medication administration in the home or at a facility closer to home, and (2) quantify the cost-savings of administering pegfilgrastim and rituximab in the outpatient versus inpatient setting.
Methods: Nurse navigators collaborated with pharmacists and regional providers to determine an optimal location for medication administration. Safety concerns and medication costs were considered. Navigation data from January 1, 2014, to May 31, 2014, were utilized to identify patient encounters involving services closer to home collected by 3 nurse navigators. Encounters were specific to the administration of pegfilgrastim or rituximab. Drug cost-saving data from the first 5 months of 2013 and 2014 were compared utilizing medication administration records. Specifically, location of service (inpatient vs outpatient) and associated drug costs utilizing average wholesale price were examined. Data collected included length of stay defined as 1 night’s stay per dose, number of doses administered, and overall estimated cost-savings.
Results: Fifty encounters were identified; 48 patients received pegfilgrastim in the outpatient setting at VMC, regional facility, or at home. This corresponded to an approximate total savings of $204,370. Similarly, 2 patients received rituximab, which corresponded to an approximate total savings of $9605. In 2013, 3.46% ($46,835) of all pegfilgrastim administrations at VMC were done in the inpatient setting; in 2014, it was 2.75% ($29,803). In 2013, 12.54% ($84,389) of all rituximab administrations for hematologic malignancies at VMC were done in the inpatient setting; in 2014, it was 6.62% ($39,107). In addition, 32 overnight inpatient stays were prevented, corresponding to an estimated savings of $67,136.
Conclusions: When comparing 2013 with 2014, a 0.71% decrease in inpatient administration of pegfilgrastim and a 5.92% decrease in inpatient administration of rituximab were found. There was an estimated total cost-savings of $281,111 within the 5-month study period. This confirms that utilizing navigation to coordinate care closer to home has a positive financial impact on the healthcare system. Future areas of study include examining patient satisfaction and adherence to plan of care as it relates to coordination of care by cancer care navigators.
Teamwork; Implementing a Chemotherapy Checklist to Improve Efficiency, Safety, and Adherence for Patients Receiving Oral Chemotherapy
Elizabeth Sunderland, RNBC, BSN, OCN; Carolyn Fansler, RN, BSN
Background: The face of chemotherapy administration has changed dramatically over the past decade. Oral chemotherapy is becoming a more popular option for patients facing cancer treatment. The number of oral chemotherapy agents and their usage has shed light on unique challenges. Many hurdles are associated with prescribing, dispensing, reimbursement, adherence, safety, and education. In our practice, we were noticing gaps in care. Physicians were not sharing who they started on oral chemotherapy agents; therefore, patients were not properly educated, resulting in an influx of poorly managed side effects. Patients were also unsure how to obtain their drug, creating disjointed interdisciplinary involvement.
Objectives: Our primary objective was to improve patient care by updating standards and guidelines for our practice based on the updated 2013 American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS) guidelines on the usage of oral chemotherapeutics. Second, we wanted to streamline the process and create a user-friendly flow for both the patient and the practice.
Methods: We created an interdisciplinary task force consisting of physicians, clinical nurse coordinator, nurse navigator, pharmacist, administrative assistant, and social worker. We reviewed the 2013 ASCO/ONS guidelines on the usage of oral chemotherapeutics with our present practice, realizing success would require a team effort. Each practitioner defined their roles/responsibilities in the confusing paradigm of oral chemotherapy usage.
Results: Our end result was the creation of an oral chemotherapy checklist that is initiated when a patient is prescribed an oral chemotherapy agent. The list serves as a pathway from initial screening, informed consent, written prescription, order verification, precertification, insurance authorization, education on patient copay, dispensing, drug interaction screening, patient/family education, start date, labs, follow-up, and phone calls. Each practitioner signs off when they have completed their task/responsibilities so all team members know where the patient is in the process of initiating treatment. This checklist has improved care 2-fold: improved communication among the team serving the patient, and improved efficiency, safety, and adherence for patients taking oral chemotherapy.
Conclusion: Although taking an oral chemotherapy agent may sound more appealing to patients, understanding the process of obtaining the drug, paying for it, and appropriately taking and reporting side effects is an overwhelming scenario. Initiating treatment requires the assistance of the entire multidisciplinary team.
Navigation: Patient Experience, Clinical Outcomes, and Business Performance
Tricia Strusowski, MS, RN
Oncology Solutions, LLC
Background: Over the years, the role of the navigator has become an essential component for cancer programs. As navigators were hired, the need for evidence-based tools and guidelines became a high priority. Navigation programs need to demonstrate strong metrics in regard to patient experience, clinical outcomes, and business performance.
- To provide assessment tools for implementing a strong navigation program that is Commission on Cancer (CoC)-compliant and focused on patient- and family-centered care
- To identify program success metrics for patient experience, clinical outcomes, and business performance
A quality navigation program must be created and modified to meet the patient population needs, which are identified through completion of a thorough community needs assessment. A part of the CoC Standards for 2015, the assessment aids in understanding the patients’ specific needs and barriers to care in the community. This creates a strong foundation for the navigation program across the entire continuum of care since the role of the navigator is to assess the patients’ and families’ understanding of their diagnosis and treatment, identify and remove barriers to care, provide psychosocial screening, and coordinate support staff and resources.
The navigation matrix, created by the National Comprehensive Cancer Center (NCCN) Program Navigation Networking Committee, is a tool that helps with evaluating all the components of the program. Every navigation program is unique, and the role of the matrix is not to gauge one program against another but to provide guidance to create a strong program. The matrix categorizes 16 elements with ranking levels 1 through 5, including key stakeholders, quality measures, clinical trials, etc.
As the navigation program is built, patient experience, clinical outcomes, and business performance should be a priority. This will ensure the patient is always at the forefront, and high-quality clinical standards will help ensure financial strength.
In a recent survey, an Institute of Medicine (IOM) report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis”, revealed that the number one response from cancer patients was “listen to me.” Patients want to participate in the decision-planning sessions with their healthcare team. To ensure a superb patient experience, some tools and measures to utilize are:
- Measurement of outcomes/interventions related to barriers to care and distress screening
- Patient experience survey
- Patient education packets for surgery
- Survival toolkits for families
Method: The poster abstract will provide sample tools and metrics to ensure CoC compliance and address concerns documented in the IOM report.
Measuring clinical outcomes elevates the standard of oncology care. Every navigation program needs to incorporate research and quality measures into its foundation. Some examples are:
- Clinical care in accordance with NCCN or other national guidelines
- Survivorship surveillance plan compliance/monitoring
- Creation of standing order sets by cancer disease site for multidisciplinary teams
Strong business performance is very important for maintaining a navigation program. Navigation programs can be very expensive and return on investment is critical. Some financial outcomes to measure include:
- Decrease in emergency room visits and readmissions
- Medication reconciliation program
- Patient retention rates/decrease outmigration
Conclusion: Successful navigation programs demand solid metrics that are patient-centered and evidence-based. Patient experience and outcomes are imperative for a state-of-the-art cancer program. This presentation will provide ideas and examples that will further enhance your navigation program. Tools and metrics will be shared at the Academy of Oncology Nurse & Patient Navigators Conference.
Prehabilitation Improves the Physical Functioning of a Newly Diagnosed Lung Cancer Patient Before and After Surgery to Allow for a Safe Surgical Resection and Decreased Hospital Length of Stay: A Case Report
Elizabeth Hunt, RN, MSN, CRRN, CCM; Kristen VanderWijst, PT; Bobbi Stokes, PTA; Regina Kenner, RN; Kathryn Duval, MS, CCC-SLP; Messina Corder, RN, BSN, MBA
Mary Washington Healthcare
Background: Patients diagnosed with cancer often present with decreased functional status because of age, deconditioning, and comorbidities—all factors that may influence surgical intervention as a potential treatment option. The Survivorship Training and Rehabilitation (STAR) Program team, which includes nurse navigators at Mary Washington Healthcare, piloted a prehabilitation program for patients with lung cancer to evaluate readiness for surgery through improved physical and emotional well-being. Objective: This case study reports on the impact of a cancer prehabilitation program that included physical therapy and nurse navigator interventions in an effort to improve patient readiness for lung cancer surgery.
Methods: MS is a 75-year-old woman diagnosed with stage IA lung cancer with comorbidities of osteoarthritis and chronic knee and back pain. Her initial symptoms included dyspnea at rest and with exertion, limited functional mobility, and severe deconditioning. The thoracic surgeon referred her to the STAR Program for prehabilitation in an effort to decrease surgical risk. The physical therapist utilized evidence-based practices to improve the patient’s mobility, endurance, and strength. MS was also screened for distress and referred to the nurse navigator program, where an assessment identified and interventions reduced distress triggers and barriers to care.
Results: Three weeks after the initial diagnosis, MS underwent bronchoscopy for staging and started prehabilitation 5 days later. Prehabilitation lasted 6 weeks, and she underwent lung resection and then had 6 weeks of physical therapy followed by transition to a community-based exercise program at the YMCA. Functional outcomes included a 6-Minute Walk Test baseline (992 feet), after prehabilitation (1120 feet; 13% improvement) and after surgery/rehabilitation (1130 feet; 14% improvement); Timed Up and Go baseline (13 seconds) and after surgery/rehabilitation (8 seconds; 38% improvement); and, the Movement Assessment Log (53% decrease in impairment). MS no longer experienced dyspnea at rest or on exertion. The navigator was instrumental in providing emotional support, education, and guidance on treatment decisions. MS had a shortened postoperative stay of 3 days versus the usual 4 to 5 days and a successful discharge to home.
Conclusions: This case study demonstrated the following results regarding prehabilitation: (1) improved the patient’s health above baseline status at diagnosis; (2) decreased surgical risk; (3) decreased hospital length of stay; and (4) combined with rehabilitation after surgery, the patient’s overall health and functional status was better than it was at diagnosis. The STAR Program staff at Mary Washington Healthcare decided to implement a permanent protocol with physical therapy and nurse navigation specifically for patients with lung cancer. The team is working with the thoracic surgeon to identify appropriate patients and plans to further evaluate the impact on surgical readiness and postsurgical function.
Assessing Cancer Patient Supportive Needs Through Dual Screening for Physical and Emotional Problems
Elizabeth Hunt, RN, MSN, CRRN, CCM; Regina Kenner, RN; Kathryn Duval, MS, CCC-SLP; Messina Corder, RN, BSN, MBA
Mary Washington Healthcare
Background: Cancer and its accompanying treatments can cause significant physical and emotional side effects that impact quality of life for many patients. The ability to screen patients at key intervals at any stage of treatment may identify physical and/or emotional factors with an opportunity to intervene and improve outcomes. A key component to early identification is not only completing an appropriate distress screen but also a physical screening focused on impairments and function. This is called “dual screening” and is recommended by the Survivorship Training and Rehabilitation (STAR) Program.
Objective: To evaluate cancer patient functional and support needs through a dual screening process.
Methods: As part of the STAR Program, the outpatient cancer care team implemented the STAR Program Physical Impairment and Functional Assessment Screening Tool–Diagnostic Use: Survivor General modified to include questions from the Distress Thermometer to screen for both physical problems and emotional distress. Patients were screened over 4 months during their treatment visit at outpatient infusion or radiation therapy. The screening questionnaire was divided into sections with yes/no questions regarding nutrition, emotional and psychosocial issues, and functional issues. Any section that had trigger questions answered “yes” or had any 2 questions answered “yes,” generated a discussion with the patient regarding available services. The patient did not necessarily receive an automatic consult to the service unless an obvious immediate intervention was needed.
Results: The goal was to screen 40 patients. Over the 4-month period, 77 patients were screened. A total of 59% of the patients had a diagnosis of breast, lung, or prostate cancer. The STAR Program team found that more than 60% of patients met the criteria for a physical therapy consult, 50% for occupational therapy, and close to 30% for speech language pathology. In addition, nearly 10% of patients met the criteria for a nurse navigator consult and 17% for nutrition. Actual consults to these services were not consistent with what the need showed—there was a demonstrable gap in care. Of the 77 screenings, 12% of patients followed through with the suggested consults for physical therapy, speech language pathology, and/or navigator services.
Conclusions: The STAR Program team identified a significant need for supportive services that continued beyond the screening process, suggesting that screening alone is not sufficient for patients to receive necessary services. Realizing that a more proactive approach was needed, the team modified the STAR Program Referral/Physician Order Form to integrate with the dual screening tools. This change in the screening process is now being measured to determine whether patients will be better able to access care.
Supporting Evidence-Based Practice in Nurse Navigation
Sharon Gentry, RN, MSN, AOCN, CBCN; Laurie Mathis, RN, OCN, CBCN; Jamie Calcutt-Flaherty, RN, CBEC
Novant Health Derrick L. Davis Cancer Center
Background: Original research from 2011 demonstrated that a positive experience with a breast nurse navigator decreased outmigration from the healthcare system. The annual revenue attributed to this decrease covered the costs of the navigation program.1 Despite the gain of patients, an average of 30 to 45 patients with breast cancer were leaving our program annually.
Desimini and colleagues showed that placement of a nurse navigator early in the breast care continuum decreased outmigration after 1 year from 240 patients per year to 28, fully covering the additional salary cost.2 Similarly, Balderson and Safavi reported that patient navigation generated enough revenue in 3.5 months to cover 2 full-time navigators, and each navigator added $150,000 in hospital revenue.3
Objectives: The purpose of this project was to decrease breast cancer patient outmigration through a redesigned breast nurse navigation process. A secondary objective was to promote clinical trial participation.
Methods: In an effort to strategically align breast nurse navigation upstream in the patient experience, the critical element of diagnosis disclosure was moved from the primary care physician to the radiologist at the breast imaging center. An additional breast nurse navigator was placed in the imaging center who took on the responsibility of following up with all biopsied diagnostic breast patients within 72 hours. All negative biopsies were called with their results, except for those with benign pathology that would need further surgical follow-up. The benign patients needing further treatment and all positive biopsy patients remained on the schedule to be seen at the imaging center for their diagnosis. The radiologist shared the diagnosis, and the nurse navigator provided education on breast cancer type, prognostics, and next steps.
Results: In 2012, 45 patients with breast cancer left the system for various reasons despite the presence of breast navigators. After the systemic change of placing a breast nurse navigator further upstream in the care process, only 25 patients left the system in 2013. This was a drop from an outmigration rate of 6.31% to 3.97%, which equaled a 63% decrease in patients leaving the system for care. In comparison with cost-savings from the original study in 2011, this further decrease brought in $272,500 of revenue to the healthcare system. Interestingly, the influence of this change in navigation contact was seen within 6 months since the outmigration rate fell to 3.97% at that time and remained consistent throughout the year.
The secondary objective to promote clinical trial participation was also successful. Each stage III patient (excluding inflammatory patients) was screened for consideration of neoadjuvant chemotherapy. Within 1 year of the new breast navigation process, there was a 20.4% increase of eligible patients who had a neoadjuvant consult prior to surgery. Several studies in the current literature promote this role for nurse navigators to increase clinical trial involvement.4,5 The nurse navigator is the key to a trusting relationship of care, which allows the introduction of a clinical trial at an earlier stage in the care continuum.
Conclusions: Nurse navigation can decrease patient outmigration in the breast care setting and provide revenue to support the position. Nurse navigation can have a role in patients’ awareness of availability of clinical trials and positively influence clinical trial participation.
1. Advisory Board Company. Document revenues for returned patients. “Realizing the Promise of Navigation.” Nursing Executive Center (2011): Pages 38-39.
2. Desimini EM, Kennedy JA, Helsley MF, et al. Making the case for nurse navigators. Oncol Issues. 2011;September/October:26-33.
3. Balderson D, Safavi K. How patient navigation can cut costs and save lives. HBR Blog Network. http://blogs.hbr.org/2013/03/how-patient-navigation-brings/. Accessed June 18, 2014.
4. Gonzalez M, Berger M, Bryant D, et al. Using a minority matrix and patient navigation to improve accrual to clinical trials. Oncol Issues. 2011;March/April:59-60.
5. Holmes DR, Majo J, Lyonga DE, et al. Increasing minority patient participation in cancer clinical trials using oncology nurse navigation. Am J Surg. 2012;203:415-422.
Navigator Role in Clinical Trial Education and Accrual: Fox Chase Cancer Center Partner Initiative
Elaine Sein, RN, BSN, OCN, CBCN; Kelly Filchner, MSN, RN, OCN, CCRC
Fox Chase Cancer Center Partners
Background: The navigation process has opened a unique opportunity to enhance clinical trial recruitment practices. Navigators, who are often the first point of contact of the patient’s entry into a health system, have the ability to introduce basic clinical trial concepts to the patient so that the patient can explore this option within his or her care trajectory. Navigators are from various practice backgrounds and possess different levels of knowledge and attitudes regarding clinical trials. The goal of this project was to investigate reasons for variation in care and to develop strategies to implement change.
Objectives: Evaluate the knowledge base and comfort level of nurse navigators in discussing clinical trials with their patients.
Methods: The Fox Chase Cancer Center Partner Initiative (FCCCP) navigator and research nurse subcommittee created a knowledge-based survey of clinical research concepts and used a short attitude survey adopted from “ENACCT Oncology Staff in Cancer Clinical Trials Survey 2008” to assess knowledge base, comfort levels, and attitudes in clinical trials. This survey was distributed to FCCCP navigators and was extended to the Academy of Oncology Nurse & Patient Navigators (AONN+) membership through SurveyMonkey mechanism.
Results: A total of 159 navigators participated in the survey: 40% practice in academic institutions, 60% in nonacademic institutions. A total of 100% FCCCP and 85% AONN+ institutions participated in clinical research and 57% FCCCP and 78% AONN+ navigators discussed clinical research with their patients. A total of 78% of navigators strongly believed cancer clinical trials are important in finding better ways to prevent, diagnose, or treat cancer; 67% strongly agreed if someone they loved were diagnosed with cancer, they would encourage him/her to find out more about participating in an appropriate clinical trial. Sixty percent of navigators were comfortable or extremely comfortable with most of the knowledge questions: awareness of clinical trials, phases of clinical trials, therapeutic versus nontherapeutic trials, common research terms, eligibility criteria, informed consent, educational tools available, current collaboration with the research team, and ability to identify appropriate patients for a trial. However, responses related to when they introduce clinical trials to patients and how the navigator interacts with the research team varied greatly across the sites.
Conclusion: There was strong interest from navigators to find methods to collaborate with the research team. Strategies were developed to bring navigators and research teams together to determine roles in the clinical trial process and identify strategies to educate navigators on key focus areas. Targeted educational programs and tools to support navigator information regarding clinical trials will be instituted, and metrics to track success and barriers will be established.
Identifying Newly Diagnosed Cancer Patients Through a Call Center Process Improvement
Patricia Hegedus, RN, OCN, MBA; Sharon Bartelt, RN, MSN, MBA, CPHQ, CSSBB, OCN; Kirsten Beeker, RN, BSN, OCN, CBCN
Gibbs Cancer Center & Research Institute
Background: Spartanburg Regional Healthcare System (SRHS)’s Gibbs Cancer Center & Research I