Background: To maximize the impact of breast cancer patient navigation at The George Washington University (GW) Cancer Institute, this project mapped the patient experience across the cancer continuum to identify how and where navigators could contribute to improving the quality of cancer care.
Methods: The experience of patients with breast cancer was documented while they were undergoing cancer screening, diagnosis, and treatment. The patient navigation team mapped patients’ experiences using a process created and described by The Advisory Board Company. The Advisory Board Company developed the process by identifying best practices through interviews with its members.
Results: The maps generated discussion about how system fragmentation and gaps in care affect patient care; they also generated discussion regarding potential ways that navigators can help patients on their journey through the complex cancer continuum and improve the overall patient experience. The navigation team worked together to identify feasible quality improvement projects to meet patient needs identified in the mapping process.
Conclusions: Patient experience maps can be used to develop targeted quality improvement strategies for patient navigation programs. Process maps can identify system issues, variations across departments, and gaps in services, and foster communication between clinics regarding opportunities to improve services. For the GW Cancer Institute’s navigation team, mapping the patient’s process along the cancer care continuum helped prioritize quality improvement projects, illustrated how navigators can contribute to quality improvement, and ensured navigators were focused on core navigation duties.
The George Washington University (GW) Cancer Institute, in partnership with the GW Medical Faculty Associates and the GW Hospital, has established a comprehensive patient navigation service over the past 7 years to assist patients throughout the breast cancer continuum. In 2013, the institute’s navigation team—3 nonclinically licensed patient navigators, 2 nurse navigators, a cancer center social worker, and a navigation supervisor—mapped the treatment flow of patients with breast cancer. The objectives were to document gaps in the system as well as identify and implement quality improvement (QI) projects that would optimize patient care.
A navigation supervisor began this process by researching approaches to process mapping. Process mapping is described by The Advisory Board Company,1 the Midland Region Cancer Control Project,2 and Shockney.3 The Midland Region Cancer Control Project utilizes a process mapping methodology developed by the Cancer Services Collaborative Improvement Partnership, which is a National Health Service program that makes improvements to cancer care. Its methodology was comprehensive, but the process was more rigorous than resources allowed. For example, the Midland District Health Boards included epidemiologic data, patient feedback, and input from 130 staff members.2 Shockney’s patient flow resource was discovered after the mapping project was finalized. The Advisory Board Company’s method was chosen for its ease of implementation by a small team that was focused on identifying concrete QIs within a 6-month period. All approaches were valued for being iterative and inclusive.
Key steps in the patient experience mapping project included the following: (1) determining the approach, (2) forming a team, (3) establishing realistic goals, (4) drafting patient experience maps, and (5) refining the maps through broader stakeholder engagement.
Determining the Approach
The Advisory Board Company’s process suggested diagramming each step in the patient experience. The GW Cancer Institute found that this allowed its navigators to discuss operational issues and opportunities for improvement in a nonthreatening manner. The process involved an examination of the separate steps in the cancer care continuum from referral for an abnormal finding to completion of treatment and discharge from cancer care. Information about the patient’s care was documented by focusing on what happened to the patient, including communication, administrative, and diagnostic processes throughout his or her cancer episode.
Forming a Team
The navigation supervisor took the lead to ensure the mapping project was initiated, QI projects were implemented, and QI progress was measured. She engaged the previously mentioned core team of 3 nonclinically licensed patient navigators (patient navigators), 2 nurse navigators (nurse navigators), and a social worker. Together, this group was referred to as “navigators” or collectively as “the navigation team.” This navigation team documented typical patient experiences and identified performance improvement goals by describing the ideal patient experience. These findings were shared with breast care nurses and physicians to verify perceptions.
Establishing Realistic Goals
The main goal of the project was to maximize the impact of the navigation team by identifying patient needs, care coordination gaps, and system fragmentation that the navigators could feasibly address. The navigation supervisor selected process improvements over which the navigators had control to help demonstrate their impact. A key to success was to ensure goals were specific and achievable. A main challenge throughout the course of this project was remaining focused, as the maps detailed a highly complex series of appointments, staff interactions, departments, and services needed for breast cancer care, including referrals to outside organizations. The process maps provided an opportunity to show that the navigator’s role is critical in coordinating cancer care and highlighted how navigators can lessen fragmentation for patients. A primary goal was to coordinate a seamless cancer experience for each cancer patient.
Drafting the Patient Experience Maps
First, the navigators diagrammed the patient flow for each clinical area, including breast imaging, breast surgery, hematology/oncology, radiation oncology, and the survivorship clinic. Multiple drafts of the diagrams were discussed as a team, and opportunities were identified to best utilize each navigator and avoid duplicating work. Many different drafts were shared with staff members until they agreed that the charts accurately represented the actual process for a patient with breast cancer. The team examined when and how referrals are made to the navigators, the ideal time for referral to the Thriving After Cancer survivorship clinic, and the best process to assess barriers to care and screen for distress. Themes emerged such as capacity limits of clinics and staff, lack of awareness of available psychosocial support for patients and families, risk of breakdown in communication, and an overall lack of care coordination. The identification of these themes served as a starting point for discussing solutions.
The navigation team refined the maps through a consensus-based process until the flow for a patient with breast cancer was completely diagrammed. QI initiatives were prioritized based on feasibility of the navigation team to address the identified gaps. Final drafts of the flowcharts were standardized and abbreviations eliminated to ensure comprehension across departments.
Refining the Maps Through Broader Stakeholder Engagement
A broader group of stakeholders were engaged to validate project findings and ensure support for resulting QI initiatives. These stakeholders included nurses, physicians, and radiology staff. The GW Cancer Institute focused on the Breast Imaging & Intervention Center initially, as its patient navigator was being asked by multiple team members to assist with administrative tasks, distracting her from focused navigation for patients. The maps were a useful discussion point with the Breast Imaging & Intervention Center team because they highlighted patients’ needs and how the patient navigator and nurse navigator could meet these needs. The GW Cancer Institute continues to use the maps to strengthen relationships with clinical staff. The maps also promote the services that navigators can provide to support care coordination and raise awareness for critical psychosocial care, including survivorship and rehabilitation services.
The patient experience maps demonstrate the complexity of treatment for a patient and highlighted the need for navigation support. Cancer care is delivered in a variety of settings and involves many services from imaging through treatment and rehabilitation. Cancer treatment often includes surgery, chemotherapy, and radiation. The flowchart, as shown in the Figure, provides a detailed depiction of the experience a patient with breast cancer has in just 1 clinical area. Similar maps were created for additional clinical areas, including hematology/oncology, radiation oncology, breast surgery, and the survivorship clinic. As shown in the Figure, 1 patient navigator and 1 nurse navigator work together in the Breast Imaging & Intervention Center.
During our process, several key issues and themes emerged, including the following:
- There is a strong risk of breakdown in communication and coordination across the care continuum
- Patients must take several steps to implement their transitions through screening, diagnosis, multiple modes of treatment, and posttreatment survivorship. Adding to this complexity, these steps are usually over a long period of time with several “handoffs” between services
- Handoffs during patient transition points were highlighted as critical points where navigators could support the medical team to ensure patient follow-up.
The project resulted in QI initiatives for each member of the navigation team. See the Table for a breakdown of gaps in the care continuum and resulting improvement initiatives for each clinical area mapped. The QIs identified in the Table improved handoffs between navigators across clinical departments and ensured more timely access to follow-up care. Another significant result of the project was documentation, approval, and implementation of a distress screening policy to ensure earlier psychosocial support services. This process has been identified as a best practice.4
To date, the following progress has been made within the Breast Imaging & Intervention Center:
- Improved tracking of women called for follow-up after a screening mammogram, reducing loss to follow-up
- Development of a telephone-based navigation assessment tool
- Development and delivery of an educational presentation that identifies referral codes for screening mammogram, diagnostic mammogram, core needle biopsy, fine needle aspiration, and stereotactic biopsy, along with an explanation of the different indications for these procedures to reduce common referral mistakes from federally qualified health centers
- Strengthening of relationships in the community to fast-track services for at-risk women
- Reduced wait times for patients who require additional testing.
Mapping the patient experience across clinical departments can help to identify gaps in care and prioritize QI strategies. While this process improvement project was resource intensive for staff, it laid the groundwork for continuous QI. Sustained efforts are critical to ensure improvements are made in cancer care. The process proved to be effective in engaging staff across clinical departments while minimizing resistance. Opportunities for QI were often complicated and, therefore, not easy to address. Further, capturing data to measure QIs can be challenging in a busy clinic, but evaluation is critical to show impact.
The GW Cancer Institute mapping project focused on how patient navigators and nurse navigators could meaningfully contribute to QIs to better the patient experience. The project resulted in adjustments to navigator duties to ensure navigators were focused on addressing the gaps that most impacted timely, patient-centered care. A systematic distress screening policy was documented and implemented in partnership with the hematology/oncology social worker. Finally, the survivorship clinic received increased referrals as a result of this process. The GW Cancer Institute will periodically revisit the mapping process to initiate new QI projects.
Strengths of this approach are flexibility to respond to the unique needs of patients in a particular clinic or health system and the capacity to adapt as patient and system needs change.
Acknowledgments: Navigators Monica Dreyer, MA; Eva Ruiz, BS; Diana Garcia, BS; Elizabeth Hatcher, RN, BSN; and Leshia Hansen, RN, BSN, MPH, contributed to the mapping project.
Source of Funding: This project was directly supported by the Avon Foundation for Women. Support for the GW Cancer Institute’s navigation program is provided by the Avon Foundation for Women, the Susan G. Komen Foundation, the American Cancer Society, and operational funds.
Author Disclosure Statement: Ms Kapp does not have any disclosures to report. Ms Pratt-Chapman reports being a grant recipient of Genentech and Amgen and an advisor to Pfizer; she indicates that the companies did not fund any aspect of the manuscript or activities described within it.
- The Advisory Board Company. Oncology Roundtable Interviews and Analysis. Patient experience mapping tool. 2011.
- Hewitt J, Scanlan L; Midland District Health Boards. Midland Region Cancer Control Project: Patient Mapping Project. www.midlandcancernetwork.org.nz/file/fileid/12557. Accessed February 6, 2015.
- Shockney LD. Becoming a Breast Cancer Nurse Navigator. Sudbury, MA: Jones and Bartlett Publishers; 2011.
- Pratt-Chapman M, Kapp H, Willis A, Bires J. Catalyzing patient-centered care: start where you are and share what you know. Oncology Issues. January/February 2014:30-39.