At the Academy of Oncology Nurse & Patient Navigators (AONN+) Annual Meeting in November 2016, the AONN+ Standardized Navigation Metrics Task Force unveiled the first standardized navigation metrics for measuring patient experience, clinical outcomes, and return on investment (ROI). According to Tricia Strusowski, MS, RN, Manager at Oncology Solutions, Inc, navigators were excited about the prospect of the 35 new metrics but unsure about how to implement them. So, at the AONN+ West Coast Regional Meeting, Ms Strusowski and Cheryl Bellomo, MSN, RN, OCN, ONN-CG, delved deeper into the metrics and provided tools to employ in their implementation.
“The Answer Is Metrics”
Over the past decade, great strides have been made in navigation. Myriad programs have been developed, program efficacy has been improved within institutions, and the collective vision has been expanded. Progress has been made in role delineation and through the development of competencies and certification exams designed specifically for patient and nurse navigators. Literature reviews demonstrate that navigation improves patient satisfaction, decreases barriers to care, increases timely access to care, improves continuity of care and symptom management, and provides emotional support and patient empowerment.
But until the introduction of the AONN+ standardized metrics, the role of the navigator in the cancer care continuum had not been validated, and programmatic success had not been accurately measured. “When asked how we demonstrate the value of navigation in our institutions, no matter the size of the institution, our role along the care continuum, or the tumor type, the answer is ‘metrics,’” said Ms Bellomo, oncology nurse navigator at Intermountain Southwest Cancer Center.
The navigation metrics, based on the 8 AONN+ domains for certification (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/Health Economics, and Research/Quality/Performance Improvement), measure the impact of the navigator from prevention through treatment and end of life. “The earlier navigators get involved in the continuum, the more outmigration is decreased and patient retention is increased,” added Ms Strusowski.
Patient Experience, Clinical Outcomes, and ROI
“On a daily basis, patients and their families tell us about the impact we’ve had. They give us cards and gifts that touch the heart and are meaningful, but we can only communicate the efficacy of what we’re doing through data and metrics,” explained Ms Bellomo. Metrics are used to accurately measure performance and evaluate the success of the navigator role in cancer programs. They improve the care of patients by monitoring and measuring outcomes and are necessary to sustain the role of the navigator. Metrics for evaluating navigation programs should include measures that assess reductions in barriers to care as well as improvements in the delivery of timely, effective, and equitable cancer services.
The “patient experience” is increasingly emerging as a more enhanced method for measuring navigation success. The 2013 Consumer Assessment of Healthcare Providers and Systems (CAHPS) cancer survey identified that patients’ expectations were exceeded when they felt that their healthcare provider actively listened and incorporated their personal psychosocial goals into the treatment plan. “We have to remember that this whole process is about them, not us,” said Ms Bellomo. “We have to make sure we understand where they’re coming from, and what they know, don’t know, and wish to know.”
Ms Strusowski added that the CAHPS survey led them to ask questions of patients very differently. “In regard to research metrics, we got a lot of information from the CAHPS survey,” she said. “We began to ask patients, for the first time, whether or not they felt like a real part of the discussions with their physicians and healthcare team.”
In the realm of clinical outcomes, Ms Bellomo suggested using metrics that are already being addressed, such as distress screening, treatment adherence, and timeliness of care. “We as navigators can have an impact on clinical outcomes,” she said. “We just need to choose the appropriate metrics.”
ROI ensures the financial strength of a program, but this area of business performance metrics tends to make navigators feel out of their comfort zone, she noted. However, ROI is becoming increasingly important to the administrators of cancer programs, underlining the need for navigators to become more business savvy. “Now we have our own budgets and departments,” said Ms Strusowski. “We have to be able to show we can maintain them.” Five major goals that support ROI for a navigation program include removing barriers, promoting treatment adherence, enhancing revenue, decreasing preventable emergency department (ED) visits, and decreasing hospital readmissions. “When patients are in the ED with vomiting, diarrhea, or constipation, that’s all preventable and is a huge opportunity for ROI,” she added.
Why Do We Need Standardized Metrics?
According to Ms Bellomo, navigation programs should utilize the same metrics regardless of the model of navigation, and programs should remain relevant to what is occurring in value-based cancer care programs. Metrics should be defined in a uniform manner, using national guidelines and evidence-based quality sources. “This is what’s truly going to help make the metrics more valuable and evidence-based and show a greater impact of the role we play,” she said. “By using standardized metrics, we as navigators can partner more closely with one another and join in on the same mission and vision: to enhance quality care for our patients and the institutions that we serve.”
The AONN+ Standardized Navigation Metrics Task Force aimed to ensure that the metrics could be used by all organizations as a baseline to improve the efficacy and sustainability of their programs. The standardized metrics provide a starting point for all navigation programs, but each program should add their own additional metrics that are unique and relevant to their own institution. “Programs are developing at very different rates, and we always have to remember that navigation metrics should reflect the goals of our cancer programs,” she explained. “But there’s no sense in spinning your wheels measuring things you have no impact on.”
Ms Strusowski stressed the value of utilizing the resources created by the task force, such as a 100-page source document within the white paper that provides a comprehensive review of the metrics, including definitions, criteria (Patient Experience, Clinical Outcome, ROI), ranking that designates the value and strength of the metric, identification of metric links to multiple domains, and the evidence-based literature that supports the metrics (https://aonnonline.org/metrics-source-document).
Now That We Have the Metrics, What Do We Do With Them?
“First, don’t try to hit all 35,” said Ms Strusowski. “Don’t even go there.” Start slow, she advised. Pick a few of the low-hanging fruits—metrics already being collected—and set yourself up to succeed (eg, number of new cases, open cases, and closed cases per month). Build discrete and reportable fields into the electronic medical record, and limit narrative.
Start with metrics that support national guidelines since these are being collected anyway. Explore the idea of creating easy-to-use navigation dashboards, and audit and monitor your program until you reach your internal goals or national benchmarks. Identify where to find source data (eg, electronic medical record, tumor registry), and when those data will be collected, and utilize the AONN+ drop-down responses in the source document. “A lot of thought went into those responses,” she said.
Create a plan to meet your metric goal. When collecting a metric, have a “check-in status.” Is the new process to meet the metric goal working? If not, either change it or give it a bit more time. Brainstorm new opportunities, and keep reporting simple and understandable, she said. When a metric is reached, continue to monitor it for about a quarter. “Be done with it, but go back and revisit it to make sure you’re still okay. You have 35 other metrics to pick from, so move on to the next one,” she said. “This is how to provide highly coordinated care.”
In the climate of value-based cancer care, she emphasized the value of sharing the metrics among staff, administration, physicians, performance improvement department, Cancer Committee, etc. “If you share these metrics with your physicians, they’ll be astonished at the crossover,” she said. “For the first time, we’re working on some of the same metrics, instead of in silos.”
Incorporate them into your quality improvement goals, and educate navigators on the AONN+ metrics to ensure everyone understands and is collecting the data in the same manner. “Even though we’ve given you the metric, the definition, and a drop-down response, make sure your staff actually understands them,” she reiterated, adding that the field of navigation is constantly changing, so annual competency verifications are imperative.
In January of this year, AONN+ created a monthly Navigation Metrics Subcommittee, and in the fall of 2017, the AONN+ Task Force will debut a Navigation Metrics Repository.
“Bottom line, there’s no way we’re going to grow our programs or ensure the sustainability of navigation without showing our value through metrics,” added Ms Strusowski. “But as for the future, the sky’s the limit.”