Patient and nurse navigators play an important role in the care of patients from screening through treatment and into survivorship. Whether helping address barriers to care, coordinating care, supporting transitions of care, or providing education or referrals, navigators perform activities that can and should be measured. Many navigators keep spreadsheets or use their medical record system to document the patients they navigate. These data can provide the core information for conducting quality improvement activities.
Nurse and patient navigators can be part of a team that conducts process improvement efforts in cancer centers. Not only can navigators collaborate with the team to improve patient experience, clinical outcomes, and return on investment with these efforts, but they can also demonstrate their own value as navigators to the team and to leadership. For a novice navigator with limited research or process improvement experience, there are several simple steps to follow to embark on a project.
Identify problem area for patients or the clinic processes – Navigators can use their own navigation tracking spreadsheets to identify common barriers/problem areas, hospital or cancer center needs assessment results, cancer committee study or cancer registry reports, patient satisfaction survey data, state health department or CDC data, or other source to pinpoint an area for a quality improvement project or study.
Establish goals and identify relevant measures – SMART (Specific, Meaningful, Action Oriented, Realistic, and Timely)—see the Introduction to this article.
Identify methods and metrics – See the Academy of Oncology Nurse & Patient Navigators (AONN+) metric repository, organized by domain, found on the website (aonnonline.org).
Collect and analyze data – Data can be collected for a certain period or until data for a certain number of patients are gathered. Simple tabulation is sometimes all the analysis that’s needed. Guidance regarding data analysis may be found within your own healthcare institution, an AONN+ regional network group, or through the AQUIRE Subcommittee at AONN+.
Report/Publish – Write up a report for use within your own institution to document your efforts and achievements, write an abstract for submission to the AONN+ conference, or write an article for the Journal of Oncology Navigation & Survivorship.
Novice Navigator Case Study
In an effort to improve patient care through quality improvement activities, the staff at a community-based cancer center recognized that their county had the highest incidence of head and neck cancers in the state. They also analyzed the patient flow and challenges occurring in the clinic for head and neck patients and found that these patients were having trouble navigating the healthcare system. In particular, these patients were overwhelmed with managing the various scheduled consults, tests, and procedures necessary prior to starting treatment. Because they weren’t adequately informed and guided, patients became confused about scheduled appointments and frequently didn’t show or went to the wrong appointment. As a result, the recommended treatment was not started in a timely manner.
The team recognized that the core of these problems could be addressed by focusing on one of the goals of their mission-oriented organization, which is to offer appropriate education to patients to deliver the best care possible. As a group, they decided that their objectives were to:
- Develop and implement a process to streamline scheduled appointments, tests, and procedures
- Incorporate a navigator to guide the patient from time of initial diagnosis through the continuum of care
- Encourage treatment adherence through education
- Increase the rate of successful treatments by taking a systematic approach to symptom management
Central to achieving these goals, the center:
- Implemented a Head and Neck Cancer Patient Care Plan for each patient. The plan included coordination of appointments with the medical oncologist and the radiation oncologist to facilitate a plan of care. This included arranging for port placement, imaging for PET/CT scans, appointments for surgery, feeding tube consult, nutrition consult, speech pathologist, and dental evaluation. It also included a surveillance schedule and appointments on a calendar for patients.
- Assigned a navigator to work with the patients, their families, and the physicians
- Had the team develop a chemotherapy education bag that included
- information for the patient about an oral care protocol to promote early detection and management of stomatitis
- information about chemotherapy-induced peripheral neuropathy and recommendations for management, including safety concerns and prevention of falls
- a skin care protocol to promote early detection and management of dermatitis secondary to chemotherapy/biotherapy and radiation treatments
- an explanation of neutropenia—what it is, and what it means to patients and their families
- Developed a color-coded chart featuring 3 zones to visually indicate for patients and their families what should be done under various circumstances. (The green code indicates being at goal and stable; the yellow zone indicates caution and lists symptoms that mean a doctor should be called; the red zone lists symptoms that require calling 911 or taking the patient to the emergency department)
- Developed a nutritional tip sheet for patients undergoing treatment to educate them in managing taste dysfunction and changes in eating habits. It included a copy of a BMI chart that nurses use when assessing patients
- Implemented a chemotherapy class that patients and families can attend in addition to the initial individual chemotherapy instruction. The class optimizes the learning experience and standardizes education given to patients
Implementation of the Head and Neck Cancer Patient Care Plan closed the information gap, coordinated care, and decreased wait time for treatment initiation. Patient adherence to treatment increased, and scheduled appointments were attended, enabling patients to complete the recommended treatment. Involving the navigator at the initial diagnosis and through the care continuum further strengthened this process. The team collected time to treatment data at the beginning of the study and throughout the study and process improvement phase. The baseline data, before the team implemented process improvement changes, on time to treatment initiation were 45.38 days. After implementing changes and process improvement, the data for diagnosis to treatment initiation decreased in the following year to 19.2 days and then to 12.6 days in the subsequent year.
The educational materials provided with protocols for detection and management of stomatitis, skin care, peripheral neuropathy, and neutropenia provided patients with tools they needed to help be responsible for their own care. The team developed and implemented a prechemotherapy and postchemotherapy class survey that further validated the importance of reinforced, standardized education.
The prechemotherapy and postchemotherapy class surveys were given to 56 patients. Prior to the class, 21 patients (38%) felt they were prepared for their first chemotherapy treatment, whereas 35 (62%) felt they were not. After the classes were completed 56/56 (100%) of the patients felt prepared and knowledgeable about their treatment plan and side effects. The following day the patients received a call from the oncology nurse, who answered any questions they had regarding their treatment plan and side effects. At those calls, 100% of the patients knew their medication names and side effects and felt less anxious about their planned treatment.
The creation of consistent messages and patient education and the development of the Head and Neck Cancer Patient Care Plan have led to improved care coordination and better outcomes for the patients.
Quality improvement can have a positive impact on patient care and outcomes and patient satisfaction, as well as demonstrate the value of the navigators. Improving processes in your center means that you are providing better care for your patients. A novice navigator doesn’t need to be intimidated by undertaking a quality improvement project; even simple projects can yield meaningful results as long as some basic steps are followed. As one navigator said, “if you’re doing something that’s working, share it!” For more information and support, please refer to the AONN+ website under Evidence into Practice or contact one of the authors of this article for more information about the AQUIRE Subcommittee, which supports members in conducting quality improvement projects through resources and mentorship.
The authors can be contacted as follows:
Marian E. Gilmore, RN, OCN, ONN-CG
Dana-Farber/Brigham & Women’s Cancer Center
Pamela Goetz, BA, OPN-GC
Sibley Memorial Hospital, Johns Hopkins Medicine
Barbara McHale, RN, BS, OCN, ONN-CG, CBCN
Retired, Hildegard Medicus Cancer Treatment Center