In 2017, the Academy of Oncology Nurse & Patient Navigators (AONN+) identified 35 evidence-based navigation metrics relevant to cancer care.
These navigation metrics support over 270 value-based cancer care and oncology standards and serve to demonstrate the value of navigation.
“The work to identify these metrics served as a launching pad for continued efforts to study navigation metrics and implementation activities,” said Monica Dean, HON-OPN-CG, Director, Patient Navigation Program Development at AONN+. “But we know that applying metrics to your navigation programs has been a success in some areas, and in some areas it has been a challenge.”
But now, the AONN+ Navigation Metrics Toolkit (www.aonnonline.org/navigation-metrics), introduced in 2020, is making it easier for navigators and care teams to implement the metrics and is providing additional momentum for programs that are already underway. At the AONN+ 11th Annual Navigation & Survivorship Conference, Ms Dean, along with Danelle Johnston, MSN, RN, HON-ONN-CG, OCN, Senior Vice President, Mission Delivery at the Cancer Support Community, and Tricia Strusowski, RN, MS, independent oncology consultant, provided an in-depth overview of the successes and challenges associated with implementing the metrics into navigation programs and gave attendees a glimpse into the usefulness of the AONN+ Navigation Toolkit in demonstrating the value and sustainability of oncology navigation.
History of the Metrics
The 35 baseline navigation metrics are based on the 8 AONN+ domains for certification—Professional Roles and Responsibilities, Patient Advocacy, Psychosocial Support Services Assessment, Care Coordination, Community Outreach and Prevention, Operations Management, Survivorship/End of Life, and Research and Quality Performance Improvement—and can be used by all institutions regardless of their model of navigation.
After identifying the metrics in 2017, AONN+, the American Cancer Society, and Chartis Oncology Solutions conducted a national research multisite study in 2018 to assess the extent to which navigation programs could implement 10 of the 35 metrics. “We chose metrics that aligned with many of the national standards and indicators for navigation performance, those that will show impact and return on investment for navigation programs,” said Ms Dean.
In 2020, AONN+ completed the AONN+ Navigation Toolkit to help navigators, oncology program administrators, healthcare executives, and other clinicians who are linked to navigation to understand and support the integration of standardized metrics measurement into their normal business processes.
The toolkit reflects the current recommendations from AONN+, as well as recommendations from the pilot study and best practices gleaned from navigators and navigation experts across the nation.
“We really took the outcomes from the study, both qualitative and quantitative, and applied them to the toolkit to help navigators and navigation programs see—through case studies—how to overcome challenges and turn them into successes,” she said.
The toolkit provides navigators with guidance on how to select, implement, report, and utilize navigation metrics as they engage in quality/performance improvement and strategic decision-making. “We believe implementing navigation metrics will really be transformative to cancer care, since metrics can help to drive and sustain quality improvements,” she added.
Demonstrating the Value of Navigation
According to Ms Strusowski, sustaining support in today’s value-based environment is difficult without measurable results or metrics, and feedback from administrators regarding the metrics has been overwhelmingly positive.
“Please remember that the metrics initiative and the navigation toolkit can really help with your Commission on Cancer accreditation,” said Ms Strusowski. “Now more than ever, each program needs to have their metrics in place and be utilizing some of the 35 evidence-based navigation metrics in regard to patient experience, clinical outcome, and return on investment.”
She pointed out that demonstrating the value of navigation is already in the navigator’s job description, so this should not be viewed as additional work or responsibilities. Providers, including healthcare systems, health plans, physicians, program administrators, and navigators, must be held accountable for demonstrating that they provide and improve quality of care through quality measures. “This is your responsibility,” she reiterated.
The metrics identified in the navigation toolkit are critical to help the navigation field demonstrate its value and contributions to achieve and improve quality patient care. “So share the navigation toolkit with your key stakeholders and administrators,” she said.
Using the metrics provides a financial incentive as well, since value-based payment programs have components that reward healthcare organizations for certain patient- focused activities or outcomes. For example, Medicare’s Quality Payment Program, which repealed the sustainable growth rate formula and changed the way Medicare rewards clinicians for value over volume, streamlines multiple quality programs under the Merit-based Incentive Payment System and gives bonus payments for participation in eligible Alternative Payment Models.
Lessons Learned from Implementation
After completion of the metrics pilot study, 5 core metrics were identified by the researchers as universally applicable: navigator competencies, navigation caseload, barriers to care, psychosocial distress screening, and interventions. These 5 areas have specific impact on navigation and on the quality of patient care delivered by navigators.
“These were navigation activities that were directly linked to the navigator and what they do from day to day,” Ms Johnston explained. “What’s important is that these metrics help navigators to transform overall cancer care.”
Ms Strusowski pointed out that implementing the metrics is much easier when they align with preexisting workflows and processes. Creating a unified template to capture all metrics (and integrating it into the electronic health record [EHR]) can be incredibly useful, as evidenced by one of the study sites in the pilot program. Ms Johnston added that it is crucial to be able to integrate all pertinent data into the hospital’s EHR system or to feed data into any navigation-specific system.
Additional support—from IT (since the goal is to move toward automated data collection), clerical/administrative departments, and the study team—is also invaluable when integrating the metrics into practice.
The study team found that navigators were more motivated to collect data on metrics they thought demonstrated the value of their program. The metrics unanimously perceived as useful included barriers to care, psychosocial distress, and social support referrals. It stands to reason then that navigators were less motivated to collect metrics they did not find relevant, but these more “irrelevant” metrics varied depending on the navigation model.
Ms Johnston again stressed the importance of oncology nurse and patient navigators understanding that active participation in data collection, analytics, and reporting outcomes is part of the professional role.
“I want you as the navigator to recognize your responsibility around metrics and process improvement and your role in helping to drive quality care and practice transformation,” she said. “This is not added responsibility; it’s truly part of your core competency as a navigator.”
However, it is not solely the role of the navigator, she added. Collecting data on the AONN+ metrics requires participation from the entire care team (as well as key stakeholders like physician champions, chief executive officers, chief operating officers, and administrators). The AONN+ Navigation Toolkit was designed to help equip the team for this responsibility and can help immensely in streamlining the data collection process.
Getting Started with Implementation
Getting started implementing the metrics involves identifying key stakeholders, conducting a cancer program community needs assessment to analyze and identify patient needs for navigation metrics, and then evaluating services and gaps in care to understand where data might be missing. Next, review your cancer program’s objectives and goals.
“How can you align the goals for your navigation program with the overall cancer program goals? Where can you find some synergy, so you’re not redoing processes, but really coming together to help drive practice transformation?” asked Ms Johnston, adding that there is nothing wrong with starting by measuring some “low-hanging fruit” metrics that will ensure early victories.
After deciding on which metrics to implement and determining the navigation team’s readiness to implement those metrics, establish baseline data (you need to know where you started to know how far you have come). Finally, leverage process improvement methodologies (ie, process maps, Lean Six Sigma, etc) to support metrics implementation.
If collecting data on a certain metric has become a streamlined process, do not continue to collect it, she advised. Rather, do pulse checks on it on a quarterly basis to make sure that data collection is being maintained.
“Challenge your program to grow; move forward and identify another metric that can help you drive practice change,” said Ms Johnston. “Navigators are in a unique position in the healthcare team to be able to help transform practice, and that’s why metrics are so important; they help to tell your story.”