Navigation Metrics Toolkit

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August 2020
© 2020, American Cancer Society, Inc.

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Definitions for Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 2: National Quality Standards and Quality Indicators . . . . . . 14
Chapter 3: AONN+ Navigation Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Chapter 4: Common Challenges and Facilitators to Collecting Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 5: Identification of Key Stakeholders to Support the Metrics Measurement Process . . . . . . . . . . . 29
Chapter 6: Working with Stakeholders to Choose the Right Metrics for Your Program . . . . . . . . . . . . . . . . . . . . . 36
Chapter 7: Identifying Data Sources/Systems and Integrating Data into EHR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Chapter 8: Creating Your Navigation Metrics Dashboard . . . . . . . . . . . . 56
Chapter 9: Performance Improvement Processes and Tools . . . . . . . . 63
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

August 2020
To the Users of This Toolkit:
In 2017, AONN+ identified 35 evidence-based navigation metrics that were relevant to cancer care. The work to identify these 35 metrics served as the launching pad for continued efforts to study navigation metrics and implementation activities. In 2018, AONN+, the American Cancer Society, and Chartis Oncology Solutions conducted a national research multisite study to assess the extent to which navigation programs could implement a set of 10 of these 35 metrics. The selected metrics aligned with what many perceive to be national standards and indicators for navigation performance. With the pilot study completed, the next step was to develop a toolkit to help navigators, oncology program administrators, healthcare executives, and other clinicians who are linked to navigation understand and support the integration of standardized metrics measurement into their normal business processes.
This toolkit reflects the current recommendations from AONN+, recommendations from the pilot study, as well as best practices gleaned from navigators and navigation experts across the nation. 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 be transformative to cancer care since metrics can help drive and sustain quality improvements. This toolkit was developed to make it easier for navigators to start that journey and to provide additional momentum for programs that are already on their way. Key Programmatic Questions to Drive Metrics Implementation are provided for you in Appendix 1.
We hope this toolkit is a valuable resource for navigators, administrators, and cancer programs to demonstrate the value and sustainability of oncology navigation.

Dawn Wiatrek, PhD Strategic Director Cancer Treatment Access American Cancer Society

Danelle Johnston, MSN, RN, HON-ONN-CG, OCN Chief Nursing Officer, Sr. Director of Strategic Planning and Initiatives Academy of Oncology Nurse & Patient Navigators

This toolkit was developed with input and guidance from healthcare professionals across the United States – tenured medical personnel who have worked for many decades to serve patients with cancer. A debt of gratitude is owed to each individual for volunteering his or her time to help develop this toolkit. Additional thanks are owed to the funding partners that made its development possible.
AONN+ National Standardized Evidence-Based Metrics Task Force Danelle Johnston, MSN, RN, HON-ONN-CG, OCN, Co-Chair Elaine Sein, RN, BSN, Co-Chair Tricia Strusowski, RN, MS, Co-Chair Cheryl Bellomo, MSN, RN, ONN-CG, OCN Elizabeth Brown, MSN, MHA, RN, NE-BC, OCN Sharon Gentry, RN, MSN, ONN-CG, AOCN, CBCN Rizzo McHale, BS, RN, ONN-CG, OCN, CBCN Nicole Messier, BSN, RN, OCN
National Evidence-Based Oncology Navigation Metrics: Multisite Exploratory Study to Demonstrate Value and Sustainability of Navigation Programs – Study Team Danelle Johnston, MSN, RN, HON-ONN-CG, OCN – Co-Principal Study Investigator Lesley Watson, PhD – Co-Principal Study Investigator Megan Cotter, MPH – Study Investigator Alex Glonek – Study Investigator Elaine Sein, RN, BSN – Study Investigator Kelley D. Simpson, MBA – Study Investigator Tricia Strusowski, RN, MS – Study Investigator

National Evidence-Based Oncology Navigation Metrics: Multisite Exploratory Study to Demonstrate Value and Sustainability of Navigation Programs – Study Sites Abington-Jefferson Health, Asplundh Cancer Pavilion, Abington, PA Capital Health Cancer Center, Trenton, NJ Centra Health, Alan B. Pearson Regional Cancer Center, Lynchburg, VA MaineGeneral Health, Harold Alfond Center for Cancer Care, Augusta, ME Medical University of South Carolina, Hollings Cancer Center, Charleston, SC Rutgers Health, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ University of Arizona Cancer Center, Phoenix, AZ University of Colorado Health, Fort Collins, CO
Megan Cotter, MPH Monica Dean, HON-OPN-CG Danelle Johnston, MSN, RN, HON-ONN-CG, OCN Elaine Sein, RN, BSN Tricia Strusowski, RN, MS Lesley Watson, PhD Dawn Wiatrek, PhD
AONN+ National Metrics Committee Toolkit Review Team Tricia Strusowski, RN, MS, Committee Chair Debbie Bickes, MN, RN, OCN, ONN-CG Joyce Bynum, RN, BSN, OCN, ONN-CG, CCM, CMF Trish Tatrai, RN, MS, OCN, CBCN Sandra Walters, RN, CBCN, ONN-CG Stacey L. Webb, MPA/HCA, BSN, RN, ONN-CG Lianna Willhite, RN, BSN, CBCN, ONN-CG

Definitions for Abbreviations

APM – Alternative Payment Models
An alternative payment model (APM) is a payment model that rewards providers for delivering high-quality, cost-efficient care, as opposed to fee-for-service payment models that reward healthcare providers for the volume and types of care they provide.
CO – Clinical Outcome

MIPS – Merit-based Incentive Payment System
The Merit-based Incentive Payment System (MIPS) is one of the two payment tracks created under the Medicare Access and CHIP Reauthorization Act (MACRA); the other is the Advanced Alternative Payment Model (AAPM) track. MIPS adjusts payment based on performance in four performance categories:

Clinical outcome is the measurable change in health, function, or quality of life that results from medical intervention(s).
CoC – Commission on Cancer
The Commission on Cancer (CoC) is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, which promotes cancer prevention, research, education, and monitoring of comprehensive quality care.

■ Quality – based on the Physician Quality Reporting System (PQRS)
■ Cost – based on the Value-based Payment Modifier (VBPM)
■ Promoting Interoperability (PI) – based on the Medicare EHR Incentive Program (Meaningful Use)
■ Improvement Activities – requires activities designed to improve clinical practice or care delivery leading to improved outcomes
NAPBC – National Accreditation Program Breast Centers

C-suite refers to the executive-level managers within a company. Common C-suite executives include the chief executive officer (CEO), chief financial officer (CFO), chief operating officer (COO), and chief information officer (CIO).
IT – Information Technology
Information technology is the study or use of systems (especially computers and telecommunications) for storing, retrieving, analyzing, and sending information.

The National Accreditation Program for Breast Centers (NAPBC) is a consortium of national, professional organizations focused on breast health and dedicated to the improvement of quality outcomes of patients with diseases of the breast through evidence-based standards and patient and professional education.
OCM – Oncology Care Model
The Oncology Care Model is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multi-payer model is designed for discrete six-month instances, or episodes of care, especially those involving chemotherapy—the start of chemotherapy treatment triggers the six-month episode. The program combines fee-for-service payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.


ONN – Oncology Nurse Navigator
An ONN is a clinically-trained individual who is responsible for identifying and addressing barriers to timely and appropriate cancer treatment. The ONN guides the patient through the cancer care continuum from diagnosis through survivorship. More specifically, the nurse navigator acts as a central point of contact for a patient and coordinates all components involved in cancer care, including surgical, medical, and radiation oncologists; social workers; patient education; community support; financial and insurance assistance; etc. This person has a clinical background and is a critical member of the multidisciplinary cancer team.
PE – Patient Experience
Patient experience encompasses the range of interactions that patients have with the healthcare system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities. Patient experience does not start or stop at the hospital or healthcare provider’s door. It includes all interactions, virtual or physical, extending to clinical and non-clinical personnel.
PI - Performance Improvement
Performance improvement is determined by measuring the output of a particular business process or procedure, then modifying the process or procedure to increase the output, the efficiency, or the effectiveness of the process or procedure
QI – Quality Improvement
Quality improvement is a systematic, formal approach to the analysis of practice performance and efforts to improve performance. A variety of approaches—or QI models—exist to collect and analyze data and test change.
NOTE: These definitions were accessed through organizational websites and other common website sources.

QOPI – Quality Oncology Practice Initiative
The Quality Oncology Practice Initiative (QOPI®) is a quality program designed for outpatient-oncology practices to foster a culture of self-examination and improvement. Participating practices can report on more than 150 evidence-based quality measures and receive individual performance scores by practice, site, and provider, as well as benchmarked scores aggregated from all participating practices.
ROI – Return on Investment
Return on investment is a performance measure that can be used to evaluate the efficiency of an investment or compare the efficiency of a number of different investments. ROI tries to directly measure the amount of financial return on a particular investment, relative to the investment’s initial cost.
SCP – Survivorship Care Plan
A survivorship care plan is a record of a patient’s cancer and treatment history, as well as any checkups or follow-up tests needed in the future. It may also list possible long-term effects of your treatments, and ideas for staying healthy.
TS – Treatment Summary
A treatment summary is simply a document that details the cancer treatments a patient has received. This record should include any surgery, chemotherapy (or other medical therapy), and radiation therapy. The summary should list the diagnosis, stage (using the TNM system when possible), and any relevant information from the pathology report.
VBPCC – Value-Based Purchasing in Cancer Care
Value-based purchasing (VBP) is a provider payment system that rewards providers for improvements in clinical performance. This system is being tested by Medicare and other payors for cancer care (VPBCC) in an effort to hold providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.

Executive Summary

Executive Summary
Because evidence guides practice, it is essential for oncology navigation programs to identify core metrics and standardize data collection activities to demonstrate program outcomes in the value-based environment that is currently dominant and will continue to be so in the future.1 However, the oncology navigation field has lacked clarity about which metrics are most relevant and has failed to provide oncology navigators with a common framework for navigation measurement. Since 2015, AONN+ has been engaged in a process to develop standardized metrics and, most recently, has completed a pilot study to test a subset of these metrics. This toolkit was created to support navigators and navigation leaders who want to establish the relevance and acceptance of their navigation efforts through the implementation of metrics.

Through an extensive literature review, AONN+ defined three main areas of measurement for understanding and prioritization: patient experience (PE), clinical outcomes (CO), and return on investment (ROI).2 In 2017, through continued research, AONN+ identified 35 evidence-based navigation metrics that touched at least one of these three areas of measurement. In 2018, AONN+, the American Cancer Society, and Chartis Oncology Solutions conducted a national, multisite research study to assess the extent to which navigation programs could implement a set of 10 of these metrics. Eight healthcare organizations agreed to participate in the pilot project. These organizations served as test sites to assess what could be learned through the implementation of selected navigation metrics over a six-month period.
The selected metrics aligned with national standards and indicators for navigation performance. They were also selected based on the likely availability of data from participating navigation programs. The goal of the pilot project was to study what could be learned through the implementation of the 10 selected metrics, including the feasibility of implementation, and to identify facilitators and barriers to implementation.

Informal surveys at AONN+ national meetings indicate that only 50% of navigators track a set of navigation metrics. This toolkit is designed to help navigators, oncology program administrators, healthcare executives, and other clinicians who are linked to navigation understand and support the integration of standardized metrics into their normal business processes.
This toolkit will provide navigators with guidance on how to select, implement, report, and utilize navigation metrics as they engage in quality/ performance improvement and strategic decisionmaking. The toolkit will illustrate how navigators can elevate their work by:
■ Diving deeper into the use of metrics
■ Investing in stakeholder relationships
■ Engaging information technology and performance improvement leaders
■ Creating dashboards to capture and manage navigation outcomes
■ Using metrics to implement performance improvement initiatives for navigation efforts


Executive Summary

To illustrate how navigation metrics operate in the real world and to help other programs manage similar challenges, this toolkit includes case studies based on the experiences of the eight sites that participated in the navigation metrics pilot study. For six months, the organizations shared historical data, tracked standardized metrics using a unified platform, and disclosed feedback on facilitators and barriers to metrics implementation. Many of these barriers are not surprising: challenges related to information technology (IT), inconsistent methods of capturing data from electronic medical records, health system process barriers, navigation processes that were not standardized within a system or institution, processes that were poorly defined in scope, and misunderstanding of the navigation metrics definitions. Each study site completed at least one quality initiative to improve its implementation of the metrics and demonstrate how to overcome some of the barriers they encountered.
After reviewing findings from the pilot study using the 10 selected standardized metrics (See Appendix 2), the study team identified five navigation metrics that were understandable, applicable across all participating navigation programs, and relatively easy to implement.3 These five metrics are highlighted below.

Proposed core metrics that are likely universally applicable:











These five areas have specific impacts on navigation and the quality of patient care that is delivered by the navigator. More importantly, by implementing navigation metrics, navigators help to transform overall cancer care.


Executive Summary

Implications of Implementing Metrics for Navigation Practice
■ Transformative ■ Helps with the evaluation of
professional practice and care delivery ■ Defines oncology navigation practice
and outcomes
– Quality care delivery – Health outcomes – Overall value throughout the cancer
care continuum
■ Necessary for the sustainability of navigation

Regardless of what specific metrics might be selected by a given healthcare organization, the pilot study showed that navigation programs face challenges with metrics implementation overall and struggle to define processes for data capture and reporting. These are key activities to metrics implementation that must be addressed.
This toolkit provides suggested solutions for common challenges and serves as a guide to help navigators, navigation leaders, and healthcare executives understand how to collect, assess, and use selected navigation metrics to launch their navigation programs, better manage oncology navigation programs, and support sustainability for their navigation programs. The toolkit reflects the current recommendations of AONN+ and ACS. These recommendations are informed by many factors, including, but not limited to, this pilot study.


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Navigation Metrics Toolkit