There is a gap in the literature regarding the key areas that measure the success of navigation programs—patient experience (PE), clinical outcomes (CO), and business performance or return on investment (ROI) metrics—that will demonstrate the sustainability of navigation programs. In the report published by the Institute of Medicine (IOM), Ensuring Quality Cancer Care, the recommendation is that quality care is measured using a core set of metrics: “To ensure the rapid translation of research into practice, a mechanism is needed to quickly identify the results of research with quality of care implications and ensure that it is applied in monitoring quality.”1
The objective of this initiative was to develop standard metrics in the areas of PE, CO, and ROI using the Academy of Oncology Nurse & Patient Navigators (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). These domains contain a comprehensive list of all areas in which navigators practice to provide quality patient care and financial stability for their organizations.
The project team leaders developed a proposal that was submitted to the AONN+ Executive Leadership for approval and support to fund this initiative. The AONN+ leadership accepted the proposal and organized a project team of content experts. AONN+ formed this team to create standardized metrics in the 3 identified areas focused on PE, CO, and ROI using the AONN+ domains. The project team leaders held a WebEx to roll out the project, timelines, and expectations of each team member and outlined the preparation required prior to retreat. Each member completed a literature review on the assigned domain for which they had validated expertise. Each member used measure development criteria ensuring feasibility, meaningfulness, and breadth of metric to guarantee reliability and validity. AONN+ held a 1-day retreat with the task force members to review metrics for each domain, literature support, and benchmarks, and finalized a set of standardized metrics. Using the Likert scale, the team ranked metrics to determine which met rigorous review and were acknowledged as high validity that all navigation programs can utilize.
The task force developed standardized metrics that focus on the AONN+ certification domains for navigation, concentrating on PE, CO, and ROI. After completion of an extensive literature review and putting each metric through rigorous criteria to ensure the accuracy and soundness of each, 35 metrics were developed. These are baseline metrics all institutions can use regardless of the structure of their navigation program. The task force recognizes that navigation programs are developing at different rates within diverse structural organizations and settings, and that will determine which standardized metrics will be essential to measure outcomes for their specific navigation program. As disease-specific certification evolves, additional evidenced-based disease-specific metrics will need to be developed to dovetail into the standardized navigation metrics.
Navigation was formally introduced as part of the continuum of care in oncology by Harold P. Freeman, MD, in 1990 when he created a navigation program to decrease time-to-care disparities in the underserved breast cancer population in Harlem. As far back as the 1990s there was valid proof that navigation plays a significant role in decreasing time to care.2
The Oncology Nursing Society (ONS), the Association of Oncology Social Work (AOSW), and the National Association of Social Workers define navigation as: “Individualized assistance offered to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality health and psychosocial care from pre-diagnosis through all phases of the cancer experience.”3 ONS published core competencies for navigators in 2013.4 The American Cancer Society (ACS) created its own formal navigation program in 2005,5 and the Commission on Cancer (CoC) added patient navigation as a standard in 2015.6
The Academy of Oncology Nurse & Patient Navigators (AONN+) is a national organization whose mission is dedicated to improving patient care and quality of life by defining and enhancing and promoting the role of oncology nurse and patient navigators. AONN+ recently established a navigation certification program using the evidence-based domains cited in the Table. These domains contain a comprehensive list of all areas in which navigators practice to provide quality patient care and financial stability for their organizations.
We have made significant strides over the past 10 to 15 years in both the development of navigation programs and in proving the efficacy of these programs for our patients as well as the institutions that care for them.7 Navigation has been widely accepted by national organizations such as ONS, AOSW, ACS, CoC, and the National Accreditation Program for Breast Centers. One of the IOM’s key initiatives is for Care Coordination to improve the quality of care, to better utilize resources, to decrease overall cost of care, and to address the need for professional societies to prioritize, fund, and develop meaningful quality measures.8
Several articles and research projects have discussed various measures that can be used to capture the impact of navigation; most of these discuss time-to-care metrics, patient satisfaction, and measures that assist with care for the underserved, but few discuss the broad range of measures that validate the role of navigation in all areas of oncology patient care.9 It is well-known that each navigation program is developed to meet the needs of the patients and the institution where the program is being created, and that indicators to measure the success of that program need to be tailored to the goal of the navigation program. Metrics for evaluation of patient navigation must be conceptualized to reflect those aspects of diagnosis and treatment in which navigators can have an impact for the specific program being evaluated.10
That being said, there is a void in the literature regarding the key areas that measure the success of navigation programs: PE, CO, and business performance or ROI metrics that will prove the sustainability of navigation programs.
The goal of the Standardized Navigation Metrics Task Force, under the umbrella of the AONN+ Evidence into Practice Committee, was to provide a list of standard metrics that can be used by all organizations as a baseline to prove the efficacy and sustainability of their programs. That does not mean it will be an all-inclusive list, because there are no cookie-cutter navigation programs, and each program will have additional metrics to capture regarding their own program. These standard metrics will provide a starting point and baseline metrics for all navigation programs that are evidence-based through literature support, patient preference, and clinical practice using the AONN+ domains of certification as reference points.
At the AONN+ annual conference in Las Vegas on November 17, 2016, it was announced that the AONN+ Evidence into Practice Metrics Subcommittee had created 35 evidenced-based national navigation metrics that all programs would be able to utilize in their navigation model. After an extensive literature search that took several months to complete, the team utilized the 8 AONN+ certification domains as well as the categories of PE, CO, and ROI. The AONN+ navigation certification domains were utilized because AONN+ has been recognized by the CoC to be the content experts for oncology navigation.
Prior to this announcement, cancer programs had a difficult time demonstrating the success of their oncology navigation programs on a national level; cancer programs have not been able to compare their programs because each program has created its own metrics or have none at all.
Data and metrics reporting are best suited to communicate patient navigator efficacy. The challenge was that whereas navigation programs have existed for decades, standardized national metrics to measure program success have been missing. After a comprehensive literature search on the topic of navigation metrics, we identified 3 main categories of metrics:
- Business performance/ROI
- Clinical outcomes
- Patient experience
The “patient experience” is increasingly emerging as a more enhanced method for measuring navigation success. The 2013 Consumer Assessment of Healthcare Providers and Systems cancer survey identified that patients’ expectations were exceeded when they felt their healthcare provider actively listened and incorporated their personal psychosocial goals into the treatment plan. The results of this survey also confirm the importance of ensuring that navigators and support staffs know how to provide the appropriate level of education. Asking about their experience(s) and encouraging active participation in their treatment discussions increased the level of understanding and satisfaction of the patients and their family.11,12
CO metrics are much more familiar to healthcare providers as clinicians have always measured success through patient clinical outcomes. Some of these metrics include distress screening, pathway compliance, and timeliness of care.
Business performance metrics, unlike PE or CO, are much less familiar for navigation programs. Yet, this category is becoming increasingly important as cancer program administrators question the ROI for navigation services.12
Navigation programs have been incorporated into cancer programs over the past 10 to 20 years to support the IOM report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, and the new CoC Standards, Chapter 3: Continuum of Care.8,13 It is essential that administrators and key stakeholders measure their ROIs for the navigation programs as well as measure PE and CO. Administrators need to report metrics and outcomes to ensure sustainability of their navigation programs.
With the development of the 35 national evidence-based navigation metrics collected from over 300 source documents, all navigation programs—no matter the model of navigation chosen—can utilize the same metrics to measure success and sustainability.
The source document provides comprehensive review of the metrics: definitions, criteria (ROI, PE, CO), ranking that designates the value and the strength of the metric using a Likert scale of 1 to 10 (1 = low, 10 = high), identification of metric links to multiple domains, and the evidenced-based literature that supports the metrics. The source document can be accessed at www.aonnonline.org/metrics-source-document/.
Call to Action
The challenge was that while navigation programs had existed for decades, standardized national metrics to measure program success had yet to be created and standardized. Now that the metrics have been formalized, AONN+ strongly encourages each navigation program to identify key metrics from the 35 standardized metrics that will be valuable for their organization to measure and report outcomes. It is imperative for navigation to continue to build a strong sustainable business case and demonstrate that these metrics need to be measured, collected, and reported.
AONN+ will develop a metrics repository for programs to report outcomes, share lessons learned, and share what performance improvement initiatives have been implemented to enhance and improve navigation processes. This provides a vehicle to share data nationally and begin to develop standardized reporting. Publishing the findings to further build on evidence for the vakue of navigation is vital to ensuring navigation program sustainability. The outcome metrics will be able to demonstrate with actual measurable data that navigation can impact on ROI, PE, and CO.
The authors gratefully acknowledge the Standardized Metrics Task Force team: Sharon Gentry, RN, MSN, AOCN, CBCN; Elizabeth Brown, MSN, MHA, RN, NE-BC, OCN; Nicole Messier, BSN, RN, OCN; Barb McHale, BS, RN, OCN, CBCN; Cheryl Bellomo, MSN, RN, OCN; Linda Bily, MA, CSA; and Vanessa Rodriguez, MSW. The authors also wish to thank AONN+ for the continued support and resources toward this initiative.
Metrics per Domain
- Institute of Medicine. Hewitt M, Simone V, eds. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press; 1999.
- Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117(15 Suppl):3539-3542.
- ONS, AOSW, and NASW Release Position Statement on Patient Navigation. Oncology Times. 2010;32(10):62.
- Oncology Nursing Society. Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/ONNCompetencies_rev.pdf. 2013.
- Institute for Alternative Futures. American Cancer Society navigation program. www.altfutures.org/pubs/DRA/Report_07_02_Patient_Navigator_Program_Overview.pdf.
- Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Commission on Cancer Standard 3.1. www.facs.org/~/media/files/quality%20programs/cancer/coc/programstandards2012.ashx.
- Paskett ED, Harrop JP, Wells KT. Patient navigation: update on the state of the science. CA Cancer J Clin. 2011;61:237-249.
- Institute of Medicine.Delivering High-Quality Health Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.
- Crane-Okada R. Evaluation and outcome measures in patient navigation. Semin Oncol Nurs. 2013;29:128-140.
- Guadagnolo BA, Dohan D, Raich P. Metrics for evaluation of patient navigation during diagnosis and treatment: crafting a policy-relevant research agenda for patient navigation in cancer care. Cancer. 2011;117(15 Suppl):3565-3574.
- American Institutes for Research. Developing the CAHPS Survey for Cancer Care: Executive Summary: Preliminary Findings CAHPS Cancer Survey. October 28, 2012.
- Strusowski T, Stapp J. Patient navigation metrics: measuring the impact of your patient navigation services. Oncology Issues. 2016;56-63.
- Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Chapter 3: Continuum of Care Services. www.facs.org/~/media/files/quality%20programs/cancer/coc/programstan dards2012.ashx.