Expert Commentary From Lisa Shalkowski, Director of the Breast Care Program, and Lisa Demko, Six Sigma Master Black Belt at Virtua Health

Program Support

A Word From the Experts
Expert Commentary From Lisa Shalkowski, Director of the Breast Care Program, and Lisa Demko, Six Sigma Master Black Belt at Virtua Health
09/11/2008

Virtua Health Takes a Novel Approach to Establishing a Patient Navigation Program

Virtua Health, a multihospital health care system headquartered in Marlton, NJ, consists of 4 acute care hospitals, 2 long-term care facilities, and over 22 ambulatory sites. Virtua focuses a significant infrastructure around its clinical service lines, known as 'Programs of Excellence,' to provide state-of-the-art care and technology in a convenient community setting. Its service lines include oncology, cardiology, women's and children's health, orthopedics, and neurosciences. A rigorous, strategic planning process is used to develop and execute tactics to improve clinical outcomes and service delivery. Ellen Feinstein, Assistant Vice President for the Oncology Program of Excellence, proposed creating a patient navigation program to offer a superior customer experience within 20 miles of Philadelphia's academic medical centers offering several other provider options.

Goals of the Virtua Breast Care Patient Navigation Program

Virtua's primary service area has approximately 900 new breast cancer cases per year, 50% of which are first diagnosed and/or treated at Virtua Health. The strategy behind developing a patient navigation program is to create a personalized approach to breast care that differentiates Virtua. The goals of the program are to enhance communication between the various disciplines and referring physicians and support patients in the treatment decisions and emotional complexities of breast care, while improving patient satisfaction. The navigation program also allows for more efficient use of physician time spent with patients and increases the efficiency of the office. Another goal is to increase patient satisfaction and retention to Virtua's own programs and services. Other goals include:

  1. Providing a single, consistent point of contact for patients
  2. Improving patient's preparedness for treatment through education and support
  3. Helping expedite patient access to diagnostic and treatment procedures
  4. Improving the relationship between Virtua and primary care physicians (PCPs), and PCPs and specialists

Design for Six Sigma

Virtua Health determined it was best to use its Six Sigma approach. Six Sigma is a business management strategy, originally developed by Motorola, which has widespread application in many sectors of industry, including health care. This statistical problem-solving approach is used to reduce variation and 'hard-wire' measurable improvements to business operations using input and buy-in from key stakeholders. Through the use of internal consultants, multidisciplinary teams work on initiatives that focus on delivering the best quality of care that can be measured and sustained over time. Virtua made the determination to use the Design for Six Sigma (DFSS) tool in creating a new breast health program based on customer requirements and following the DFSS methodology (Define, Measure, Analyze, Design, and Verify). The table below outlines some of the metrics developed out of the DFSS approach as it was applied to Virtua's patient navigation program.

A detailed DFSS methodology was followed in determining the best model for the navigation program and involved extensive research on the part of the Virtua project team. The team determined best practices through site visits and telephone interviews; Voice of the Customer (VOC) focus groups with patients and caregivers; and surveys completed by PCPs, specialists, and office managers to determine the critical components of quality care and service delivery. The team found that many of the programs they researched had failed to recognize the importance of collecting baseline data from the beginning to track the success of the program and justify additional resources required to expand the program beyond pilot phase.

A Pilot Plan

A patient navigation team was created and led by Lisa Shalkowski, Director of the Breast Care Program, and Lisa Demko, Six Sigma Master Black Belt. During the initial Define phase, the team developed a current-state process map that defined 60 separate steps patients may take from abnormal screening through treatment. The team utilized critical-to-quality (CTQ) requirements identified by customers to design the future-state process to deliver navigation services. The project team determined the systems and structures that would make the navigation program successful. They researched workflow issues, such as the patient navigator's job description, training and equipment needs, roles of the office manager and physician, etc. They built in opportunities for course corrections if something in the process wasn't working. Through it all, they strived to identify the ideal way to meet patients' needs and to ensure that any patient with an abnormal finding or in need of breast cancer treatment had immediate access to a patient navigator.

A long-term project plan (multigenerational plan) was designed, with the first phase consisting of a pilot program that was limited to 2 distinct markets within the system. Patients in need of navigation were identified by a large OB/GYN practice. The second phase, currently being implemented, has expanded to offer navigation services to all of Virtua's affiliated OB/GYN practices. There are 3 navigators presently on staff. Though housed in 2 navigation offices, the navigators often visit the physician offices they support, as well as accompany patients to specialists' offices or on other off-site visits.

The program is focused on 2 types of patient navigation: access navigation (for abnormal screening results) and care navigation (from cancer diagnosis through post-treatment surveillance). The 'access navigator' is a dedicated scheduler with exemplary customer service skills who is responsible for ensuring patients with an abnormal mammogram result are able to quickly access diagnostic consultations and procedures with specialists. The 'care navigator' is an oncology nurse who follows patients from cancer diagnosis through active treatment, often lasting up to 9 months, and into surveillance.

Upon entering the breast care navigation program, newly diagnosed patients are given a Patient Journey Binder, which is a valuable resource that includes educational material, supportive care information, and a section that allows patients to keep track of their schedules, results, appointments, and procedures. Multidisciplinary treatment planning conferences, which include the social worker, nurse navigator, and physician, are held regularly to discuss each patient's progress and needs.

Outcomes Metrics Development

Virtua knew that the development of a customized user-friendly database for the navigation program would be critical to its success. With the cooperation and support of the information technology department, a database was created that captures the key touch points at which navigators typically intervene on their patients' behalf, such as after an initial chemotherapy treatment. In fact, this database eliminates some of the onerous paperwork that can easily overwhelm navigators with a typical patient load of 100 clients, 30 to 50 of whom are in the active treatment phase of their cancer journey. This Web-based system has also recently been made available to physicians within the Virtua medical staff to enable them to track their patients through the cancer care continuum.

Another purpose of this database is to capture key metrics that can be used both to monitor the success of the program and document gained efficiencies to senior leadership. Queries can be run at any time so that quantitative improvement measures can be easily accessed and compared.

The metrics used by Virtua's navigation program were derived from extensive research into the needs of patients and expectations of physicians. The table below shows some of those metrics and the degree to which they were met during the pilot which began in third quarter 2007 through first quarter 2008.

2008 Navigation Metrics

 Jan 08Feb 08Mar 08
Navigator Assignment MetricCompliance
24 hrs = 100%
Compliance
24 hrs = 100%
Compliance
24 hrs = 100%
Within 48 hours from referral, navigator will be assigned to patient
Target: 24 hours
Patient Initial Contact MetricCompliance
15/18 24 hrs = 83%
48 hrs = 100%
Compliance
13/19 24 hrs = 68%
48 hrs = 100%
Compliance
7/11 24 hrs = 64%
48 hrs = 100%
Within 48 hours of assignment, navigator will contact patient
Target: 24 hours
Treatment Plan MetricCompliance
8/9 = 89%
1/9 - 1 day late
Compliance
= 100%
Compliance
= 100%
100% of diagnosed patients receiving navigation service are presented at treatment plan conference within 10 business days of being assigned
PCP Letter MetricCompliance
= 100%
Compliance
= 100%
Compliance
= 100%
Within 10 days of referral to program, program introduction letter is sent to referring physician/PCP
Virtual Surgery MetricCompliance
= 100%
Compliance
= 100%
Compliance
= 100%
80% of diagnosed patients are retained as surgical patients
Patient Binder MetricCompliance
= 100%
Compliance
= 100%
Compliance
= 100%
100% of referred patients receive Patient Journey Binder
Oncology Specialist MetricCompliance
= 100%
Compliance
= 90%
1/10 - 1 day late
Compliance
= 89%
1/10 - 1 day late
Within 3 weeks of definitive surgery date, patient sees appropriate oncology specialist for treatment consult
Radiation Oncology MetricCompliance
= 100%
Compliance
= 100%
Compliance
YTD = 100%
80% of diagnosed patients are retained as Radiation Oncology patients
Surveillance Plan Letter MetricCompliance
7/8 = 88%
1/8 = 5.8 days
Compliance
= 100%
Compliance
= 100%
Within 5 business days of treatment conclusion, letter and surveillance plan sent to referring physician/PCP
Patient Satisfaction100%
Very Satisfied
96%
Satisfied
97%
Satisfied
Satisfaction with educational instruction and responsive answers to questions
Supportive service referrals met my needs100%
Very Satisfied
94%
Satisfied
95%
Satisfied
Overall experience with the navigation program100%
Very Satisfied
100%
Very Satisfied
100%
Very Satisfied
Physician Satisfaction100%
Very Satisfied
100%
Very Satisfied
100%
Very Satisfied
Level of satisfaction with care coordination
Overall satisfaction with navigator program100%
Very Satisfied
100%
Very Satisfied
100%
Very Satisfied

Expansion of the Navigation Program

Virtua physicians see more than 3000 new cancer cases per year. After demonstrating the successful implementation of the breast cancer navigation program, Virtua implemented a colorectal navigation pilot, which follows the same framework established in the breast program. The goal is to connect patients to, and retain them in, the Virtua system for follow-up care.

A Successful Program

Virtua found that 3 elements have been critical to the success of the patient navigation program: (1) buy-in and support from top-level executives; (2) application of the DFSS methodology to design the service; and (3) a customized database that both facilitates implementation and tracks the success of the program. Some examples of the impact of the project are:

  1. Patient satisfaction ratings have been at 100%
  2. Of the 400 women with abnormal mammograms referred to the program by their OB/GYN, 98% have remained in the Virtua system compared with a prior retention rate of 50%
  3. The number of days from abnormal finding to surgical consult has been reduced from a pre-pilot average of 30 days to 12 days post-pilot, with the majority of patients being seen in less than 1 week
  4. Virtua physicians are now asking to be part of the program

This commentary shows that DFSS methodology can be utilized to design a new service to meet customer requirements and can improve the patient and caregiver experience. The methodology also supports physicians in their care by improving communication and information sharing between Virtua's PCPs and specialists. Engaging customers and key stakeholders in the process of designing and sustaining the navigation service is critical to success. The involvement of physicians from the outset essentially turned them into champions of the program and increased their willingness to collaborate with staff to deliver an outstanding patient experience for Virtua's breast care patients. Overall, DFSS was used to improve patient care and make personalized changes in the patient's experience.