Interview with the Innovators

Navigation Collaborations: AONN+, Sarah Cannon, and the Cancer Moonshot Program

April 2017 Vol 8, No 4 —April 12, 2017

An Interview with Crystal Dugger, RN, BSN, MBA, of Sarah Cannon, the Cancer Institute of HCA

Ms Dugger joined Sarah Cannon in 2011 and serves as the assistant vice president of clinical operations, where she is responsible for developing the solid tumor and nurse navigation programs for Sarah Cannon, the global Cancer Institute of Hospital Corporation of America (HCA).

Sarah Cannon offers integrated cancer services with convenient access to cutting-edge therapies for those facing cancer in communities across the United States and United Kingdom. It is nationally recognized for its many successes, such as the offering of hundreds of clinical trials, cutting-edge molecular profiling capabilities, and more than 1000 stem cell transplants performed annually throughout the Sarah Cannon Blood Cancer Network. Further, it is also notable for offering individualized patient navigation services provided by oncology-trained nurses. The program consists of 200 specially trained nurse navigators who have logged more than 70,000 patients into their iNavigate software system.

Sarah Cannon has invested in nurse navigation programs to ensure a navigator is there to assist patients through every step of their cancer journey. Specifically, nurse navigators at Sarah Cannon remove barriers to care to ensure patients are able to stay compliant to the treatment plan. Sarah Cannon nurse navigators are responsible for:

  • Reinforcing patient education concerning their cancer diagnosis, treatment options, and clinical trial availability
  • Empowering patients through education so they can be actively involved in making treatment decisions with their healthcare providers
  • Advocating for the patient to ensure their personal goals in care are met
  • Coordinating office visits across medical disciplines to streamline cancer care delivery
  • Facilitating communication between all members of the healthcare team
  • Participating in multidisciplinary team conferences to promote collaboration in cancer treatment, and
  • Relaying relevant information to all providers

Sarah Cannon’s dedication to a navigation program coincides with the spirit of the mission of the Academy of Oncology Nurse & Patient Navigators (AONN+). Several navigators from Sarah Cannon have provided input that helped to shape the direction of AONN+ and its projects and programs, such as the credentialing program, the introduction of standardized national navigation metrics, and the promotion of navigation programs. AONN+ is proud of this collaboration, and even more so after the recent announcement that former Vice President Biden’s Cancer Moonshot Program sought input from Sarah Cannon in collaboration with AONN+ to improve cancer care in our country.

Specifically, it is the collective goal to incorporate navigation techniques in all phases of the treatment spectrum to address prevention, screening, early detection, diagnosis, treatment, and palliative and supportive care.

The publishers of JONS had the pleasure of speaking with Crystal Dugger from Sarah Cannon about the evolution of oncology navigation programs, how Sarah Cannon became one of the first institutions to champion navigation programs, and their collaboration with the Cancer Moonshot Program to promote navigation techniques.

JONS To begin, how do you define an oncology nurse navigator?

Ms Dugger An oncology nurse navigator is an oncology nurse whose role is to ensure patient compliance to their treatment plan. They accomplish this by removing barriers to care and educating the patient, providing emotional support, and coordinating all aspects of the patient’s care.

We should also address the definition of a patient navigator or lay navigator. These are often navigators who are survivors themselves and either volunteer in cancer centers or are employed in an organization to assist patients emotionally and sometimes provide education within certain parameters.

Sarah Cannon has initially placed their focus on the clinical nurse navigation role.

JONS We’d like to hear more about your career path from oncology nurse to assistant vice president of clinical operations at Sarah Cannon.

Ms Dugger I started as an oncology staff nurse on the oncology floor. I have yet to have a job I did not love, including that role. Harold Freeman reported on cancer navigation in the late 1990s, and I was offered a navigation role in 2000.

The nurse navigation role truly propelled my career in a direction that I have absolutely loved and never dreamed was possible. It gave me a better understanding of the entire patient experience as well as the opportunity to create relationships with physicians and administrators to improve the cancer program. Being the face of the cancer program through my role as nurse navigator led me into another role as a director of a cancer center in Knoxville, TN. From there I became a Health Service Line Leader of St. Mary’s and Baptist Hospitals of East Tennessee (now Tennova in Knoxville); that experience gave me the opportunity to lead a national program here at Sarah Cannon.

JONS We noticed you not only have RN and BSN degrees but also a master’s degree in business administration. How has that complemented your career?

Ms Dugger I believe the ability to understand the whole experience from the patient’s side, physician’s side, and from a facility’s perspective on their return on investment has helped me to be successful. My MBA has helped me understand an important part of the picture: It doesn’t matter how passionate you are about a program if you can’t ensure that it is financially sustainable.

St. Mary’s and Baptist was part of the CHP Hospital system. In that system, I remember hearing the Sisters of Mercy say “no money, no mission.” Every program has to be able to sustain itself. You have to be diligent with the money and the resources so we can take care of all patients.

JONS How has Sarah Cannon risen to become a prime example of navigation, and how has it impacted your patient outcomes?

Ms Dugger Many times, when a nurse accepts a navigator position, their training could be as simple as being told to “go forth and navigate.” At Sarah Cannon, navigators receive training specific to the oncology field.

To provide the proper training, we had to start at the beginning with the question, “what is a cancer navigator?” If you asked 10 people, they would give you 10 different definitions of that role. Then we had to identify the problem we were trying to solve. We decided that if a patient can’t follow through on their individualized treatment plan that our physician experts have come together to create, then it doesn’t really matter how amazing the treatment plan is. Barriers to care exist for a plethora of reasons. We must listen and advocate for our patients to ensure we are meeting their goals of care. Are they trying to get to their daughter’s graduation? Is that the goal? Is quality of life more important than anything else? We need to understand the goals of the patients, and then ensure they are educated and empowered to participate in treatment decisions.

In identifying the problems we were trying to solve, we were able to create a standardized program with a job description, orientation, training program, and most importantly, standardized metrics that look at quality, patient engagement, timeliness of care, patient satisfaction, physician engagement, and programmatic efficiencies. Our physicians are now creating pathways, which have further improved our ability to standardize the processes within our programs.

In order to truly be successful, all the stakeholders involved (patients, physicians, and administrators) must know and support these goals. What set us apart was focusing on standardization through training and orientation, a standardized terminology, and the standardized metrics.

JONS Can you offer advice as to how other navigation programs can enhance their programs from a metrics standpoint?

Ms Dugger When first starting out, I suggest focusing on as few as 3 metrics, giving 1 metric to each stakeholder. One metric for patients, 1 for physicians, and 1 for facilities. Currently, at Sarah Cannon, we have 12 metrics, and we continue every year to add depth to those metrics. In addition, become best friends with your cancer registrar. They have a world of cancer program data that usually go untapped.

JONS How has the initiation of navigation programs impacted patients directly?

Ms Dugger Back in the nineties, there was so much excitement because navigation actually improved survival. They achieved this by ensuring patients stayed compliant to their treatment plan. Many times, we are only focused on the drug that we’re putting into the infusion, but we also need to be concerned about the whole picture, the whole patient, what their goals are, and identifying the barriers to their care.

We also want to ensure that patients have a positive experience through the entire continuum. For example, patient satisfaction is a metric that is very important to us and can be strongly related to timeliness of care.

JONS You were recently contacted by the White House and asked to partner with the Cancer Moonshot Program. Can you describe the program and their interest in Sarah Cannon?

Ms Dugger The Moonshot aims to aggressively decrease the current expected timeline for cancer cures. This includes increasing the number of clinical trials and increasing patient access to care.

One of the things that really interested the Joe Biden Moonshot Task Force in Sarah Cannon was our ability to impact change in the community hospital setting. The Hospital Corporation of America (HCA), of which Sarah Cannon is a part, has approximately 165 hospitals across the United States. So when we’re successful at something and are able to implement a program across all hospitals, then we truly have implemented care across the country. When we are successful, that means that we have found something that could successfully raise the bar not just in our centers but across the nation.

This is important, because 85% of cancer patients are treated in community hospitals. If a person has to fly across the country to receive their care, this isn’t the best case scenario for the patient. I think most would agree that the best scenario is having quality treatment close to home and the patient’s support system.

That is why the Moonshot was so interested in our program. We have standardized a navigation program across the United States that ensures oncology nurses are working with physicians to provide patients with the best care. Together, we have built pathways that we ensure our patient’s follow.

The goal of AONN+ and Sarah Cannon is to standardize the role of a nurse navigator and to show that this is a legitimate profession for an oncology nurse that has a very specific role, a very specific scope, and very specific expected outcomes. Ultimately, it improves the care for patients, it engages your physicians, and it helps your facilities to have a strong cancer program.

JONS What does recognition by the Moonshot mean to your institution?

Ms Dugger Having the Moonshot recognize our program as a solution to improve care coordination and patients’ access to clinical trials has been a game changer for us. Recognizing what we have accomplished thus far and what our goals are for the future, I believe it absolutely has helped the visibility of navigation programs. In my opinion, AONN+ and Sarah Cannon have propelled that body of work substantially forward just by being a part of the Moonshot and having a tangible goal of moving the standardization across the country through this initiative.

JONS Do you have any advice for smaller community programs on how they can effectively initiate or integrate a navigation program into their practice?

Ms Dugger Sarah Cannon is not 1 huge institution, it is a network of unified experts who live within large and small community health systems across the country. For some of our larger institutions, they don’t need 1 general navigator, they may have 5 breast navigators because that’s what they need to effectively navigate their patients. But if you only have 50 breast cancer patients coming through your system, your 1 navigator may be able to focus on more than 1 tumor site.

I can’t reiterate enough that cancer registry is the backbone of any good cancer program, small or large. Once you understand what your cancer population looks like, you may find that 75% of the cancer patients who walk through your doors represent 3 specific tumor sites. You can focus your navigator in those 3 areas, whereas in a really large organization, you may find that you need a navigator for breast, a navigator for lung, and a navigator for gastrointestinal cancers.

JONS What is the first thing a practice should do before initiating a navigation program?

Ms Dugger First things first; you need to do an assessment of your program—we call it a gap analysis. You need to understand your program, including what tumor sites your program most frequently treats. Then you need to determine and understand the barriers to care.

I once heard great advice from Lillie Shockney, cofounder of AONN+, when you are starting a navigation program—the advice was to literally follow a patient through the program, without saying a word, and watch how they experience the program. Did they know where to park? How many steps did it take them to carry their oxygen behind them and to get where they’re trying to go? Was there someone there to greet them? Was the registration clerk nice? These are things you don’t necessarily think about because you’re really thinking about the experience when they’re in the chair in the infusion center. But that’s not the experience of the patient and their family. Their experience is so much more than that.

I would also advise people to know your goals. Use the outcomes metrics that AONN+ and Sarah Cannon has created and know what you’re trying to achieve. Take advantage of the certification programs. Use these resources to train and educate the navigators in your program. Make sure you have a navigation leader who is invested in the success of the program, understands the program, and is measuring outcomes through some type of monthly score card that is shared with key administrators and key physicians so they also understand the successes and can create action plans where you’re not meeting the goal.

And last but not least, create a physician advisory board that’s tumor site–specific around the areas that you’re going to navigate and keep them engaged and involved in the care of your patient. Cancer is a team job, so we have to work together to ensure the best care for our patients.

JONS Thank you for your time today and continued success on your mission to improve the lives of patients through navigation.


Ms Dugger joined Sarah Cannon in 2011 and serves as the assistant vice president of clinical operations, where she is responsible for developing the solid tumor and nurse navigation programs for Sarah Cannon, the global Cancer Institute of Hospital Corporation of America (HCA).

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Last modified: April 23, 2021

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