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Improving Nonclinical and Clinical-Support Services: Lessons From Oncology

Open AccessPublished:July 04, 2018DOI:https://doi.org/10.1016/j.mayocpiqo.2018.05.002

      Abstract

      Nonclinical and clinical-support personnel serve patients on the front lines of care. Their service interactions have a powerful influence on how patients perceive their entire care experience, including the all-important interactions with clinical staff. Ignoring this reality means squandering opportunities to start patients out on the right foot at each care visit. Medical practices can improve the overall care they provide by focusing on nonclinical and clinical-support services in 5 crucial ways: (1) creating strong first impressions at every care visit by prioritizing superb front-desk service; (2) thoroughly vetting prospective hires to ensure that their values and demeanor align with the organization's; (3) preparing hired staff to deliver excellent service with a commitment to ongoing training and education at all staff levels; (4) minimizing needless delays in service delivery that can overburden patients and their families in profound ways; and (5) prioritizing the services that patients consider to be most important. We show how cancer care illustrates these principles, which are relevant across medical contexts. Without nonclinical and clinical-support staff who set the right tone for care at every service touchpoint, even the best clinical services cannot be truly optimal.

      Abbreviations and Acronyms:

      MA (medical assistant)
      A 6-year-old boy with cancer, whom we will call Ben, loved seeing the clinic's receptionist, Donna. She always welcomed him joyfully and talked to him as if he were a grown-up. When Ben passed his reading exams at school, Donna gave him lollipops. Ben often would have appointments with different clinical doctors, nurses, and technicians, but Donna was the consistently “familiar face” who eased his anxiety. She was the first person who interacted with Ben on clinic visits, even though just briefly, and she started his day with a smile.
      Reception is just one of many cancer-care services that may occur before the patient sees the doctor. These services can be categorized as nonclinical (eg, front-desk reception and financial counseling), clinical support (eg, laboratory, patient navigation), and clinical (clinicians' direct patient care). Nonclinical and clinical-support services delivered with creativity, efficiency, empathy, and extra effort have the potential to frame—and strongly influence—patients' and families' perceptions of overall service quality. Although the quality of the clinical encounter is paramount, the benefits of properly setting the stage and preparing patients (and families) to visit the clinician should not be underestimated. Perceptions of early services can create a “halo effect” that endures through later services.
      • Murphy K.R.
      • Jako R.A.
      • Anhalt R.L.
      Nature and consequences of halo error: a critical analysis.
      • Oxford Dictionary
      Definition of halo effect in English.
      Although we focus on oncology to illustrate the importance of nonclinical and clinical-support staff in creating the overall patient experience, the potential impact these staff members have on patient perceptions is relevant to any health care context where patients interact with nonclinical staff.
      Consider an encounter in which a friendly phlebotomist with a calming manner draws a patient’s blood after check-in, and another in which the phlebotomist is harried and stern. The first experience can positively influence how the patient perceives the subsequent interaction with the doctor; the second can have the opposite effect. The influence of early interactions on later experiences is termed a “halo effect.”
      • Van Doorn J.
      Is there a halo effect in satisfaction formation in business-to-business services?.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      Halo effects do not occur for all service elements.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      Research shows that service elements that are difficult to evaluate are more susceptible to halo effects, which gives rise to “selective halo effects.”
      • Van Doorn J.
      Is there a halo effect in satisfaction formation in business-to-business services?.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      For example, the friendliness and empathy of a receptionist is easier for patients to judge than the technical aspects of clinical care.
      • Van Doorn J.
      Is there a halo effect in satisfaction formation in business-to-business services?.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      • Bendapudi N.M.
      • Berry L.L.
      • Frey K.A.
      • Parish J.T.
      • Rayburn W.L.
      Patients’ perspectives on ideal physician behaviors.
      In this way, exemplary service outside examination or hospital rooms can favorably influence how patients and families perceive the technical services provided inside them, and vice versa.
      • Van Doorn J.
      Is there a halo effect in satisfaction formation in business-to-business services?.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      Although studies examining how halo effects influence patient perceptions of care are rare, a quasi-experimental study conducted in 2 locations of a private oncology practice provides a case study of these effects for nonclinical and clinical-support services.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      The study demonstrates that patients' perceptions of their interactions with frontline service employees (eg, receptionists) radiates to other parts of the service to influence subsequent perceptions about clinicians' technical skills and expertise. The study involved 2 stages. First, during a 4-week period, 250 patients at each location completed a comprehensive survey about their service perceptions. Three weeks later, 12 receptionists at one of these locations (the “intervention” practice) received a full day of interpersonal skills training and education in communication, empathy, and service recovery; no intervention occurred at the other location. Two months after the initial survey, it was readministered in the same way to 250 patients at each location. Usable responses came from 772 patients in all.
      The results indicated that mean perception scores for interpersonal attributes, such as empathy as demonstrated by nonclinical staff, were significantly higher for the intervention practice (P>.05), as were scores for difficult-to-evaluate attributes, such as clinician expertise and skill (P>.05). Mean scores did not differ significantly for nonbehavioral attributes such as timeliness (P>.05). Thus, the service training and education intervention for oncology clinic receptionists improved patients' perceptions of their performance not only on easier-to-evaluate attributes such as friendliness and explanation but also “spilled over” to positively influence perceptions of unrelated, harder-to-evaluate attributes such as clinician expertise and skill.
      • Dagger T.S.
      • Danaher P.J.
      • Sweeney J.C.
      • McColl-Kennedy J.R.
      Selective halo effects arising from improving the interpersonal skills of frontline employees.
      We believe this effect is relevant across medical contexts, not just oncology care. Medical specialties such as cardiology and orthopedics, which commonly incorporate clinical-support services in addition to nonclinical services, are likely to be particularly susceptible to selective halo effects.
      The influence of nonclinical and clinical-support staff in shaping patients' overall perceptions of their care should not be underestimated because this can lead to underinvestment in these services. Patient experience is shaped by every point of contact. Studies show a consistent positive association between patient experience and adherence to therapy, clinical effectiveness, safety, and utilization of care.
      • Doyle C.
      • Lennox L.
      • Bell D.
      A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.
      • Anhang Price R.
      • Elliott M.N.
      • Zaslavsky A.M.
      • et al.
      Examining the role of patient experience surveys in measuring health care quality.
      As emerging value payment models incorporate quality and patient experience metrics into reimbursement rates, it is a wise investment for medical practices to evaluate every touch point of care. In addition, the overall patient experience affects practice reputation, by both word-of-mouth and online reviews.
      In this article, we propose 5 service principles to improve nonclinical and clinical-support services and, thereby, strengthen the service provided to patients. We discuss and illustrate the principles in the text and provide additional detail in the Table.
      TableImplementig the Five Recommendations in Practice
      RecommendationExampleInterventionOutcomes
      Strong first impressionsMarin Cancer CareEncourages front desk staff to:
      • Know patients, their disease and treatments
      • Personalize experience
      • Facilitate coordination of care
      • Satisfaction scores show that 95% of patients report front staff as helpful, friendly, and courteous
      Hire for fit and valuesMarin Cancer CareHiring and retention plan:
      • Extensive new-hire process
      • Pays well
      • Flexible schedules for some positions
      • Bonuses when the practice does well
      • Promotes from within, providing staff a pathway for career progression
      • More than 90% of patients rate service as “very good” or “excellent”
      • More than 95% of patients would recommend Marin Cancer Care to others according to an external survey
      Integris Cancer InstituteHiring philosophy:
      • Hire employees for job satisfaction and not just salary
      • Hire for fit with entire team
      • Wait for the right candidate rather than just filling the position
      • Improved patient satisfaction scores (see data below)
      Training and educationIntegris Cancer InstituteStaff training and education on:
      • “Power of courtesy”
      • “What does a ”remarkable” patient experience look like to you?”
      • Empathetic communications
      • Patient satisfaction scores went from the 75th percentile to the 99th percentile during a 2-y period after the inception of a more comprehensive training and education program
      Marin Cancer CareBroadens the job to improve service and efficiency:
      • Rotate new staff through each department
      • Front- and back-office staff are cross-trained to provide job enrichment and better coverage
      • Staff are encouraged to:
      • o ask questions
      • o change things if they can be improved
      • A well-prepared staff contributes to higher patient satisfaction (see data above) and lower employee turnover
      Minimize delaysAmbulatory Treatment Center of MD Anderson Cancer CenterTo minimize delays:
      • Performs early IV assessment
      • Streamlines short-duration appointments
      • Fast-tracks completion of chemotherapy orders
      • Provides early notification to pharmacy of medications
      • New IT to support internal communication and care coordination
      • Overall patient waiting time was reduced by more than 25%
      • Resulting in more than 3.6 additional patient appointments per day
      • The annualized potential financial opportunity of this exceeds $1 million
        • Kallen M.A.
        • Terrell J.A.
        • Lewis-Patterson P.
        • Hwang J.P.
        Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center.
      Henry Ford Cancer Center OncoStat ClinicsTo provide more immediate care: OncoStat Clinics placed throughout market area to provide timely access to patients undergoing chemotherapy and experiencing adverse effects
      • Patients receive care for urgent needs without needing to visit an emergency room
      • Clinical flow for physicians improved because of fewer nonscheduled patients requiring emergent interventions
      Prioritize servicesFinancial counseling and assistance

      Marin Cancer Care
      Financial counselors:
      • Verify insurance coverage for each patient
      • Work closely with local hospitals, diagnostic service providers, and insurance companies to get authorizations in place to minimize delays
      • Provide a written benefit summary to the patient at their first visit with an opportunity to work with the financial counselor if they choose
      • Help connect the patient with needed resources, such as financial, transportation, and home care needs
      • More than 95% of patients rated the information provided about treatment costs, financial arrangements, and insurance claims as very good or excellent
      • Billing was rated as clear by more than 95% of patients
      • Staff received a high rating for their helpfulness when assisting patients with billing and insurance
      Minnesota Oncology (Minneapolis)Financial counselors educate patients about their insurance benefits including:
      • how much of the annual deductible has been paid
      • the difference between co-payments and co-insurance
      • any benefit caps in place
      • Counselors explain the total costs of treatment, out-of-pocket expenses, and the practice’s payment policy. They meet with patients regularly to stay abreast of the financial implications of care
      • Offering access to financial experts reduces patient anxiety and stress, contributing to their overall well-being
        • Gesme D.H.
        • Wiseman M.
        A financial conselor on the practice staff: a win-win.
      • Time-consuming financial discussions are removed from patient interactions with the clinician, reception staff, and the billing office
        • Gesme D.H.
        • Wiseman M.
        A financial conselor on the practice staff: a win-win.
      • Clinicians are able to spend more time on complex cases or see more patients to increase revenue
        • Gesme D.H.
        • Wiseman M.
        A financial conselor on the practice staff: a win-win.
      Patient education Monash Children’s Hospital and Royal Children’s HospitalPediatric patient education is used before clinicians consider sedating patients. Play therapists reduce anxiety by using:
      • Mock MRI sessions (full-scale replicas of MR imaging units devoid of internal magnets)
      • MR-compatible audiovisual systems
      • Feed-sleep manipulation strategies
      The play therapist is able to assess from the session whether a child will be able to undergo an MRI without sedation and provides a recommendation to the child’s medical team
      • General anesthesia rates decreased by 8.6%
        • McGuirt D.
        Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
      • 98% of children went on to have a successful MRI procedure
        • McGuirt D.
        Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
      • Translated into estimated annual net savings of $117,870
        • McGuirt D.
        Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
      Thomas Jefferson UniversityTechnology-enabled patient education:
      • Virtual Environment Radiotherapy (VERT) software (which is like a flight simulator) provides life-size visualizations and 3-dimensional views to simulate the patient experience
        • Marquess M.
        • Johnston S.P.
        • Williams N.L.
        • et al.
        A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy.
      • Reduced patient anxiety
        • Marquess M.
        • Johnston S.P.
        • Williams N.L.
        • et al.
        A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy.
      • Clarified patient expectations
        • Marquess M.
        • Johnston S.P.
        • Williams N.L.
        • et al.
        A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy.
      Patient navigation

      The University of Alabama at Birmingham Health System Cancer Community Network (CNN)
      Use of lay navigators:
      • Lay navigators are carefully selected and trained in evidence-based methods
      • Care maps provide a workflow diagram and indicate the timing for patient-navigator interactions
      • Comprehensive distress assessment determines the patient’s mental state
      • Software is used to capture data across the patient experience and allow for better coordination of care across medical teams
        • Rocque G.B.
        • Partridge E.E.
        • Pisu M.
        • et al.
        The patient care connect program: transforming health care through lay navigation.
        • Rocque G.B.
        • Pisu M.
        • Jackson B.E.
        • et al.
        Patient Care Connect Group
        Resource use and Medicare costs during lay navigation for geriatric patients with cancer.
      • Patient satisfaction was higher for navigated patients than for matched comparison patients
        • Rocque G.B.
        • Partridge E.E.
        • Pisu M.
        • et al.
        The patient care connect program: transforming health care through lay navigation.
      • Total costs decreased by $781.29 per quarter for navigated patients vs control group during the 3-y study period (2012-2015)
        • Rocque G.B.
        • Pisu M.
        • Jackson B.E.
        • et al.
        Patient Care Connect Group
        Resource use and Medicare costs during lay navigation for geriatric patients with cancer.
      • Emergency department visits, hospitalizations, and intensive care unit admissions all decreased significantly for navigated patients
        • Rocque G.B.
        • Pisu M.
        • Jackson B.E.
        • et al.
        Patient Care Connect Group
        Resource use and Medicare costs during lay navigation for geriatric patients with cancer.
      IV = intravenous; IT = information technology; MR = magnetic resonance; MRI = magnetic resonance imaging.

      Create a Strong First Impression

      Front-desk staff in many medical clinics make the crucial first impression; their organizational, interpersonal, and emotion-management skills, plus their preparation for and engagement in the work, set the tone for the visit.
      • Welling R.
      The importance of medical receptionists.
      In their complex role, these staff control the internal geography of waiting spaces
      • Neuwelt P.M.
      • Kearns R.A.
      • Browne A.J.
      The place of receptionists in access to primary care: challenges in the space between community and consultation.
      for anxious patients and families. They do so in full view while juggling multiple tasks: checking in patients, answering phones, and responding to requests from clinical staff. In addition to managing patients’ demands and expectations, these employees need to meet the efficiency and productivity demands of the organization.
      • Singh J.
      Performance productivity and quality of frontline employees in service organizations.
      Often these staff feel “caught in the middle.”
      • Singh J.
      Performance productivity and quality of frontline employees in service organizations.
      Efficiency is essential but insufficient for such a high-emotion service as health care.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      Front-desk staff need to be ambidextrous,
      • Yu T.
      • Patterson P.G.
      • De Ruyter K.
      Achieving service-sales ambidexterity.
      which in health care means engaging with patients in a way that is friendly, warm, and empathetic while also delivering service that is efficient and error free. This tension can lead to job stress and dissatisfaction, which in turn can negatively affect the patient experience.
      • Hartline M.D.
      • Ferrell O.C.
      The management of customer-contact service employees: an empirical investigation.
      Indeed, our interviews with adult cancer patients reveal just how dehumanizing these experiences can be, if these elements are not in balance. One patient commented, “We are just like cattle in a corral—line up, hand out your card, don't make eye contact, don't ask any questions, here's your paperwork, move along, next patient.”
      The most effective front-desk staff remain calm and professional when serving an upset or verbally abusive patient (emotional neutrality) and adjust their performance with each patient's circumstances and personality (emotional switching).
      • Ward J.
      • McMurray R.
      The unspoken work of general practitioner receptionists: a re-examination of emotion management in primary care.
      They strive to know their patients, listen well, alert colleagues if a patient is in unusual distress, and keep waiting patients informed about delays. These frontline service employees, who are often underpaid, stressed, overworked, and undertrained in various types of service organizations,
      • Hartline M.D.
      • Ferrell O.C.
      The management of customer-contact service employees: an empirical investigation.
      influence critical first-impression service perceptions.
      Medical practices should prioritize investing in superb front-desk service. This will involve hiring people who demonstrate the ability to be ambidextrous and juggle the many roles played by these staff. It also means investing in their professional development to improve their skills and knowledge. Larger practices should consider providing administrative support for frontline staff to help the clinic run smoothly. For example, Northwell Health Monter Cancer Center, based in Long Island, New York, has invested in an administrative coordinator (a sort of “traffic cop”) at the laboratory front desk to provide support, such as printing out orders and vial labels for the phlebotomists or helping a patient who requires extra attention.

      Hire the Person, Not the Résumé

      Patients do not distinguish between the quality of the service and the quality of the people performing it.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      The first rule of execution in a labor- and skill-intensive service organization is to hire people who can effectively perform the service.
      • Berry L.L.
      Competing with quality service in good times and bad.
      In health care, that means setting high standards and looking beyond the résumé into a person’s teamwork orientation, communication skills, emotional strength, and core values, including compassion and integrity. To serve successfully and find personal reward in a health care setting, one must endure others' fears and stresses (emotional capacity) and bounce back from difficult encounters (emotional resilience).
      • Wirtz J.
      Winning in Service Markets: Success Through People, Technology and Strategy.
      • Weinberg D.B.
      • Avgar A.C.
      • Sugrue N.M.
      • Cooney-Miner D.
      The importance of a high-performance work environment in hospitals.
      Résumés do not capture a candidate's emotional capacity and resilience.
      Working with patients and families is likely to intensify staff members' “emotional labor” whereby they often must manage their feelings, expressions, and body language to successfully fulfill the job's requirements.
      • Rafaeli A.
      • Sutton R.I.
      Expression of emotion as part of the work role.
      • Hennig-Thurau T.
      • Groth M.
      • Paul M.
      • Gremler D.D.
      Are all smiles created equal? how emotional contagion and emotional labor affect service relationships.
      A patient's insensitive, rude, or angry remark does not merit an equivalent response from the service provider. Similarly, staff must be able to cope with getting to know patients, sometimes children, and their families who may be facing daunting medical challenges, including a terminal diagnosis. Hiring staff with emotional intelligence is essential in medical care.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      Excellent service organizations seek candidates with not just the right technical skills but with the right values that mirror the organization's. Multiple staff typically interview finalist candidates and weigh in on hiring decisions. The recruitment process could include psychometric, personality, and aptitude tests to identify candidates who “fit” the job,
      • Wirtz J.
      Winning in Service Markets: Success Through People, Technology and Strategy.
      as well as open-ended “behavioral” interview questions designed to reveal a person's values and emotional strength, such as “Tell me about a time you interacted with a disagreeable person and how you dealt with it.”
      The leadership teams at Marin Cancer Care in northern California and Integris Cancer Institute in Oklahoma City understand that working with cancer patients on a daily basis requires certain traits that many people do not possess. Both organizations use team interviews to get a broader perspective on job candidates. This gives team members (including frontline staff) a voice in the hiring process, signaling that they and their feedback are valued. As a result, staff take more “ownership” over the training and integration of new hires, and the candidates themselves gain more insight into the organization's culture.

      Prepare Performers to Perform

      Being well prepared strengthens self-confidence, which directly influences one's motivation to serve well.
      • Berry L.L.
      Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success.
      Training focuses on skills improvement (the “how”), which is essential but insufficient. Service providers also need education (the “what” and “why”). Physicians, nurses, and senior administrators commonly attend courses, conferences, and other ongoing educational events, but nonclinical and clinical-support staff are often left out.
      • Neuwelt P.M.
      • Kearns R.A.
      • Browne A.J.
      The place of receptionists in access to primary care: challenges in the space between community and consultation.
      This is a lost opportunity to instill greater engagement in the work, improve the performance of patient-facing staff, facilitate promotion from within, and possibly reduce turnover and its hidden costs (eg, replacing employees with less-experienced ones).
      • Berry L.L.
      Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success.
      Excellent service organizations include all staff in ongoing developmental activities because personal growth is central to finding fulfillment in work. Learning is an antidote to staleness, mental fatigue, and burnout.
      • Berry L.L.
      Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success.
      • Shanafelt T.D.
      • West C.P.
      • Sloan J.A.
      • et al.
      Career fit and burnout among academic faculty.
      Learning through service simulations (eg, viewing video scenarios depicting upset patients and then discussing how best to respond) and “off-stage” practicing (eg, role-playing difficult service encounters and receiving peer feedback) can be effective. Athletes and musicians practice; service providers should practice, too. Service-mindedness and teaching skills should be among the criteria for internal promotion because middle managers are best positioned to mentor others in service excellence. When Integris Cancer Institute opened in 2009, it invested in onsite training and education for all staff with particular emphasis on avoiding departmental silos, promoting teamwork, and understanding the life upheaval that cancer patients and families experience. As the institute grew, Integris started to “let some things slip,” according to an interview with a senior administrator. In 2016, management recommitted to “getting back to our basic roots.” Patient experience is now a standing agenda item at leadership team meetings, and all managers are accountable for their staff’s service performance. A template was created for leaders to do both patient rounds and employee rounds. Hallmarks of service excellence were incorporated into various new training and education modules (eg, service recovery).

      Attack Needless Delay in Service Delivery

      Operational inefficiencies cause unnecessary delays as patients in an emotionally vulnerable state wait for test results, procedures, and appointments. As one oncology nurse manager told us: “Waiting is suffering. Patients are scared. They don't feel well. We don’t do a good job communicating about delays. Some delays are out of our control, but most are within it.” When patients are anxious, delays heighten uncertainty reactions while commonly eliciting feelings of annoyance, irritation, and frustration.
      • Jacobson J.O.
      • Rotenstein L.S.
      • Berry L.L.
      New diagnosis bundle: improving care delivery for patients with newly diagnosed cancer.
      • Visser M.R.
      • van Lanschot J.J.
      • van der Velden J.
      • Kloek J.J.
      • Gouma D.J.
      • Sprangers M.A.
      Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired.
      • Paul C.
      • Carey M.
      • Anderson A.
      • et al.
      Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey.
      • Taylor S.
      Waiting for service: the relationship between delays and evaluations of service.
      • Thompson D.A.
      • Yarnold P.R.
      • Williams D.R.
      • Adams S.L.
      Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department.
      Keeping anxious patients informed about the reason for an unexpected delay and what timing to expect is important in minimizing psychological distress that can lead to negative emotions.
      • Thompson D.A.
      • Yarnold P.R.
      • Williams D.R.
      • Adams S.L.
      Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department.
      The best option is to minimize avoidable delay. Little or no delay requires no explanation or apology.
      Transforming waiting time in the facility into meaningful activity for patients and families, such as providing relevant health-related material or appropriate entertainment, is beneficial. This is particularly important for pediatric patients and their families. In this setting, providing distraction is critical to reducing the anxiety and stress associated with waits. At Monash Children's Hospital in Australia, oncology patients and family members have access to playrooms, music therapy, and/or daily arts and crafts programs. For expected delays, such as when patients come in for pathology and a follow-up appointment (involving up to a 2-hour wait for pathology results), movies are shown in the hospital's in-house cinema. Patients arrive at a designated time for blood work and then they go to the cinema to watch a scheduled movie. Parents are texted when blood results are returned and it is time to see the doctor.
      Health care involves many moving parts, and improving operational efficiency to minimize delays requires a steadfast commitment to investigating potential bottlenecks, searching for processes that can be eliminated or redesigned, and developing tools to improve productivity. Speed-of-service innovation, led by staff closest to the work and supported by management, is essential in delivering high-quality cancer care. At Segal Cancer Centre in Montreal, a simulation model showed that better matching patient arrival times with capacity—and reducing extended interruptions during the pharmacist validation steps (from 33% of prescriptions to 10%)—could reduce average patient wait times by 44%.
      • Suss S.
      • Bhuiyan N.
      • Demirli K.
      • Batist G.
      Toward implementing patient flow in a cancer treatment center to reduce patient waiting time and improve efficiency.
      Northwell reengineered laboratory order reviews to occur before the patient visit so that patients know at check-in whether laboratory tests are needed before or after the visit, or not at all. The clinical team conducts a previsit review of what the patient needs and enters a note into the scheduling system used by front-desk and laboratory staff.
      Henry Ford Cancer Institute, in Detroit, has developed a workflow checklist for medical assistants (MAs) so that all key components of check-in are systematically addressed and the patient is “doctor-ready.” In addition to standard steps such as taking patients' vitals, reviewing medications, and ordering refills, the checklist reminds the MA to administer separate depression and quality-of-life screening tools when they are due. The MA then enters the data into the medical record for the physician to see. Patients also periodically complete an overall distress screening questionnaire on an iPad, which the MA orders when due. An audit tool was created to spot-check MA performance in completing all steps.

      Prioritize Services That Matter Most

      Hearing directly from patients and family caregivers is essential in prioritizing services. Kaiser Permanente's cancer program uses patient advisors, who participate in either an oncology-specific advisory council or process-improvement teams for each cancer type. Program administrators report that incorporating patient advisors accelerates change, energizes the team, prioritizes improvements, and produces consistent feedback about patients' needs regardless of cancer type. Initiatives developed with the influence of patient advisors at Kaiser Permanente include expansion of nurse navigation, financial counseling, interactive patient education materials, shared decision-making tools, standardization of analgesia for invasive procedures, timeliness improvements, and a cancer-wellness program.
      Strong organizations excel in prioritizing services that customers themselves prioritize. This principle clearly applies across health care contexts. In cancer, the oncology literature,
      • Wagner E.H.
      • Aiello Bowles E.J.
      • Greene S.M.
      • et al.
      The quality of cancer patient experience: perspectives of patients, family members, providers and experts.
      • Patel M.I.
      • Periyakoil V.S.
      • Blayney D.W.
      • et al.
      Redesigning cancer care delivery: views from patients and caregivers.
      Kaiser Permanente's advisor feedback, and our own primary research (L.L.B., T.S.D.) and clinical experience (K.A.D.) with cancer patients and families align in identifying nonclinical and clinical-support services that patients value most. These include financial counseling and assistance, patient education, and patient navigation services. When offered proactively and performed well, valued services can create pleasant surprise, the key to exceeding customers’ service expectations.
      • Berry L.L.
      Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success.

      Financial Counseling and Assistance

      As if the physical and emotional tolls were not enough, many cancer and other seriously ill patients, including those with health insurance, also pay a heavy financial toll.
      • Meeker C.R.
      • Geynisman D.M.
      • Egleston B.L.
      • et al.
      Relationships among financial distress, emotional distress, and overall distress in insured patients with cancer.
      • Shen C.
      • Zhao B.
      • Liu L.
      • Shih Y.-C.T.
      Financial burden for patients with chronic myeloid leukemia enrolled in Medicare part D taking targeted oral anticancer medications.
      • Stump T.K.
      • Eghan N.
      • Egleston B.L.
      • et al.
      Cost concerns of patients with cancer.
      • Zafar S.Y.
      • Peppercorn J.M.
      • Schrag D.
      • et al.
      The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.
      • de Souza J.A.
      • Kung S.
      • O’Connor J.
      • Yap B.J.
      Determinants of patient-centered financial stress in patients with locally advanced head and neck cancer.
      • Fenn K.M.
      • Evans S.B.
      • McCorkle R.
      • et al.
      Impact of financial burden of cancer on survivors' quality of life.
      • Chino F.
      • Peppercorn J.M.
      • Rushing C.
      • et al.
      Out-of-pocket costs, financial distress, and underinsurance in cancer care.
      Loss of income from illness coupled with medical expenses can have a devastating impact on a family's financial stability. Cancer, for example, is a leading cause of personal bankruptcy.
      • Ramsey S.
      • Blough D.
      • Kirchhoff A.
      • et al.
      Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.
      • Meropol N.J.
      • Schrag D.
      • Smith T.J.
      • et al.
      American Society of Clinical Oncology. American Society of Clinical Oncology guidance statement: the cost of cancer care.
      One study found that 29% of insured cancer patients reported high to overwhelming financial distress and a strong association between financial distress and overall distress.
      • Meeker C.R.
      • Geynisman D.M.
      • Egleston B.L.
      • et al.
      Relationships among financial distress, emotional distress, and overall distress in insured patients with cancer.
      Many cancer patients and their families need financial navigation services.
      • Sherman D.
      Oncology financial navigators: integral members of the multi-disciplinary cancer care team.
      Marin Cancer Care employs an experienced staff of financial counselors who meet with all patients to review insurance benefits and determine whether their resources can cover costs. The staff are both expert and proactive in helping patients who need financial assistance find it from pharmaceutical companies, foundations, oncology societies, government, and hospital charities. They view their role as patient advocates. As one counselor told us, “Patients in 30 days can owe a boatload of money.”

      Patient Education

      Educating patients (and families) about what to expect before each phase of their medical journey can help defuse negative emotions such as anxiety and fear. Well-run cancer centers review the process and answer questions before a patient's first radiation or chemotherapy treatment session. As an infusion nurse told us, “The anxiety level is so high for a new chemo patient when they sit in that chair for the first time and get an IV line inserted. A common question is ‘What am I going to feel now (or this evening)?’”
      Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, has found that patients who experience virtual-reality simulation of radiation therapy are significantly less anxious and have clearer expectations about the therapy than do patients who receive traditional preparation.
      • Marquess M.
      • Johnston S.P.
      • Williams N.L.
      • et al.
      A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy.
      Monash Children's and the Royal Children's hospitals in Australia have a full-scale mock magnetic resonance imaging unit (with sound and motion) in which children can practice, before their scans, putting themselves or their favorite soft toys through the scanner to demystify the procedure and reduce stress and anxiety. Practicing in the mock machine resulted in an 8.6% reduction in general anesthesia rates. Comparing the cost of the mock magnetic resonance examination including staff and maintenance with that of general anesthesia gives an estimated annual net savings of $117,870.
      • McGuirt D.
      Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
      Seton Medical Center's cancer practice has developed patient education packets for each kind of cancer that include information on symptoms, treatment adverse effects, self-care tips, and nutrition. Based in Austin, Texas, Seton Medical Center is a “safety-net” institution serving many low-income patients; it offers a free 8-week “Nutrition and Exercise on a Budget” course in which attendees receive nutritional instruction and shopping tips in a grocery store, participate in preparing and eating nutritious foods, and learn about affordable exercise options. Northwell has onsite oncology dietitians who seek to meet with each new patient and family to do a nutritional assessment; provide customized counseling; and help patients manage loss of appetite, taste changes related to chemotherapy, nausea, medication-related weight gain, and other issues. Patients receive the phone numbers of dietitians, who teach nutrition classes the patients can attend.

      Patient Navigation

      Serious illness can quickly transform independence to dependence. In cancer, patient navigation services, when performed effectively, can help patients and families negotiate the maze of complex care.
      • McGuirt D.
      Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
      Having a knowledgeable, savvy, well-networked “go-to” person who is accessible when needed, able to answer questions (or find the answers), creatively solve problems, and calm emotions can be a valuable resource. Moreover, patient navigators can provide proactive support for patients during stressful periods that can be predicted ahead of time—for example, being present for a meeting at which the patient learns about a cancer relapse.
      • Blayney D.W.
      • Simon M.K.
      • Podtschaske B.
      • et al.
      Critical lessons from high-value oncology practices.
      • Carroll J.K.
      • Humiston S.G.
      • Meldrum S.C.
      • et al.
      Patients' experiences with navigation for cancer care.
      • Gabitova G.
      • Burke N.J.
      Improving healthcare empowerment through breast cancer patient navigation: a mixed methods evaluation in a safety-net setting.
      • Ranaghan C.
      • Boyle K.
      • Meehan M.
      • Moustapha S.
      • Fraser P.
      • Concert C.
      Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review.
      • Lee T.
      • Ko I.
      • Lee I.
      • et al.
      Effects of nurse navigators on health outcomes of cancer patients.
      • Ferrante J.M.
      • Chen P.H.
      • Kim S.
      The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial.
      Patient navigators in oncology care commonly provide services such as making appointments, clarifying information, providing a knowledgeable voice during emotional spikes, and briefing clinicians on specific patient concerns. Navigators can facilitate patient participation in clinical trials.
      • Fouad M.N.
      • Acemgil A.
      • Bae S.
      • et al.
      Patient navigation as a model to increase participation of African Americans in cancer clinical trials.
      They may also help to address child care, financial need, and inadequate family support if social workers and financial counselors are not on staff.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      Navigation services may be categorized as instrumental, which are task-oriented, and relational, which strengthen an interpersonal connection.
      • Jean-Pierre P.
      • Hendren S.
      • Fiscella K.
      • et al.
      Understanding the processes of patient navigation to reduce disparities in cancer care: perspectives of trained navigators from the field.
      Many lower-income cancer patients lack easy transportation to and from appointments, and navigators or social workers can try to help. Transportation for a patient who takes 3 buses to reach the clinic or has limited funds to buy gas, or who must minimize time away from work, may require private philanthropy to fund gasoline cards, taxi services, special arrangements with a local bus company, or even an institution-controlled bus service. After all, unless a patient can be treated at home, no transportation means no treatment.
      Debate over the cost-effectiveness of patient navigators is ongoing,
      • Freund K.M.
      • Battaglia T.A.
      • Calhoun E.
      • et al.
      Writing Group of the Patient Navigation Research Program
      Impact of patient navigation on timely cancer care: the Patient Navigation Research Program.
      due in part to limited high-quality research and wide variation in navigation program quality.
      • Wells K.J.
      • Battaglia T.A.
      • Dudley D.J.
      • et al.
      Patient Navigation Research Program. Patient navigation: state of the art or is it science?.
      • Paskett E.D.
      • Harrop J.P.
      • Wells K.J.
      Patient navigation: an update on the state of the science.
      The strongest evidence of benefit is the navigator's role in improving rates of screening.
      • Wells K.J.
      • Battaglia T.A.
      • Dudley D.J.
      • et al.
      Patient Navigation Research Program. Patient navigation: state of the art or is it science?.
      • Paskett E.D.
      • Harrop J.P.
      • Wells K.J.
      Patient navigation: an update on the state of the science.
      Most research focuses on clinical indicators, such as screening rates and treatment outcomes, but patient and family caregiver perceptions of benefit also matter when assessing cost-effectiveness. Patients have reported emotional, informational, problem-solving, and logistical assistance from navigators.
      • Carroll J.K.
      • Humiston S.G.
      • Meldrum S.C.
      • et al.
      Patients' experiences with navigation for cancer care.
      • Gabitova G.
      • Burke N.J.
      Improving healthcare empowerment through breast cancer patient navigation: a mixed methods evaluation in a safety-net setting.
      • Ranaghan C.
      • Boyle K.
      • Meehan M.
      • Moustapha S.
      • Fraser P.
      • Concert C.
      Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review.
      • Lee T.
      • Ko I.
      • Lee I.
      • et al.
      Effects of nurse navigators on health outcomes of cancer patients.
      • Ferrante J.M.
      • Chen P.H.
      • Kim S.
      The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial.
      The use of “lay” (peer) navigators appears to be gaining traction, thanks in part to a successful program developed at the University of Alabama at Birmingham Health System. The lay navigators are carefully selected and trained in evidence-based methods to activate, engage, and empower patients in their health care. Patient satisfaction is high, with 89% of navigated patients indicating that they would recommend the program to cancer patients.
      • Rocque G.B.
      • Partridge E.E.
      • Pisu M.
      • et al.
      The patient care connect program: transforming health care through lay navigation.
      Mean total costs declined by $781.29 more per quarter for navigated patients compared with matched comparison patients during the study period (2012-2015).
      • Rocque G.B.
      • Pisu M.
      • Jackson B.E.
      • et al.
      Patient Care Connect Group
      Resource use and Medicare costs during lay navigation for geriatric patients with cancer.
      The annual reduction in costs for navigated patients was $19 million due to declines in both inpatient and outpatient costs.
      • Rocque G.B.
      • Pisu M.
      • Jackson B.E.
      • et al.
      Patient Care Connect Group
      Resource use and Medicare costs during lay navigation for geriatric patients with cancer.

      What About Costs?

      The 5 service principles relating to nonclinical and clinical-support staff influence how patients perceive their entire care experience. The principles are interrelated, and the greatest service improvement is likely to result when all are enacted. For example, a strong front-desk experience can set in motion a favorable halo effect that can then be derailed by a long, frustrating delay. Patients will value specific services more when they are delivered well, requiring effective hiring, training, and education of the staff performing them. Realistically, a medical practice cannot do everything at once, and devoting extra attention to first impressions, hiring right, and staff preparation is a strategic place to start. This is because these initial steps contribute quickly to—and set the tone for—overall service improvement in the practice, including “spilling over” to patients’ perceptions of clinical quality.
      Balancing service-improvement initiatives with financial goals is challenging, of course. Service-improvement costs commonly are more evident than the benefits, particularly in traditional fee-for-service rather than value-based payment systems. The costs of a new training and education program or of raising certain nonclinical position wages from slightly below market to slightly above market are clearly evident. Less readily apparent is the cost of a bad service experience or the increase in glowing word-of-mouth recommendations from patients who receive excellent service. An analysis of nearly 35,000 online reviews of doctors nationwide found that customer service—not physicians' medical expertise or skill—account for 96% of patient complaints about their health care experiences on the Internet.
      • King R.H.
      • Stanley J.
      • Baum N.
      Hard internet truths: 34,748 online reviews reveal what patients really want from doctors.
      The financial pressures buffeting many medical practices unfortunately encourage sacrificing long-term service improvement for short-term cost savings. However, if those savings undermine service quality, they will weaken the practice for what are likely to be even more turbulent and competitive conditions in the future.
      Marin Cancer Center balances the service-improvement vs cost-management tension well. First, nonclinical staff are offered secure positions, which positively affects staff morale and enables continuity of care. Second, Marin Cancer Center promotes from within, giving staff a career pathway and motivating them to work toward personal employment goals. Third, it cross-trains front-end and back-office staff to provide job enrichment and better coverage for the practice. Fourth, Marin Cancer Center eschews raises in favor of generous bonuses when the practice does well financially, encouraging staff to achieve financial targets.
      Integris Cancer Institute seeks to hire staff who work for the organization for more than just the salary and who are intrinsically motivated to excel; its motto: is “Patient first, always.” Integris Cancer Institute management recognizes the necessity of adequate staffing levels. Otherwise, service will suffer despite strong infrastructure and excellent employees. Managers make a special effort to provide a supportive work environment for employees, and to be transparent and involve staff in decision making, when possible. A strong organizational culture has provided a buffer during times when Integris could not offer salary increases or bonuses to staff, or when staff have had to “work short” because staff volumes were inadequate. In sum, Marin Cancer Center and Integris Cancer Institute have been able to hire employees who value workplace benefits—such as role flexibility, tenure, personal development, career pathing, management transparency, and a positive working environment—over earning the highest possible salary.

      The Caring in Health Care

      Perceptions of a medical practice's quality derive from a dynamic, cumulative process as patients assess specific services that, together, constitute the overall experience. When nonclinical and clinical-support staff serve patients and families well, their impressions can create a “spillover effect” influencing perceptions of other aspects of the service. Their ability to effectively serve on a personal level can make a substantial difference for patients, who are often in pain, uncertain, and frightened. Investing in the performance of nonclinical and clinical-support staff facilitates delivery of services that matter.

      References

        • Murphy K.R.
        • Jako R.A.
        • Anhalt R.L.
        Nature and consequences of halo error: a critical analysis.
        J Appl Psychol. 1993; 78: 218-225
        • Oxford Dictionary
        Definition of halo effect in English.
        • Van Doorn J.
        Is there a halo effect in satisfaction formation in business-to-business services?.
        J Serv Res. 2008; 11: 124-141
        • Dagger T.S.
        • Danaher P.J.
        • Sweeney J.C.
        • McColl-Kennedy J.R.
        Selective halo effects arising from improving the interpersonal skills of frontline employees.
        J Serv Res. 2013; 16: 488-502
        • Bendapudi N.M.
        • Berry L.L.
        • Frey K.A.
        • Parish J.T.
        • Rayburn W.L.
        Patients’ perspectives on ideal physician behaviors.
        Mayo Clin Proc. 2006; 81: 338-344
        • Doyle C.
        • Lennox L.
        • Bell D.
        A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.
        BMJ Open. 2013; 3: e001570
        • Anhang Price R.
        • Elliott M.N.
        • Zaslavsky A.M.
        • et al.
        Examining the role of patient experience surveys in measuring health care quality.
        Med Care Res Rev. 2014; 71: 522-554
        • Kallen M.A.
        • Terrell J.A.
        • Lewis-Patterson P.
        • Hwang J.P.
        Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center.
        J Oncol Pract. 2012; 8: e1-e7
        • Gesme D.H.
        • Wiseman M.
        A financial conselor on the practice staff: a win-win.
        J Oncol Pract. 2011; 7: 273-275
        • McGuirt D.
        Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review.
        Radiol Technol. 2016; 88: 18-26
        • Marquess M.
        • Johnston S.P.
        • Williams N.L.
        • et al.
        A pilot study to determine if the use of a virtual reality education module reduces anxiety and increases comprehension in patients receiving radiation therapy.
        J Rad Oncol. 2017; 6: 317-322
        • Rocque G.B.
        • Partridge E.E.
        • Pisu M.
        • et al.
        The patient care connect program: transforming health care through lay navigation.
        J Oncol Pract. 2016; 12: e633-e642
        • Rocque G.B.
        • Pisu M.
        • Jackson B.E.
        • et al.
        • Patient Care Connect Group
        Resource use and Medicare costs during lay navigation for geriatric patients with cancer.
        JAMA Oncol. 2017; 3: 817-825
        • Welling R.
        The importance of medical receptionists.
        • Neuwelt P.M.
        • Kearns R.A.
        • Browne A.J.
        The place of receptionists in access to primary care: challenges in the space between community and consultation.
        Soc Sci Med. 2015; 133: 287-295
        • Singh J.
        Performance productivity and quality of frontline employees in service organizations.
        J Mktg. 2000; 64: 15-34
        • Berry L.L.
        • Davis S.W.
        • Wilmet J.
        When the customer is stressed.
        Harv Bus Rev. 2015; 93: 86-94
        • Yu T.
        • Patterson P.G.
        • De Ruyter K.
        Achieving service-sales ambidexterity.
        J Serv Res. 2013; 16: 52-66
        • Hartline M.D.
        • Ferrell O.C.
        The management of customer-contact service employees: an empirical investigation.
        J Mktg. 1996; 60: 52-70
        • Ward J.
        • McMurray R.
        The unspoken work of general practitioner receptionists: a re-examination of emotion management in primary care.
        Soc Sci Med. 2011; 72: 1583-1587
        • Berry L.L.
        Competing with quality service in good times and bad.
        Bus Horiz. 2009; 52: 309-317
        • Wirtz J.
        Winning in Service Markets: Success Through People, Technology and Strategy.
        World Scientific, Hackensack, NJ2017
        • Weinberg D.B.
        • Avgar A.C.
        • Sugrue N.M.
        • Cooney-Miner D.
        The importance of a high-performance work environment in hospitals.
        Health Serv Res. 2013; 48: 319-332
        • Rafaeli A.
        • Sutton R.I.
        Expression of emotion as part of the work role.
        Acad Magm Rev. 1987; 12: 23-37
        • Hennig-Thurau T.
        • Groth M.
        • Paul M.
        • Gremler D.D.
        Are all smiles created equal? how emotional contagion and emotional labor affect service relationships.
        J Mktg. 2006; 70: 58-73
        • Berry L.L.
        Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success.
        Simon and Schuster, New York, NY1999
        • Shanafelt T.D.
        • West C.P.
        • Sloan J.A.
        • et al.
        Career fit and burnout among academic faculty.
        Arch Intern Med. 2009; 169: 990-995
        • Jacobson J.O.
        • Rotenstein L.S.
        • Berry L.L.
        New diagnosis bundle: improving care delivery for patients with newly diagnosed cancer.
        J Oncol Pract. 2016; 12: 404-406
        • Visser M.R.
        • van Lanschot J.J.
        • van der Velden J.
        • Kloek J.J.
        • Gouma D.J.
        • Sprangers M.A.
        Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired.
        J Surg Oncol. 2006; 93: 571-577
        • Paul C.
        • Carey M.
        • Anderson A.
        • et al.
        Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey.
        Eur J Cancer Care (Engl). 2012; 21: 321-329
        • Taylor S.
        Waiting for service: the relationship between delays and evaluations of service.
        J Mktg. 1994; 58: 56-69
        • Thompson D.A.
        • Yarnold P.R.
        • Williams D.R.
        • Adams S.L.
        Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department.
        Ann Emerg Med. 1996; 28: 657-665
        • Suss S.
        • Bhuiyan N.
        • Demirli K.
        • Batist G.
        Toward implementing patient flow in a cancer treatment center to reduce patient waiting time and improve efficiency.
        J Oncol Pract. 2017; 13: e530-e537
        • Wagner E.H.
        • Aiello Bowles E.J.
        • Greene S.M.
        • et al.
        The quality of cancer patient experience: perspectives of patients, family members, providers and experts.
        Qual Saf Health Care. 2010; 19: 484-489
        • Patel M.I.
        • Periyakoil V.S.
        • Blayney D.W.
        • et al.
        Redesigning cancer care delivery: views from patients and caregivers.
        J Oncol Pract. 2017; 13: e291-e302
        • Meeker C.R.
        • Geynisman D.M.
        • Egleston B.L.
        • et al.
        Relationships among financial distress, emotional distress, and overall distress in insured patients with cancer.
        J Oncol Pract. 2016; 12: e755-e764
        • Shen C.
        • Zhao B.
        • Liu L.
        • Shih Y.-C.T.
        Financial burden for patients with chronic myeloid leukemia enrolled in Medicare part D taking targeted oral anticancer medications.
        J Oncol Pract. 2017; 13: e152-e162
        • Stump T.K.
        • Eghan N.
        • Egleston B.L.
        • et al.
        Cost concerns of patients with cancer.
        J Oncol Pract. 2013; 9: 251-257
        • Zafar S.Y.
        • Peppercorn J.M.
        • Schrag D.
        • et al.
        The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.
        Oncologist. 2013; 18: 381-390
        • de Souza J.A.
        • Kung S.
        • O’Connor J.
        • Yap B.J.
        Determinants of patient-centered financial stress in patients with locally advanced head and neck cancer.
        J Oncol Pract. 2017; 13: e310-e318
        • Fenn K.M.
        • Evans S.B.
        • McCorkle R.
        • et al.
        Impact of financial burden of cancer on survivors' quality of life.
        J Oncol Pract. 2014; 10: 332-338
        • Chino F.
        • Peppercorn J.M.
        • Rushing C.
        • et al.
        Out-of-pocket costs, financial distress, and underinsurance in cancer care.
        JAMA Oncol. 2017; 3: 1582-1584
        • Ramsey S.
        • Blough D.
        • Kirchhoff A.
        • et al.
        Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.
        Health Aff (Millwood). 2013; 32: 1143-1152
        • Meropol N.J.
        • Schrag D.
        • Smith T.J.
        • et al.
        American Society of Clinical Oncology. American Society of Clinical Oncology guidance statement: the cost of cancer care.
        J Clin Oncol. 2009; 27: 3868-3874
        • Sherman D.
        Oncology financial navigators: integral members of the multi-disciplinary cancer care team.
        (https://doi.org/10.1080/10463356.2014.11883963. Accessed September 20, 2014)
        • Blayney D.W.
        • Simon M.K.
        • Podtschaske B.
        • et al.
        Critical lessons from high-value oncology practices.
        JAMA Oncol. 2018; 4: 164-171
        • Carroll J.K.
        • Humiston S.G.
        • Meldrum S.C.
        • et al.
        Patients' experiences with navigation for cancer care.
        Patient Educ Couns. 2010; 80: 241-247
        • Gabitova G.
        • Burke N.J.
        Improving healthcare empowerment through breast cancer patient navigation: a mixed methods evaluation in a safety-net setting.
        BMC Health Serv Res. 2014; 14: 407
        • Ranaghan C.
        • Boyle K.
        • Meehan M.
        • Moustapha S.
        • Fraser P.
        • Concert C.
        Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review.
        JBI Database System Rev Implement Rep. 2016; 14: 172-218
        • Lee T.
        • Ko I.
        • Lee I.
        • et al.
        Effects of nurse navigators on health outcomes of cancer patients.
        Cancer Nurs. 2011; 34: 376-384
        • Ferrante J.M.
        • Chen P.H.
        • Kim S.
        The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial.
        J Urban Health. 2008; 85: 114-124
        • Fouad M.N.
        • Acemgil A.
        • Bae S.
        • et al.
        Patient navigation as a model to increase participation of African Americans in cancer clinical trials.
        J Oncol Pract. 2016; 12: 556-563
        • Jean-Pierre P.
        • Hendren S.
        • Fiscella K.
        • et al.
        Understanding the processes of patient navigation to reduce disparities in cancer care: perspectives of trained navigators from the field.
        J Cancer Educ. 2011; 26: 111-120
        • Freund K.M.
        • Battaglia T.A.
        • Calhoun E.
        • et al.
        • Writing Group of the Patient Navigation Research Program
        Impact of patient navigation on timely cancer care: the Patient Navigation Research Program.
        J Natl Cancer Inst. 2014; 106: dju115
        • Wells K.J.
        • Battaglia T.A.
        • Dudley D.J.
        • et al.
        Patient Navigation Research Program. Patient navigation: state of the art or is it science?.
        Cancer. 2008; 113: 1999-2010
        • Paskett E.D.
        • Harrop J.P.
        • Wells K.J.
        Patient navigation: an update on the state of the science.
        CA Cancer J Clin. 2011; 61: 237-249
        • King R.H.
        • Stanley J.
        • Baum N.
        Hard internet truths: 34,748 online reviews reveal what patients really want from doctors.
        J Med Pract Manage. 2016; 31: 309-312