Publication - Strategy/plan

Quality Standards for Adult Hearing Rehabilitation Services

Published: 27 April 2009
Part of: Health and social care
ISBN: 9780755973019

Quality Standards for Adult Hearing Rehabilitation.

Improving Quality and Outcomes in Adult Audiology Rehabilitation Services through Critical Evaluation
A Quality Rating Tool for Audiology Services¹⁹

Foreword

This quality rating tool has been developed to assist providers of adult rehabilitation services in assessing their ability to deliver adult audiology rehabilitation services to meet the needs of their local population against the Quality Standards for Adult Hearing Rehabilitation Services

It is envisaged that service providers will find the format of the tool helpful in measuring their progress towards meeting and indeed exceeding the quality standards for adult rehabilitation services. Beyond use by providers for self assessment, the tool could also be employed within an external (independent) assessment process. In this application, all interested parties could regard outcomes of service quality rating as a valid and reliable indicator of the performance of providers, within the context of wider frameworks for healthcare standards set out by the UK health departments.

The publication of externally verified service quality ratings could also help potential service users (and their advisers) make more informed decisions on the services that they choose to access.

The Quality Rating Tool can be implemented in different ways, depending on the medium used, but on-line self assessment can be readily achieved.

Using the quality rating tool

This quality rating tool covers the 9 Quality Standards for adult rehabilitation services in audiology.

Standards are only part of the cycle within which services are delivered and reviewed/monitored. Assessment against the standards will inform participating stakeholders of areas of good practice and areas in need of development, performance management and consolidation. Assessment should be an ongoing service management function. External quality assurance programmes will reinforce local ratings and contribute additional objectivity and transparency.

Each section contains several quality statements relating to different criteria within the quality standards. Providers can rate their current activity against the scale 1-5 where 1 means that no elements of the quality statement are met/implemented and 5 represents full compliance with good to best practice, with graduations in between. Examples of what a score of 1 and 5 might look like have been given so that users of the tool can make better judgements about where on the scale the service corresponds. The 5 positions are:

1. No elements of the quality statement are met (or not evident*)

2. Few elements of the quality statement are met

3. Meets around half of the elements of the quality statement

4. Almost fully meets the quality statement

5. Fully compliant with good to best practice as indicated by quality statement criteria

In judging evidence of performance (assigning an overall score for each standard) those completing assessment should consider the following elements of compliance:

All examples of best practice (where there is more than one)
The population served, (eg, all geographical areas, and all facilities)
Reflecting practice over the preceding 12 week period as a minimum (prior to the date of the assessment)

* NB An inability to provide evidence of performance against a standard (sufficient for external scrutiny) cannot be regarded as compliant with good practice.

In addition, a separate field provides suggestions of evidence to assist users of the tool in their rating assessment and direct discussion for any external quality assurance visit. On completion of the quality rating tool, an overall position will indicate those areas that require further development and review.

Understanding the score

The underlying assumption used here is that, when scoring each standard, all quality statements (criteria) are equally important and therefore carry the same score weighting. Some criteria may have more aspects than others but each criteria should only be scored once. For instance when a criteria achieves 2 out of 4 different standards that the service should meet then appropriate approximate score would be 3 out of 5. A reminder of how to score the standards can be found in the rating scale at the top of each standard. For each standard, a percentage quality score can be calculated and an interpretation given of the meaning of these scores (eg needs urgent attention, needs attention, does not need attention). For instance; if a service scores a total of 32 out of 40 then the service is deemed to have 80% compliance with standard 1.

Standard 1 - Accessing the Service

1a . All patients with hearing problems and their significant other(s), who require referral (for first or subsequent appointments) to audiology services are able to:

(i) access the correct audiology service to meet their needs,

(ii) conveniently access the services they require,

(iii) see Audiology or specialist medical professionals as first points of contact, as determined by agreed local clinical criteria,

iv) gain access to audiology service as quick as any other specialist medical service.

1b Service demand and referral patterns are accurately monitored, reviewed, reported against available indicators and used to guide service planning.

1c There is effective ongoing life time maintenance of hearing aid use - including supportive care.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meets around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Please use the rating scale and examples given in the 1 and 5 columns as an indicator to help you score the self-assessment table below. Each table should only ever have 1 self-assessment score. When you perceive there to be more than 1 aspect of the table that you could give a score for, please use an average of each of the aspects.

Criteria1a.1-a.3 - Direct referral pathways

Quality Statement rationale Direct referral to audiology services is a more effective and efficient way of meeting patients' clinical needs where there is no robust evidence of otological pathology. Allocation to the wrong referral pathways (or absence of alternative pathways) means additional inconvenience to the patient and inefficient use of time and resources. Correct information to an Audiology service results in more effective use of available resources.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There is no process for patients to be referred to or access audiology directly.	All adult patients with hearing problems and their significant other(s) have access to Audiology via Direct Referral where this is clinically indicated The information about referrals and the criteria which patients need to meet to be referred is clear so that they are fully understood by referrers. Information about referral criteria and pathways, including any changes, is widely disseminated to all potential referrers on a regular basis.
Evidence sources relevant to criteria Written referral pathways, Written referral criteria, Written policy on communication with referrers, Copies of communications with referrers, Results and outcomes of audit.

Criteria 1a.4-a.5 - Ease of access

Quality Statement rationale Public Health principles promote delivery of services close to patients for their ultimate healthcare benefit. To provide an equality-based service, audiology centres must allow for all different types of patients to gain physical access to the service.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
The proximity of patients to centres that deliver audiology services is far worse than for other adult services. The audiology centres are impossible to get into and/or impossible to navigate around once inside.	The proximity of patients to centres delivering audiology services is similar to other adult services in the Board/district. The audiology centres provide ease of physical access to all areas where audiology is delivered.
Evidence sources relevant to criteria Maps of service locations against demographic information of patients relative to other adult services, Audit of services against Disability Discrimination Act, Patient satisfaction surveys.

Criteria 1a.6-a.7 - Waiting times

Quality Statement rationale Simple equity implies that no patient should be penalised by having to wait longer for a direct referral to Audiology that they would have experienced by referral to a specialist medical service. Simple equity implies that patients who have previously accessed an audiology service must be able to access it again, should the need arise, without prejudice.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Waiting times are not equal for direct/indirect referrals to Audiology The waiting time target is not known and waiting times are not monitored.	Waiting times for direct referrals to Audiology are the same as waiting times for patients who are referred to other specialist medical services, such as ENT or Audiovestibular Medicine. The maximum waiting time from referral to treatment ²⁰ of hearing should meet the national target regardless of the referral route and regardless of whether a patient is re-accessing the service or accessing it for the first time. ²¹
Evidence Data to hand ideally over several time points to indicate trends against national targets

Criteria 1b.1-b.2 - Monitoring and managing referral patterns

Quality Statement rationale The number of incorrect referrals to the specialist medical route informs the effectiveness/clarity of the criteria and compliance of referrers to those criteria. Improvements can then be made to ensure that patients are not incorrectly referred to certain services.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessm-ent score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There is no monitoring of compliance with referral criteria	The number of inappropriate direct referrals is monitored. The number of inappropriate referrals to specialist medical services is monitored. Action plans are implemented to address significant non-compliance with referral criteria.
Evidence Audit, Data to hand (for direct referrals), ideally over several time points to indicate trends.

Criteria 1b.3 - Monitoring and reviewing waiting times

Quality Statement rationale Effective allocation of health resources is reliant upon accurate information on the balance between demand for services and available resources. It is important that waiting times for all stages of the patient pathway from referral through to treatment (eg hearing aid fitting) for new and existing patients are collected and monitored in an effective manner. The use of IT systems to compute information such as demographic data and waiting times will inform allocation of services and help prevent an overload of patients accessing the same service and resources being strained.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Waiting times are not monitored.	Waiting times are monitored within the department. Monitoring of waiting times is based upon robust data collection.
Evidence Monthly data to hand from a patient management system, Audit of robustness of data collection, Policies and protocols to support data collection A random sample of relevant patients to check data collection through to presentation in reported waiting times.

Criteria 1b.4 - Service Planning

Quality Statement rationale Effective allocation of resources relies upon information on actual demand and potential/projected demand for specific services.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No data is collected regarding uptake, referral and demographics of patients.	The following data are collected, reviewed and used in annual service review: the uptake of NHS hearing aids in the local population compared with the predictive need for services, the number and type of referrals to Audiology services, demographics of locally served populations, including factors such as ethnic diversity, social deprivation and age. ²²
Evidence Data on hearing aid uptake, Data on referrals to audiology services, Data on patient demographic, Annual service review.

Criteria 1c.1 - Life long hearing aid use - ear care and wax management

Quality Statement rationale To ensure effective initial and ongoing care; agreed multidisciplinary local ear care / wax management procedures should be in place.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Advice about ear care and wax management is not systematically given to all patients There are limited ear care/wax management services There are no written agreed protocols for ear care/wax management	All patients are advised of and have access to ear care / wax management services There are protocols agreed between Primary Care, Audiology and ENT services and patients.
Evidence Written information on ear care/wax management available to all patients, Ear care/wax management services available, Written and agreed protocols for ear care and wax management

1c.2-1c.5 - Life long hearing aid use - access to hearing aid repairs and battery replacement

Quality Statement rationale Prompt access for existing hearing aid patients to a basic repair service and replacement batteries (and onward referral as necessary) is required to help maintain long term use and benefit from hearing aid use. Uptake of such services will benefit from promotion of the service to patients.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No hearing aid repairs are carried out within 2 days of the repair service receiving the hearing aid. There are no repair clinics where audiology services are delivered away from their main centre. Replacement battery requests are not fulfilled within 2 days of the request being received. No information is ever offered about repair/replacement battery services.	All hearing aid repairs are carried out within 2 days of the repair service receiving the hearing aid. Where Audiology services are delivered away from the main Audiology base; there is at least 1 clinic per month for repair services. Audiology departments will fulfill requests for replacement batteries within 2 days of the request being received. Patients are actively offered information about repair/replacement battery services at each appointment. This is provided in writing and verbally.
Evidence Clinic lists, Written information for service users on how to access repair services and battery replacements service, Log of service receipts and issues by ATOs at each stage of the process, Monitoring of logs to ensure that repairs are carried out within 2 days of receipt.

Standard 2 - Information Provision and Communication with Individual Patients

2a Timely and relevant information is provided to meet the needs of hearing impaired patients and their significant other(s), in formats that accommodate their communicative abilities.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 2a.1 - Good information prior to assessment

Quality Statement rationale Good communication before during and after intervention benefits patients - through reduction in anxieties/concerns and encouraging appropriate uptake of further care.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No written information is provided to patients and their significant other(s) prior to appointment. No reference is made to patients and/or significant other(s) about the availability of interpreting services.	Written information is provided for all new and existing patients and their significant other(s) prior to appointment about :- the service, assessment procedures, types of assessment, possible interventions and clinicians involved This will include a request to contact the department in advance of an appointment if an interpreter is required.
Evidence Written information leaflets or letters, Auditing

Criteria 2a.2 - Consent

Quality Statement rationale Good communication before during and after intervention benefits patients - through reduction in anxieties/concerns and encouraging appropriate uptake of further care.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Consent is not gained from the patient for assessment of their hearing.	Consent is gained from the patient for assessment of their hearing and their significant other(s) being present.
Evidence Written information leaflets or letters, Auditing

Criteria 2a.3-a.4 - Good information after assessment

Quality Statement rationale Good communication before during and after intervention benefits patients - through reduction in anxieties/concerns and encouraging appropriate uptake of further care.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Results are not recorded, explained or given to patients and their significant other(s) following assessment. Audiology does not provide any information regarding services offered by other agencies.	Straight after assessment, results are recorded, explained verbally and given to patients and/or their significant other(s). Information is provided, by audiology, regarding services offered by other agencies (including voluntary sector organisations).
Evidence Written information leaflets or letters, Auditing

Criteria 2a.5-a.6 - Accessible information

Written information that is clear, up to date and in a format that is accessible to the individual facilitates understanding of the service.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
The written information provided to patients has not been developed in conjunction with service user groups, does not have the crystal mark plain english approval and is not reviewed annually. No written individual management plan is provided.	All written information provided to patients: - is developed in conjunction with service user groups, has the Crystal Mark plain English approval (or similar) and is reviewed annually A written individual management plan is provided and updated at subsequent visits.
Evidence A random sample of patient records is checked to ascertain whether written IMPs are carried out and updated, Minutes of meetings to review information, Crystal mark or similar on information.

Criteria 2a.7 - Meeting specific communication/information needs

Quality Statement rationale To avoid discrimination, services should meet the specific communication and information needs of hearing impaired patients and their significant other(s) accessing the service.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Deaf awareness and communication training is not given to frontline staff as part of induction.	All frontline staff with direct patient contact ²³ receive deaf-awareness and communication training as part of their induction, This training is updated every 3 years. This training is approved by a relevant third party such as a voluntary sector organisation. The training will include deaf-blind awareness and also underline key areas of communication. ²⁴
Evidence Staff training records, Written policies, Staff CPD accreditation certificates.

Criteria 2a.8-a.9 - Accessibility of information

Quality Statement rationale Technology should be used to enable audiology staff to communicate effectively with the patient group and to ensure that the information is given in a manner that the patient understands.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Up-to-date technology is not used to support communication between patients and the audiology services.	Prior to their appointment, up-to-date technology is used to support communication between patients and the Audiology service (e.g. email, text phones, sms messaging, department websites). At clinics, up-to-date technology is used to support communication with patients (e.g. message boards and loop systems in reception areas and waiting rooms). All staff responsible for the technologies used prior to appointment and at the clinic are trained on how to use it and carry out maintenance checks.
Evidence Technology in place, Log of all staff who have received training on use of technology

Criteria 2a.10 - Lighting

Quality Statement rationale Well lit rooms help aid the ability of hearing impaired patients to lip read and improve communication generally.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
All areas used for staff and patient communication are extremely dim.	All areas used for staff and patient communication are well lit.
Evidence

Criteria 2a.11 - Involving significant others

Quality Statement rationale The involvement of significant others (e.g. spouse) in the rehabilitative process can provide improved outcomes.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Significant others are not routinely encouraged to participate in clinical contacts. Significant others are not encouraged to engage with the service.	Significant others are routinely encouraged, through formal invitation, to participate in clinical contacts (where consent has been provided). They are also encouraged to engage with the service through patient forums to facilitate planning, satisfaction auditing and information development etc.
Evidence Letters/written invitations to participate, Written policy on inclusion of significant others in clinical contacts, Consultation rooms large enough to comfortably accommodate additional people

Standard 3 - Assessment

3a All patients receive an individually-tailored audiological assessment which is carried out to recognised national standards, where available, and includes:

measurement of hearing impairment,
assessment of activity limitations related to hearing impairment,
evaluation of social and environmental communication and listening needs and an evaluation of attitudes, expectation and behaviours as a result of hearing impairment,
a relevant medical history

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 3a.1-a.2 - Acquiring information on hearing status

Quality Statement rationale The need for, and content of, any Individual Management Plan requires knowledge of a patient's hearing status. The quality of assessment is more likely to be assured if undertaken in accordance with nationally recommended procedures.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There are no written standard procedures or protocols for assessment. Written protocols and/or procedures are not available to all staff in the department	The following are established for every patient: hearing thresholds by air and bone conduction, thresholds of uncomfortable loudness levels ²⁵, additional/further diagnostic procedures as required. a relevant medical history. There are written BAA/ BSA recommended procedures or protocols available to all staff in the department and these include air and bone conduction testing, thresholds of uncomfortable loudness levels, and tympanometry.
Evidence Written protocols, Case audit

Criteria 3a.3-a.4 - Equipment calibration and test environment

Quality Statement rationale Measures are compromised if not gathered using equipment calibrated to national and international standards and if they are not used in a quiet test environment.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Equipment is not checked daily and calibrations are not always up to date Assessment is not always carried out in acoustical conditions conforming to national and international standards	Equipment is calibrated annually, and daily checks are carried out and documented to international standards. Hearing tests, with the exception of domiciliary visits, are always carried out in acoustical conditions conforming to national and international standards ²⁶ - except when the service has to be taken to the patient for clinical reasons (e.g. housebound).
Evidence Calibration and equipment check logs/certificates

Criteria 3a.5-a.6 - Acquiring other information relevant to developing an Individual Management Plan ( IMP)

Quality Statement rationale Hearing status is a necessary prerequisite, but is not sufficient information alone to configure an Individual Management Plan ( IMP) The goal of the service is to alleviate listeners' activity limitations rather than manage hearing losses. Services should select a validated self-report questionnaire to assess activity limitations related to hearing impairment. Situation-specific structured questionnaires have been shown to offer significant advantages in clinical settings over more general disability and handicap inventories (e.g. GHABP).
1 No elements of the quality statement criteria are met (or not evident)	Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
A validated self report questionnaire is not used as part of the assessment protocols and social and personal information relevant to patient management is not assessed. There is no standardised recording of information.	A self report questionnaire is a routine part of the assessment protocols ²⁷ and is used in conjunction with all information gathered relating to social circumstances, psychological impacts, communication and listening needs and expectations. Information is recorded in a standardised way and is used to develop the content of the IMP. Included in this information should be details of why an assessment or intervention could not be carried out.
Evidence Completed questionnaires, Case audit showing use of information from the questionnaire to develop IMP, Clinical record review (random sample of cases), Service policies and procedures relating to standardised gathering of information Associated service educational/promotional activity.

Standard 4 - Developing an Individual Management Plan

4a An Individual Management Plan ( IMP) ²⁸ is: -

developed for each patient, initially based on information gathered at the assessment phase,
determined in conjunction with the patient and/or their significant other(s),
updated on an ongoing basis and
accessible to the clinical team.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 4a.1-a.2 - Factors for Consideration in Developing the IMP

Quality Statement rationale An IMP is most effective if it takes into account a range of factors in addition to the type and level of hearing loss. An effective IMP also relies on consultation between the Audiology professional, the hearing impaired person and his or her significant other(s). Only when all parties are committed to the joint goals is an optimal outcome received.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Intervention is based on information about the hearing level and unstructured one to one discussions with the patient only. It does not contain an IMP.	The IMP is contained within the clinical record. It contains details of: hearing status, expectations, social circumstance, options for rehabilitation (including hearing instrument management), referral to other agencies and specific goals associated with assessment information. The IMP is agreed with the patient and significant other(s) at each appointment and a copy is made available for them.
Evidence Sample of clinical records, Service policies and procedures relating to the patient pathway and development of the IMP.

Criteria 4a.3 - Further Development of the IMP

Quality Statement rationale To be successful, IMPs need to be flexible. Flexibility within the structure of the IMP is beneficial because the content and the goals of the IMP may change over time, reflecting the positive outcomes of interventions.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
The clinical record contains information about the hearing level and intervention agreed only.	The specific goals of the IMP are recorded in the clinical record. The plan includes details of: the decision-making process, the implementation plan and proposed timescales.
Evidence Sample of clinical records, Service policies and procedures relating to the patient pathway and development of the IMP.

Criteria 4a.4 - Updating the Individual Management Plan ( IMP)

Quality Statement rationale An effective IMP will detail specific actions associated with agreed goals that take into account a listener's social, communication and listening needs, in addition to their hearing impairment and related activity limitations, e.g. living alone vs family setting vs sheltered accommodation. The IMP is flexible so that different goals can be set if the patient's circumstances/environment changes.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Information about expectations, social needs and or listening needs are not recorded over time.	Information is recorded in the patient's clinical record ²⁹ which is updated over the period of the journey through the IMP. This consists of information about the individual's hearing impairments, expectations (goals), psychological impacts, social, communication and listening needs.
Evidence Completed questionnaires, Case audit showing use of information from the questionnaire to develop IMP, Clinical record review (random sample of cases), Service policies and procedures relating to standardised gathering of information and Associated service educational/promotional activity.

Standard 5 - Implementing an Individual Management Plan

5a The Individual Management Plan ( IMP) is implemented over a series of coordinated appointments with the opportunity for revision of outcome goals at each stage.

5b Where provision of hearing aid(s) is required the service ensures:

hearing aids fitted are functioning correctly,
nationally agreed procedures and protocols are followed at a local level,
that patients are offered a hearing aid for each ear where clinically indicated,
performance of hearing aid(s) is carefully matched to individual requirements and settings recorded.

5c Following implementation of the plan, a process of ongoing support and maintenance continues.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

No elements of the quality statement criteria are met (or not evident) Please use the rating scale and examples given in the 1 and 5 columns as an indicator to help you score the self-assessment table below. Each table should only ever have 1 self-assessment score. When you perceive there to be more than 1 aspect of the table that you could give a score for, please use an average of each of the aspects.

Criteria 5a.1 - Referral to other agencies/services

Quality Statement rationale In order for agreed interventions to be effective, referral to another agency/service for interventions should be prompt so as to be based upon an up-to-date appraisal of need.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Where referral to an external agency/service is indicated, referral is never made within 7 days of appointment And/or Information about the length of referral is not available i.e. it is not recorded and/or monitored.	Where referral to an external agency/service is indicated, referral is made from Audiology within 7 days of appointment in at least 95% of cases.
Evidence Written records, Electronic records, Audits

Criteria 5a.2-a.3 - Recording interventions and their effectiveness

Quality Statement rationale Planned and coordinated intervention leads to better outcomes. Such an approach requires recording of interventions and their effectiveness to guide on-going development of the IMP.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There is no standardised recording of information about non-instrumental interventions and/or their effectiveness and/or There is no standardised recording of information about instrumental interventions and/or their effectiveness	The clinical record and IMP includes the details, justifications and effectiveness of all non-instrumental interventions implemented. ³⁰ The clinical record and IMP includes the details, justifications and effectiveness of all instrumental (hearing aid) interventions implemented. ³¹
Evidence Written records, Electronic records

Criteria 5b.1 - Ensuring hearing aids are working to specification

Quality Statement rationale Audiologists should be confident that the aid is working to specification before fitting it to a patient so that the aid does not cause harm.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Prior to use, hearing aids do not have their technical performance tested to specification.	Prior to issue; every hearing aid has its technical performance tested to specification. ³²
Evidence Written records, Electronic records, Audits

Criteria 5b.2 - Selection, fitting and verification of hearing aids

Quality Statement rationale Professional bodies and national guidelines should be followed to ensure provision meets the needs of the individual.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There are no local protocols for: Selection fitting and verification of hearing aids.	Local protocols should be in operation concerning selection, fitting and verification of hearing aids. These should comply with the latest professional body and/or national guidance. ³³
Evidence Written records, Electronic records, Audits

Criteria 5b.3 - Bilateral hearing aids

Quality Statement rationale Laboratory based evidence suggests that many patients with bilateral hearing impairment gain more benefit from hearing aids fitted bilaterally rather than unilaterally. Emerging evidence, particularly from studies of open canal fittings indicates more real life self-reported benefit too.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No patients who are clinically suitable for bilateral hearing aids are offered 2 hearing aids.	At least 95% of patients who need and are clinically suitable for bilateral hearing aid fitting should be offered 2 hearing aids.
Evidence Written protocols, Electronic records, Audits

Criteria 5b.4-b.7 - Hearing aids (Real Ear Measures)

Quality Statement rationale Evidence suggests that hearing aids are most effective when their performance is carefully matched to the requirements of the individual.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Real Ear Measurements are not used at all. Where REM is performed the acoustical target is never verified at these three different input levels (50, 65 and 80 dB). Where REM is performed measurements usually deviate from the recommended target at more than one frequency	Real Ear Measurements ( REM) of hearing aid performance are to be used to verify at least 95% of hearing aid fittings ³⁴, unless clinically contraindicated for individual patients. Where REM is performed: the acoustical target is verified at three different input levels (50, 65 and 80 dB) in more than 75% of cases. Where REM is performed: measurements do not deviate from the recommended target at more than one frequency (in 95% of cases) unless clinically indicated. The maximum power output of the hearing aid/s is checked (in 95% cases) by REM if performed, or by coupler measurement. Adjustments are made, if required, to ensure that the individual;s uncomfortable loudness level is not exceeded.
Evidence Written protocols, Electronic records, Audits

Criteria 5c.1-c.2 - Achieving ongoing use and benefit from hearing aids

Quality Statement rationale On-going use and benefit from hearing aid use is likely to be increased if the process of support and maintenance includes routine audiological reviews and potential for updating the IMP. Such provision is required to accommodate the changing rehabilitation needs of individuals.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No patients are given follow-up appointments. Review appointments are not actively offered to any patient and patients are never advised that they can self refer for reviews or repairs.	Each patient is given a follow-up appointment following hearing aid fitting within a maximum time of 12 weeks. A review appointment is offered to all hearing aid patients every 3 years (in at least 95% of cases). Patients are regularly advised that they can self refer for review or repairs at any time.
Evidence Written protocols, electronic records, audits

Standard 6 - Outcome

6a The outcome and effectiveness of the Individual Management Plan are evaluated and recorded following a post-management assessment of the impact of intervention.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 6a.1 - Measuring outcome

Quality Statement rationale The management of hearing impairment, within a comprehensive management plan, involves more than a simple technical matter of hearing aid fitting. It involves the provision of a systematic approach, supported by evidence, which addresses not only the hearing impairment, but also other related activity limitations, participation restrictions, and consequent reductions in quality of life ( QOL). Subjective outcome measures, in the form of disease-specific questionnaires, can assess the impact of a hearing impairment on the patient's communication functioning, activity limitation, and participation restrictions. This can then be used in the evaluation process to measure how effective the IMP has been. IMP's help to record multiple hearing aid outcomes; such as functional benefit, satisfaction and QOL within a single questionnaire. Measurement of outcome is required to shape further progression of IMP's.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Validated outcome questionnaires are carried out for less than 10% of patients	Validated outcome measures e.g. the Glasgow Hearing Aid Benefit Profile ( GHABP), IOI- HA and COSI are used to evaluate the outcome of intervention and further develop the IMP in at least 95% of cases (unless clinically contraindicated).
Evidence Random sample of cases, Case audit, Service audits.

Criteria 6a.2 - The clinical record and intervention outcomes

Quality Statement rationale Measurement of outcome is required to: - obtain feedback (including a progressive evidence base) on the effectiveness and benefit associated with the service delivered to the patient group. facilitate further development of IMP, and judge progress on patient outcomes.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
The clinical record contains no information about goals and outcomes	Clinical records are used to facilitate further development and judge patient progress. The records contain information about the extent to which the interventions helped meet the specified goals (outcomes)
Evidence The clinical record

Standard 7 - Professional Competence

7a The Head of Service/Clinical Lead ensures that:

Each service provides, within a governed team approach, the clinical competencies necessary to safely and effectively support the assessments and interventions undertaken,
Where tasks are undertaken by non-registered persons (e.g. volunteers) this takes place within an established competency-based framework and
Links with external agencies are in place to provide complementary service.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 7a.1 - Training and education

Quality Statement rationale To help ensure a safe and effective service, clinical audiology staff should work within their agreed Scopes of Practice and have the skills required for their contribution towards the rehabilitation of hearing impaired patients. Health Professions Council 'Standards of Proficiency' for practitioners statement details requirements for registered practitioners to remain registered. These are produced for the safe and effective practice of the professions they regulate and are deemed to be the minimum standards which are necessary to protect members of the public.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Most of the audiologists and clinical scientists are not registered at least voluntarily with a registration council.	All audiologists and clinical scientists are registered at least voluntarily with a registration council.
Evidence CPD records/portfolio, Registration status of clinical staff operating as independent practitioners

Criteria 7a.2 - Access to CPD

Quality Statement rationale Registration bodies and some employers require demonstration of regular CPD activity. Facilities to access CPD close to the point of work and the CPD being received in association with colleagues is advantageous.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Staff do not have access to sufficient CPD.	All clinical staff have evidence of access to an appropriately maintained CPD programme that provides for active participation - normally run internal to the service (or in formal association with another organisation).
Evidence CPD certificates, Training records

Criteria 7a.3 - Competency peer review

Quality Statement rationale Peer review provides a useful approach to help ensure clinical competencies are maintained.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Competency of staff undertaking clinical procedures is not verified on an ongoing or systematic basis.	Competency for all clinical procedures is verified formally by peer review observation at least every 2 years for all clinical staff undertaking such procedures. Ongoing assessment of all clinical staff's competency should also be carried out, informally, by local audiology centres.
Evidence Records of competency reviews

Criteria 7a.4 - Volunteer staff

Quality Statement rationale To ensure safe and effective outcomes for patients it is important that there are safeguards in place governing the employment and deployment of volunteers.
1 No elements of the quality statement criteria are met (or not evident )	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There are no defined quality standards for volunteer staff to work towards. There are no locally agrees scopes of practice. There are no in-house training programmes. There are no formal recruitment policies	Volunteer staff supporting the audiology service should work to clearly defined quality standards ³⁵, applicable to all such staff. These include: working to locally agreed scopes of practice, in-house training using competency-based frameworks, recruitment is compliant with national and local requirements.
Evidence Records of competency reviews, Volunteer standards and audit against them, Formalised in-house training programmes with associated records, Policies for recruitment of volunteers.

Standard 8 - Multi-Agency Working

8a Each audiology service has in place processes and structures to ensure collaborative working with the appropriate agency to meet the needs of patients through the pathway. These include:

social,
specialist audiological and
other health needs

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 8a.1- Co-coordinating multi-professional and multi-agency working

Quality Statement rationale Multi-agency collaborative working is more likely to result in services that address the needs of those hearing impaired patients who benefit from a more supportive, social environment.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Audiology does not takes a lead role in setting up meetings with any collective representatives from social work; voluntary sector organisations; local volunteer schemes and patients. Meeting are not formal, do not happen quarterly and areas of planning, development, delivery and audit of services are not discussed.	Audiology takes a lead role in setting up meetings with collective representatives from social work; voluntary sector organisations; local volunteer schemes and patients. Formal quarterly meetings take place and the planning, development, delivery and audit of services is discussed.
Evidence Minutes of meetings

Criteria 8a.2 - Referral to other agencies

Quality Statement rationale Having awareness of and appropriate links to specialist audiological services is more likely to result in the hearing and communication needs of patients being met.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No written protocols or processes are in place to support referral to any other services/ agencies.	Written protocols/processes are in place to support referral to the following services/ agencies: - Social work, Volunteer services, Voluntary organisations, Local NHS mental health services, specialist audiological and other health needs, such as, speech and language therapy and falls prevention clinics.
Evidence Referral protocols

Criteria 8a.3 - Audit of multi-professional and multi-agency working

Quality Statement rationale Awareness of and appropriate links to other health services is more likely to result in additional health needs of hearing impaired patients being met.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Audit of multi-professional and multi-agency working is not carried out.	Audit of multi-professional and multi- agency working is carried out annually and includes the take up of referral to these agencies. The Audiology Lead is aware of concerns that arise from the audit and discusses these with agencies involved before developing plans to mitigate areas of concern.
Evidence Audit outcomes Plans

Standard 9 - Service Effectiveness

9a Each service has processes in place to measure service quality

9b Each service has processes in place to regularly consult with patients and stakeholders.

9c Each service has processes in place to keep up to date with and employ key audiological innovations.

Rating Scale

No elements of the quality statement criteria are met (or not evident)

Few elements of the quality statement criteria are met

Meet around half of the elements of the quality statement criteria

Almost fully meets the quality statement criteria

Fully compliant with good to best practice as indicated by quality statement criteria

Criteria 9a1 - Patient Satisfaction Surveys

Quality Statement rationale Measurement of qualitative and quantitative data helps to inform ongoing service improvement.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Patients and significant others are not encouraged to complete surveys to determine satisfaction with the service.	Patients and significant others are encouraged to complete surveys on at least an annual basis to determine satisfaction with different elements of the service received. These include: accessibility, proximity, information provision, professionalism of staff, care and treatment and overall service received. Participation rates in the survey are checked, on an annual basis, to ensure an acceptable proportion of patients have participated and a representative sample of the local population is covered (including gender and ethnicity). Sufficient analysis and interpretation of the findings from satisfaction surveys are carried out each year by audiology services. Action plans are implemented, when needed, to address areas of concern arising from surveys. ³⁶
Evidence Copies of surveys and responses Action plans

Criteria 9a.2 - Glasgow Hearing Aid Benefit Profile

Quality Statement rationale Measurement of qualitative and quantitative data helps to inform ongoing service improvement.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Annual quantitative analysis on the quality/effectiveness of the service is not undertaken.	Annual quantitative analysis on the quality/effectiveness of the service is undertaken using GHABP.
Evidence GHABP reviews

Criteria 9b.1-b.2 - Informing and consulting with patients

Quality Statement rationale Audiology services that seek, consider and respond to the views of users will be more likely to meet the needs of their patients.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
There is no consultation with patients and stakeholders. Results from satisfaction surveys and service QRT scores are never made available or discussed with the public.	The audiology service has a framework in place to ensure regular consultation with patients and stakeholders. Results of satisfaction surveys and service QRT scores are made available and discussed with patients on an annual basis.
Evidence Calendar of planned consultation events Publication of results

Criteria 9c.1 - Responsibility for identifying new technologies

Quality Statement rationale Measurement of qualitative and quantitative data helps to inform ongoing service improvement.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
No one in the audiology service is responsible for identifying, appraising, local development or implementing new technologies.	There is a named lead in Audiology services with responsibility for coordinating the identification, appraisal of potential benefits, local development and implementation of new technologies.
Evidence

Criteria 9c.2 - Appraisal of new technologies

Quality Statement rationale Use of up to date hearing instrument technology is integral to effective service delivery and ongoing improvement. New technologies make new models of service delivery possible.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
National meetings are not held by audiology services to appraise new national/international technology developments.	Regular, national meetings are held by audiology services to appraise new national/international technology developments. Meetings include evidence from pilots/trials where the new technology has been tested. The analysis includes the potential patient benefit and the impact the technology could have on workforce and service delivery.
Evidence

Criteria 9c.3 - Implementation of new technologies

Quality Statement rationale Use of up to date hearing instrument technology is integral to effective service delivery and ongoing improvement. New technologies make new models of service delivery possible.
1 No elements of the quality statement criteria are met (or not evident)	5 Fully compliant with good to best practice as indicated by quality statement criteria	Self assessment score based on evidence sources	QA visitor score and comments	Actions / comments	Good practice example
Departments cannot demonstrate any benefit to patients from using new technology and newly - implemented technology is never monitored.	When new technology is implemented, departments should be able to demonstrate tangible benefits to patients and should continually monitor newly- implemented technology.
Evidence

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Information

Improving Quality and Outcomes in Adult Audiology Rehabilitation Services through Critical Evaluation A Quality Rating Tool for Audiology Services19

Standard 1 - Accessing the Service

Standard 2 - Information Provision and Communication with Individual Patients

Standard 3 - Assessment

Standard 4 - Developing an Individual Management Plan

Standard 5 - Implementing an Individual Management Plan

Standard 6 - Outcome

Standard 7 - Professional Competence

Standard 8 - Multi-Agency Working

Standard 9 - Service Effectiveness

There is a problem

Improving Quality and Outcomes in Adult Audiology Rehabilitation Services through Critical Evaluation
A Quality Rating Tool for Audiology Services¹⁹