Quality Standards for Adult Hearing Rehabilitation Services

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 quickly as any other specialist medical service.

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.

1a.1. All adult patients with hearing problems and their significant other(s) have access to Audiology via Direct Referral where this is clinically indicated.

1a.2.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.

1a.3.Information about referral criteria and pathways, including any changes, are widely disseminated to all potential referrers on a regular basis.

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

1a.4 .The proximity of patients to centres delivering audiology services is similar to other adult services in the Board/district.

1a.5.The audiology centres provide ease of physical access to all areas where audiology is delivered.

Simple equity implies that no patient should be penalised by having to wait longer for a direct referral to Audiology than they would have experienced by referral for 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.

1a.6. 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.

1a.7.The maximum waiting time from referral to treatment ¹of 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. ²

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

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.

1b.1. The number of inappropriate direct referrals is monitored and action plans implemented to address any non-compliance with referral criteria.

1b.2. The number of inappropriate referrals to specialist medical services is also monitored. Action plans are then implemented to address any non-compliance with the referral criteria for specialist medical services.

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 (e.g. hearing aid fitting ³) 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.

1b.3. Waiting times are monitored within the department based upon robust data collection.

Effective allocation of resources relies upon information on actual demand and potential/projected demand for specific services.

1b.4. 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. ⁴

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

To ensure effective initial and ongoing care; agreed multidisciplinary local ear care / wax management procedures should be in place.

1c.1. All patients are advised of and have access to ear care / wax management services that use protocols agreed between Primary Care, Audiology and ENT services and patients.

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.

1c.2. All hearing aid repairs are carried out within 2 days of the repair service receiving the hearing aid.

1c.3. Where Audiology services are delivered away from the main Audiology base; there is at least 1 clinic per month for repair services.

1c.4. Audiology departments will fulfil requests for replacement batteries within 2 days of the request being received.

1c.5. Patients are actively offered information about repair/replacement battery services at each appointment. This will be provided in writing and verbally.

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.

Good communication before, during and after intervention benefits patients - through reduction in anxieties/concerns and encouraging appropriate uptake of further care.

2a.1. Written information about the service, assessment procedures, types of assessment, possible interventions and clinicians involved is provided by the Audiology service for all new and existing patients and their significant other(s) prior to attending the appointment. This will include a request to contact the department in advance of an appointment if an interpreter is required.

2a.2. Consent is gained from the patient for assessment of their hearing and their significant other(s) being present.

2a.3. Straight after assessment, results are recorded, explained verbally and given to patients and/or their significant other(s)

2a.4. Information is provided, by audiology, regarding services offered by other agencies (including voluntary sector organisations).

Written information that is clear, up to date and in a format that is accessible to the individual facilitates understanding of the service

2a.5. 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.

2a.6. A written individual management plan is provided and updated at subsequent visits ( explained in further detail in appendix 4).

To avoid discrimination, services should meet the specific communication and information needs of hearing impaired patients and their significant other(s) accessing the service.

2a.7. All frontline staff with direct patient contact ⁵ receive deaf-awareness and communication training as part of their induction, which is then updated every 3 years. This training is approved by a relevant third party such as a voluntary sector organization. The training will include deaf-blind awareness and also underline key areas of communication. ⁶

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.

2a.8. 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). All staff responsible for using the technology are trained on how to use it. The application of such technology reflects the advice of representatives of local user groups.

2a.9. 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 using the technology are trained on how to use and carry out maintenance checks on it. The application of such technology reflects the advice of representatives of local user groups.

Well lit rooms help aid the ability of hearing impaired patients to lip read and improve communication generally.

2a.10. All areas used for staff and patient communication are well lit

The involvement of significant others (e.g. spouse) in the rehabilitative process can provide improved outcomes.

2a.11. 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.

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.

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

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.

3a.1. The following are established for every patient:

• hearing thresholds by air and bone conduction,
• thresholds of uncomfortable loudness levels ⁷,
• additional/further diagnostic procedures as required.
• a relevant medical history.

3a.2. 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.

3a.3. Equipment is calibrated annually and documented to international standards, and daily checks are carried out and documented to international standards.

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).

3a.4. Hearing tests, with the exception of domiciliary visits, are always carried out in acoustical conditions conforming to national and international standards ⁸.

3a.5. A self-report questionnaire is a routine part of the assessment protocols ⁹ and is used in conjunction with all information gathered relating to social circumstances, psychological impacts, communication and listening needs and expectations.

3a.6. 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.

4a. An Individual Management Plan ( IMP) ¹⁰ 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.

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.

4a.1. 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.

4a.2. The IMP is agreed with the patient and significant other(s) at each appointment and a copy is made available for them.

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.

4a.3. 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

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.

4a.4. Information is recorded in the patient's clinical record ¹¹, 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.

4a.5. Recorded updates of patient IMP occur at each appointment to reflect changing patient goals.

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

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.

5a.1. 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.

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.

5a.2. The clinical record and IMP includes the details, justifications and effectiveness of all non-instrumental interventions implemented. ¹²

5a.3. The clinical record and IMP includes the details, justifications and effectiveness of all instrumental (hearing aid) interventions implemented. ¹³

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 and
• performance of hearing aid(s) is carefully matched to individual requirements and settings are recorded.

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.

5b.1. Prior to issue; every hearing aid has its technical performance tested to specification. ¹⁴

Professional bodies and national guidelines should be followed to ensure provision meets the needs of the individual.

5b.2. 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. ¹⁵

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.

5b.3. At least 95% of patients who need and are clinically suitable for bilateral hearing aid fitting should be offered 2 hearing aids.

Evidence suggests that hearing aids are most effective when their performance is carefully matched to the requirements of the individual.

5b.4. Real Ear Measurement ( REM) of hearing aid performance is to be used to verify at least 95% of hearing aid fittings ¹⁶, unless clinically contraindicated for individual patients.

5b.5. 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.

5b.6. Where REM is performed: measurements do not deviate from the recommended target at more than one frequency (in 95% of cases) unless clinically indicated

5b.7. 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.

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

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.

5c.1. Each patient is given a follow-up appointment following hearing aid fitting within a maximum time of 12 weeks.

5c.2. 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.

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

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 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 and activity limitation. 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.

6a.1. 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).

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 and
• facilitate further development of IMP and judge progress on patient outcomes.

6a.2. 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).

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,
• Links with external agencies are in place to provide complementary service.

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.

7a.1. All audiologists and clinical scientists are registered, at least voluntarily, with a registration council.

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.

7a.2. 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).

Peer review provides a useful approach to help ensure clinical competencies are maintained.

7a.3. 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.

To ensure safe and effective outcomes for patients it is important that there are safeguards in place governing the employment and deployment of volunteers.

7a.4. Volunteer staff supporting the audiology service should work to clearly defined quality standards ¹⁷, applicable to all such staff. These include:

• working to locally agreed scopes of practice,
• in-house training using competency-based frameworks,
• recruitment compliant with national and local requirements.

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.

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.

8a.1. Audiology takes a lead role in setting up formal quarterly meetings with collective representatives from social work; voluntary sector organisations; local volunteer schemes and patients. The remit includes the planning, development, delivery and audit of services.

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.

8a.2.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, for example, speech and language therapy and falls prevention clinics.

Awareness of and appropriate links to other health services is more likely to result in additional health needs of hearing impaired patients being met.

8a.3. Audit of multi-professional and multi- agency working should be carried out annually and should include the take up of referral to these agencies.

8a.4. The Audiology Lead should be aware of any concerns that arise from the audit and should discuss these with all agencies involved before developing plans to mitigate areas of concern raised in the audit.

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

Measurement of qualitative and quantitative data helps to inform ongoing service improvement.

9a.1. 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, annually, 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 findings from satisfaction surveys are carried out annually by audiology services. The information gathered will also be used to ensure fair and equal access to services in line with Scottish Government Equality Duty requirements.

Action plans are implemented, when needed, to address areas of concern arising from surveys. ¹⁸

9a.2. Annual quantitative analysis on the quality/effectiveness of the service is undertaken using GHABP.

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

Audiology services that seek, consider and respond to the views of users will be more likely to meet the needs of their patients.

9b.1. The audiology service has a framework in place to ensure regular consultation with patients and stakeholders.

9b.2. Results of satisfaction surveys and service QRT scores are made available and discussed with patients on an annual basis.

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

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.

9c.1 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.

9c.2. Regular, national meetings are held by audiology services to appraise new national/international technology developments. This should include evidence from pilots/trials where the new technology has been tested. The analysis should include the potential patient benefit and the impact the technology could have on workforce and service delivery.

9c.3 When new technology is implemented, departments should be able to demonstrate tangible benefits to patients and should continually monitor newly- implemented technology.