Quality Standards for Paediatric Audiology Services

1a. All children shall have access to the audiological services they require in a timely fashion, with clearly defined referral pathways to audiological services that are widely disseminated and reviewed regularly.

Correct referral information results in more efficient use of available resources.

Early identification of permanent hearing problems and subsequent intervention leads to improved outcomes for the child at a later date.

Parents support the principle of early identification and intervention.

Fluctuating hearing loss can have a disadvantageous effect on the child's development.

1a.1. Clearly defined written referral pathways from all referral sources (eg newborn hearing screening, ENT, speech and language therapists, paediatricians, health visitors, GPs, education services and parents) are in place and monitored regularly.

1a.2. Routine referrals are seen within 6 weeks of receipt of referral.

1a.3. Urgent referrals are seen at the next available appointment or within 4 weeks of receipt of referral.

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

The number of incorrect referrals to the specialist medical route informs the effectiveness/clarity of referral criteria and compliance of referrers to those criteria. Improvements can then be made to ensure that children are correctly referred to appropriate services.

1b.1. The number of inappropriate direct referrals to Audiology 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 rather than Audiology, eg ENT, 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 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.

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

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

1b.4. The following data are collected, reviewed and used in annual service review:

• demographics of locally served populations, including factors such as ethnic diversity, social deprivation and age, ¹
• the number of children referred to Audiology services and their associated demographic information,
• the uptake of NHS hearing aids in the local population compared with the predictive need for services and
• the number and type of surgical interventions required for children referred to Audiology services.

2a. All referred children receive audiological assessment commensurate with their age and stage of development. In some cases this will form part of a multidisciplinary team approach of which parents are key members.

The range of audiological assessments available enables definition of degree and nature of hearing loss.

Accurate and complete assessment is required to inform decisions and discussions regarding support and management options.

It is important to be able to assess hearing status in children who may have other social, educational and medical difficulties; a multidisciplinary approach will assist with this.

Parental involvement in the assessment and habilitation process improves outcomes for the child.

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 in a quiet test environment.

2a.1. A comprehensive range of audiological assessments is available ², either in the local audiology department or by a pre-arranged referral pathway with an alternative service.

2a.2. Local care pathways detailing type, order, timing and multidisciplinary/parental involvement in assessment are available.

2a.3. Assessments are carried out in accordance with recognised national standards, where available.

2a.4. All audiological procedures use equipment which meets national and international standards.

2a.5. All equipment is calibrated at least annually, and documented to international standards.

2a.6. Daily checks are carried out and documented to international standards.

2a.7. All audiological procedures follow national standards/guidelines, where these exist. ³

2a.8. Assessments are carried out, wherever possible, in acoustical conditions conforming to national standards. ⁴

2b. The outcome of the assessment should inform a clearly defined management plan.

Prompt, accurate and complete audiological information informs the amplification process

The outcome of assessments should contribute in sufficient detail to establishment of aetiology, prognosis and further management.

2b.1. All assessments are interpreted taking into account the developmental status of the child and any co-existing medical conditions.

2b.2. Written local protocols exist which define appropriate management options arising from the assessment (such as decisions to refer, review or discharge).

3a. An Audiology Individual Management Plan ( IMP) ⁵ is:

• Developed for each child, initially based on the information gathered at the assessment phase taking into account the child's developmental age, other medical needs and the child and parental views.
• Updated on an ongoing basis.
• Accessible to the clinical team.

An Audiology Individual Management Plan is required as each child needs to be treated as an individual case as circumstances, medical condition, audiological status and family needs will vary.

There is evidence that families value joint working as it avoids duplication and there is less conflict of information.

Parental involvement improves the outcomes for the child.

3a.1. The Audiology Individual Management Plan is agreed at the end of the first appointment and updated at subsequent appointments thereafter.

3a.2. The Audiology IMP includes an initial programme of audiological management [including provision of hearing aids where appropriate], and details of ongoing assessment as required.

3a.3. The Audiology IMP includes an assessment of current priorities including the level and type of service needed from:

• audiology,
• education,
• paediatrics,
• speech and language therapy,
• social work.

3a.4. The Audiology IMP includes details of service provision from those currently involved with the child and family.

3a.5. The Audiology IMP details any requirements families have for information, family support and practical advice.

3a.6. The specific goals of the individual elements of the Audiology IMP and their timing are documented and circulated to all members of the team.

4a. The Audiology Individual Management Plan ( IMP) is implemented for each child and reviewed at subsequent appointments.

Planned and coordinated intervention leads to better outcomes.

Regular revision allows the management plan to be responsive to the child's changing needs. It also gives the plan the flexibility to incorporate additional information for the benefit of the child's management.

4a.1 The clinical record and IMP includes the details of assessments undertaken and the details, justification and effectiveness of all interventions ⁶ implemented.

4a.2. The Audiology IMP includes a set of achievable objectives which are reviewed and updated regularly.

4b. 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 and
• performance of hearing aid(s) is carefully matched to individual requirements and settings are recorded.

Audiologists ensure that the aid is working to specification before fitting it to a child so that the aid does not cause harm.

Professional bodies' and national guidelines are followed to ensure provision meets the needs of the child.

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

4b.1. Prior to issue every hearing aid has its technical performance tested to specification. ⁷

4b.2. Local protocols which comply with the latest professional bodies' and national guidance ⁸ are in operation concerning selection, fitting and verification of hearing aids.

4b.3. Real Ear Measurement ( REM) / Real Ear to Coupler Difference ( RECD) of hearing aid performance is used to verify at least 95% of hearing aid fittings ⁹, unless clinically contraindicated for individual children.

4b.4. Where REM / RECD is performed, the acoustical target is verified at three different input levels (50, 65 and 80 dB) in more than 95% of cases.

4b.5. Where REM / RECD is performed, measurements do not deviate from the recommended target at more than one frequency (in 95% of cases) unless clinically indicated

4b.6. Where REM / RECD is not possible, current internationally-recognised age-related predicted values are used in hearing aid verification.

4b.7. When REM/ RECD is not attempted/completed an explanation is recorded in the Audiology IMP.

5a. The outcome and effectiveness of the interventions contained within the Audiology Individual Management Plan are evaluated and recorded following an 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 the impact on other related activity. This requires a multi-disciplinary approach.

Subjective outcome measures, in the form of questionnaires, can assess the impact of a hearing impairment on the child's communication functioning and activity limitation. This can then be used in the evaluation process to measure the effectiveness of the intervention.

Audiology IMPs help to record multiple management outcomes such as functional benefit, satisfaction and quality of life. Measurement of outcome is required to shape further progression of Audiology IMPs.

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 the Audiology IMP and judge progress on the child's outcomes.

5a.1. Appropriate outcome measures ¹⁰ are administered to evaluate the outcome of intervention and further develop the Audiology IMP.

5a.2. Clinical records are used to facilitate further development and monitoring of children's progress. The records contain information about the extent to which the interventions helped meet the specified goals (outcomes) and document information about how each element of the Audiology IMP has been implemented, including reasons for changes or omissions.

5b. All children are offered referral for appropriate aetiological investigations as part of their ongoing management.

The outcome of aetiological investigations, as part of the ongoing management, may lead to a better understanding and management of not only the hearing loss but also the whole child. It may also provide an opportunity to identify co-existing medical conditions and prevent further deterioration of these and the hearing loss in some cases.

5b.1. Local referral guidelines are in place regarding aetiological investigations for children with hearing loss.

5b.2. Local guidelines, which reflect national guidelines, are in place regarding aetiological investigations for children with hearing loss.

5b.3. Outcomes from investigations are documented in the Audiology IMP and, as appropriate and with the family's permission, shared with other members of the multidisciplinary team.

6a. Each Audiology service demonstrates that within their team they have the clinical competencies necessary to support the assessments and interventions they undertake.

Children and young people who require ongoing health interventions must have access to high quality evidence based care, delivered by staff who have the right skills for diagnosis, assessment, treatment and ongoing care and support.

Audiology departments have a duty of care to children and families and must ensure that assessments and interventions are delivered by appropriately trained, qualified and registered clinicians.

Through the clinical governance framework, organisations can manage their accountability for maintaining high standards.

Paediatric audiology is a rapidly changing field and clinical competency must, therefore, be maintained through continuing professional development.

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

6a.1 Audiological assessment and support is undertaken by experienced staff capable of performing and interpreting such testing.

6a.2. All professional staff working in Paediatric Audiology hold the necessary qualifications and are registered with the appropriate professional registration body.

6a.3. Staff in senior positions are trained to post-graduate level supplemented by suitably assessed practical experience in Paediatric Audiology.

6a.4. 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 assessments of all clinical staff's competency should also be carried out informally by local Audiology centres.

6a.5. All assistant staff are able to demonstrate additional competency training in Paediatric Audiology along with continuing professional development ( CPD) in the areas in which they are currently working.

6a.6. All staff have basic training in child protection and deaf awareness.

6a.7. Where the competencies required by an Audiology IMP are not held within a service, clear referral routes to external providers exist.

7a. Each service has in place processes and structures to facilitate communication with children and families.

It is important that information is provided in an appropriate format.

Effective communication enables children and families to participate in the development of the Individual Management Plan and Multi-Agency Support Plan, to understand information and make informed decisions.

Children and families need clear and timely information to facilitate attendance and reduce anxiety.

7a.1. Written information regarding the audiology appointment (directions, maps, parking facilities, appointment duration, procedures, facilities, desirable baby state) is provided as part of the appointment process.

7a.2. Children and families receive verbal explanation of the audiological assessment results on the same day that the assessment is carried out.

7a.3. Children and families are provided with written information about the outcome of assessments and any supporting literature within 7 working days of the assessment. ¹¹

7a.4. Children and families are offered information on local and national voluntary support groups, such as NDCS.

7a.5. Children and families have access to information in their preferred language via the provision of translated written material, interpreters, use of language line etc.

7a.6. All staff (including reception and admin staff) 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 organisation.

8a. Each Paediatric Audiology service works within a multi-agency team, which includes each child and his/her parents.

Working as a team leads to more effective use of time and resources.

There is evidence that families value joint working as it avoids duplication and reduces the provision of conflicting information.

8a.1. Each Audiology service works within a multi-agency team, including parents, and members with expertise in:

• Paediatric Audiology,
• development of language and speech skills,
• medical aspects of audiology and
• child development and family support.

8a.2. Each multi-agency team has access to:

• paediatric otology,
• social work services,
• education services and
• voluntary agencies.

8a.3. Each multi-agency team has:

• defined written roles including a "key worker" for each case and
• an appointed coordinator.

8b. Each multi-agency team has in place processes and structures to underpin effective collaborative working and communication within the team and with outside agencies and services.

Sharing of information between agencies in a timely manner ensures that all involved are kept informed, enabling them to provide the most appropriate support to the child and family.

8b.1. Results of audiological assessments are reported to the referrer, GP, Child Health department and any other relevant professionals within 7 working days of the assessment.

8b.2. Non attendance is reported to the referrer and an appropriate professional e.g. HV, Child Health, in accordance with local guidelines/protocols.

8b.3. Systems are in place for the referral of families to other agencies and services involved in the management of children with hearing impairment.

8b.4. When Audiology refers families to other agencies and services, there is ongoing sharing and exchange of information between Audiology and these services and agencies.

8b.5. The Audiology service encourages and facilitates referral of families to appropriate voluntary organisations and parent support groups.

8b.6. Systems are in place to manage the transition from Paediatric to Adult Audiology services. ¹²

8b.7. A Children's Hearing Services Working Group ¹³, including parent representatives, meets regularly to consider the development and delivery of services for hearing impaired children and their families. The remit will include the extent to which services meet the Standards described in this document.

8c. Each service has a major role in facilitating the development and ongoing review of a Multi-Agency Support Plan ( MASP) ¹⁴ for each child who has an ongoing significant ¹⁵ hearing loss. The MASP takes into account the individual needs of the child and family, reflects the child and parental views and is clear, coordinated and flexible.

When a number of different services work with a family, the Multi-Agency Support Plan ensures that individual components of the plan are understood in relation to one another and, more importantly, in relation to the overall aims and wishes of the family.

Multi-Agency Support Plans encourage:

• joint holistic discussions of an individual child's needs,
• agreement of priorities,
• engagement with and involvement of the family and
• regular reviews of any support that is being provided, resulting in improved quality of ongoing care.

Regular revision allows the Multi-Agency Support Plan to be responsive to the child's changing needs. It also gives the plan the flexibility to incorporate additional information for the benefit of the child's management.

8c.1. The Multi-Agency Support Plan is tailored by the information gathered throughout the multi-agency assessment phase.

8c.2. The MASP is in place within 3 months of confirmation of a significant hearing loss.

8c.3. The MASP includes an assessment of current priorities including the level and type of service needed from:

• Audiology
• Education
• Paediatrics
• Speech and language therapy
• Social work and
• Specialist services, e.g. cochlear implant team.

8c.4. The MASP includes details of service provision from those currently involved with the child and family.

8c.5. The MASP includes a set of achievable objectives which are reviewed and updated regularly (at least 6 monthly for pre-school children and annually for school age children) and circulated to all members of the team.

8c.6. The team has a close working relationship and meets on a regular basis (at least every 6 months for pre-school children and annually for school age children) to ensure that the support plan is being implemented in a coordinated way and in line with the wishes and needs of the family.

8c.7. Each agency carries out its own role in the further, more detailed assessments and information gathering necessary to complete the clinical, educational and social picture of the MASP. During this process, information is fed back and shared with all other members of the multi-agency team.

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

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

9a.1. Children and/or families 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.

9a.2. 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).

9a.3. Sufficient analysis and interpretation of findings from satisfaction surveys are carried out annually by Audiology services.

9a.4. Action plans are implemented, when needed, to address areas of concern arising from surveys ¹⁶and QRT data and performance.

9b. Each Audiology service actively participates in the local Children's Hearing Services Working Group ( CHSWG). Where a CHSWG does not exist, the service is active in the setting up of such a group.

Close working with parents as well as across organisations will lead to improved services for deaf children and their families.

Effective recruitment to CHSWGs will ensure appropriate representation for the child and family, and demonstrates a truly inclusive approach.

CHWSGs can ensure that children's hearing services remain high on the agenda of those responsible for planning and delivering services at a strategic level. They can offer advice and guidance to ensure high quality services are available.

9b.1. The CHSWG meets regularly to review the multi-agency services for children and their families known to have, or considered to be at risk of having, a hearing impairment.

9b.2. The CHSWG helps to develop and improve the services delivered to deaf children and their families through the processes of ongoing support to all agencies involved.

9b.3. CHSWGs monitor the extent to which services meet the Standards detailed in this document.

9c Each service has processes in place to regularly consult with children, families and stakeholders.

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

9c.1. The Audiology service has a framework in place to ensure regular consultation with children, families and stakeholders.

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