Quality Improvement for Audiologists
Quality improvement is an ongoing activity that objectively evaluates current work practices and client care provided by educators and health care practitioners, including audiologists and speech-language pathologists (SLPs).
What is Quality Improvement?
Quality improvement (QI) is an ongoing activity that objectively evaluates current work practices and client care provided by educators and health care practitioners, including audiologists. It is a process that identifies practice trends, accepted levels of care, problems, and solutions to problems. It provides accountability related to the efficacy and efficiency of audiologic intervention and identifies those factors that enhance or hinder client care.
Why do we measure quality?
Consumers, administrators, third party payers, and policymakers are demanding objective proof that services provided by audiologists are meeting specific standards or protocols of care. Providing quality care is critical to both receiving reimbursement for that care and positive outcomes of services. It also ensures consistency in the standard of care provided by audiologists. This consistency is measured through quality improvement monitoring systems.
How is quality measured?
Quality improvement (QI) measures typically include indicators for the areas of:
- structure (e.g., facilities, equipment, qualifications of practitioners, staffing ratios, record keeping)
- process (steps taken to perform evaluation and treatment)
- outcomes (the results of evaluation and treatment)
QI monitoring systems can gather and track data retrospectively (after client discharge), concurrently (during client care), and prospectively (before client care begins). Systems to gather such data can be as simple as a checklist or as complex as an automated relational database. The database in and of itself does not improve quality; rather, these databases provide information on client care trends. When a changing trend or problem is identified, that change or problem must be addressed and resolved. It is in the resolution of the problem or action on change that we improve quality practice. QI measures may serve to identify populations currently underserved and justify additional resources to assure quality care and the enhancement of overall services.
Where do QI activities take place?
QI programs should be implemented in public and private schools, clinics, community speech and hearing centers, university speech and hearing centers, private practices, and health care settings (e.g., hospitals, rehabilitation hospitals, skilled nursing facilities). Standards and guidelines instituted by accrediting bodies (e.g., The Joint Commission, formerly Joint Commission on Accreditation of Healthcare Organizations), regulations by third party payers (e.g., Medicare, Medicaid), laws (e.g., Omnibus Budget Reconciliation Act [OBRA]), the profession itself (e.g., ASHA practice policy documents, the Code of Ethics), and consumers all require objective proof that quality services are rendered.
What is accreditation?
In today's consumer-oriented world, service providers often seek credentialing or special recognition by another agency or body of persons who give a "seal of approval" for services and goods provided to customers. This "seal of approval" in education and health care takes the form of accreditation.
How do accrediting bodies influence QI?
Accrediting bodies review ongoing quality improvement activities and programs. Accrediting bodies no longer accept paperwork compliance alone to satisfy the requirements of the accreditation process. While the documentation of ongoing QI activities is still a part of the accreditation process, today's accrediting bodies want to see QI activities that address actual client care (including the quality and appropriateness of care, the accuracy of diagnostics, the efficacy of treatment, the appropriateness of referrals, and the outcomes of services provided). Accrediting bodies want to review how the audiologist has addressed these areas, not only after the client was discharged, but also when actual care is being provided.
Accrediting bodies like Joint Commission (formerly referred to as the Joint Commission on Accreditation of Healthcare Organizations) have fostered the evolution of QI activities (referred to by Joint Commission as "performance improvement"). Joint Commission has moved from the patient care audit to more contemporary QI methods. While previous Joint Commission audits heavily emphasized data collection and were done retrospectively, new methods allow for retrospective, concurrent, and prospective review and emphasize outcomes. The outcome-oriented approach focuses on the actual performance of practitioners and clients, rather than on paper compliance and theoretical practice.
The shift in accreditation emphasis-from whether a facility can provide high quality care to whether it actually does-has become the major focus in recent years and will continue to be emphasized until quality care is firmly incorporated into the accreditation process.
What are outcome measures?
Outcome measures are not new to the field of audiology. Outcome measures can be the assessment of the benefits of an intervention such as amplification or the goals and objectives that are established after the initial diagnostic work-up of a client. Measuring client outcomes as a QI activity obligates audiologists to address the efficacy and efficiency of client interventions.
Third party payers have historically based reimbursement decisions on the progress clients make during treatment. With the pressure to contain costs, payers and administrators will no longer tolerate "carte blanche" delivery of services without monitoring the cost, benefit, and outcomes of those services.
What is an example of outcome measures?
Objective: 75% of clients will achieve stated discharge goals/objectives for hearing aid orientation.
Method of collection: 100% of discharged client files are reviewed at the time of discharge to determine if initial goals/objectives were achieved, not achieved, or exceeded.
Information is tracked by client type, clinician, and severity. Information is collected and reviewed monthly. Those clients who did not achieve or exceeded discharge goals/objectives are routed back to the primary audiologist for analysis.
Reason for non-attainment of goal/objective:
- Client-related: Motivation, attendance record, illness, severity, complications, psychosocial/economic/cultural/ethnic factors
- Treatment-related: Method, approach, client appropriateness, frequency, comprehensiveness
- Financially-related: Coverage of services by payer, limits on frequency or duration of treatment, limits on follow-up/after-care
What needs to be done after the initial outcome data is collected?
After the analysis and feedback from the practitioner, the reason for non-attainment of outcome goals/objectives may be determined to be the result of insufficient treatment or teaching sessions, with clients returning too often for instruction and education which should have been delivered during the initial or follow-up sessions. An action taken then to improve the quality of care may include:
- additional teaching sessions
- additional teaching or instructional techniques (handouts, videotapes, self-tests)
- development of a protocol or outline which all audiologists at that facility will follow when providing hearing aid orientation
To complete the QI cycle, this same indicator and method of collection will be monitored for the next few months, to determine if there is a greater incidence of clients meeting discharge goals/objectives. If so, then indeed the quality of care has been improved.
What is risk management?
Risk management consists of a process to:
- identify actual risks and potential risks
- analyze these risks in terms of financial loss and legal liability
- develop risk control techniques and systems
- implement those techniques and systems
- monitor their effectiveness
A risk management program should include: (a) safety and security precautions; (b) infection control; (c) review of all incidents and accidents; (d) prevention strategies; and (e) education of both providers and consumers.
Example: A handbook of precautions, infection control, and prevention strategies should be available in every work setting for all audiologists and staff. Annual review of this handbook and revision, when necessary, should be conducted with all employees, and at the time of employment for new employees. These reviews should be documented.
Why do audiologists need to be concerned about risk management?
Risk management falls within the umbrella of QI. A QI program may incorporate principles of risk management, using structure, process, and outcome measures. Historically, the profession of audiology was believed to be relatively "risk free." However, due to an expanding scope of practice (e.g., cerumen management), increased contact of audiologists with persons with infectious diseases, and the demands of consumers for safe and infection-free environments, audiologists must address risk management. In addition, today's environment of heightened security requires that all health care workers engage in risk management activities to keep their patients and themselves safe.
A risk management program adopts a proactive stance to prevent harm and reduce financial loss and legal liability. Risk management is the responsibility of every audiologist regardless of work setting. A risk management program should be in place at your facility and may be part of a QI program.
Example: It is more costly to have an employee on sick leave or disability leave than it is to review safety precautions and preventative strategies.
What is a consumer satisfaction measure?
A consumer satisfaction measure is a type of QI tool designed to obtain feedback directly from clients/patients regarding their perception of the quality of services rendered by your facility, the effectiveness of those services, and the outcome. A consumer satisfaction measure is a tool that should be a vital part of your QI program. It can be used to assess the treatment outcome as it relates to the initial plan of treatment and actual services delivered.
Why should I be concerned about consumer satisfaction?
Consumer satisfaction is the determining factor for providing a productive, ongoing association between your clients/patients and your facility, ensuring that your client/patient will return to your facility for follow-up or additional services, and stimulating positive word-of-mouth referrals from former clients/patients. A consumer satisfaction measure is vital if the facility administrator is to evaluate the services being provided and to ensure the desired clinical outcomes to meet the client/patient's needs. From the feedback provided by consumers, data can be collected that will enable the administrator to make changes in programming for QI.
How can we measure consumer satisfaction?
Consumer satisfaction can be assessed by various measures. Typically, satisfaction surveys or questionnaires are designed to assess the client's perception in several areas and across various parameters, including facilities, timeliness, interactions with clinical and support staff, service delivery, and patient outcomes.
With the consumer satisfaction measure a basic component of a QI program, practitioners can obtain valuable feedback that can be incorporated into a performance evaluation system.
Quality Improvement Articles from the Special Interest Groups
The following reports and forms were adapted from: Lynn, D. & Riquelme, L.F. (1997). Q.I. - The Easy Way: A Practical Guide for Developing Quality Improvement Programs. Glenmont, NY: New York State Speech-Language-Hearing Association.