Quality Indicators for Professional Service Programs in Audiology and Speech-Language Pathology
Working Group on Quality Indicators
Since 1959, the American Speech-Language-Hearing Association (ASHA) has ensured the provision of quality services to persons with communication disorders by establishing a standards program for the accreditation of professional service programs. Standards were developed by the Council on Professional Standards in Speech-Language Pathology and Audiology (Standards Council). The Professional Services Board (PSB) was responsible for implementing the standards and overseeing the professional services accreditation program. In 2001, ASHA's Council on Professional Services Accreditation in Audiology and Speech-Language Pathology (CPSA) replaced the PSB and became responsible for setting standards for professional service programs and for monitoring compliance with those standards through the accreditation process. The most recent version of the standards—approved by the Standards Council in 2000—became effective January 2002.
At its spring 2001 meeting, ASHA's Legislative Council (LC) passed a resolution to eliminate the accreditation of professional services programs and the CPSA, via a 3-year phase-out period, effective December 31, 2001 (LC 9-2001). Also, as part of the Association's commitment to quality services for consumers, the LC passed another resolution (LC 10-2001) to develop and disseminate quality indicators by January 2005 that will serve as a resource for professional service programs.
The purposes of this resource document are to
identify and describe indicators of quality;
assist programs in self-evaluation activities;
provide a guide for the development of policies and procedures that will facilitate the provision of quality professional service.
The principles that underlie this document reflect accepted best practices and include many of the components covered in the 2002 Standards. Whereas the Standards were developed for use in the accreditation of professional service programs and provided necessary and minimum requirements in a variety of areas, the guidance provided in this document is intended to specify components that are typically present in quality clinical service programs but do not constitute requirements. The document is intended to be self-explanatory. It can be used to provide a framework for programs in the development stages as well as to assist in establishing a means of documenting progress toward improving quality of service provisions by audiologists and speech-language pathologists. Some of the functions of the quality indicators are to
help professionals seeking to improve quality of service delivery;
inform other professions, accrediting bodies, funding sources, and other regulatory agencies of the essential elements of quality in programs that provide speech-language pathology and audiology services;
guide the development of new clinical service programs;
provide a basic framework for self-evaluation, program modification, and future planning in existing programs;
demonstrate to facility administrators and governing bodies the goals to be achieved in developing and operating quality clinical service programs;
enable programs to generate a detailed written report of quality service provision that might be used to fulfill requirements of accrediting and regulatory agencies;
help students and practicing professionals understand the components involved in providing quality care;
educate consumers and the general public about the important indicators of quality clinical service programs in audiology and speech-language pathology.
A working group was charged with the task of developing quality indicators to be available to disseminate to members and others by January 1, 2005. Members of the Working Group on Quality Indicators included Susan Bartlett, Jaynee Handelsman (Chair), Dianne Meyer, John Tonkovich, Marilyn Dunham Wark, and Kelly Appler (ex officio). Sue T. Hale, VP for Quality of Service in Speech-Language Pathology, served as the monitoring officer. In the development of the indicators, the working group considered the contents of the 2002 Standards as well as other ASHA resource documents and input from key stakeholders.
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The quality indicators emphasize the currency, appropriateness, and effectiveness of service delivery in the practice of audiology and speech-language pathology. Concepts of individualization of services to the needs of the persons served, consideration of various service delivery models, interdisciplinary team participation, age and area specific staff competencies, and data driven decision making are featured. Indicators reflect the need to consider all aspects of communication by both speech-language pathologists and audiologists. They emphasize the ongoing nature of program evaluation and performance improvement. While the two professions of audiology and speech-language pathology are guided by their scope of practice statements, individual programs may deliver some or all services from those scopes of practice. Intrinsic to these indicators is the assumption that every aspect of a program is driven by its individual stated purpose and scope of services.
The quality indicators cover five topic areas, each of which applies to professional service programs in speech-language pathology and audiology in any setting (e.g. school based, health care, and private practice):
For each of these, there is a statement of the underlying principle followed by key components of the application of the principle. A question-and-answer format has been used to assist programs in thinking about the application of the components to their specific needs and the needs of the persons they serve. The topic areas are discussed sequentially, in that they build upon one another, similar to a pyramid. For example, since all aspects of a program are based upon the definition of its clients and the services to be provided, the first task for a program is to define the purpose and scope of services. Similarly, for program evaluation and performance improvement to be meaningful, the components of service delivery and program operations must first be specified. Finally, ethical practices of the program and its staff apply to all areas of program operations.
When used as a tool for program self-assessment, these indicators provide a framework for generating a quality report. A written narrative summary of the self-assessment findings, according to this framework, might be used to document the program's voluntary adherence to these quality indicators to administrators, payers, accrediting agencies, and other stakeholders.
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The program articulates its purpose and identifies the populations it serves.
The program has a written statement that describes its purpose.
What is the written purpose of the program?
Some programs define their purposes through the use of a mission statement, vision statements, and/or organization values. The purpose typically is developed by gathering input from staff at all levels of the program.
The scope of program services is clearly defined with respect to population, disorders, and types of services provided.
What is the program's scope of services?
A program's scope of service is part of the broader scope of practice. It is defined by taking into account the characteristics (e.g., age, impairment, activity limitation, cultural and linguistic background, demographics) of persons served, communication disorders or communication variations (e.g., accented English, corporate communication, professional voice), and types of services.
The program demonstrates how its purpose and scope are integrated within the purpose of the overall institution.
How does the program's written purpose relate to the purpose of the institution?
A program may be part of a larger institution, in which case its statement of purpose and scope reflects the overall purpose of that larger institution. This particular guideline does not apply to programs that are not a part of a larger institution.
Information concerning program purpose and scope of services is made available to the public.
How does the program disseminate information about its purpose and scope of services?
The public has access to information about the purpose and scope of services of the program. Information about a program's purpose and scope of services is made available to the public and may be disseminated through means such as brochures, public service announcements, Web sites, conferences, workshops, and direct mail.
The program has attainable goals and measurable objectives that are consistent with its purpose and scope of services and that are directed toward the provision of quality services.
What are the program's goals and objectives?
Goals and objectives typically are formulated by gathering and analyzing information from a variety of sources (e.g., staff, persons served, other stakeholders, management reports, program outcomes). Goals are broad in scope: for example, “the program will better serve a designated clinical population that is currently underserved.” Objectives are more focused and are measurable. A sample objective might be “The program will increase the number of ‘outstanding’ ratings on patient satisfaction surveys by 10%.” Attainable goals are relevant, realistic, and achievable based on current or expected market conditions and resources (e.g., human, financial, physical facility). Goals and objectives may be set within a long-term strategic plan or may be short-term, focused issues. In addition, programs may set annual business goals as well as service provision goals. A program's goals and objectives relate to its purpose and scope of services.
What impact do the program's goals and objectives have on its delivery of quality services?
It is evident that there is an improvement in the quality of services if the goals and objectives are appropriately formulated, measured, and achieved.
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Within its defined scope of services, the program delivers services appropriate to the needs of the persons served and consistent with the current knowledge and skills related to the practices of audiology and speech-language pathology.
The program follows established practices for initiation and termination of service, and follow-up.
What criteria are used to determine initiation and termination of service?
Programs develop initiation and termination criteria based on factors such as preferred practices, empirical evidence, medical status, diagnosis, staff knowledge and skills, prognosis, acuity, outcome of treatment, participation of persons served, organization policies, finances, and legal mandates and regulations.
What follow-up procedures are in place?
Programs develop follow-up procedures to assess factors such as maintenance of outcomes, satisfaction of the persons served and other relevant stakeholders (e.g., referral sources, payers, classroom teachers, employers), and follow through on recommendations made at the time of termination of service.
The program has developed diagnostic guidelines that are based on sound scientific principles and evidence, consistent with its scope of services, and appropriate to the needs of the persons served.
What are the program's diagnostic guidelines and how were they developed?
Programs develop diagnostic guidelines by considering factors such as empirical evidence, preferred practices, staff knowledge and skills, cultural and linguistic variables, as well as the program's scope of services. In addition, the guidelines relate to the needs of the persons served (see ASHA's 2004 Technical report, Evidence-Based Practice in Communication Disorders: An Introduction ).
The program has developed treatment guidelines that are based on sound scientific principles and evidence, that are consistent with its scope of services, and that are appropriate to the needs of the persons served.
What are the program's treatment guidelines and how were they developed?
Programs develop treatment guidelines by considering factors such as empirical evidence, preferred practices, staff knowledge and skills, cultural and linguistic variables, as well as the program's scope of services. In addition, the guidelines relate to the needs of the persons served (see ASHA's 2004 Technical report, Evidence-Based Practice in Communication Disorders: An Introduction ).
Diagnostic and treatment practices are individualized to meet specific needs of persons served, including
age and developmental status
cultural and language background
federal, state, and local regulations and/or policies.
How are diagnostic and treatment practices individualized to meet the needs of persons served?
One way a program might choose to individualize diagnostic practices is to allow additional time for persons requiring interpreters or translators. Another example of individualization is to adapt the treatment modality to enable a child with physical limitations to participate in an outdoor group activity.
The program's professional staff considers a variety of service delivery models and selects an appropriate model for persons served.
How does the program's professional staff determine what service delivery model is best for persons served?
A variety of service delivery models are available. These include, but are not limited to, care that is team based, classroom based, pull out, individual, group, collaborative, home and community based, family centered, and consultative. Professional staff considers the needs and preferences of persons served with sensitivity to culture, linguistic background, and gender in selecting diagnostic and treatment materials and service delivery models.
The program uses established policies for referring persons served to other sites or programs when the needs of persons served exceed the program's scope or availability of services.
What are the program's policies when the needs of persons served exceed the scope or availability of services?
The program has written policies for managing persons served when it cannot meet their needs. Policies include criteria for referral to other providers and a process for decision making.
Within their respective scopes of practice, audiologists address speech-language issues and speech-language pathologists address hearing issues.
How do audiologists address speech-language pathology issues and/or how do speech-language pathologists address hearing issues?
There is documentation that audiology evaluations consider the communication status of the persons served and that speech, language, communication, and swallowing evaluations consider the hearing status of the persons served in order to determine if referral to the other profession is necessary.
For each person served, the program maintains accurate, legible, and complete records that are protected with respect to confidentiality and that comply with legal mandates and regulations.
How does the program assure that records are accurate and complete?
Written policies exist that define “accurate and complete” records. These include items such as identification data and case history; referral information; pertinent correspondence; applicable legal forms; signed and dated reports; and documentation of follow-up activities. Records are legible and systematically organized.
How is confidentiality of the records guaranteed?
Written policies exist that describe procedures used to ensure protection of patient and staff records. Those policies are consistent with applicable legal mandates and regulations. All staff members within the program are trained regarding confidentiality of records. Persons served are also informed about the policies regarding protection of their records.
Persons served participate in determining their plans of care.
In what way do the persons served participate in determining the plan of care?
Professional staff members within the program solicit and consider input from persons served as part of the process in establishing a plan of care. Documentation of the plans reflects this process.
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The structure and function of program administration assure effective and efficient program operation.
The program has established policies and procedures that reflect the program's purpose and scope of services, which are communicated to program personnel and followed.
How are policies and procedures established to reflect the program's purpose and scope of services?
Policies and procedures are written by administrators and/or a committee of knowledgeable individuals in the organization. Ideally, professional staff members are included in the development process. Care is taken to reflect the purpose and scope of services in the policies and procedures. All policies and procedures are reviewed and updated on a regular basis.
How are policies and procedures communicated to the program's personnel and how does the program determine if the policies and procedures are applied consistently?
The program's policies and procedures are published in a resource manual and disseminated to all personnel or, at the least, located in an area that is accessible to all. Personnel are informed of revisions to the manual, and methods exist to determine if the policies and procedures are followed.
Administrative structures indicate clear lines of authority and responsibility.
What are the program's lines of authority and responsibility?
Organizational charts can clearly represent the lines of authority in a program. Job descriptions outline the levels of authority and responsibility and are available to staff.
The knowledge and skills of program administrators are consistent with job responsibilities and level of decision-making authority.
How does the program determine that the knowledge and skills of the program administrator(s) are consistent with the responsibilities of the job and the level of authority to make decisions?
Qualifications, responsibilities, and authority of the designated professional are shown in a written job description. If the program director is not an audiologist or speech-language pathologist, it is recommended that a credentialed professional is designated to represent the professional staff when decisions regarding clinical services are being made.
Administrators lead staff in formulating attainable program goals and measurable objectives.
How does the leadership of the program work with the staff to formulate attainable program goals and measurable objectives?
Program goals and objectives are developed in collaboration with qualified and credentialed professional staff representing the clinical services offered. Staff members and/or leadership typically review goals and objectives regularly, modifying and updating as needed.
Program operations are in compliance with applicable legal mandates and regulations.
What are the legal mandates and regulations the program is required to follow, and where are the reference materials located?
Administrators and professional staff members are knowledgeable about all applicable legal mandates and regulations at the federal, state, corporate, and facility levels. Copies of these mandates/regulations are easily accessible for review. Written policies and procedures describe how the program will comply with the applicable legal mandates and regulations.
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The program has the human resources necessary to fulfill its purpose and scope of services and to achieve its goals.
Professional staff providing clinical services has appropriate qualifications and valid credentials to provide those services.
What qualifications and credentials are required for audiologists and/or speech-language pathologists working within the program?
Minimal criteria for speech-language pathologists and audiologists are specified by a number of groups, including professional orgnizations, departments of education, and licensure boards. Program policies indicate the education, experience, skills, and other credentials needed for staff that independently provide clinical services, taking into account the current requirements of all appropriate groups. Programs can refer to the ASHA policy documents for information regarding clinical certification requirements and to government regulatory agencies for guidance.
How does the program monitor the currency of the credentials of professional staff members once they are employed by the program?
Programs typically maintain a personnel file for each employee, which includes copies of credentials such as ASHA certification, state license, registration, specialty certifications, and continuing education records. Professional staff members submit documentation of the currency of their credentials on an annual basis.
How does the program make certain that nonlicensed and noncertified staff providing clinical services (including students) are appropriately supervised?
The amount and type of supervision needed for nonlicensed and noncertified staff are designated by program policies and are consistent with legal mandates, accreditation and certification standards, and other pertinent directives. Typically, programs maintain logs that document the amount and type of supervision. In addition, programs provide periodic performance assessments of such staff and students.
All program personnel are in compliance with applicable legal mandates and regulations pertinent to the performance of their job responsibilities.
What are the program's policies and procedures for making certain that staff meet legal mandates and regulations?
Some legal mandates and regulations (e.g., licensure, certification, or registration) apply only to specified staff. Other legal and regulatory directives (e.g., privacy, health precautions, or corporate compliance issues) apply to all staff. Programs provide staff with information needed to meet legal requirements. Usually, programs monitor staff compliance through training and assessment programs and by documenting credentials.
Assignments are made in accord with staff members' professional qualifications and specific competencies.
How does the assignment of caseload take into account each professional's qualifications and specific competencies?
The knowledge and skills required of clinical staff are considered foremost when making assignments; these may include, but are not limited to, specialized skills in working with persons across the age span, expertise with specific communication disorders and differences, and procedural competencies. The clinician's qualifications and areas of expertise are consistent with clinical assignments.
For each of the areas of clinical practice represented in the program's scope of services, someone on the staff maintains competence. There is a mechanism in place to make certain that these competencies are established and maintained.
How are the skills and competencies needed by clinical staff established?
Programs have processes for determining the skills and competencies needed across staff to provide their scope of services. Clinical practice statements and ASHA guidelines are good resources for identifying needed skills and competencies. This information is reviewed periodically and is available to all staff.
How are the skills and competencies needed by clinical staff maintained?
Maintenance of skills and competencies can be addressed in a number of ways, such as continuing education, mentoring, in-services, and providing a minimum number of services or procedures. It is important that programs provide ways for staff to maintain skills and competencies as well as to develop new ones when needed.
The program assumes responsibility for providing opportunities for continued professional growth and development for staff at all levels of the organization.
How does the program provide for continued professional growth and development of staff?
Providing high quality clinical services requires continued professional learning. Programs can support continued learning by providing financial support, release time, on-site training, mentoring or sharing of clinical expertise, journal clubs, client staffings, in-services, and other activities and materials that result in the acquisition or refinement of knowledge and skills. A variety of educational resources and learning opportunities are available for staff, taking into account individual learning styles and needs. Programs usually maintain annual records of staff continuing education activities.
Written personnel policies and records are maintained and updated on a periodic basis.
How are the program's personnel policies established?
Programs that are part of a larger organization typically have personnel policies and procedures that have been developed by the institution, while independent programs develop policies and procedures appropriate to their setting and needs. In both cases, personnel policies address issues including, but not limited to, position descriptions, vacation and sick time, benefits, personnel records, grievances, and leaves of absence. Personnel records include evidence of current licensure, continuing education, certification, or other requirements. Policies provide for periodic staff performance appraisals.
What procedures are in place for maintaining and updating personnel records?
The content of personnel records and the individual's access to the records are specified by personnel policies. Each employee's personnel file may include items such as hiring documents (e.g., curriculum vita, contract, position description), copies of credentials (e.g., ASHA certification, state license, and continuing education records), salary information, individual staff member goals, and documentation and results of periodic reviews. The personnel file includes records of changes or updates for these items.
Individual staff workloads are adjusted to achieve a balance between program needs and available staffing without compromising the quality of service delivery.
What are the procedures to make certain that each staff member has adequate time for fulfilling all job responsibilities noted in the position description?
Staff schedules reflect that each staff member has sufficient time for planning, record keeping, supervision, follow up, equipment maintenance, and other job-related activities. Staffing policies and procedures discriminate between workload and caseload, and they ensure that quality service delivery is not compromised by workload fluctuations.
How does the program manage client caseload and other program activities relative to available staff?
Programs have policies and procedures for managing fluctuations in caseload and other work activities. These policies may include staffing needs (both professional and support staff), waiting list policies, initiation and termination of service criteria, staff recruitment, and staff productivity and absences.
Program support services are adequate for the volume and scope of program activities.
How does the program address the need for adequate support services?
Inadequate support services may impact the quality and viability of clinical services. Programs assess their needs for support services, including clerical and administrative assistance, technical support, access to office machines and technology, business staff, and professional assistants. Support services must be adequate for the volume and scope of program services. Resources allocated for support services (e.g., salaries, space, and equipment) are consistent with the need.
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The program's financial resources and their management are appropriate for program operations.
The program has financial resources that are sufficient to provide appropriate services with a reasonable expectation of continuity.
How does the program determine if the financial resources are sufficient to support the operations of the program?
Resources provide adequate financial support for personnel, space, equipment, materials, and supplies to provide services continually across the designated scope of service. Staff member requests are considered when developing the budget.
The program's financial management is conducted in accordance with established policies and procedures, including those related to determining fees, using acceptable accounting procedures, budgeting, and maintaining accountability to relevant groups.
How does the program manage its finances in accordance with the policies and procedures established?
The program has an identifiable process for budget development that shows expenses and revenues consistent with the program's goals and scope of services. There are written procedures for monitoring the program's expenditures, billing, collection of fees for services and/or products, and donations received.
The program's financial management complies with legal mandates and regulations.
How does the program document that its financial management complies with legal mandates and regulations?
The program maintains written documents that specify policies and procedures addressing the applicable laws and regulations regarding all financial matters of operation. These mandates and regulations may include, but are not limited to, those of third-party payers and the state and federal governments.
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The program has a physical plant and suitable environment to conduct program activities and to provide for the safety and welfare of persons served.
The equipment, materials, and supplies of the program are current and adequate to meet program needs.
The program's physical facilities are adequate for conducting activities that meet the program's purpose and scope of services and comply with applicable building and safety codes.
How does the program's physical plant support its purpose and meet the needs of persons served?
Programs have facilities that are clean, of adequate size and design, and treated to achieve noise abatement. The facility's climate control system is maintained regularly to make certain that all work and storage areas are appropriately ventilated, heated, and cooled.
How does the program monitor its compliance with safety codes?
There is evidence that safety inspections are conducted regularly and that the facility meets applicable local, state, and federal safety codes for fire protection, mechanical lifts, lighting, and electrical systems. An emergency evacuation plan exists, and regular evacuation drills are conducted in accordance with the appropriate authority's regulations for safety.
The program's physical facilities and services are accessible to persons with activity limitations in compliance with applicable legal mandates and regulations.
How does the program safeguard that the physical facility is accessible to all persons served, including its personnel?
Standards established by the Americans with Disabilities Act (1990 and all updates) provide guidance for programs to develop and implement procedures for ensuring accessibility. Information contained in Section 4.0 of Part 36 (“Nondiscrimination on the basis of disability by public access and commercial facilities”) specifies standards for accessible design.
How does the program make certain that its compliance with applicable mandates and regulations is current?
Plans are made to conduct routine inspections of the facility, to check currency of compliance, and to take any action necessary for addressing inconsistencies.
The program's physical facilities and service environment are designed to minimize communication barriers for persons served.
How has the program considered the communication limitations of persons served in the design of their physical facilities and service environments?
Programs may use signs and emergency signaling systems that accommodate individuals with all types of communication limitations. Administrators and professional and support staff are instructed on how to communicate with persons who have a range of disorders (e.g., hearing loss, aphasia, laryngectomy) and communication differences (English language learners). The program's services are adapted to meet the preferences and needs of persons served, with sensitivity to the persons' culture.
The program establishes and maintains an environment that protects the health and safety of persons served and program personnel by implementing policies that address universal precautions, infection control, risk management, radiation exposure, and emergency preparedness.
How does the program protect the health and safety of all persons served?
Written policies and procedures that focus on risk management address those circumstances that potentially endanger health and safety. These include, but are not restricted to, infection control, medical emergencies, equipment safety, radiation exposure, weather emergencies, natural disasters, and physical plant catastrophes (power failure, radiation leaks, evacuations, etc.).
How does the program implement its health and safety procedures?
Contingency plans are necessary for managing events that may endanger the health and safety of persons served. When a risk management program is conducted, it is necessary to post universal precautions for implementing infection control measures in areas that are at risk for health and safety violations. Signage that illustrates proper hand washing is situated throughout the facility. Training is regularly provided to staff regarding health and safety procedures.
How does the program prepare its facility to implement its health and safety precautions?
Administrators and professional and support staffs are trained to recognize and respond to emergency situations. These may include, but are not restricted to, CPR training, incident reporting procedures, and evacuation procedures. Structural barriers are eliminated and all areas of the program's facilities are easily accessible by all persons. Policies and procedures for maintaining a safe and healthy environment are reviewed at least annually for currency.
Non-facility-based services are delivered in environments that are suitable for conducting program activities and that minimize risk to the persons served.
What criteria does the program apply to determine that non-facility-based environments are safe and appropriate for persons served, including personnel?
When services are delivered in non-facility-based environments, the program develops and applies guidelines for determining the suitability of such sites. Criteria may include accessibility (such as lack of barriers), safety, structural stability, compliance with prevailing building codes, proximity, availability of equipment, materials and supplies, standards of clinical practice, support personnel, and security for all persons served, including the individuals who provide services. Programs approve non-facility-based sites according to the criteria prior to the delivery of services.
Equipment, materials, and supplies available are consistent with state of the art practices and reflect preferred practice patterns, best available empirical data, and professional consensus.
How does the program select and implement equipment, materials, and supplies that will be used in diagnostic and treatment activities?
Using a range of criteria, the program's administrators and professional staff select materials, equipment, and supplies to meet the needs of persons served. These criteria may include validity and reliability of particular test instruments, treatment materials or protocols, theoretical bases underlying their development and use, robustness of the results from empirical studies, practicality, usefulness, cost, format, availability, product reviews in professional and trade journals, and applicability to the communication disorders served by the program.
How are materials, equipment, and supplies monitored?
An inventory of materials is maintained and updated at least annually; materials, equipment, and supplies that are outdated, broken, or unsuitable are removed from the inventory and discarded.
All equipment is maintained in safe and effective working order.
What steps does the program take to make certain that equipment, materials, and supplies are maintained appropriately and that they are up-to-date, safe, and in working order?
Policies and procedures exist that cite the care and maintenance of the program's equipment, materials, and supplies. They also specify the frequency, schedules, and persons responsible for carrying out routine safety and maintenance. Routine maintenance is documented and reviewed regularly. When equipment does not meet safety standards or is not in working order, it is repaired or removed from inventory.
Equipment that requires periodic calibration is maintained and checked in accordance with current industry standards and benchmarks.
How does the program meet industry standards and benchmarks for calibration of equipment?
Calibration is conducted using guidelines from the American National Standards Institute (ANSI) and equipment manufacturers. Calibration procedures (including electrical, acoustical, and mechanical) are established at the time of equipment installation, and regularly scheduled calibration checks are conducted and documented. Daily biologic checks are performed and all calibration activities are logged, documented, and reviewed on a regular basis. Policies and procedures specify what happens when equipment is out of calibration.
Hearing testing services are offered in a sound-treated test environment that meets the standards of ANSI and that is of sufficient size to accommodate procedures appropriate to the services offered.
How does the program show evidence that its test environment meets ANSI standards and that it is an adequate size to meet the needs of persons served?
Records of calibration of audiometric equipment provide evidence of compliance with universal standards for noise levels. The amount of ambient noise in sound-treated test environments is documented through frequent and systematic measures that are conducted according to ANSI guidelines. Sound-treated rooms/suites comply with industry standards related to electromagnetic, acoustic, and fire suppression qualities.
What is “sufficient” size?
The size of the test environment depends on: 1) the nature of the services provided; 2) the size and type of equipment, furnishings, and materials; and, 3) the mobility status of the persons served.
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The quality of services provided is evaluated and documented on a systematic and continuing basis, and results are used to make program modifications or improvements. These quality evaluations address both program and client outcomes.
The program has a written plan and process for evaluating the effectiveness and efficiency of its performance.
What is the program's process for evaluating the effectiveness and efficiency of its performance?
A written plan describing the process for evaluating a program's effectiveness and efficiency is developed and implemented. On a periodic and systematic basis, program outcomes are reviewed to determine the effectiveness of the services provided and the efficiency of the program's operations in terms of resources used.
The plan provides for data collection from relevant stakeholders, the program's operations, and clinical outcomes.
How are data collected from relevant stakeholders?
The program's plan for evaluating effectiveness and efficiency includes a mechanism for obtaining data from relevant stakeholders. Patient satisfaction surveys, surveys that elicit satisfaction information from referral sources and payers, and data obtained from focus groups are some ways in which programs might collect data from relevant stakeholders. These data are periodically reviewed and compared with relevant or previously established benchmarks.
How are data from the program's operations collected?
Relevant information from a program's operations is included in the assessment of the program's effectiveness and efficiency. Budgetary reports, expense reports, revenue reports, variance reports, capital expenditures, and other reports that summarize resource utilization are some examples of data that might be used from the program's operations. These data are periodically reviewed and compared to relevant or previously established benchmarks.
How are data from clinical outcomes collected?
A program may collect data from clinical outcomes in a number of ways. These might include the use of nationally recognized outcome measures, the percentage of goals achieved by persons served, the average length of stay or duration of services provided, and the volume of persons served. These data are periodically reviewed and compared to relevant or previously established benchmarks.
The program's performance improvement process includes periodic and systematic reviews of clinical service delivery, including
outcomes of persons served
staffing, staff competence, and staff development
How does the program's performance improvement process address pertinent aspects of clinical service delivery?
The program periodically and systematically reviews information about its clinical service delivery. Specifically, the program may review data from
outcomes of persons served that relate to goals achieved and/or satisfaction with services delivered;
clinical guidelines for the delivery of services that might include initiation and termination of service criteria, clinical protocols, and clinical pathways;
the level of staffing needed to accomplish the program's clinical service delivery goals, staff competencies in delivering the clinical services, and areas of staff development necessary for delivering the clinical services.
As a result of these periodic reviews, the program makes modifications in its clinical service delivery as necessary in an effort to improve program performance.
The program's performance improvement process reflects evidence-based practice and includes periodic and systematic reviews of program operations, including
scope of services
attainable program goals and measurable objectives
physical facilities and environment
equipment and materials
safety procedures and emergency preparedness
compliance with legal mandates and regulations
How does the program's performance improvement process address pertinent aspects of program operations?
The program periodically and systematically reviews information about its operations. The program's purpose and scope of services are reviewed on an ongoing basis to ascertain that they continue to be relevant to the clinical services delivered. The program's measurable objectives are reviewed to determine the extent to which program goals have been achieved. The budget is reviewed periodically throughout the year and compared with actual income and expenses as a means of measuring ongoing stability of financial operations. The program's administration/leadership, physical facilities and environment, and equipment and materials are reviewed to determine the extent to which they continue to meet the needs of the program's clinical service delivery. The program's safety procedures and emergency preparedness plans are reviewed to determine the extent to which they are current and relevant. Ethical conduct policies and practices are reviewed to make certain that they meet the needs of the program and the persons it serves. Program compliance with legal mandates and regulations is also periodically reviewed. As a result of each of these periodic reviews, the program makes modifications in its operations as necessary in an effort to improve performance.
Data from the program performance reviews are documented, analyzed, and used to modify clinical service delivery and program operations.
How are data from the program performance reviews documented and analyzed?
Programs prepare a written report of performance reviews that documents and analyzes data from clinical service delivery and program operations. These reports or a synopsis of them are typically made available to staff members at all levels of an organization.
How are data used to modify clinical service delivery and program operations?
Programs demonstrate the changes in service delivery or operations that have resulted from performance improvement reviews. For instance, programs might demonstrate specific clinical service delivery options that have been created, eliminated, or modified as a result of data identified in performance improvement reviews. Similarly, changes in program operations that have resulted from factors identified in the program's performance improvement activities also would be identified.
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Programs have policies that promote the adherence to ethical principles and rules of conduct. Ethical policies are infused into all aspects of service delivery and program operations and upheld by staff at all levels of the organization.
The program does not discriminate in its services and employment practices on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, impairment, or activity limitation.
What are the program's written policies regarding nondiscrimination?
Programs draft policy statements regarding nondiscrimination that apply to people seeking employment within the program as well as to people seeking professional services from the program. The statements are made available to consumers and are understood by all staff.
How does the program monitor compliance with its policies of nondiscrimination?
Various monitoring options exist, including periodic review of recruitment and hiring data, as well as review of referral, initiation, and termination of service data.
Policies relating to clinical decisions in audiology are made by appropriately credentialed audiologists; policies relating to clinical decisions in speech-language pathology are made by appropriately credentialed speech-language pathologists.
How do clinical decisions made within the program relate to staff members' credentials?
The program's written guidelines specify that all clinical decisions regarding the provision of clinical speech-language pathology services are made by speech-language pathologists and clinical decisions regarding the provision of services in audiology are made by audiologists. Note: Refer to the Human Resources section of this document for information regarding credentials for speech-language pathologists and audiologists.
Appropriately credentialed audiologists and speech-language pathologists must supervise persons engaging in any aspect of clinical service delivery who do not have appropriate credentials. The nature, amount, and accessibility of supervision are commensurate with the knowledge and skills of the supervisee and other legal mandates and regulations.
Does the program use noncredentialed persons in the delivery of clinical services?
In many programs, support personnel are used in some aspect of the provision of clinical services. When that happens, the program has written guidelines regarding the specific nature of the tasks that are within the purview of noncredentialed staff as well as clearly defined supervision requirements. Furthermore, the program's written guidelines specify the educational and experiential qualifications of each type of support person employed in the program.
What are the program's written policies regarding the supervision of noncredentialed staff in clinical service delivery?
Written policies exist regarding the amount and type of supervision provided to noncredentialed staff as well as the relationship between qualifications, competence, job task, and degree and type of supervision provided. Program personnel are encouraged to refer to existing ASHA policy documents when drafting their own guidelines for supervision. In addition, program guidelines for supervision conform to legal mandates, as well as agency and school district regulations.
How does the program assess whether supervision is appropriate for noncredentialed personnel?
Evaluation of the appropriateness of supervision could include things such as comparing logs of supervision against established guidelines for supervision, obtaining feedback from persons supervised as well as from supervisors, and evaluating clinical outcomes of persons served. Modifications of supervision guidelines are data driven and are assessed on a periodic and systematic basis.
The program has a written code of conduct for the ethical behavior of its staff.
What is the program's code of conduct, and how was it developed?
A program might be part of a larger organization that has established institutional codes of conduct, in which case the program might adapt the more general code to reflect criteria that are specific to its purpose and scope of services. Speech-language pathologists and audiologists are bound by the code of ethics of the professional organizations to which they belong, in addition to any ethical codes established by other applicable regulatory bodies (e.g., state licensure boards, Department of Education policies). Noncredentialed staff might also be bound by ethical codes of other parent organizations. The code of conduct for individual programs typically reflects standards for behavior that are in concert with other ethical codes and that are general enough to apply to all staff within the program.
How are staff informed about the code of conduct?
Program staff members are typically informed about the code of conduct at the time of hire. In addition, staff members might participate in periodic review of the code.
The program has a written process for managing complaints.
What is the program's complaint process?
A program may be part of a larger institution, in which case it has a complaint process that uses established guidelines of the larger institution. For programs that are not part of a larger institution, program personnel develop a procedure for addressing complaints from program staff and from consumers of the program. The procedure may include how a complaint can be made, how it will be investigated, how a resolution will be decided, and how the complainant will be notified of the outcome.
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Activity limitations: See activity/participation limitations and restrictions. The World Health Organization (2001) combined the terms “activity limitations” and “participation restrictions.” Previously, activity limitations were defined as “difficulties an individual may have in executing activities” and replaced terminology of “disability.”
Activity/participation limitations and restrictions: Combined terminology to refer to “an associated reduction in the ability of an individual to execute tasks in different settings both in a clinic and the patient's real life environment.”
Acuity: As used in this document, refers to time post-onset.
Appropriately credentialed: Refers to licenses and/or certificates required for practice by various administrative units (e.g., professional associations, boards of health, boards of education).
Currency: State of the art.
Diagnostic: Term that is defined as assessment, individual evaluation.
Disability: According to ICF, this is a general term that includes impairments, activity limitations, and participation restrictions.
Empirical evidence: The use of experimental data to support a specific strategy or clinical method.
Facility-based programs: Refers to those programs that are typically housed in the site where they are administered (e.g., educational settings, hospitals, rehabilitation centers, private practice offices).
Goals: Broad areas identified to be accomplished in a designated time frame.
Impairments: Defined by ICF as “problems in body function or structure such as a significant deviation or loss.”
Institution: Organization within which the program resides (e.g., hospital, university).
Job description: A written document describing specific duties, responsibilities, and job-related tasks. Also known as a position description, functional statements, or qualification standards.
Legal mandates: Legal directions or instructions from a group in authority.
Legal regulations: State or federal laws.
Maintenance of outcomes: Over a prolonged period of time. Also referred to as durability of outcomes.
Medical status: Severity of illness.
Mission statement: Overarching defining principle of an organization or agency.
Objectives: Specific steps identified to achieve the broader goal.
Participation restrictions: See activity/participation limitations and restrictions. Previously, participation restrictions were defined as “problems an individual may experience in involvement in life situations” and replaced terminology of “handicap.”
Patient/client: See Persons served.
Performance improvement process: A systematic and organized approach designed to identify, change, and evaluate areas of functioning within a program or of an individual's contribution to it. Also known as “quality improvement,” “quality assurance,” “continuous quality improvement.”
Persons served: Any individual or group who is affected by the delivery of services. This may include clients, families, caregivers, and others directly affected such as educational, medical, and rehabilitation personnel.
Policies and procedures: A policy is a guiding principle created by a governing body that is used to influence and determine decisions and actions. Procedures are the ways in which the policies are to be carried out.
Preferred Practices: Covers ASHA Preferred Practice Patterns, clinical practice guidelines, and best practices. Preferred Practice Patterns define universally applicable characteristics of activities directed toward individual patient/clients, and that address structural requisites of the practice, processes to be carried out, and intended outcomes. Clinical Practice Guidelines are a recommended set of procedures for a specific area of practice, based on research findings and current practice, that details the knowledge, skills, and/or competencies needed to perform the procedures appropriately (ASHA Desk Reference, Volume 1).
Program: The entity that provides speech-language pathology and/or audiology services.
Protected health information: According to the Health Insurance Portability and Accountability Act (1996), “PHI” comprises any information that may identify an individual through his or her health records. This includes, but is not limited to, an individual's name, birth date, social security number, address, identification number, and medical record number.
Protocols: Clinical practice patterns customized to specific setting and program.
Purpose: Specific aims of the program (vision).
Scope of practice: ASHA policies for the practices of speech-language pathology and audiology. Two separate documents serve to describe services, to provide resource information, and to identify those activities that require ASHA certification.
Scope of services: Those portions of the scope of practice that are included in a program. Scope of services includes definitions of clinical populations.
Screening: An initial probe to determine if further evaluation is warranted.
Supervisee: Any individual who is being supervised; this may include student clinicians, noncredentialed employees in a program, technicians, and others who may require any amount of supervision.
Values: See purpose.
Vision: See purpose.
World Health Organization (WHO): The United Nations specialty agency established in 1948 whose objective is for all persons to attain complete physical and mental health and social well being. Among its many responsibilities, WHO issues the “ICD” (International Statistical Classification of Diseases and Related Health Problems) and “ICF” (International Classification of Function, Disability, and Health) regulations and standards.
Workload: All activities subsumed under a position (e.g., administrative, teaching, research, mentoring, clinical).
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The following policy statements, guidelines, articles, and saleable products from the American Speech-Language-Hearing Association (ASHA) are included as related resources to professional programs providing audiology and/or speech-language pathology services. This list is not meant to be exhaustive or limiting; rather, it should serve as a starting point to assist programs in all settings in development, self-assessment, and improvement.
American Speech-Language-Hearing Association. (2004). Admission/discharge criteria in speech-language pathology. ASHA Supplement, 24, 65–70.
American Speech-Language-Hearing Association. (2003). Appropriate school facilities for students with speech-language-hearing disorders: Technical report. ASHA Supplement 23, 83–86.
American Speech-Language-Hearing Association. (1985, June). Clinical management of communicatively handicapped minority language populations. Asha, 27 (6).
American Speech-Language-Hearing Association. (1985, June). Clinical supervision in speech-language pathology and audiology. Asha, 27, 57–60.
American Speech-Language-Hearing Association. (2003). Code of ethics. ASHA Supplement, 23, 13–15.
American Speech-Language-Hearing Association. (1991). Considerations for establishing a private practice in audiology and/or speech-language pathology: Technical report. Asha, 33(Suppl. 3), 10–21.
American Speech-Language-Hearing Association. (2002). Cultural Competence Checklists. Available from www.asha.org/practice/multicultural/self/.
American Speech-Language-Hearing Association. (2004). Evidence-based practice in communication disorders: An introduction [Technical report]. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2004). Guidelines for the training, use, and supervision of speech-language pathology assistants. Rockville, MD: Author.
American Speech-Language-Hearing Association. Issues in Ethics Statements. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services. ASHA Supplement 24, 152–158.
American Speech-Language-Hearing Association. (1990, April). Major issues affecting delivery of services in hospital settings: Recommendations and strategies: Technical report. Asha, 32, 67–70.
American Speech-Language-Hearing Association. (1997, Spring). Multiskilled personnel: Technical report. Asha, 39(Suppl. 17), 13.
American Speech-Language-Hearing Association. (1993). National health policy: Back to the future: Technical report. Asha, 35(Suppl. 10), 2–10.
American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of audiology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (1999). Practical tools and forms for supervising speech-language pathology assistants. Rockville, MD: Author.
American Speech-Language-Hearing Association. (1987, March). Private practice. Asha, 29, 35.
American Speech-Language-Hearing Association. (1994). Professional liability and risk management for the audiology and speech-language pathology professions: Technical report. Asha, 36(Suppl. 12), 25–38.
American Speech-Language-Hearing Association. (1993, March). Professional performance appraisal by individuals outside the professions of speech language pathology and audiology: Technical report. Asha, 35(Suppl. 10), 11–13.
American Speech-Language-Hearing Association. (2004). Scope of practice in audiology. ASHA Supplement, 24, 27–35.
American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (1983, September). Social dialects. Asha, 25, 23–27.
American Speech-Language-Hearing Association. (2004). Support personnel. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2003). Technical Report: American English Dialects in press. Asha Supplement 23.
American Speech-Language-Hearing Association. (2004). The training, use, and supervision of support personnel in speech-language pathology: Position statement. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2000). Working with speech-language pathology assistants in school settings. Rockville, MD: Author.
Council for Clinical Certification in Audiology and Speech-Language Pathology. (1997). Standards and implementations for the certificate of clinical competence of practice in speech-language pathology. In Rockville, MD: Author. Available from http://www.asha.org/policy/.
Council for Clinical Certification in Audiology and Speech-Language Pathology. (1997). Standards and implementations for the certificate of clinical competence in audiology. In Rockville, MD: Author. Available from http://www.asha.org/policy/.
Council on Academic Accreditation in Audiology and Speech-Language Pathology. (2004). Standards for accreditation of graduate education programs in audiology and speech-language pathology. Available from http://www.asha.org/policy.
National Joint Committee for the Communication Needs of Persons with Severe Disabilities. (2003a). Position statement on access to communication services and supports: Concerns regarding the application of restrictive “eligibility” policies. ASHA Supplement, 23, 19–20.
National Joint Committee for the Communication Needs of Persons with Severe Disabilities. (2003b). Supporting documentation for the position statement on access to communication services and supports: Concerns regarding the application of restrictive “eligibility” policies. ASHA Supplement, 23, 73–81.
Paul-Brown, Diane. (1994, May). Clinical record keeping in audiology and speech-language pathology In process of revision. Asha, 36, 40–43.
World Health Organization. (2001). International classification of functioning, disability and health (ICF). Geneva, Switzerland: Author.
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