Quality Control program for Audiology Practices

Based on NZAS Professional Practice Standards, Section 88 Hearing Services Notice, The Australian Commission on Safety and Quality in Health Care, the NZ Ministry of Health Auditing Requirements, and other NZ legislative requirements relating to health professional practices.
The Ministry requires that audiology practices “have systems and processes for the ongoing improvement of the quality of … hearing aid services”. (Section 88 Hearing aid Services Notice 2011)

It is suggested that self-auditing is performed by IANZ clinics for two years consecutively, using “Sound Practice” auditing system by Geethal Systems (password-protected); third year has external auditor (done electronically, using “Sound Practice” system, with specific documents scanned and sent if requested to a range of participating doctors and Ear-Nose-and-Throat and other specialists who have agreed to be auditors for IANZ.

Auditing requires that when requested, policy and other documents, and examples of files with names of patients redacted are sighted; training records etc are sighted.

1. Patient Health and Disability Rights – Copy on wall clinic; English and Maori.
   
2. Patient and Clinician Rights statement specific to audiology visible.
   
3. Prices for clinic services visible/available.
   
4. Disclosure of ownership and links to manufacturers – statement visible in clinic.
   
5. Complaints procedure/information available in waiting room.
   
6. Privacy Act staff awareness: training record; dates; names of those attending, what covered.
   
7. Section 88 of the Hearing Aid Services Notice; staff awareness of requirements; record of training.
   
8. Copies of Section 88 and Privacy Act and Privacy Code available in clinic; staff training recorded.
   
9. Confidentiality agreements signed by all staff regarding patient and clinic information.
   
10. Cultural awareness; understanding of the Treaty of Waitangi and its implications. Training record.
    

1. Name of HR company available to Practice for advice, unless Practice large enough to have own HR dept.
   
2. Job descriptions available.
   
3. Contracts in place for all staff.
   
4. References followed up and documented for new staff.
   
5. Practice has a documented orientation procedure for new staff/clinicians.
   
6. There is a resource about the practice procedures available for new staff/clinicians
   
7. Performance reviews that support individual development and improvement done at least annually.
   
8. Regular staff meeting records kept.
   
9. Clinicians have access to continuing education to keep them up to date with recent developments in hearing aid products, software and other hearing-related technology. Records available of this over past year.
   
10. Mechanisms are in place to monitor that the clinical workforce are working within their agreed scope of practice. (Supervision records, clinical files reviewed, dates when reviewed and what reviewed; any action taken recorded)
    
11. Clinicians working with children have police clearance, and therefore comply with Vulnerable Children’s Act.
    
12. Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role.
    
13. The clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development.
    
14. Procedures to encourage teamwork exist. Records/ description available
    
15. Analyse feedback from the workforce on their understanding and use of safety and quality systems.
    
16. Holiday and leave policy in place. (Copy of policy sighted)
    
17. Flexible work policy in place. (Copy sighted)
    
18. Staff have information about how to comply with Health and Disability Consumers’ Rights.
    
19. Processes are in place to support the workforce to recognise and report complaints.
    
20. Feedback is provided to the workforce on the analysis of reported complaints, and used as an opportunity for improvement.
    
21. Workforce access to training on patient-centred care and engagement of patients in their care.
    
22. Checks of staff understanding of how to focus the clinic on patient and family-centred care.
    
23. Maori greetings and other phrases for use by staff in eg emails, when appropriate, available.
    

1. Written policy in place. (eg membership of Medical Protection Society, available for IANZ clinicians gives access to free dispute resolution services as well as legal advice).
   

1. Copy available in clinic on request (NZAS or IANZ/IAA, or both).
   

1. Clinic Complaints policy and procedures understood by staff. Training record available.
   
2. Complaints Brochure/information available to patients in waiting room.
   
3. Information regarding patient right to complain to Health and Disability Commissioner/Privacy Commissioner available to patients.
   
4. Health and Disablility Code advocates contact information available to patients.
   

1. Continuing Education Points (CEPs) kept up to date – current certificate on wall of clinic.
   
2. Other relevant clinician qualifications on wall of clinic.
   
3. Clinicians working with young children outside scope of adult rehabilitation; paediatric certificates up-to-date.
   
4. Supervision: supervisor signs off on supervisee work as per NZAS requirements.
   
5. Supervision: records of activities, evaluation of progress, summary of feedback etc given as per NZAS requirements (NZAS Professional Standards part B, sect 3, page 24)
   
6. Identity of clinician doing work and making notes recorded clearly in patient file.
   
7. Clinicians work within their scopes of practice (eg only MNZAS audiologists may do ACC work; paediatric certificate-holders can do paediatric work; Audiometrists’ scope of practice available).
   
8. Clinicians refer to another professional when work falls outside their scope/ expertise/ training. Examples of referrals on request.
   
9. Conflicts of interest recognised and dealt with/documented.
   
10. Information on interpreters available in each clinic.
    
11. ACC and ENABLE clinician provider numbers available for each clinician doing funded work.
    
12. If available, WINZ CURAM number for individual audiologists to be a registered supplier with WINZ on behalf of patients.
    
13. Information regarding other funding options for patients (eg NZAS, Vincentian Foundation) in clinic.
    
14. Ownership of clinic, “Statement of Independence” or other ownership links displayed.
    

1. Electrical safety of equipment certified and tagged by electrician. Sighted/ photograph sent.
   
2. Calibration dates up to date on test equipment; specifically, on audiometers and tympanometers. Calibration certification sighted.
   
3. Most recent ISO certification of sound-treated test area; certification done by accredited lab visible on wall of each clinic room that is sound-treated or has a sound-treated booth. Certification sighted. (Certification is five-yearly).
   
4. Minimum of: otoscope with spare bulbs, otoclip for listening to aids, audiometer for pure-tone air-conduction, bone conduction and speech testing; tympanometer; Real Ear Verification machine; portable dremel or fixed grinder/polisher; hearing aid cleaning equipment such as microvacuum, equipment for taking ear impressions for moulds – ideally in each clinic site.
   

1. Parking close by. (Photographic evidence if requested)
   
2. Disability access to clinic entrance (Photographic evidence if requested).
   
3. Waiting area clean, comfortable (Photographic evidence if requested) .
   
4. Relevant information about the service provided, in a way accessible to patients
   
5. MOH subsidy and Funding brochures and other information brochures available.
   
6. Seats with arms (to help elderly patients get up more easily)
   
7. Carpets, if any, secure (eg double-sided tape securing rugs if on a wooden floor.
   
8. Feedback invited/suggestion box/feedback forms/other method of feedback collection used
   
9. Names of clinicians and their qualifications (Audiologist; Audiometrist; MNZAS; Provisional etc) visible in waiting room.
   
10. Building consent (if clinic new) document(s) available.
    

1. Clean, private clinic area, where door can be closed for confidential counselling of patient and discussion of needs.
   
2. Adequate heating and cooling available.
   
3. Adequate lighting.
   
4. Seating for family member or other person(s) if required in clinic room.
   
5. Hand-washing area in clinic room, or hand-sanitiser, if wash basin is in another room.
   

1. Toilet access for the disabled available.
   

1. Accurate, integrated and readily accessible patient clinical records available to the clinical workforce.
   
2. Patient identifying information documented.
   
3. Clinician carrying out testing clearly named.
   
4. Ethnicity data collected in accordance with Ministry of Health protocols.
   
5. MOH Ethnicity data protocols document available to staff.
   
6. Patient General Practitioner/doctor noted in file.
   
7. Relevant patient case history taken.
   
8. Needs assessment/ communication goals (this may be noted according to patient descriptions, or using verified questionnaires such as the HHI, COSI etc).
   
9. Audiometric test results recorded according to accepted NZ conventions.
   
10. Calibration date of audiometer recorded on test results
    
11. Test results and any issues (eg non-organic, hyperacusis, misophonia) described in notes.
    
12. Summary of post-assessment discussion with patient/ significant others.
    
13. Description of specific recommendations (Assistive Listening Devices, Aids, level of technology in relation to communication needs/budget, counselling, referrals, communication training, do nothing, etc).
    
14. Estimate of costs and number of visits (eg quotes saved/scanned in file).
    
15. Note made of when to follow up, and follow-up appointment notes recorded.
    
16. Hearing aid fitting procedure and fitting activities (if aids fitted).
    
17. Real Ear Measurements or other hearing aid verification measures (if aids fitted) with reference prescription.
    
18. Specific recommendations for further management, if required.
    
19. Copies of any correspondence/ medication lists (letters, emails etc).
    
20. Signed consent forms when required to release health/audiological information.
    
21. Other signed agreements (eg trial agreements, finalisation agreements, second-hand hearing aid waiver forms etc).
    
22. Costs: clear indication of bundled or unbundled costings, and what is included/not included. Expected maintenance/ongoing costs. Copy in file.
    
23. Record of outcomes, patient feedback forms available.
    
24. Data collected from patient feedback systems are used to measure and improve health services in the organisation.
    
25. Other professionals and services involved in multi-disciplinary management recorded.
    

1. Assessments are carried out by a named clinician, using agreed and documented testing procedures (eg NZAS standards/protocols), which are available to clinicians.
   
2. The use of agreed clinical guidelines by the clinical workforce is monitored by a designated audiologist within the practice.
   
3. Reasons for truncated tests noted in file.
   
4. Hearing tests are carried out in an ISO-certified sound-treated environment (room or booth).
   
5. If hearing testing not carried out in ISO-certified sound-treated area, note made on hearing test/in file with reason (eg in-home test due to disability/illness).
   
6. Appropriate cross-checks must be performed wherever possible (eg bone and air conduction in audiometry; speech testing of some kind; immittance testing etc).
   
7. Where cross-checks not performed, noted in file/on audiogram and reason.
   
8. Appropriate masking is used and recorded where indicated.
   
9. Audiometric equipment calibration date recorded on audiogram/ in file.
   
10. Vestibular testing follows recognised standards/protocols.
    
11. Electrophysiological tests follow recognised standards/protocols.
    
12. Auditory Processing Disorder and other testing such as Tinnitus Assessments follow recognised standards/protocols. If departing from these, then reasons recorded (eg APD testing under the age of seven).
    
13. Hearing aid verification is performed using Real Ear Measures whenever possible; record in file.
    
14. Annual reviews encouraged for patients with genetic, likely progressive hearing losses.
    
15. Test results are stored securely in patient file (electronically or paper form)
    
16. Test results are given or sent to patient on request, and a copy offered on day of test if appropriate.
    
17. If hearing aid being considered, copy of Ministry of Health Subsidy Scheme or Funding Scheme provided to patient.
    
18. If a hearing aid is not being considered, record in file of other hearing rehabilitation course followed using other means to help patient.
    

(For details of recommended amplification procedures and policies, see NZAS professional Practice Standards Part B Section 14, Amplification, pages 96 and 97)

1. Evidence of needs assessment regarding patient and requirements.
   
2. Evidence that patient has been offered a choice of products/devices in file.
   
3. Evidence in file that aid is appropriate for patient.
   
4. Evidence that patient has been given an adequate trial period in file: ie fitting appointment with a minimum of 2 follow-ups and a trial period of at least 4 weeks for a first-time user.
   
5. Hearing aid programming information saved in computer
   
6. Acoustics set appropriately in software
   
7. Feedback manager run
   
8. Objective Real Ear Measures performed appropriately and saved in file.
   
9. Notes on fitting procedure/problem solving/ subjective responses of patient to sounds/balance between aids etc in file.
   
10. Evidence that patient is satisfied with aids, referring to initial patient needs assessment if possible.
    
11. If an insurance claim replacement, evidence that the aid is at least the same level of technology that the patient had prior to loss or damage. (Specifically to avoid providing lower technology but claiming for more advanced technology).

1. Teleaudiology, if practiced, must have a named MNZAS audiologist at one end of the connection.
   
2. The teleaudiology connection must be secure and private.
   
3. All aspects of procedure documented and signed off by named clinician.
   
4. The remote hearing assistant must have adequate training in:
   1. Otoscopy and earcanal/eardrum conditions (including when to refer);
   2. Taking ear impressions safely;
   3. Measurement of receiver lengths;
   4. Understanding of appropriate acoustic coupling;
   5. Grinding and polishing moulds which are uncomfortable;
   6. Real Ear Measurement probe tube placements;
   7. Troubleshooting and repair of aids;
   8. Cleaning and micro-vacuuming equipment, and access to this equipment;
   9. Explaining and showing patient how to insert and maintain hearing aids;
   10. Cerumen management.
       
       

1. Clear referral pathways to other health professionals: ENTs, GPs, Hearing Therapists, Deaf-Blind coordinators, Vestibular experts, neurologists, psychologists, Cochlear Implants etc
   
2. Referral letters (incoming and outgoing) kept in patient file
   
3. If referral is indicated, permission obtained from patient and referral made to appropriate specialist (NZAS Professional Standards part B section 18 page 113)
   
4. “Resources for older people and their families” document available for patients
   

1. Written procedures available.
   
2. Sterilistion of equipment – written protocols available.
   
3. Staff trained in procedures – dates of training.
   

1. Hazards list/Hazards register checklist available in each clinic.
   
2. Staff accident report template available.
   
3. Significant events – template to record this is available.
   
4. Each clinic has a designated health and safety officer who does regular checks and reports.
   
5. At least one staff member in each clinic has an up-to-date First Aid Certification.
   
6. Earthquake evacuation procedure visible in clinic.
   
7. Fire Exits clearly marked.
   
8. Exit doors can be opened from inside without a key.
   
9. Disability toilet.
   
10. First aid kit available.
    
11. Fire extinguisher available.
    
12. Emergency radio in clinic.
    
13. Emergency cell-phone in clinic, or staff cellphone designated for emergency use.
    
14. Earthquake strapping used to secure cupboards, shelves etc.
    

It is assumed that by contacting the clinic and making an appointment, that the patient consents to be seen by the audiologist. However, in the case of trialling/purchasing of equipment:

1. The patient will sign their understanding regards trial period and costs – copy in file.
   
2. The patient will sign their agreement to keep the equipment/device once the designated trial is completed successfully – copy in patient file.
   
3. If patient unable to sign or understand treatment, designated carer will do so.
   
4. If c) is the case, then record of Health Power of Attorney in file.
   
5. Records in patient notes or quote forms that a choice of products/technology levels/manufacturers were offered.
   
6. Patient offered time to think about choice/discuss it with family/others if required.
   
7. Patient encouraged to bring family/other to appointment. Eg Notices in waiting room/ information given over phone/on website encouraging patient to bring family /whanau /other support person to come to appointment if desired.
   
8. When referring to other health professional (eg GP, ENT, neurologist, etc) permission obtained from patient for release of notes and noted in/scanned into file.
   

1. Patient records secure (electronic security/ paper-based, locked room, alarm)
   
2. Regular electronic backup if held in electronic form
   
3. Patient files/ patient management database password-protected (if electronic format)
   
4. When clinician out of clinic room, computer locked (control/alt/delete) or screen monitor on timer.
   
5. Notes made in file are linked to/signed by responsible clinician.
   
6. Scanned or unneeded documents with patient information are shredded or disposed of by a security company.
   
7. Records are legible.
   
8. Abbreviations understood by others, or list of abbreviations available
   
9. Records (including complaints) held for at least 15 years or more, given audiology treatment may last for decades.
   
10. Transfer of files only done with patient permission; signed copy of patient permissions held on file.
    
11. Requested files provided to requestor (either patient, or health-power-of-attorney holder; or other health professional who can provide patient-signed release of notes request within three days or less.
    
12. Evidence of power of health attorney in file where patient unable to sign themselves.
    
13. Patient given the right to choose their provider in the event a practice ceases to exist or splits.
    
14. Regardless of l) patient has the right to choose their health provider/practitioner.
    
15. If practice ceases to exist, records must be provided to patient, or transferred to another entity which agrees to accept responsibility via Power of Attorney.
    
16. If a practice is jointly owned, a policy is written when practice set up, covering what will happen if the practice is split, including what happens to records of patients being seen by more than one practitioner.
    

1. The impact on patient safety and quality of care is considered in business decision-making.
   
2. The business must operate on sound business principles. (Letter from accountant attesting to this available on request to auditor).
   
3. Business continuity plan in place. (See www.getprepared.org.nz/businesses )
   

• Business insurance up-to-date and adequate coverage held.
  
• Indemnity insurance held. (Eg Medical Protection Society or other).
  
• Sensitive business information held securely in one place (IRD#; bank account#; passwords to access various things such as patient database required for running of business).
  
• Secure cloud-based storage for company information, eg Tresorit, or other
  
• Up-to-date Standard Operating Procedures manual; copy in each clinic, held electronically or in paper form.
  
• Written contingency plan in the event of earthquake, flood or other emergency sighted.
  
• Chartered accountant used by Practice, and holds copies of accounts and finances
  
• Secure cloud-based or other accounting system used – password protected if electronic
  
• Secure cloud-based or other patient database used – password protected if electronic
  

1. Written IT/computer/social media policy available in practice.
   
2. Confidentiality forms signed by staff.
   
3. IT management company or expert used by practice.
   
4. Anti-virus-software in place and up-to-date.
   
5. Electronic data storage policy in clinic
   

Last updated February 2018