Quality Improvement in Paediatric Hearing Services: recommended actions for immediate implementation
NHS England has recently written to all Integrated Care Boards (ICBs) with recommendations for immediate action in paediatric audiology. The recommendations are an interim measure, whilst a National Paediatric Hearing Improvement Programme established by NHS England to support providers and ICBs to improve the quality of these services, reviews the whole system.
The programme is undertaking work to understand the scale of the problem and the number of children who have been affected, and to develop the strategic tools and interventions to support sustainable improvements. BAA are involved in the steering group and across the work groups.
The recommendations are:
1. Leadership and quality governance
There should be a named senior-level clinical lead for each provider who has oversight and responsibility for audiological assessments and clinical interpretation undertaken by each service.
The named senior lead should have extensive clinical, scientific, and leadership skills in audiological diagnostic assessments and interpretation (appendix 1). Options for collaborating with other providers to access the expertise should be considered.
There should be an established route to the organisation’s quality governance team for reporting issues and incidents.
Each ICB quality board should ensure they receive regular quality reports from paediatric hearing services in line with local service reporting arrangements.
2.UKAS IQIPS accreditation scheme
The UK Accreditation Service (UKAS) has operated an improving quality in physiological services (IQIPS) scheme since 2012 for the accreditation of audiology services.
The UKAS IQIPS (Improving quality in physiological services) is the only recognised accreditation standard for physiological science services inclusive of audiology services and provides the evidence for CQC regulatory purposes. Currently a minority of paediatric audiology services (and physiological sciences services in general) have UKAS IQIPS accreditation.
The provider/trust should be working towards UKAS IQIPs accreditation and the ICB should ensure that there are plans in place to implement, achieve, or maintain accreditation using the available tools, and that there is oversight of quality management systems.
Services that are new to accreditation could approach pathology quality managers or UKAS IQIPS accredited Audiology Services to learn from established accredited services about the process. Services that are not IQIPs accredited should formally register this as a quality risk in their quality reporting system.
3. Paediatric audiology quality standards
For services that are not UKAS IQIPS accredited, heads of services in collaboration with the clinical lead should provide an external evidence-based assessment of their provision against the current standards outlined in:
• The British Society of Audiology (BSA) guidelines for the early audiological assessment and management of babies referred from the Newborn Hearing Screening Programme
• The British Academy of Audiology (BAA) Quality standards in paediatric audiology, with specific reference to standard 3 (assessment and aetiology) and standard 6 (skills and expertise).
• A self-assessment audit tool is available for services which must be triangulated with evidence-based external peer assessment of clinical practice.
(Appendix 2 provides an example of a current NHS regional evidence-based desk top peer review assessment being led by the Regional Healthcare Scientist to meet this recommendation.)
The recommended actions should be owned at provider level by the named clinical lead with associated improvement action plans and service risks developed with system quality groups including the ICB quality lead, the Regional Quality Group, and where appropriate regional medical directors and regional chief healthcare scientists.
All UKAS IQIPS accredited services should report progress against the recommended actions in their most recent assessment report to their local quality governance group and the ICB/ regional quality groups.
4. Peer review of diagnostic auditory brainstem response (ABR)
Services providing diagnostic auditory brainstem response (ABR) assessment must be actively engaged with internal and external peer review and external quality assurance (EQA) processes in accordance with the British Society of Audiology (BSA) guidance.
Monthly summary outcomes, of peer review should be approved by the provider’s/ trust’s clinical lead, including a cumulative monthly report, who will escalate learning, improvement, and concerns within the provider and system quality groups (ICB and region).
5. Historical peer review
Where risk of harm is identified, the provider/trust quality governance team should agree the risk-based approach to historical peer review of cases. Implementation and outcomes of historical peer reviews should be communicated to the system quality groups; ICB, and region for escalation.
Incident management teams are to be instigated where risk of harm is identified. The incident management approach should include a full-service review and development of an improvement plan that is agreed by the ICB Quality and the Regional Quality Group.
6. Patient safety and duty of candour
Following historical peer review, any incidents should be reported to the provider/trust patient safety teams and in parallel, communications to patients and families affected should be agreed by the provider/trust in conjunction with ICB leads and regional medical directors.
In the event of a patient safety incident being identified, ICB leads should ensure that there is an appropriate patient safety lead identified within the provider/trust for the audiology service. They should refer to the NHS England » Patient Safety Incident Response Framework and supporting guidance and The duty of candour: guidance for providers (cqc.org.uk).
7. Data, records and documentation management
Services must maintain appropriate record keeping in line with national guidelines and arrangements for other diagnostic services, and what would be expected in UKAS accredited services. BAA Quality Standards in British Academy of Audiology and Records and Document Management – NHS Digital
Record keeping should include the retention of diagnostic data and accurate, timely data entry onto the national database, Smart for Hearing (S4H). All professionals should have access to essential data/case notes that are required in management and decision-making process for patients, including where patient care is delivered by multiple services in the ICB area.
All providers should risk stratify their paediatric waiting lists to ensure those needing urgent appointments are prioritised. For example, priority for children referred following bacterial meningitis and those identified as part of this incident response.
All providers should ensure that they are reporting activity and waiting times to DM01 in line with the criteria set out in the national DM01 guidance. This ensures there are no patients being held on other waiting lists that should have been reported under DM01.
8. Workforce competency
The service workforce should work to the professional standards of practice as outlined in the Academy for Healthcare Science good scientific practice, and in line with requirements of statutory and accredited professional registers and the Academy for Healthcare Sciences standards.
The competency of the workforce to perform, interpret or supervise paediatric audiology assessments should be reviewed according to the BAA Quality Standards in Paediatric Audiology2 with specific reference to Standard 3 (Assessment and Aetiology) and standard 6 (Skills and Expertise).
For every member of staff, there must be a competency record and access to refresher training by professional organisations. Members of the workforce who cannot evidence their competency should be supervised by someone who can demonstrate competency to practice. ICB leads and regions should support services to access funding and resources for training and continual professional development.
9. Workforce health and wellbeing
Where patient safety issues are identified in services, provider/trusts should identify a named health and wellbeing lead for the paediatric audiology workforce. This person should be able to identify immediate support for staff health and wellbeing as well as training programmes such as resilience and handling difficult situations. The workforce should also be made aware of NHS England » The national speak up policy so that they have a confidential route to escalate concerns.
10. Mutual aid
ICBs, clinical leads, and heads of service should link with their regional teams to identify regional mutual aid capacity that could support services if historical peer review, training, or excessive waiting times are identified.
Instructions for return
• The findings and proposed actions need to be shared via established quality governance routes – System Quality and Regional Quality Groups.
• ICBs should provide the ICB Executive Quality Lead (e.g, Nursing Director or Medical Director) with monthly updates on their risks and issues for each of their services from 30 October 2023. These should be escalated to an NHSE convened Regional Operational Paediatric Hearing Services Improvement Group.
• The table in the document outlines the key information required to demonstrate compliance against the recommended actions to ICB Executive Quality Leads. It is critical that an evidence-based approach is adopted to demonstrate compliance. We appreciate the nature of gathering the information will be iterative.
Appendix 1 – Competency framework for paediatric audiology clinical lead Education/ qualifications
• MSc in Audiology or equivalent (or assessed study at M-level)
• Higher Certificate of Clinical Competence/ Certificate of Audiological Competence (or equivalent) and
• HCPC or GMC registration with RCP (or SPIN module in Paediatric Audiovestibular Medicine)
• Leadership or management qualification
• Member of an Audiology Professional group (eg BAA, BAPA).
Academic/Clinical Knowledge and Skills
• Expertise in paediatric clinical auditory assessment and management
• In- depth working knowledge of current national standards, policies, professional recommendations, and guidelines.
• Experience of clinical diagnostic quality management, governance and assurance, including assessment against UKAS IQIPS
• Detailed knowledge of hearing devices their processing strategies and other relevant technologies and experience of assessment against these
• Awareness of emergent research and technologies for hearing assessment and amplification devices
• Proven ability to lead and work co-operatively within a team including MDTs’.
• Ability to always behave appropriately towards patients, external professional collaborators, and colleagues.
• Significant specialist experience in an area of Audiology.
Appendix 2 – Example: Paediatric Audiology Hearing Services – Peer Review Evidence Template (see document)
Download the letter here: PRN00622_ii_Quality Improvement in Paediatric Hearing Services – recommended actions for immediate implementation letter_310823
Download the recommendations here: PRN00622_i_Paediatric Hearing Services Improvement Programme – system recommendations for immediate action_August 2023