01.04.12
Improving audiology services
Source: National Health Executive March/April 2012
NHS Improvement’s director of audiology improvement Fiona Thow considers the way to improve audiology services throughout the NHS.
NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in redesigning clinical pathways in cancer, diagnostics, heart, lung, stroke and audiology services, which have helped to improve patient experience and outcomes at over 250 sites across England.
It has worked in partnership with the Department of Health National Audiology Programme since July 2008, supporting services. In assisting 12 challenged sites to reduce waiting times and subsequently supporting 18 sites to improve the quality of patient experience, it identified and tested four winning principles:
• Direct access
• One-stop clinics
• Care closer to home – community services
• Developing protocols for patients with complex hearing problems.
Six out of the 18 pilot sites went onto a prototype phase to test these principles further. Emerging learning was shared via strategic health authority clinical lead networks, presentations and workshops including to the British Academy of Audiologists and also via an audiology e-bulletin. Strong partnerships were also forged with third sector partners, including the National Deaf Children’s Society, Action on Hearing Loss and British Tinnitus Society Association, to support and input into the improvement work.
The hospitals involved have continued to develop their services and pathways with larger numbers of patients, using their input to shape future developments. Commending the work, the Department of Health’s chief scientific officer Professor Sue Hill said: “These pilot sites, working with NHS Improvement have applied Lean principles to demonstrate how improvements can be made across the pathway that will change the way audiology services should be delivered in the future.”
During the project, it was demonstrated that service improvements could be made in a variety of settings.
Nottingham University Hospitals NHS Trust wanted to re-design the support provided for patients who routinely required access to hearing aid assessments and simple repairs. The new pathway aimed to be more efficient and cost effective and also, importantly, offer patients care closer to home, therefore improving accessibility, whilst maintaining or improving quality. Accepting that an ageing population will inevitably lead to an increase in demand, it was also agreed to test how a well trained workforce would provide services in future. A further aim was around providing evidence that the service could be delivered safely and effectively using the support of associate practitioners. This was tested and measured by comparing clinical and patient outcomes between existing and new pathways.
Patients, commissioners, managers and clinicians (all grades) provided direct input into the piloting and prototyping phase. New pathways and a redesigned procedure were introduced, reducing clinic time for most patients and improving the department’s ability to manage capacity. Services are now provided in a range of community locations with more than 5,000 patients offered this ‘closer to home’ treatment. Evaluation has shown patient visits fell by 46% and the time spent in clinics dropped 43% ensuring a greater number of patients can be seen within existing resources - demonstrated in the diagram below. There are now further plans to provide similar services in additional locations in the future.
The audiology team at Sherwood Forest Hospitals NHS Foundation Trust identified that up to 73% of GP referrals to ENT (ear, nose and throat) outpatient clinics met the direct access audiology service criteria for tinnitus management. Patients reported that delays in accessing services added to the emotional impact of tinnitus and that professionals were providing inconsistent information.
New guidelines were drawn up to allow GPs to refer directly to audiology clinics or via an agreed pathway to ENT. These services are provided by audiologists and hearing therapists who have access to ENT consultants and can request MRI scans if required.
Core measures were identified and agreed with patient focus groups. These were seen as key to establishing whether any implemented changes were a true improvement – or just added more variation into the patient pathway. To demonstrate quality and productivity benefits, the measures included: clinical outcomes, process, defects, patient satisfaction and staff satisfaction. Variation in the referral to assessment times were identified by use of statistical process control (SPC) charts (see diagram). Root cause analysis on the outliers from mean also identified issues such as delays in redirection of referral from ENT, DNAs and variation in capacity due to staffing leave.
Activities that delayed the consultation process (eg clinic room stock levels being low) were identified and overcome. Some tasks were simplified and combined – for example, patients agreeing a follow-up appointment while at the clinic. Telephone follow-up and partial booking were implemented to reduce DNAs. Waiting times have been reduced from up to 28 weeks to less than four, with fewer followup appointments required. Since the end of the prototype phase, around 250 patients have used the service and it has progressed with a second audiologist now supporting the clinic and a satellite clinic set up at Newark Hospital providing treatment ‘closer to home’.
Michelle Booth, clinical lead for Adult Audiology at the trust, is now cascading this good practice to other audiology professionals across the country and is working with both the British Tinnitus Association and GPs to promote the work and help further improve management of tinnitus patients.
One of the patients who has benefitted from the new approach added: “I was one of the first patients to use the new unit. They had time to look into my condition in detail and fitted me with new digital aids.
“With the aids on, the noise is almost not there at all.
“I am forever indebted to the work of the staff at the unit."
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