1c. There is effective ongoing rehabilitation and aftercare of balance assessments - including supportive care. To ensure effective initial and ongoing care; agreed and national vestibular management procedures should be in place. Access for existing vestibular patients to clinics is necessary in a timely fashion. Uptake of such services will benefit from promotion of the service to patients. 1c.1. All patients are advised of and have access to vestibular management services that use protocols agreed between primary care, vestibular audiology, ENT services and patients. Clear protocols that are applicable to all patients. Details of how patients are made aware of protocols Evidence of the successful implementation of the protocols. e.g. patient satisfaction scores 1c.2. Audiology departments will fulfil requests for further appointments within the national referral to treatment guidelines. Audit of return patients Patient satisfaction scores 1c.3. Patients are offered information about local and national balance services. Evidence of available information, written information sheets, websites etc. Standard 2: Communicating with Patients
STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 2a. Timely and relevant two way information is possible to meet the needs of patients and their significant other(s). This should be in formats that accommodate any communication difficulties (and possible hearing impairment). Good communication before, during and after intervention benefits patients - through reduction in anxieties/concerns and encouraging appropriate uptake of further care and self management. Written information that is clear, up to date and in a format that is accessible to the individual facilitates understanding of the service and self management options. 2a.1. Individual communication needs and preferences are identified, recorded and actioned. Patient information in patient management system identifying individual communication needs and preferences. 2a.2. Written information about the service, types of assessment, medication requirements, possible interventions, after effects and clinicians involved is provided by the vestibular audiology service for all new and existing patients and their significant other(s) prior to attending the appointment. Written information leaflets and letters Audit to check if appropriate information sent and received. Patient feedback 2a.3. Consent is gained from the patient for any vestibular assessment and for their significant other (s) being present. Consent evidenced in patient management system 2a.4 Written information prior to appointment includes a request to contact the department in advance if communication support if required and encourages to invite significant other(s). Written information leaflets and letters Audit to check if appropriate. Patient feedback 2a.5. During assessment, results are recorded and an appropriate explanation of the results is discussed with the patient and/or significant other(s). A report is made available for medical notes. Audit cross checking the date of the appointment with record of test result and journal entries
Technology should be used to enable audiology staff to communicate effectively with the patient and to ensure that the information is given in a manner that the patient understands. in its use. The application of such technology reflects the advice of representatives of local user groups. 2a.11. At clinics, up-to-date technology is used to support communication with patients. Technology such as loop systems and message boards in place. Staff training logs. Service logs Minutes of meetings Patient satisfaction scores 2a. 12. Up to date technology (e.g video clips, websites) is used following appointments to support the self management of technical interventions and communication needs. Examples of support information on website. Examples of links to video clips.
The involvement of significant others (e.g. spouse) in the rehabilitative process can provide improved outcomes. 2a.11 Written information is available that encourages patients and their significant others to engage and communicate with the service through patient forums which facilitate planning, satisfaction, auditing and information development. Written information Leaflets/posters Policies Minutes of meetings Standard 3: Assessment STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 3a. All patients receive an individually-tailored vestibular assessment which is carried out to recognised national standards, where available, and includes: The need for, and content of, any Individual Management Plan (IMP) requires knowledge of a patient's balance status. The quality of assessment is more likely to be assured if 3a.1. The following are individually established for every patient where clinically indicated: Full History Otoscopy PTA Written protocols Case Summary of discussions about medical history, aetiology and further diagnostic assessment within journal entry that
Tympanometry Conjugate eye movements/smooth pursuits Walking assessment Romberg Dix Hallpike Additional/further diagnostic procedures as required lead to the development of the IMP and onward referral. Examples of onward referral letters 3a.2. There are written BAA/ BSA recommended procedures or protocols available to all staff in the department and these include, air and bone conduction testing, tympanometry, caloric, eye movement and vestibular evoked myogenic potentials Written protocols 3a.3. Equipment is calibrated annually and documented to national standards, and daily checks are carried out and documented to national standards. Calibration and equipment check logs/certificates Clear protocols for calibration including how to report faulty equipment. 3a.4. Vestibular assessment always carried out in appropriate conditions conforming to national standards. Vestibular assessment carried out using correct equipment Health and Safety logs 3a.5. A patient specific battery of bedside testing, and situation specific structured questionnaire are used as a routine part of the Completed questionnaires Case audit showing the gathering and recording of information
a relevant medical and vestibular history. assessment of activity limitations related to vestibular impairment, patient centred vestibular results vestibular rehabilitation if required undertaken in accordance with nationally recommended procedures Measures are compromised if not gathered using equipment calibrated to national and international standards and if they are not used in an appropriate test environment. A relevant medical history is required to develop and IMP Understanding the motivations and behaviours as a result of vestibular impairment will enable an appropriate IMP to be developed. Vestibular assessment information is a necessary prerequisite, but is not sufficient information alone to configure an IMP Services should select a battery of tests to assess activity limitations related to vestibular impairment. Situation-specific structured questionnaires 3a.6. Information is recorded in a standardised way and is used to develop the content of the IMP. Included in this information should be details of why an assessment or intervention could not be carried out. Relevant service policies and procedures regarding standardised gathering of information Staff training
have been shown to offer significant advantages in clinical settings. Standard 4: Developing an Individual Management Plan (IMP) STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 4a. All patients should have an individually developed plan for the management of their needs. This plan: Is initially based on information gathered at the assessment phase, Is determined in conjunction with the patient and/or their significant other(s), Is accessible to the clinical team, Includes recommended interventions to best meet the patients needs. An Individual Management Plan approach is most effective if it takes into account a range of factors in addition to the type and level of hearing loss. An effective IMP relied on consultation between the vestibular audiology professional, the patient and his or her significant other(s). Only when the parties are committed to the joint goals is an optimal outcome achieved. To be successful, IMPs need to be flexible. Flexibility within the structure of the IMP is beneficial because the content and goals may change over time, reflecting the positive outcomes of interventions. An effective IMP will detail specific actions associated with agreed 4a.1. Within in the audiology vestibular service there is an agreed approach to IMP development. Service wide (SBG) guidelines on use, development and implementation of IMPs, including reference to agreed needs, actions and outcomes. Audit of clinician’s compliance with service guidelines. 4a.2. The IMP includes agreed needs, actions and outcomes. Audit of clinical record to ensure inclusion of information on each individual’s vestibular status, expectations, social status, option for rehabilitation, referral to other agencies and specific goals. Results from individual clinician’s peer review demonstrating compliance
goals that take into account a clients vestibular needs related to their activity limitations, e.g. social circumstances v physical circumstances v emotional reactions. with service approach to IMP use. 4a.3. The specific goals of the IMP are recorded in the clinical record. The plan includes details of: the decision-making process, the implementation plan proposed timescales specific goals associated with assessment information Audit of clinical record to ensure inclusion of information on each individual’s vestibular status, expectations, social status, option for rehab, referral to other agencies and specific goals. 4a.4. The IMP is agreed and updated with the patient and significant other (s) at each appointment. As actions are completed, new actions are agreed and new needs are identified. Service procedures referring to the development and provision of IMP Audit of IMP provision Feedback from patients and/or significant others within service satisfaction questionnaire relating to their participation in development of agreed needs.
The IMP is flexible so that different goals can be set if the patient’s circumstances/environment changes. 4a.5. The clinical record includes details of: The decision making process leading to IMP development and Proposed timescales of IMP delivery. Service procedures referring to clinical record keeping. Case study audit of clinical record Results from individual clinicians peer review Standard 5: Implementing and Individual Management Plan (IMP) STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 5a. The Individual Management Plan is implemented over a series of appointments with the opportunity for revision of needs, actions and outcomes at each stage. The series of appointment is timely and may be Planned and coordinated intervention leads to better outcomes. Such an approach requires recording of interventions and their effectiveness to guide ongoing development of the IMP. In order for agreed interventions to be effective, referral to another agency/service should be prompt so as to be based upon up to date appraisal of need. 5a.1. The clinical record and IMP includes the detail, justifications and effectiveness of interventions implemented. This included referrals to other agencies. Data relating to numbers of proportions of people being provided with vestibular rehabilitation and those who are not. Service procedures referring to clinical record keeping. Case study audit. Patient feedback 5a.2. Where referral to another agency/service is indicated, referral is made from audiology within 7 days of the appointment in at least 95% of cases. Audit of time from patient appointment to referral being sent. 5b. Where provision of vestibular rehabilitation services are required the service ensures: each client receives an individually tailored Audiologists should be confident that the client is physically and emotionally able to perform the rehabilitation exercises appropriately. 5b.1. Prior to rehabilitation patient’s abilities are assessed and recorded. Copies of local evidence based criteria and policies Audit against these criteria/policies. Examples of journal entries within patient management system.
vestibular rehabilitation plan nationally agreed procedures and protocols are followed at a local level, Professional bodies and national guidelines should be followed to ensure provision meets the needs of the individual. Copies of patient prescription for rehabilitation exercises. Patient survey. 5b.2. Local protocols should be in operation concerning selection and prescription of rehabilitation exercises. These should comply with the latest professional body and/or national guidance. Service protocols concerning selection and prescription of rehabilitation exercises. Audit of compliance of staff to service protocols Results from individual peer review demonstrating compliance with service guidelines on clinical record keeping. 5c. Following implementation of the plan, a process of ongoing support continues. On-going benefit from vestibular rehabilitation exercises is likely to be increased if the process of support and maintenance includes routine vestibular reviews and potential for updating the IMP. Such provision is required to accommodate the changing rehabilitation needs of individuals. 5c.1. Each patient is given a follow-up appointment for following rehabilitation exercise prescription within a maximum waiting time of 8 weeks and local protocols are used to determine the most appropriate method of follow up. Follow up waiting times Direct observation of wait times with patient management system Where different methods of follow up are used (face to face, telephone, group) a local protocol outlining the process for determining the appropriate method of follow up should be in place. Audit against the above protocol.
follow up set out in local protocols. Standard 6: Clinical Effectiveness STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 6a. The outcome and effectiveness of the Individual Management Plan are evaluated and recorded. The management of clients with vestibular impairment, within a comprehensive management plan, involves more than a technical matter of vestibular assessment. It should involve the provision of a systematic approach, supported by evidence, which addresses not only the vestibular impairment, but also other related activity limitations and consequent reductions in quality of life (QoL). Subjective outcome measures, in the form of condition-specific questionnaires, can assess the impact of a vestibular impairment on the patient's activity limitation. This can then be used in the evaluation process to measure how effective the IMP has been. IMP's help to record multiple vestibular rehabilitation outcomes; such as functional, 6a.1 Individual outcomes are evaluated and recorded for all patients. Outcomes are directly related to the needs within the IMP and are recorded within the IMP. Audit of IMP and related outcome measures. Direct observation within the patient management system during external Local policies and procedures relating to recording individual outcomes Outcome statements for each need. A record of goal setting for patient rehabilitation. 6a.2. The outcomes contain information of the extent to which the specified goals have been met and include a validated quantitative measure which is appropriate for all the interventions implemented. Quantifiable outcome scores being used for all identifiable needs. 6a.3 Outcomes are used to monitor patient progress and to further develop the IMP which may result in the identification of further actions required. Audit of the development of a patients IMP based on their individual outcomes.
Registration bodies and some employers require demonstration of regular Continuing Professional Development (CPD) activity. Facilities to access CPD close to 7a.5. All clinical staff participate in CDP activity Local protocols for ensuring staff attend and record CDP Discussions with staff during external audit visit 7a.6. Competency is verified formally by peer review observation ensuring all procedures are covered over a two year period for all clinical staff undertaking such procedures. Local and national procedure/process for peer review Peer review checklist for all procedure and/or appointment types List of details/dates of completed peer reviews
Collaboration appropriate to patient and service needs should be identified and established and may be with internal and external agencies and services. Having awareness of and appropriate links to specialist services is more likely to result in the needs of patients being met. Planning and coordinating services in collaboration with other relevant partners (including service users and their significant others) is more likely to result in services that better address the needs of the patient. 8a.2.Written protocols/processes are in place to support referral to other services. Copies of referral protocols Evidence through referral rates to collaborative partners 8a.3. Evaluation of individual’s outcomes specific to these referrals is undertaken. Patient feedback/outcome reporting Evidence of actions and patient outcomes following outward referral recorded within the patient record. 8a.4. Vestibular audiology works strategically with collaborative partners. Referral pathways Standard 9: Service Improvement STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES)
9a. Each service has processes in place to measure service quality. Quality measures are used to plan and implement service improvements Measurement of qualitative and quantitative data helps to inform ongoing service improvement. 9a.1. The vestibular audiology service has a framework in place to ensure ongoing collection of qualitative and quantitative data relating to service performance and service user experience and the annual reporting of this data. Service review framework that outlines the what, when, where and how this data will be collected and reported. 9a.2. Patients and significant other are encouraged to complete anonymous surveys on at least an annual basis to determine satisfaction with different elements of the service received. Evidence of coverage that ensures an acceptable proportion of patients have participated and a representative sample of the local population is covered (including gender, ethnicity, and all location of service delivery). 9b. Each service has processes in place to regularly consult with patients and stakeholders Audiology services that seek, consider and respond to the views of users will be more likely to meet the needs of their patients. 9b.1. The vestibular audiology service has a mechanism in place to capture views of patients and stakeholders. Local framework for consultation agendas and minutes of consultation events. Patient satisfaction surveys. 9b.2. Results of satisfaction surveys and service QRT scores are made available and discussed with patients on an annual basis. Direct observation during external audit visit 9c. Each service has processes in place to keep up to date with and Use of up to date vestibular technology and models of service delivery is integral to effective 9c.1 The vestibular audiology service has a systematic approach to the coordination, Local procedures/policies for appraisal of innovations