Managing an Irish Audiology Department in a Challenging Environment

1
Managing an Irish Audiology Department in a
Challenging Environment

• 2009
• Martin Cromb
• Head of Department/Chief Audiologist
• Childrens University Hospital
• Temple Street, Dublin 1

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Introduction

• Head of Audiology since November 2002
• Share experiences and challenges over the last 7
  years
• Talk will include some Lean Management approaches
  although not exclusively about Lean Management

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Providing a World Class Audiology Service

• Unlimited trained staff
• State of the art facilities and equipment

4
The Reality

• Finite resources for most countries
• Allocation of resources varies from country to
  country

5
How does ROI compare?

• ROI has approximately 1/3 of the number of
  Audiology Professionals per head of population
  compared to the UK / England
• Can we provide the same level of services?

6
Audiology Staff a Scarce Resource

• It is important that Audiology staff are used
  appropriately
• The ISA Audiology questionnaire 2008 found that 8
  out of 22 Audiology Departments (36) had no
  admin staff
• Implication is Audiology staff are spending time
  doing admin work instead of seeing patients

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CUH Audiology Department

• Department structure
• 3.5 WTE permanent staff. Same staffing levels as
  2000.
• Martin Cromb Head of Dept/Chief Audiologist
• Jennifer Sim Deputy Head/ Senior Scientist
• Louise McCusker Senior Audiologist
• Cliona Carey 0.5 WTE Admin Assistant
• 2 x 0.5 WTE staff on temporary contracts
• Caroline Doherty Associate Audiologist
• Cora McDermottroe Admin Assistant

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Good Skill Mix

• Enough staff able to perform all clinical
  activities
• Good flexibility for e.g. annual leave, sick
  leave etc.
• Senior staff performing specialised work most of
  the time

9
Role of the Associate Audiologist

• To provide a supporting role for
  Audiologists/Scientists
• VRA / Distraction
• Screening
• A/C audiometry and Tymps
• ? Neonatal screening

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Services Provided by CUH Audiology Department

• Diagnostic services are provided for
• CUH Professionals, including 4 ENT Consultants
• Neonatologists based at the Rotunda Maternity
  Hospital

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Activity Level

• Overall activity levels have increased between
  2003-2008
• Tests at ENT outpatients have remained constant
  at approx 1700 per year
• Assessments at SFC have increased
• 2003 829 assessments performed
• 2006 1344 assessments performed
• 2008 1636 assessments performed

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Waiting Lists for SFC

• 2003 - 6 weeks waiting period
• 2006 12 months waiting period
• 2009 6 months waiting period

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Development of Services

• 4th ENT Consultant
• More comprehensive range of assessments from 2002
  onwards
• In 2002 OAEs introduced
• In 2002 existing ABR equipment was utilised
• In 2003 ABR under G/A was introduced
• In 2003 VRA was introduced

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Increase in Demand

• Large increase in referrals for objective
  measurement testing
• In 2002, 16 children under 3 years of age had an
  objective measurement assessment.
• In 2003, 60 children under 3 years of age had an
  objective measurement assessment.
• In 2006, 133 children under 3 years of age had an
  objective measurement assessment.
• Over 50 of these children were referred by the
  Rotunda Maternity Hospital.
• The development of an un-resourced ad-hoc
  at-risk Hearing Screening Programme for the
  Rotunda Hospital

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Crisis, What Crisis?

• 2006 waiting lists of 12 months
• Increase in demand for services
• No increase in staff due to staff ceiling

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Agreement for a Structured At-risk Screening
Programme

• In 2006 an agreement was reached with
  Representatives from CUH, PCCC HSE Dublin North
  East, HSE Hearing Services, Deaf Hear, Rotunda
  Maternity Hospital and the Cochlear Implant Unit
  at Beaumont Hospital.
• Phase I Screening of babies, who have spent
  greater than 48 hours in Neonatal Intensive Care
  Unit (NICU), using Automated Auditory Brainstem
  Response (AABR) testing.
• Establishment of the programme to act as a
  springboard towards UNIVERSAL Newborn Hearing
  Screening.

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Progress Prior to Launch

• Funding secured in 2007
• Assessment of facilities at the Rotunda
• Job descriptions
• Purchase of AABR equipment
• Recruitment and training of staff
• Funding for 3 WTE Audiology Professionals,
  0.5 WTE Admin assistant

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UNHS Steering Group

• Formation of UNHS Steering Group at the
  instruction of Brendan Drumm
• Funding for CUH at risk screening program
  withdrawn due to the belief that UNHS would be
  implemented in the near future.
• In the meantime Rotunda Hospital continued to
  refer increasingly larger numbers of at risk
  babies to CUH
• Holles Street requested at risk screening service
  due to withdrawal of services from Eye and Ear
  Hospital

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What Happened Next?

• Multidisciplinary Team Meeting including ENT,
  Neonatologists, Chief Executive of CUH, Patients
  Services Manager and Audiology
• Outcome Service defined.
• no new service for Holles Street
• limited service for Rotunda Hospital

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• Doing The Best
• With What Weve
• Got

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To review or not to review, that is the question

• Individual Clinical Judgement used prior to 2008
• Patients sometimes received a different service
  depending on which member of staff was seen
• Review procedures and policies were created in
  2008
• More standardised approach when reviewing

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3 Areas Covered

• Review following behavioural assessment, children
  lt 3 years of age
• Review following a satisfactory neonatal
  assessment
• Review following referral to Hearing Aid Services

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Targeting Resources by Working in Partnership
with ENT

• Basis for the procedure created for behavioural
  assessment review.
• Most children lt 3 referred to Audiology have a
  mild/moderate hearing loss with flat tymps. B/C
  testing is rarely possible.
• Prior to 2008 some staff would review, others
  would leave the decision to review to ENT
• Prior to 2008 referrals sent to Audiology
  following grommet insertion were usually not
  given priority

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Consequences of the System Prior to 2008

• Some children had multiple assessments between
  ENT appts
• Was value added by doing this?
• Some children referred to Audiology after surgery
  were tested when grommets were blocked/extruded
• Possible delay in diagnosis of S/N hearing loss

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Action Taken

• Discussion with ENT
• Clarified ENT are responsible for requesting
  further testing following surgery or to monitor
  if surgery not appropriate.
• reduction in the no. of reviews between ENT
  appts
• Referrals for post grommet testing are now given
  priority appts.
• Resources are targeted to out-rule underlying S/N
  hearing loss

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Review after Satisfactory Neonatal Assessment

• Risk of delayed onset hearing loss
• NHSP guidelines were used as a basis for the
  procedure
• Evidence based approach

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Referral to Hearing Aid Services

• CUH provides diagnostic services
• When there is definite diagnosis of hearing loss
  requiring hearing aids, patients are not reviewed
• Avoids duplication of work performed by Community
  Audiology Services

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Reduction of Admin Work and Duplication of
Appointments

• Standardised reports
• Tick box stickers
• Staff tick the box indicating what written/verbal
  information has been given
• In response to National Hospitals Office
  requirements for documentation of advice given to
  parents/patients
• New recording system using PAS to eliminate
  duplication of appointments

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Ownership Issues

• Limited number of rooms, computers and telephones
• Resources follow Departmental needs
• No one owns any given room or equipment

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Role of the Head of Department

• Responsible for the most appropriate use of the
  depts resources
• Determines what work is booked in for each member
  of staff depending on
• Referrals received
• Availability of rooms, equipment and staff

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The Future

• Sound Field Room Refurbishment
• 8 weeks without testing facilities
• How do we reduce impact on waiting lists?
• Solution
• ? Change in working week
• ? Longer hours leading up to refurbishment
• ? Time in lieu when work is being carried out
• New sound attenuating room
• Capacity issues are limiting the number of sound
  field testing assessments

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Conclusion

• In the last 7 years tried to develop services
  using a structured resourced approach
• Redefinition of services provided has been
  required in an environment of changing resources
• Optimisation of resources at any given time is an
  ongoing process
• Moving towards greater standardisation by
  creating policies and procedures

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• Thank you for your time
• Any Questions

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