Hospital Evaluation and Outreach: A State Example

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Hospital Evaluation and Outreach A State Example
Stephanie Disney, Lou Ann Jones, and Carolyn
Kisler Kentucky UNHS Regional Coordinators
Assessment and Adaptation In 2004 the Kentucky
EHDI Team met to review the manual and the
evaluation tool, following completion of annual
hospital evaluations. During this assessment
issues involving ambiguity of language, scoring,
and new state requirements were discussed.
Minimal changes involving the manual language
were approved, implemented and reviewed.
Additionally, areas of the evaluation tool were
broken into smaller units for clarification and
scoring purposes. Finally, a continuous quality
improvement section was added to assist hospital
programs deal with specific areas of weakness
rather than simply looking at the total
score. The EHDI team continues to work closely
with the UNHS hospitals in Kentucky to support
those programs and provide the assistance
necessary to provide quality, seamless services
to families. Therefore, the Hospital Compliance
Manual and the evaluation tool and process
continue to be works in process.
Introduction The Early Hearing Detection and
Intervention process begins at the level of the
hospital hearing screen. Referral rates, nursing
training, and hospital communication and contact,
all significantly impact the ability of the
entire EHDI system to provide quality, seamless
services to families. In 2002 the Kentucky EHDI
team developed a hospital compliance manual that
addresses several key compliance issues
including Test Protocols, Hospital Policy and
Procedures, Equipment, Test Area, Data
Submission, Hospital Data Monitoring, Contact and
Consultation, Parental Consent and Information,
and Annual Staff Training. Within these topic
areas important concepts such as referral rate,
dissemination of parental information, equipment
maintenance, number of tests performed, and
information submission is addressed.

• The Ten Standards
• Test Protocols
• Policy and Procedure
• Equipment
• Test Area
• Data Submission
• Hospital Data Monitoring
• Specific Data Monitoring
• Contact and Consultation
• Parental Information

• The Hospitals
• Births per year 55,000/year
• Low 200 or fewer
• Medium 1000 or fewer
• High 1000 or greater
• Nursery issues
• LDRP Units
• Well baby
• NICU Level 1, 2, 3
• Combinations
• Variety of test equipment
• AABR
• DPOAE
• TEOAE
• Variance of division of labor

Governors Focus for Kentucky Health Care
Education Economic Growth Ernie Fletcher
Governor James W.
Holsinger, Jr., M.D.

Secretary Cabinet
Goals Provide the best preventative services
through our public health programs Provide the
most outstanding services for families and
children Provide the finest health care possible
for people in our state facilities Protect
children, elders, and people with disabilities,
and prevent abuse Build quality programs
across-the-board and Make a difference in the
lives of all Kentuckians. Secretarys Guiding
Principles for Professional Personal Lives Do
the right thing the right way the first time. All
decisions must pass the three-way test Is it
Legal? Is it ethical? Is it moral? Quality
service is the most effective service.

• Aim
• Promote excellence
• Provide consistent standards for all hospital
  hearing screening programs in Kentucky
• Provide guidelines that encourage continuous
  quality improvement
• Provide a standardized method of program
  evaluation
• Enable hospitals to achieve the highest rating
  within the parameters of their own facility
• Evaluate each hospital program annually
• Promote compliance through education,
  evaluation and specific support

Locations of UNHS Hospitals
Never tell people how to do things. Tell them
what to do and they will surprise you with their
ingenuity. George S. Patton
There are 59 UNHS hospitals in Kentucky
2005 Hospital Annual Evaluation Score Summary
Page
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Hospital Evaluation and Outreach A State Example
Norton Suburban Hospital Louisville, KY
Ireland Army Community Hospital Ft. Knox, KY
Three Rivers Medical Center Louisa, KY
Birthrate 450/year No Nursery/LDPR Screening
done by Early Detection and Intervention
Staff Screening Equipment AuDX Refer rate
4 Test Rate (prior to discharge) 86 Test Rate
including out patient 95 2003 Evaluation Date
of Evaluation April 7, 2004 EDI Staff
now have authorization to use procedure room in
LDPR area and to transport neonates to that quiet
area for screening. Weekend discharges still are
not screened as inpatients.

• Current Continuing Education Trainings Offered
  for Hospital Staff
• Introduction to UNHS in Kentucky
• The Risk Indicators Late Onset and/or
  Progressive Hearing Loss
• A Sound EnvironmentNoise and the NeonateA
  model for protecting and preserving the health of
  the pre-term or fragile newborn
• Improving UNHSBe guided by the ten standards
• Educating Parents of Neonates on Early Hearing
  Detection and InterventionWindows of Opportunity
  

Birthrate 5000/year Three nurseries located on 2
floors Level III NICU
Birthrate 160/year Single Nursery Screening
Equipment Madsen ECHO Screen Refer rate
5 Test rate 98

Screening Equipment ALGO 3, ALGO 2 (2
units) Refer rate 2 Test Rate 98 2003
Evaluation 2004 Evaluation

• Future Building Opportunities
• Build on these hospital relationships to
  educate providers, parents, and the community
  about Early Hearing Detection and Intervention
  (EHDI)
• Build on these hospital relationships to
  identify areas of community strengths and
  weaknesses that impact the EHDI follow up goals.
• Build a team of community partners that
  includes hospitals, community leaders, service
  providers, health departments, educators, parents
  and other stakeholders, to focus on the
  development of a community infrastructure that
  assures follow-up for all newborns who refer on
  the hearing screening.
• Build a team spirit that seeks to motivate,
  equip and mentor fledgling EHDI community groups
  as they seek to find ways to meet the national
  goals.

Screening Personnel Audiology Partners--Staff
from a local ENT office
2003 Evaluation Date of Evaluation June17, 2004
Acknowledgements Kentuckys UNHS Hospitals,
Reviewers of Hospital Compliance Manual, Joint
Committee on Infant Hearing (JCIH), American
Academy of Pediatrics (AAP), National Center for
Hearing Assessment and Management (NCHAM), and
the Centers for Disease Control-EHDI Division.