Professional Practice Profile

IHS Board Adopts Practice Profile for Dispensers

What does a hearing instrument specialist do?

(This article originally appeared in The Hearing Professional July/August 2004.)

This is a common question not only in the consumer marketplace, but also on licensing boards and in regulatory entities. To formalize the answer for all, the IHS Board of Governors voted to adopt an official practice profile. This document would constitute a uniform, standardized description of services that would serve to fortify and strengthen the profession by virtue of its universal application. Very importantly, this comprehensive declaration of dispensing characteristics and expectations defines the unique role of the hearing instrument practitioner and distinguishes your profession from the other members of the hearing healthcare team.

After considerable research and review of draft proposals, the Board ultimately concluded that the best option for a dispensing practice profile was one already implemented by the National Board for Certification in Hearing Instrument Sciences (NBC-HIS).

Leading up to that decision, IHS President W. F. Samuel Hopmeier, BC-HIS, invited Laura Dennison, BC-HIS, CCCA, author of NBC-HIS practice profile, to chair the IHS Scope of Practice Committee. The committee mission was to evaluate the NBC-HIS profile relative to IHS specificity and suggest any changes they deemed necessary to better represent the IHS perspective. They recommended only minor rewrites, which were approved and incorporated into the final document.

Dennison points out that the practice profile was based on a Role Delineation Study commissioned by NBC-HIS because that study was an accurate snapshot of the best practices of our profession both in this country and in Canada.-  The format was reflective of similar profiles in other areas of the hearing healthcare field.

The NBC-HIS Role Delineation Study was written by Ayres D. Costa, PhD. He explains that the development of a professional practice profile is part of a systematic process that must be based on a legally-defensible job analysis. A series of Role Delineation Studies (1982, 1991, 2000) provide this basis.

- A role delineation goes beyond the typical job analysis in that it serves both to describe and differentiate the role, he says. Job description entails two aspects: what tasks are frequently performed by dispensers and what tasks are critical aspects of the professional competence of dispensers. Dr. D- Costa feels the practice plan is a key step in establishing the professions identity and range of competence. The document truly represents the hearing instrument dispensing profession, articulates and specifies its areas of safe, effective services and serves as a document that state governments and the public can recognize, he says.

NBC-HIS Chair Wayne Jacobson is proud of NBC-HIS’s participation in the development of the practice profile and believes it will be an invaluable asset to the hearing profession. He credits it with summarizing and logically formatting what dispensers do so that when asked that question there is a complete and concise document to put forth. He states that the profile is written in a broad, non-prejudicial form that avoids some of the turf discussions from the past.

Jacobson further comments that the profile will be useful in consumer education. “Professionally, we are maintaining and upgrading the standard to become Board Certified,”  he says. “In today’s marketplace, more consumers are looking for the Board Certified designation when deciding where and how to get hearing help. Board Certification is an easily understood concept for the consumer and gives them one more benchmark to use in making a decision to improve their hearing and their life.”

In his dual role as IHS governor and chair of the International Institute for Hearing Instruments Studies, Jay McSpaden, PhD, BC-HIS, CCCA, has been involved in the profile adoption process from the very beginning. He asserts that one very significant purpose of the document is to facilitate the expectation and delivery of top quality care to the patient. - The profile establishes standards of work, counseling approaches to patients, interprofessional responsibilities and practice management procedures which ensure delivery of a high level of professional care,-  he says.

President Hopmeier underscores this point. “With the adoption of this profile, we have a definitive statement that covers the scope and quality of our professional healthcare services. It’s a tremendous step forward in educating the consuming public and lawmakers alike about the integrity, credibility and competencies of hearing instrument dispensers.”

A Professional Practice Profile for The Hearing Instrument Professional

In some ways the field of hearing aid dispensing has changed dramatically in the last few years. In other ways it has changed very little. Driving these changes have been forces such as the following:

1) New programmable and digital technology

2) Better educated consumers

3) The internet

4) Disposable hearing aids

5) The use of computer technology in hearing aid fitting

All of these changes have required the hearing instrument professional to become more technically adept than ever before. However, as D. Costa (1991) noted in the 1991 NBC-HIS Role Delineation Study:  “Hearing aid specialists serve people. Understanding people, winning their confidence and being able to help them accept amplification, are critically important competencies in this profession.”  That statement is as true now as it was then. As Gitles (1999) pointed out, the dispensing profession needs to be re-invented with full recognition of the client-dispenser relationship.

The most recent NBC-HIS Role Delineation Study (D. Costa, 2000) found that the vast majority (90%) of today’s dispensers are college educated. Yet, this profession lacks the identity and definition usually provided by a formalized university program. Other professional disciplines that include hearing aid dispensing within their scope of practice are designed to cover many other areas as well. McSpaden (1994) noted that a major problem for the field arises from the fact that the three types of hearing health care providers:  physicians, audiologists, and hearing aid dispensers, bring very different training perspectives to their practices.

An educational program specializing in hearing instrument sciences is a necessity in order to meet the needs of the growing population of hearing impaired. The Canadian model started at Grant-McEwan College in Edmonton, Alberta has been the foundation on which other new programs around the US and Canada are being developed. The goal of the dispenser is to improve the quality of patient communications, and to offer patients the best hearing instruments and assistive listening devices. The dispensers of the future are also trained to recognize problems that need help beyond their own area of expertise, to make proper referrals, and to work cooperatively with other professionals. Today, the focus is on revolutionary hearing instrument technology and its promise for the hearing impaired, thus offering a higher level of hearing experience for an unprecedented better quality of life.

The national Quality of Life Study (HIA-NCOA, 1999) estimated that there are about 30 million persons in the USA (about 10% of the population) with some degree of hearing loss, and fewer than 6 million of these (less than one in five) wear a hearing instrument. McSpaden (1994) estimated that there are approximately 2500 physician offices, 7000 audiologists, and 7000 hearing aid dispensers currently practicing in the USA. While this workforce is numerically inadequate (1 dispenser for 1800 clients), and needs to increase ten-fold, the problem for consumers is compounded by a lack of standardized information about dispensing practice characteristics and expectations. Although the public excoriations of confusing dispensing claims and practices (AARP, 1980) are now relegated to history, the need for a public document presenting a national dispenser practice plan remains as critical as ever.

This document summarizes the scope of dispenser services as defined by the 2000 NBC-HIS Role Delineation Study of Hearing Aid Dispensers (D. Costa, 2000). This Role Study is similar to a job analysis, and it was based on a national survey of the critical tasks and responsibilities performed by hearing instrument dispensers. The NBC-HIS Role Studies have provided the Competency Model used in the development of the IIHIS International Licensing Examination for hearing instrument dispensers and the NBC-HIS Board Certification Examination in the Hearing Instrument Sciences.

Simply put, the purposes of this document are twofold:

1. To provide a model hearing aid dispenser practice plan for state/provincial licensing boards, and

2. To provide consumers, government agencies, and other interested parties, official information about the specific services and understandings a patient has the right to expect from a competent hearing instrument dispenser.

The following guiding principles and assumptions were used in the development of the Professional Practice Profile for Hearing Instrument Dispensers:

• Safety and health of the patient are the most important considerations in all practice decisions and actions.
• All dispensing procedures are performed in a manner as to prevent bodily injury and infection.
• Hearing aids may be only part of the answer for improved communication; therefore, it is important to recognize and to encourage the use of other assistive listening devices for patients.
• Hearing health care requires a team effort. Dispensers must work with other professionals, as needed, to maximize patient care and inter-professional collaboration.
• Dispensers form a partnership with each of their patients to help achieve total communication with their own world, thus enabling their development and participation in all aspects of their life.
• All equipment must be maintained according to the manufacturer’s specifications and recommendations. Equipment must be properly calibrated and necessary records maintained.
• Decontamination, cleaning and disinfection of multiple-use equipment must be carried out according to facility specific infection control policies and manufacturer’s guidelines.
• Ambient noise levels in the test environment must meet ANSI standards.
• Documentation must be maintained in accordance with local regulations, and in keeping with good professional practice.

The NBC-HIS 2000 Role Delineation Study analyzed the responses of survey responders to 100 tasks in terms of the frequency with which each task was performed, and in terms of the level of supervision occurring with each task performance. Sixteen broad procedures were identified using statistical clustering of the tasks. These sixteen procedures were then grouped into 6 major areas as follows:

I. Assess patient presenting problem and needs

II. Test and analyze patient hearing

III. Prescribe and analyze hearing aid

IV. Fit, adjust, program, and service hearing aid

V. Counsel and help rehabilitate patient

VI. Manage office and practice

In the Professional Practice Profile the following components are detailed for each of the six areas outlined above. Unfortunately, space does not permit inclusion of the detailed areas here.

1. Expected Outcomes

• Although results vary from person to person and the outcome cannot be guaranteed, a reasonable statement of prognosis may be made to the patient, the family, and other professionals.
• While patient satisfaction is the ultimate determining factor in a successful fitting, measurement and monitoring of results should be done to ensure and/or improve the quality of service.
• Regularly scheduled follow-up services should be provided to assess the need for other services and to monitor the effectiveness of the fitting and/or the level of hearing.

2. Indications for Procedures

• Hearing screening may be used to identify individuals who may need further hearing evaluation and/or hearing rehabilitation.
• Services are provided when there is a reasonable prognosis of benefit to the patient.

3. Procedures

• All procedures are done in accordance with standard levels of practice.
• Counseling of the patient and family/caregiver is critical to the understanding of the nature of the communication problem and to the setting of reasonable expectations from services.
• When indicated by results of procedures, referrals are made to the appropriate medical and/or other professional.
• The lifestyle, preferences, special needs, and economic priorities of the patient are critical components of the products recommended by the dispenser.

4. Professionals Who Perform the Procedures

• Only those professionals who hold professional licenses (certification in Alabama) which allow hearing aid dispensing, and who have appropriate training and experience may provide specific procedures.

Great strides have been made in raising the standard of care that dispensers give their patients. It is vitally important to bring more professionals into this field as our population ages. It is hoped that the detailed road map  provided in the Professional Practice Profile can help us provide a more professional and uniform level of service to our hearing impaired patients.

1. ASSESS PRESENTING PROBLEM AND NEEDS

Expected Outcomes

• Identification of factors in the patient’s background that may put him at risk for hearing problems
• Identification of FDA red flags that would require a referral for medical evaluation
• Identification of other medical problems that may have an impact on the methods used for other procedures and/or expected outcomes of hearing aid fitting.
• Identification of family members’ concerns regarding patient’s hearing difficulties
• Exploration of patient attitudes and expectations of amplification
• Identification of problems with hearing and understanding
• Identification of daily activities and impact of hearing loss on lifestyle
• Identify impact of hearing loss on family, friends, and in the workplace

Indication for Procedure

• Individuals being seen for either hearing screening or hearing evaluation.

Procedure Methods

• Typically consists of a combination of written answers to a series of questions, elaboration of those answers by oral questioning, and behavioral observation.
• Areas covered include but are not limited to:
  • family history of hearing loss,
  • incidence and duration of childhood hearing-related illnesses, information regarding dizziness,
  • loss of balance,
  • tinnitus,
  • current medication/drug history,
  • history of noise exposure and acoustic trauma.
  • In addition it is beneficial to elicit family members concerns about patient’s hearing difficulties, the patient’s attitudes and expectations regarding amplification, and the patient’s own assessment of their hearing difficulties.
• Additional areas that must be covered include but are not limited to:
  • questions regarding history of ear surgeries,
  • diseases and treatments,
  • information regarding past experiences with amplification
  • questions and observation regarding ear deformity,
  • pain,
  • sudden hearing loss,
  • ear infection,
  • disease,
  • drainage or blockage requiring medical referral.

2. TEST AND ANALYZE HEARING

Expected Outcomes

• Basic hearing evaluation is conducted to quantify and qualify hearing loss on the basis of perceptual responses to acoustic stimuli and to describe any associated communication disorders.
• Results of the evaluation may result in recommendations for more advanced testing, medical referral, amplification consultation, assistive listening device consultation, or follow-up recommendations.
• Speech discrimination tests are performed for additional information about a hearing loss
• Evaluation may result in recommendation for a medical referral, amplification, aural rehabilitation, and/or counseling.
• Determine need for medical referral based on audiometric air-bone gap results.
• Determine degree, type, and configuration of hearing loss from test results.
• Hearing instrument efficacy will be determined by pre-post audiometric measures

Indications for Procedure

• Hearing evaluation may be done when a hearing screening is failed.
• Hearing evaluation is generally prompted by self-referral, family referral, failure of an occupational hearing test, or referral from other professionals.

Procedure Methods

• Hearing evaluation is preceded by eliciting the hearing history and assessing the hearing problem. This is followed by examination of the external ear canal and cerumen management, if necessary.
• The standard audiometric tests consist of pure-tone air and bone conduction testing with appropriate masking. Some professionals also choose to do loudness growth testing at this time.
• Speech testing includes speech awareness and/or speech reception threshold tests, speech discrimination tests, and establishing MCL and UCL thresholds (appropriate masking used as required). In addition further information can be gained by doing unaided and aided sound-field discrimination tests and by testing binaurally as well as monaurally.
• Special audiometric tests are performed for additional information about a hearing loss.
• Evaluation may result in recommendation for a medical referral, amplification, aural rehabilitation, and/or counseling.
• Procedures such as immittance audiometry (tympanometry and reflexes) are quite common
• Procedures to assess cochlear versus retrocochlear (i.e., eighth cranial nerve, brainstem, or cortical) auditory disorders include:
  • Acoustic reflex threshold
  • Tone decay testing
  • PiPb rollover testing
• Special procedures for testing infants and children or evaluating tinnitus are also sometimes called for.
• Evaluate the reliability and validity of the test results.
• Evaluate test results to determine the presence of collapsed ear canals.
• Evaluate aided sound field measures and/or real-ear aided performance measures.

3. PRESCRIBE AND ANALYZE HEARING AIDS

Expected Outcomes

• In consultation with the patient and family, taking into account their lifestyle, special needs, hearing aid style, technology, and price category preferences, selecting the hearing aid that will best fit their needs.
• Provide measurable results of improved hearing thresholds and ease of communication.
• The appropriate specifications for the hearing aid will be selected.

Indications for Procedure

• Individuals identified with hearing loss who have reached a level of acceptance regarding their loss that they are ready to seek help from amplification

Procedure Method

• Determine hearing aid needed for severity, type, and configuration of hearing loss, keeping in mind the patient- s history, lifestyle, and audiogram.
• Discuss with patient the various levels of technology and their different price categories to aid in determination of hearing aid prescription.
• Identify physical limitations affecting hearing instrument selection.
• Prior to dispensing the hearing aid, verification of hearing aid performance is conducted via a listening check to rule out excessive circuit noise, intermittency, and/or poor sound quality.
• Perform electroacoustic analysis to determine if hearing aid is performing according to manufacturer specifications.
• Conduct electric current drain measurement of hearing aid.
• Confirm telecoil function.
• Programmable and digital hearing aids should be programmed prior to patient’s arrival to ensure integrity of programming system and hearing aids.

4. FIT, ADJUST, AND SERVICE HEARING AIDS

Expected Outcomes

• Appropriate earmold/hearing aid shell configuration and material will be selected for maximum comfort and hearing aid performance.
• Alleviation of a problem with physical or acoustic comfort (i.e. occlusion, loudness, discomfort)
• Restore the aid to manufacturer's specifications

Indications for Procedure

• Patient is being fitted for new amplification
• Patient or family report a problem with the function, comfort, or benefit being received from the hearing aid.

Procedure Methods

• Assess ear canal for ear impression visually inspect for size, length, and direction.
• Perform proper ear impression procedures, e.g. otoblock placement.

• Determine earmold/hearing aid shell configuration and material.
• Examine surface of earmold and instrument for damage and sharp edges.
• Perform physical fitting of coupler and instrument.
• Appropriateness of physical fit should be assessed through ease of insertion and removal, cosmetic appeal, comfort, absence of feedback, placement of microphone port/ports and ease of volume control use when present.
• Program selected hearing aids to patient's baseline audiometric data.
• Adjust/modify hearing instrument electronics based on patient feedback.
• Make venting modifications as needed for reduction of occlusion effect and or to control feedback. Modify shell or ear mold for improved, more comfortable fit
• In the event the patient returns with a malfunctioning hearing aid, conduct in-office internal inspection of ear mold and instrument and take appropriate corrective action (suctioning wax and debris from receiver and microphone ports, cleaning corrosion from battery contacts, replace earmold tubing, etc). If in-office repair is not possible return aid to manufacturer for repair and offer the patient a loaner hearing aid to use while his is being repaired.
• If the hearing aid needs to go to the factory for repair, and it is out of warranty, inform the patient of the charges and repair warranty.
• Validation of fitting should be done either with sound field testing using frequency specific thresholds and/or aided speech discrimination and speech reception thresholds or with real ear aided measurements.
• Reprogram hearing aids based on patient feedback.

5. COUNSELING AND AURAL REHABILITATION

Expected Outcomes

• Dispensers assist patients in coming to grips with the reality of their hearing loss and in the process of accepting amplification or other assistive listening devices.
• Dispensers educate the family and the patient in the ramifications of a hearing loss and what is a reasonable expectation for improved communication with amplification.
• To facilitate listening in various acoustic environments.
• To provide alerting systems.
• To augment the benefits of the hearing aids.
• To establish procedures for follow-up.
• To provide information to allied health-care professionals.

Indications for Procedure

• Individuals who have had their hearing evaluated.
• Individuals who are being fitted with amplification.
• Individuals who need more help than their hearing aids can provide in various situations.

Procedure Methods

• Explain otoscopic examination and audiometric assessment to patient.
• Discuss patient- s reactions to hearing instruments.
• Discuss with patient various treatment options, e.g. different levels of technology, different styles of hearing instruments.
• Provide patient with hearing rehabilitation exercises.
• Explain hearing instrument use in different listening environments.
• Instruct patient on proper instrument insertion and removal techniques.
• Counsel patient on cerumen management.
• Counsel patient regarding care and use of instrument.
• Counsel patient on battery life and insertion/removal techniques
• Counsel patient on telephone usage with hearing instruments, and assistive listening device coupling as necessary.
• A hearing aid usage schedule is determined.
• Counsel patient on amplification expectations and limitations.
• Discussion of appropriate expectations for amplification include: improved communication, freedom from unwanted feedback, minimization of the occlusion effect, and more auditory benefit in quiet than in noise.
• Patient is advised of their legal rights for hearing aid adjustment, replacement and return.
• Self-assessment tools that measure degree of hearing handicap, and/or pre- and post-fitting satisfaction are an appropriate tool for measuring patient satisfaction.
• Instruct patient/family in effective listening techniques with hearing aids.
• Counsel family members about patient’s adjustment and use of hearing aids.
• Provide patient with information concerning environmental modifications that can ease communication
• May provide patient with information on speech-reading or other aural rehabilitation classes.
• May also include demonstration and information on devices to enhance:

·         telephone usage

·         listening to television

·         listening in church

·         listening in restaurants and other difficult listening environments

·         listening in the classroom or auditoriums

·         telephone, doorbell, smoke alarm alerting systems

-          Formulate long-term treatment program

-          Establish methods for recording care from treatment to rehabilitation.

-          Counsel patient on importance of follow-up visits.

-          Provide physician, with patient's permission, your audiometric evaluation and recommendations. Communicate with other allied-health professionals as appropriate.

6. OFFICE AND PRACTICE MANAGEMENT

Expected Outcomes

• Equipment will be maintained according to sanitary guidelines and manufacturer’s specifications.
• Records will be maintained in an organized and efficient manner.
• Clinical/ professional knowledge and skills will be current.

Indications for Procedure

• To standardize professional standards and practices.

Procedure Methods

• Maintain equipment to standards of sanitation and cleanliness.
• Supervise sanitization and cleanliness of office personnel.
• Maintain equipment according to manufacturer- s specifications.
• Conduct biologic check of audiometric equipment.
• Perform cerumen management procedures using standard techniques/equipment.
• Recruit, train and develop professional and administrative staff.
• Establish supervisory procedures to ensure quality care.
• Develop marketing and advertising plans.
• Provide certification to patient to receive amplified telephone systems where appropriate.
• Identify sources of patient referrals.
• Establish and maintain quality assurance procedures.
• Adopt and follow a professional code of ethics.
• Maintain adequate professional liability protection.
• Design, implement, and monitor hearing care/conservation programs.
• Make presentations at hearing conservation programs.
• Identify multi-cultural and under-served groups needing hearing care.
• Know governmental laws and guidelines affecting the dispensing profession.
• Update clinical/professional knowledge and skills.
• Attend professional seminars, conferences, and association conventions.
• Maintain patient records in accordance with governmental regulations.
• Develop and maintain effective patient/business information systems.
• Formulate short and long range business plans.
• Upgrade office computer systems (hardware and software).

Great strides have been made in raising the standard of care that dispensers give their patients. It is vitally important to bring more professionals into this field as our population ages. It is hoped that the detailed road map provided in the Professional Practice Profile can help us provide a more professional and uniform level of service to our hearing impaired patients.