Hospital Evaluation and Outreach: A State Example Stephanie Disney, Lou Ann Jones, and Carolyn Kisler Kentucky UNHS Regional Coordinators Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity. George S. Patton 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 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 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 Variety of philosophies I.e. Military vs. Civilian Rural and urban facility Variety of follow up support systems Staffing and other issues The Ten Standards Test Protocols Policy and Procedure Equipment Test Area Data Submission Hospital Data Monitoring Specific Data Monitoring Contact and Consultation Parental Information Staff Training. 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. 2005 Hospital Annual Evaluation Score Summary Page There are 59 UNHS hospitals in Kentucky Locations of UNHS Hospitals Governor’s 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. Secretary’s 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.