Choosing an audiometry provider

Some tips on what to look for when choosing an audiometry provider to comply with your health screening obligations. For clarity, I do have a horse in this race but that doesn't change what I believe the key things are which you should be looking for if you are buying in audiometric screening from an independent provider. Also have a look at the companion page on 'signs of poor audiometry' which lists some clear signs that the audiometric testing is not being done quite as it should be.

Training of audiometric testing technicians

Bearing in mind there is no legal national standard for this, how are they or their screening technicians trained? Entirely in-house or a mix of in-house and external provider? What have they done to ensure the people doing the assessments will be competent? The British Society of Audiology has an approved syllabus for the training of audiometric test screening technicians so ask them to show this has been followed. I would always look for the company to have sent its employees on a course provided by a third party as well as their own in-house training - it is of much more comfort to know a third party has said the audiometry technician is competent as well as their own employer. 

What results are you provided with?

Will they provide you with all the results or summary data only? Be sure what level of report you want. Personally, you the client are buying the services so I think you should be provided with all the data and that means the classification of result and the full audiograms for each person. That way if you need to provide it to an insurer you have it, or if you choose a different supplier in the future you have it for ongoing comparison. Several times over the years I've come across audiometry-providing companies using the data as a way to force a client to remain with them by making it extremely difficult for anyone to get hold of the screening results data. That's frankly shameful and they don't deserve your business.

Otoscope examination

Make sure they include the otoscope part - the looky down the ear bit. If they don't do that they aren't doing it properly. Time and time again I've come across suppliers skipping this. This is a fundamental part of the British Standard governing pure tone audiometry. 

Reusing single-use speculae

Ask what they do with the speculae - these are the plastic cone bits which go into the ear when having a look down them with the otoscope. They are single-use unless they are metal and autoclaved between examinations and no external provider ever uses these metal ones. Wiping them down with an alcoholic wipe or something similar and then reusing them is horrible and above all, cheap. If a company is cheap enough to be doing this, for speculae which cost about 7p each, then you don't want them doing your testing.

Referrals

There are two issues to ask about and watch out for with this. 

Firstly, ask what they do with Category 3 and Category 4 cases, and if they say they always refer to a specialist then that is a huge black mark against them. Not all Category 3 and 4 cases need to be referred, (more information here) and if they say they do chances are you are getting a technician who isn't looking at tests individually to see what is going on, but is just sitting there, pressing a button and doing whatever the computer says with little thought or knowledge.

And secondly, ask where they are referring people to. You can oversee this yourself by sending them to their own GP and that is perfectly fine. If the audiometry screening company offers to refer to their own in-house GP or specialist then that is a little questionable. Now they actually have a vested interest in getting the maximum number of referrals in, either to increase the charges they can give you as the client, or to justify an inflated annual maintenance contract if they have gone down the contracted route. If they offer to do this, personally I would say you should walk away and go elsewhere. Audiometry is not an excuse to sell more services, no matter how nicely it is dressed up in sales fluff.

See their in-house operating procedure

Ask to see their in-house procedure for conducting a series of hearing tests. If the procedure doesn't include a daily verification check of the audiometer before the first test is done, don't use them. This is a mandatory part of the British Standard governing workplace audiometry and is a part of the L108, and is done to ensure the audiometer is reading correctly on that day, not just when it was last calibrated. If they don't do this then how on earth do they know the audiometer is functioning correctly that day, especially if it is a mobile provider where the equipment is moving about between jobs.

Do they measure noise levels in the audiometric testing room?

As they are moving about between testing locations they should do a basic measurement of the noise levels in the room they are to test in, or in the booth if they are testing in a mobile audiometry unit. This is important. Without it, how do you know the tests were being done in a quiet enough environment and the attendees could hear the headphone noises rather than other noise going on around them. If you get a claim a few years down the line, how do you prove the audiometric test was done in a suitable environment without someone holding a record of what the noise levels were on that day? If they don't do this, my advice is to walk away as that's a big chunk of reliability stripped away from the results meaning your money is giving you much less value. They don't have to use a full-on noise meter, but should have something which can say, 'yes, it was around 38dB in there on that day'.

This isn't just hypothetical - I have been involved in insurance claims where one of the first things the insurer defending the employer ask was 'what was the noise level when the test was being done?'.

How many people is the technician testing at once?

If the answer to this is anything other than 'one', walk away. I have come across a provider with a mobile unit which has two audiometry booths in it and the technician sitting in the middle, running two tests at once. Not only will the technician never give their full attention to the attendee, it is also terrible for medical confidentiality. 

In screening, the audiometry technician should be looking at many things. and one of those is not just what result the attendee obtain but also how they obtained it. Were they nice and decisive, or wobbling about all over the place, unsure if they heard it or not and probably guessing a little more. If the audiometry technician has two tests going at once this cannot be done, which goes to the second issue...

People always take different amounts of time to complete an audiometric test, meaning if two people start at the same time, one will always finish first. The technician will then be getting that person out of the booth and explaining their result to them while the second one is still doing the test, so they aren't watching the result, and will be able to hear what's going on. It distracts the attendee and completely destroys medical confidentiality.

How many people is the technician testing per day?

An ideal is four per hour, five is just about OK.

Put it this way, the review of the pre-test questionnaire will take at least a couple of minutes to do properly, more with someone who has a history of issues. The otoscopic examination another 30 seconds, then another 30 seconds to sit them down and get the headphones on, then a screening test takes about seven minutes - some people may be a little faster but some will be slower. Get them out again and already you are on around 11 minutes. Another minute or two to explain the result to them and you are looking at 12 to 13 minutes from start to finish. That gives two minutes to clean the headphones, update the records and prepare for the next person.

From experience it is possible to increase this to five an hour but at this rate the screening technician is really motoring. When I did this it was a series of ten minute appointments at ten past the hour, twenty, thirty, forty and fifty, but then a gap on the hour itself as you need some catch-up time to avoid the schedule running late. Without that gap the only way to hit six tests an hour every hour is to really shorten every element of the test and just get them in and out as fast as possible with the bare minimum of interaction and analysis. That's not a good way to do test - it may be cheap, but it's not good value and I would avoid any service provider who does that.