TheHearingReview2019 - The Need For Standards in Audiology PDF

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Opinion | March 2019 Hearing Review

Why up-to-date practice standards for the
profession of audiology are necessary
By John A. Coverstone
In creating and adopting standards of practice for audiology,

we provide a shield for ourselves and our patients that will
demonstrate the high level of care audiologists are capable of
providing, improve confidence in audiology care, deter others
from infringing on the audiology scope of practice, and protect
each other from legal threats which may arise in the future.
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Perhaps the most fundamental aspect of training and clinical
practice in any area of modern healthcare is standardization. While
experimental treatments and poorly understood diseases exist, you
would not expect to encounter dramatically different approaches to
treating a broken bone, a case of the measles, diabetes, a heart
https://www.hearingreview.com/practice-building/need-standards-audiology 1/13
condition, a rotator cuff injury, or astigmatism. Closer to our

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profession, we expect pediatricians and family practice physicians
to adopt the American Academy of Pediatrics (AAP) guidelines for
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ear infection management, we expect ENT surgeons to follow
established procedures for surgical methods, and we expect our
colleague’s hearing exam to be consistent with ours. Most
important is that patients expect to be faced with similar options,
receive similar guidance, and achieve similar outcomes regardless
of the individual practitioner they visit.
The standardization of a profession arises from a general

agreement among members of the profession to follow the
published evidence and to update their practices when indicated.
This often happens when a representative population of experts in
a subject area agree that practices should change and update the
published standards for that area. It is incumbent upon training
programs to teach the same current methods to students, and it is
vital among practitioners to update their methods and tools to
achieve better outcomes as additional information becomes
available from research.
Moreover, members of a profession should adhere to the same

standards of practice. If different “standards” exist, then it could
easily be argued that no standard of practice exists. Imagine
yourself interpreting an audiogram where the audiometer was
calibrated to one of several different standards. The time we would
all spend converting data would be immeasurable! Similarly, all
members of a profession must be involved, through direct or
indirect representation, in standards development. Otherwise,
there is a very real risk that any published standards will be
severely weakened by low acceptance and possibly even by the
standard itself being weak due to exclusion of knowledgeable
experts.
There are many terms which are used to describe the way in which
a healthcare provider practices. It is important to establish a
common definition for what it is we should achieve in creating
practice standards.
Scope of Practice
A 2005 report by the Federation of State Medical Boards1 defined

scope of practice as the:
“…definition of the rules, the regulations, and the boundaries within

which a fully qualified practitioner with substantial and appropriate
training, knowledge, and experience may practice in a field of
medicine or surgery, or other specifically defined field. Such
practice is also governed by requirements for continuing education
and professional accountability.”1
Scope of practice is typically defined by state licensure laws and

represents a minimum standard of practice. It does not indicate
what methodologies are appropriate or “how” one should practice;

it simply outlines the procedures that a practicing provider should
be able to perform adequately if they have completed training at an
accredited program and passed the practical and knowledge-
based examinations accepted for their profession.
Scope of practice is defined in state law, due to the authority of the

states to define practices within their boundaries. However, scope
of practice is typically very homogenous throughout the United
States, as professions in the past 50 years have worked to define
an appropriate scope for their practitioners and then write these
into law in each state. In the period between 2003 and 2007, US
audiologists worked to update state laws so that a more universal
scope of practice was adopted. As a result, current laws governing
audiology practice are very similar, with minor differences noted for
procedures that are not universally part of audiology training
programs, such as cerumen management.
Standard of Practice
While scope of practice primarily describes the “what,” other

standards describe the “how.” Perhaps the best definition of a
standard of practice comes from the definition of standards of
nursing practice by the Mosby’s Medical Dictionary.2 Adapted for
audiology, this would read, “a set of guidelines for providing high-
quality audiology care and criteria for evaluating care. Such
guidelines help assure patients that they are receiving high-quality
care. The standards are important if a legal dispute arises over the
quality of care provided a patient.”3
It is important to note that standards of practice are developed and

maintained by the profession. In a moment, we will discuss
standards that are adopted by the legal system and sometimes
taken out of the hands of professionals—sometimes even adopted
against common practice of professionals. However, it is vital for a
profession to have standards developed internally so there is a
reference for those outside the profession to judge the decisions of
those practicing within the profession.
Clinical Protocols/Clinical Practice Guidelines
The terms clinical protocols and clinical practice guidelines are

often used to describe the same idea. According to the US
Department of Health and Human Services,4 “Clinical Protocols
and/or Clinical Practice Guidelines are systematically developed
statements that help physicians, other practitioners, case
managers, and clients make decisions about appropriate health
care for specific clinical circumstances.”
Clinical practice guidelines may be one of the most important tools

of a healthcare profession. They provide the “how” that scope of
practice and standards of practice do not, and they may provide
specialty-level detail that expand on Standards of Practice
statements. These are commonly referenced by courts and others

outside the profession when seeking guidance on standard
practices of a profession.5,6
Some organizations have even eschewed the term “practice

guidelines.” The American Academy of Opthalmology publishes
“Preferred Practice Pattern Guidelines,” which is intended to
recognize that no two patients’ needs are the same and a single
approach cannot ensure quality of care. The American Medical
Association uses the term “Practice Parameters” to promote the
idea that guidelines should be flexible and allow for individualized
treatment plans.7
Clinical practice guidelines provide details about the recommended

procedures for completing diagnostic, evaluative, and therapeutic
tasks. They address appropriate procedures for patients with
specific conditions and often guide clinicians in the decision-
making process during these encounters. As with standards,
practice guidelines have a sound scientific basis and should be
based on expert consensus. They should not be exclusionary due
to membership, employment affiliations, or other factors, and
should be widely available to members of the profession.
Standard of Care
Multiple legal sources provide essentially the same definition for

standard of care: “The only degree of prudence and caution
required of an individual who is under a duty of care.”8-11 More
commonly, standard of care is described as what a similarly
qualified provider would do, given the same patient with the same
condition, under the same set of circumstances. Various
publications in the legal field have debated whether this is what a
“reasonable provider” would do, whether this is what a “similarly
qualified provider” would do, or whether this is what the “average
provider” would do, given a set of circumstances.
Thus, standard of care is a legal term and not a medical one. This
standard arises from legal precedent as courts determine whether
a provider accused of malpractice acted appropriately or not.
However, courts are governed by people, and therefore differing
opinions exist regarding how to use published guidelines, whether
they automatically protect individuals following them, whether they
have significant bearing on what a “reasonable” person would do in
their circumstance, and so on.
However, the most dangerous course of all would be to find

yourself a defendant in a lawsuit where no standards exist and
have the court unilaterally decide what the standards for your
profession should be.
Best Practices
All the preceding standards describe a common minimal or

acceptable standard for a profession. Best Practices go beyond
what the minimum or average practitioner would do and describe
those methods believed to achieve the best possible results with
patients. Merriam-Webster defines best practices as, “a procedure
which has been shown by research and experience to produce
optimal results and that is established or proposed as a standard
suitable for widespread adoption.”12
In other words, best practices should result in best outcomes. They

are not necessarily the most common practices, although are
frequently promoted as those which should be adopted as
standards. Many times, best practices will gain adoption in a
profession and become the standard of practice. It should be the
goal of any profession that best practices become universal
practices so that every patient receives the best possible care and
outcomes.
The Need for Practice Standards
Practice Standards serve many important functions for a

profession. When standards are established for a healthcare
profession, training programs may teach to those standards. This
both provides a guideline for faculty curriculum development and
helps to ensure that students completing training at institutions
across the country are similarly prepared to enter practice. The
presence and widespread adoption of practice standards provide a
framework to design curriculum, develop advancement criteria and
assessment tools, and produce examination material to
appropriately assess a candidate’s readiness to begin independent
practice. Without standards, all these aspects of training are
weakened when considered on a national scale.
Standards also help to ensure similar practices among providers.

While it may be true that all members of a profession do not
adhere to the same standards, this is generally the goal of the
profession so that patients will receive a similar—and hopefully
high-quality—level of care by visiting any practitioner. If this
expectation is not met, it is feasible to assume that patients will be
reluctant to seek the services of that profession due to the
uncertainty introduced by the adoption of differing methodologies
and the likely difference in outcomes that will result.
It is therefore incumbent upon members of the profession to seek

continuing education in their area of practice and stay current with
emerging methods. In failing to do so, practitioners will necessarily
create for themselves a disparate set of knowledge and skills. This
will likely result in varying outcomes, depending on how old the
methodology is which they continue to utilize.
There may also be ethical implications for having standards in a

profession. In fact, it could be argued that adoption of standards
(or not) have ethical ramifications and that ethics depend on
standardization. Many people may consider it self-evident that
adhering to standards is the most ethical way to practice any

profession. Some may consider it arguable whether the reverse is
also true. However, this question bears consideration: Is it possible
to have ethical standards without having practice standards?
We would argue that it may not be possible to establish what is or

is not ethical behavior if a profession has not established
standards that are based in evidence, created and vetted by
experts in that area of practice, and widely adopted by those
practicing in that area. For instance, if there is no agreed-upon,
widely published, and adopted standards for what procedures
should be used, then it can only be the personal views of
every practitioner that decide what should or should not be done to
accomplish that procedure. As a result, instead of an ethical
principle calling for practitioners to achieve a minimum standard, it
becomes ethical for anyone to achieve any standard of their
choosing. An ethics board which would condemn the practices of
an individual without referencing an accepted standard is simply
holding that person to the arbitrary choices of the board members.
Last, and equally important, is the safeguarding of the profession.

Relevant threats to the profession may come in two ways. First is
the threat that a profession without widely adopted standards
creates a public perception that many—or even any—methods are
deemed satisfactory. This may further create a perception that
individuals without the same training and investment in the
profession are able to do the same work and achieve the same
outcomes. When there are no standards, there are probably no
well-defined outcomes, and therefore fuzzy outcomes seem much
easier to achieve.
The other potential threat to the profession comes from legal

action. This has been a much lesser concern for audiologists than
for many other healthcare professions, but it is worth some
discussion. Audiology is more recognized as a profession than at
any time in history, and, recently, audiology practices have been
widely questioned in some areas. Particularly in light of current
trends, such as less costly instrumentation for patients, it may be
reasonable to assume that patients will expect better outcomes
from traditional devices. If so, patients may also be more prone to
seek legal action if their expectations are not met or if an error in
communication results in personal or financial injury. As one
explores this topic, it becomes apparent there is no guarantee in
legal outcomes (see sidebar below); however, having well-
developed standards provides a reference for those outside the
profession—including officers of the court—and allows audiologists
to have a voice in determining appropriate practices.
As the sidebar about legal precedents demonstrates, consideration

is given to the customary practices of a profession; however, the
standard of care does not make average practice the definitive
factor in determining negligence. What common practices do you
employ which omit procedures that are accessible, harmless,
inexpensive, and brief—and yet may significantly improve

outcomes for your patients?
There are two early legal precedents that helped define

“standard of care” as the term is used today, both cited in
Peter Moffett and Gregory Moore’s article “The Standard of
Care: Legal History and Definitions: the Bad and Good
News,”9 which was written in 2011 specifically for emergency
medicine physicians. The article provides excellent
background about the history of standard of care
interpretation in the courts.
Tugboat owners and radios. The first precedent Moffett and

Moore discuss arose entirely outside medicine. In 1932, a
tugboat named the T.J. Hooper had been caught in a storm off
the Jersey coast, and the two barges it was transporting sunk.
The owner of the tugboat was sued by the owners of the
barges, who stated that the T.J. Hooper was not safe to be at
sea because it did not have a radio to receive storm warnings.
They also asserted that it was “customary” for tugboats to
have a radio, technology that would have prevented the T.J.
Hooper from towing their barges during a storm. At the time,
the customary definition of the legal standard was, essentially,
“what is typically done.” The judge in this case—whose real
name was Justice Learned Hand—found in favor of the barge
owners, but not because of custom. His decision, in fact,
stated that it was not customary for tugboats at the time to
have a radio receiver. However, he asserted that the practice
was “reasonable,” meaning that the owners of the tugboat
would have been prudent to have a radio and therefore could
be held liable.
This was an important precedent because it failed to excuse a

customary practice. As worded in Justice Hand’s written
statement, “…a whole calling may have unduly lagged in the
adoption of new and available devices. It never may set its own
tests, however persuasive be its usages. Courts must in the
end say what is required; there are precautions so imperative
that even their universal disregard will not excuse their
omission.”13
Ophthalmologists and a simple test for glaucoma. Importantly,

Justice Hand’s statement was quoted in a 1974 decision by the
Supreme Court of Washington,14 which is the second
precedent described by Moffett and Moore. In this case, a
patient sued her ophthalmologist after going blind from
glaucoma. The ophthalmologist won both the initial trial and
first appeal based on expert testimony that the patient was
under 40 years of age and the incidence of glaucoma in this
group was only 1 in 25,000. Therefore, it was not standard to
test patients under age 40 with tonometry. The Supreme Court,

however, decided that the test was inexpensive and harmless
to the patient and should have been offered. This is an
important decision because it also held the defendant liable to
practices that were not commonly performed at the time. In the
end, the court established a bar of reasonable prudence, rather
than average practice.
Future decisions by US courts served to further define the

standard of care in medicine, including establishing minimal
competence as the standard, not average level of skill. As Moffett
and Moore9 point out, a standard of “average” competence would
leave 50% of practitioners below the standard. Courts have also
held that poor outcomes are not a measure of competence, as a
physician is not an insurer of health or a guarantor of results.
Instead, the standard is the level of skill generally possessed by
others practicing in the field under similar circumstances.
There are variations as to how courts have used clinical practice

guidelines.5,6,9 Introduction of a document, such as a clinical
practice guideline, would typically be considered hearsay in a court
because the author is not available to testify or allow cross-
examination. However, several cases involving clinical practice
guidelines have suggested that guidelines possessing some
scientific validity may be used as “learned treatises” and avoid
being excluded based on the hearsay rule. Clinical practice
guidelines have been used to support an expert witness testimony,
impeach an expert witness, defend practitioners who adhere to the
guidelines, and suggest that physician deviance from the guideline
indicates deviation from the standard of care.
In the end, clinical practice guidelines are strongest when based in

evidence, developed by recognized experts in the area of practice,
maintained current, and followed by the individual accused of
negligence. Practitioners ignoring accepted practice guidelines run
the risk of being found negligent by legal proceedings.
Development and Maintenance of Practice Standards
If universal standards are to be developed and maintained for the

profession of audiology, this must be done in a systematic and
generally accepted fashion so the resulting standards are accepted
by the profession and are legally defensible. No
standards/guidelines may be created without a thorough practice
analysis of the profession. Fortunately, the American Board of
Audiology (ABA) developed an outstanding practice analysis,
published in 2015, which provides a foundation for many standards
and other programs in the profession.
A newly created professional entity, Audiology Practice Standards

Organization (APSO, www.audiologystandards.org), proposes the
following process for development of national standards in
audiology:
Standards should be based in evidence to the greatest extent

possible. When evidence is lacking or conflicting, expert
consensus should be reached to establish a standard.
Standards should represent a high level of care that provides

positive outcomes for our patients and that is achievable for all
licensed audiologists.
Subject matter experts involved in initial creation of standards

should, to the greatest extent possible, be representative of
specialty subgroups, practice settings, length of practice
experience, and ideology, as it is recognized that some
procedures may include multiple accepted practices.
Subject matter experts should be largely comprised of

audiologists practicing in the subject area. Researchers and
other non-practicing colleagues should be welcomed and
included but limited appropriately.
Development of practice standards should be facilitated by an

independent individual who is experienced in standards
development.
Notification of standards under development should be available

to all members of the profession.
All developed standards should be published to the entire

profession for review, discussion, and comment. This should be
regardless of membership or credentials maintained by the
practitioner (except state licensure, which is required to
practice).
Feedback received should be duly considered by subject matter

experts, even when representing opinions or evidence are
provided which were initially rejected.
Standards should be published so that they are accessible to all

members of the profession.
Standards should be reviewed and updated in a time frame

determined by subject matter experts to be necessary to
maintain the standards as current.
Some exemplary standards and guidelines do exist in audiology,

most notably those by Valente and colleagues.15-17 Unfortunately,
most of these are now 10-20 years old and current practices are
eclipsing the relevance of those standards. Additionally, due to the
period in which they were formulated, some were developed in
more closed circles with more limited review and comment by the
general profession than might be afforded today. It is impossible to
understate the importance of reviewing and updating (as
necessary) standards at regular intervals. Without doubt, there are
significant resources which must be dedicated to both developing
and maintaining standards for the profession.
Many audiologists may also wonder what standards they should

follow in developing their own clinical guidelines. Ultimately, each
practitioner must decide on the integrity and relevance of each
standard, should more than one published standard exist. We
strongly believe that the preceding ideals of standards
development indicate when a strong standard exists that is worthy
of adoption by the majority of the profession.
In creating and adopting standards of practice for audiology, we

provide ourselves and our patients a shield that will demonstrate
the high level of care audiologists are capable of providing,
improve confidence in audiology care, deter others from infringing
on the audiology scope of practice, and protect each other from
legal threats which may arise in the future. This is of paramount
importance to the profession at this time and worthy of the time,
effort, and expense required to build a solid foundation for the
practice of audiology.
Acknowledgements
This article was submitted on behalf of the Audiology Practice

Standards Organization (APSO) Board of Directors. For more
information about APSO, visit: www.audiologystandards.org.
John Coverstone, AuD, is President and CEO of Sentient

Healthcare, which includes his private practice, Audiology Ear
Care in New Brighton, Minn, and is Past-president and a current
Board Member of the Audiology Practice Standards Organization
(APSO). As part of his business, he also works as an educational
audiologist for more than 65 schools in Minnesota. Dr Coverstone
co-hosts the Audiology Talk and the American Tinnitus
Association’s (ATA) Conversations in Tinnitus podcasts, and writes
for ATA. He previously worked in hearing instrument and medical
equipment manufacturing, and served as the 2015 Chair of the
Board of Governors for the American Board of Audiology (ABA). Dr
Coverstone has been involved in numerous audiology
organizations, including serving on the Board of Directors of the
Minnesota Academy of Audiology and as that organization’s
President in 2012.
Correspondence can be addressed to Dr Coverstone at:

jcoverstone@sentienthealthcare.com
Citation for this article: Coverstone JA. The need for standards
in audiology. Hearing Review. 2019;26(3)[Mar]:24-29.
Image: © Tzogia Kappatou | Dreamstime.com

References
1. Federation of State Medical Boards. Assessing scope of

practice in health care delivery: Critical questions in assuring
public access and safety.
http://www.fsmb.org/siteassets/advocacy/policies/assessing-
scope-of-practice-in-health-care-delivery.pdf. Published 2005.
2. Mosby Elsevier. Mosby’s Medical Dictionary. 8th ed. Maryland

Heights, MO: Elsevier Health Sciences; 2008.
3. American Nurses Association. Nursing: Scope and standards of

practice. 2nd ed. Silver Spring, MD: American Nurses
Association;2010.
4. Institute of Medicine, Lohr KN, Field MJ. Clinical practice

guidelines: Directions for a new program. Washington, DC:
National Academies Press; 1990.
5. Mello MM. Of swords and shields: The role of clinical practice

guidelines in medical malpractice litigation. University of
Pennsylvania Law Review. 2001;149(3):645-710;2001.
6. Mackey TK, Liang BA. The role of practice guidelines in medical

malpractice litigation. AMA Journal of Ethics. 2011;13(1):36-41.
7. Walker RD, Howard MO, Lambert MD, Suchinsky R. Medical

practice guidelines. Western J Med.1994;161(1):39-44.
8. Strauss DC, Thomas JM. What does the medical profession

mean by “standard of care?” J Clin Oncol.2009;27(32):e192–
e193.
9. Moffett P, Moore G. The standard of care: Legal history and

definitions: The bad and good news. Western J Emergency
Med.2011;12(1):109-112.
10. MedicineNet.com. MedTerms Medical

Dictionary. https://www.medicinenet.com/script/main/art.asp?
articlekey=33263. Accessed February 26, 2018.
11. Wikipedia. Standard of Care [definition].

https://en.wikipedia.org/wiki/Standard_of_care. Accessed Febru
ary 26, 2018.
12. Merriam Webster Dictionary. Best Practice

[definition]. https://www.merriam-
webster.com/dictionary/best%20practice.
13. TJ Hooper v. Northern Barge Corporation HN Hartwell & Son,

Inc, v. Same. 60 F.2d 737 (2d Cir.
1932). https://law.justia.com/cases/federal/appellate-
courts/F2/60/737/1542549/
14. Helling v. Carey. 83 Wn. 2d 514

(1974). https://law.justia.com/cases/washington/supreme-
court/1974/42775-1.html
15. Valente M, Bentler R, Kaplan HS, et al. Guidelines for hearing

aid fittings for adults. Am J Audiol.1998;7(1):5-13.
16. Valente M, Abrams H, Benson D, et al. American Academy of

Audiology (AAA). Guidelines for the audiologic management of
adult hearing impairment. https://audiology-
web.s3.amazonaws.com/migrated/haguidelines.pdf_53994876e
92e42.70908344.pdf. Published 2006.
17. Valente M, Barninger KH, Oeding K, et al. American Academy of

Audiology clinical practice guidelines: Adult patients with severe-
to-profound unilateral sensorineural hearing loss.
https://www.audiology.org/sites/default/files/PractGuidelineAdult
sPatientsWithSNHL.pdf. Published June 2015.
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1 Comment
Sam Yao on March 15, 2019 at 7:56 am

One of the challenges of not easy to set up the standard is that the
audiology work is more perceptual and subjective for individuals.
Deep learning technology is highly suitable for this kind of ‘blurry’
field. I am working on it.
REPLY
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4/25/2020 The Need for Standards in Audiology - Hearing Review

TRENDING: New Drug Promises Relief from Tinnitus, Epilepsy     SEARCH 

Hearing Loss  Products  Practice Building  Inside Hearing  Resources  Magazine

The Need for Standards in Audiology GN Hearing Introduces In-ear Tes

Earlens Contact Hearing Solution

Toward Standardization of Basic

Reducing Hearing Aid Delay for O

Ida Institute Launches Online Co

Opinion | March 2019 Hearing Review

In creating and adopting standards of practice for audiology,

condition, a rotator cuff injury, or astigmatism. Closer to our

The standardization of a profession arises from a general

Moreover, members of a profession should adhere to the same

A 2005 report by the Federation of State Medical Boards1 defined

“…definition of the rules, the regulations, and the boundaries within

Scope of practice is typically defined by state licensure laws and

what methodologies are appropriate or “how” one should practice;

Scope of practice is defined in state law, due to the authority of the

While scope of practice primarily describes the “what,” other

It is important to note that standards of practice are developed and

Clinical Protocols/Clinical Practice Guidelines

The terms clinical protocols and clinical practice guidelines are

Clinical practice guidelines may be one of the most important tools

statements. These are commonly referenced by courts and others

Some organizations have even eschewed the term “practice

Clinical practice guidelines provide details about the recommended

Multiple legal sources provide essentially the same definition for

However, the most dangerous course of all would be to find

All the preceding standards describe a common minimal or

In other words, best practices should result in best outcomes. They

The Need for Practice Standards

Practice Standards serve many important functions for a

Standards also help to ensure similar practices among providers.

It is therefore incumbent upon members of the profession to seek

There may also be ethical implications for having standards in a

adhering to standards is the most ethical way to practice any

We would argue that it may not be possible to establish what is or

Last, and equally important, is the safeguarding of the profession.

The other potential threat to the profession comes from legal

As the sidebar about legal precedents demonstrates, consideration

inexpensive, and brief—and yet may significantly improve

There are two early legal precedents that helped define

Tugboat owners and radios. The first precedent Moffett and

This was an important precedent because it failed to excuse a

Ophthalmologists and a simple test for glaucoma. Importantly,

test patients under age 40 with tonometry. The Supreme Court,

Future decisions by US courts served to further define the

There are variations as to how courts have used clinical practice

In the end, clinical practice guidelines are strongest when based in

Development and Maintenance of Practice Standards

If universal standards are to be developed and maintained for the

A newly created professional entity, Audiology Practice Standards

Standards should be based in evidence to the greatest extent

Standards should represent a high level of care that provides

Subject matter experts involved in initial creation of standards

Subject matter experts should be largely comprised of

Development of practice standards should be facilitated by an

Notification of standards under development should be available

All developed standards should be published to the entire

Feedback received should be duly considered by subject matter

Standards should be published so that they are accessible to all

Standards should be reviewed and updated in a time frame

Some exemplary standards and guidelines do exist in audiology,