Patient satisfaction, by definition, implies that the patient is satisfied with the amplification we have provided during the evaluation and treatment process. The term also implies that the patient is wearing the amplification system as prescribed and that our treatment results in an improvement in the patient’s quality of life.

In practical, business terms, patient satisfaction also means that the hearing aid system was not returned for credit at the end of a "trial," "adjustment," or "evaluation" period, and that they would refer other patients to us for services. Assuming that we have excellent professional skills, that we have pre-qualified the patient, that we understand what they expect from the treatment, and that we send them out of the fitting session with the "right" fit the first time, we should expect no (or very few) returns for credit.

The Ideal World...

In the world of "perfect" evaluation, pre-qualification, and treatment, the modern clinician should be able to expect and accomplish:

• Verification of the first fit. Making sure that we are fitting the amplification characteristics that we think we are fitting is crucial. This, of course, is irrelevant if one actually believes that manufacturer’s algorithms are exact, and that there are no significant differences between human ears and hearing losses. The evidence, of course, says otherwise.¹
• Direct involvement of the patient in the treatment process. This implies that the clinician is able to provide an understanding of the hearing loss and its affects on speech intelligibility in quiet and in noise, and that the patient is able to both visualize and hear the results of treatment with speech/sounds encountered in real life.
• Direct involvement of the family or significant others in the evaluation and treatment process. This also entails providing significant others with a practical experience that gives them insights into the patient’s hearing loss. Ideally, that experience should be both visual and auditory, using voice and sounds that the patient encounters in the real world.
• Presentation of a high-tech image to the patient and family. This reinforces confidence in the treatment process and the sophisticated nature of our services.
• Cost-effective treatment for patients and clinicians. To stay in business, hearing care professionals need to reduce patient visits, solve fitting problems, and bill enough in order to pay for the equipment and services used in the treatment process. Patients are willing to pay for a service that is seen as high tech and as having value, even when it is not covered by health insurance.
• Efficient problem solving. This involves real-world stimuli and sophisticated treatment technology.

How Do Most Clinicians Work Now?

In the "Basic Business Skills" class I teach at PCO, my "students" are practicing clinicians with experience in the dispensing world. It is relatively easy to cause a defensive response by asking them how they verify their treatment. In many, cases, the answer is simple: they don’t. If your office operates similarly, you’re not alone; although most clinicians (57%) own real-ear measurement (REM) equipment, fewer than one-quarter (23%) use it during a routine adult hearing aid fitting.² Others, being more practical, look at verification as a function of whether or not the patient returned the amplification system for credit.

Most who actually do verify their fittings state that they use soundfield tests or traditional REM. This is all well and good until I then ask them if they fit digital hearing aids. If the clinician fits a high percentage of digital technology (over 90% of all hearing aids dispensed last year were digital), I then ask them what they "turn off" to complete the measurements. If one treats only with analog technology, then soundfield and REM tests are appropriate and useful. This is not true of digital aids, where one must turn off noise reduction, use an artificial signal, etc.

Besides the obstacles in using these verification procedures, patients and family members rarely understand what they are seeing and experiencing. In fact, their experiences during the verification process may be useless in the real world. Soundfield and REM measurements are not always useful for persuading a patient to purchase a hearing aid, problem solving, or the creation of a clinician-patient partnership.

The Problem Solver: Speech Mapping

Not to be overlooked, there is a growing percentage of my students who know one of the best kept secrets to patient satisfaction as defined above: speech mapping. I and my students who use this technique know that it is becoming the "gold standard" in treatment verification. It is also a powerful and useful business tool.

Speech mapping first had an impact on the verification process thanks to the article by Cunningham et al.³ describing a reduction in patient visits and other positive benefits of using this technique. Ross and Smith⁴ and Bonta and Smith⁵ added to the information base by describing the clinical applications of speech mapping. A specific protocol for use of the procedure was outlined. At the time these articles were published, in addition to the clinical application of other speech-mapping systems like VeriFit, monaural measurements were the norm and only one ear could be measured at a time. This increased the time and inconvenience of making a complete measurement.

The following details the use of the AURICAL Visible Speech (AVS) system, which is tailor-made for patient counseling, hearing loss, and amplification simulation and speech mapping. This system can work in the full-service, clinical environment, as well as retail environments where the dispensing professional may not have access to surround sound or NoahLink. The system is also ideal for servicing patients in their homes or in residential care facilities.

If Speech Mapping is so Good, What Are Clinicians Afraid Of?

Sampling hundreds of practicing clinicians who don’t use speech mapping, their rationale for non-use can be broken down into three primary issues:

1. It takes too much time. This is especially true for clinicians working in busy medical practices, where treatment time is at a premium.
2. Inserting a probe microphone to the tympanic membrane is uncomfortable or painful for the patient.
3. The equipment is expensive, and the cost is not justified.

New speech-mapping equipment and the innovative use of it in the treatment process provides solutions to each of these objections.

Time. The AVS system is truly binaural, and requires little time for calibration. It is also intended for use with NoahLink and a sound system. For these reasons, the verification process can be accomplished in less than 5 minutes in the majority of cases. The added time is justified since it allows for increased customer satisfaction, fewer return visits for trouble shooting, greater first-fit accuracy, and a significant reduction in returns for credit. The efficiency and impact of the system can be improved even further with a surround-sound system, such as GN ReSound’s RAVE.

Probe-mic insertion. Modern probe tubes are easy to insert and fix in place. Placement of the tube in the ear canal can be observed using the OtoCam, and it is now rare for a patient to experience pain or discomfort. It is not necessary to "bump" the tympanic membrane; one is required only to achieve tube placement beyond the second bend in the ear canal.

Expense. Use of a speech-mapping system leads to a reduction in the number of returns for credit, increased sales through use of the hearing loss simulation feature of the software, and up-selling to higher technology through demonstration of performance in noise. Additional collection of fees for use of the system when the patient is past their complementary service time period or presenting with an aid not fit by the clinician leads not only to equipment cost recovery, but profitability. The financial investment in AVS is recovered quickly since it is both easy and effective to use in the treatment process.

Maximizing the Impact of Speech Mapping

The setup of the equipment is critical if the clinician wants to maximize the impact of the procedure. I would recommend the use of a flat-screen monitor in the examination area, so that the process is readily visible to the patient and family. A surround-sound system, like RAVE, is also recommended because of the huge sound library available and because it is easy to demonstrate the directional features of high-end technology, noise reduction capabilities, and directionality. Features of the AVS include:

Wireless, Bluetooth technology. The patient wears a light comfortable harness which is can be coupled to NoahLink. While this may seem to be a small issue, the physical arrangement of the equipment encourages the clinician to use speech mapping more often since its use is very time efficient.

Advanced simulators. The state-of-the-art Hearing Loss Simulator and Hearing Instrument Simulator offer an effective and efficient means for involving the family or significant other in the treatment process. These features are displayed rapidly and the software is intuitive. This provides an efficient and effective presentation useful in convincing the patients of hearing aid benefit, while involving their family in the process—a technique that can "make or break" the treatment process.

Binaural performance. True binaural performance, with easy application and no need for individual (and time-consuming) separate calibration of microphones.

Expedient and intuitive. The system is time efficient, allowing the clinician to focus more on counseling and less time on equipment manipulation. It also features intuitive, easy-to-use software. I trained an audiology assistant to perform the procedure with comfort and efficiency in less than 1 hour.

Real-life sound options. AVS offers sound files with a wide range of real-life sounds to generate and measure. It also has the ability to record a significant other’s voice (looped) or other sounds that are critical to the success of the treatment.

Handy fine-tuning tool. Dispensing professionals have the ability to make changes in the hearing instrument programming while AVS is active in the "on-top" mode. Similar to other clinicians,1 we have learned from many patient fittings that what is "supposed" to be happening to programming is not always "happening." AVS provides an objective tool for measuring and visualizing what is actually occurring at the tympanic membrane, increasing the effectiveness of adjustments and involving the patient directly in the process.

How to Use the Equipment in the Clinical Process

Remembering the components of patient satisfaction and other elements that contribute to a successful clinical process, I consider the following to be important applications of AURICAL Visible Speech:

1. Fit amplification correctly the first time by using AVS during all first fittings.
2. Demonstrate the effects of the hearing loss for the family or significant other through the use of the Hearing Loss Simulator. This process leads to improved understanding and support from the family, which is critical to success.
3. Use AVS to involve the patient in the amplification adjustment process. The patient can now "see" and "hear" the effects of adjustment, leading to more patient confidence in the process and technology.
4. Always use AVS for evaluation of hearing aids that were delivered to the patient through another source. Use of the procedure leads to patient confidence because the clinician and patient have an objective and "real life" tool for making decisions about the appropriateness of the fit that is independent of the often perceived goal of simply "selling" a new hearing aid.
5. Consultative selling and convicting the client to purchase the aid is facilitated using the high-tech, real-world AVS system, where benefit can be both seen and heard during the demonstration process.
6. Troubleshooting efficiency goes up when AVS is used as part of the process. For example, for those of us who are older ("seasoned") audiologists, both internal and external feedback can be visualized when it may not be heard.
7. Documentation of special programs. For example, instead of simply asking the patient to listen to the office phone to determine the audibility of the dial tone and speech, AVS can be used to determine whether or not those signals are audible. Adjustments can then be made in real time, making the fitting "right" the first time.
8. Staff training is another important application of AVS. By using this technology in a demonstration, new products and benefits can be seen and heard by office staff who are so critical in patient-solution process.
9. Evaluation of new products and device features is another important function of AVS. In short, this process is critical to determining what is real and what is "hype."

Financial and Business Impact of Speech Mapping

As a clinician and business manager, I am interested in not only covering my costs, but creating new profit centers that have a positive and critical affect on patient care. The financial and quality-of-care issues involved with speech mapping have been well documented by those of us who have used it. With the introduction of AURICAL Visible Speech, representing a significant improvement in the easy of clinical use and the impact on the patient, the financial impact of this process can be readily apparent. That impact includes:

• Fewer unpaid office visits for adjustments to the amplification system.
• Significant reduction in returns for credit when the patient is pre-qualified during the intake and fitting process.
• An increase in sales, where multi-sensory demonstration of benefit to the patient and family is a significant issue.
• An increase is sale closures to patients who present with inadequate amplification systems not provided by the clinician. Additionally, clear demonstration of improvement in technology can be experienced by the patient through a demonstration process using AVS.
• Generation of charges for the procedure after services associated with the hearing aid sale are no longer included. The vast majority of patients readily see the value of the procedure, and this process should eventually replace the hearing aid evaluation that many clinicians don’t do (along with incomplete use of soundfield or REM testing).
• The AVS is an effective marketing tool, where patients with existing hearing aids are exposed to activities like consumer seminars and/or open houses. Both the hearing loss and effects of amplification can be demonstrated through the Hearing Loss Simulator and Hearing Instrument Simulator.

This article was submitted to HR by Kenneth E. Smith, PhD, a private practice audiologist who has worked in the Kansas City area for more than 30 years. A past president of the Academy of Dispensing Audiologists (ADA), Smith teaches basic business skills in Pennsylvania College of Optometry’s AuD program. He also serves as a consultant for the industry through his company, Industry Consulting Services, evaluating new products and working to develop business models for their application. Correspondence can be addressed to HR at or Kenneth Smith, PhD, Hearing Associates, 8901 W 74th St, Ste 150, Shawnee Mission, KS 66204; .

References

1. Aarts NL, Caffee CS. The accuracy and clinical usefulness of manufacturer-predicted REAR values in adult hearing aid fittings. Hearing Review. 2005;12(12):16-22.
2. Strom KE. HR 2006 dispenser survey. Hearing Review. 2006; 13(6):16-39.
3. Cunningham D, Lao-Davila R, Eisenmenger B, Lazich, R. Study finds use of live speech mapping reduces follow-up visits and saves money. Hear Jour. 2002;55(2):43-46.
4. Ross T, Smith K. How to use live speech mapping as part of a hearing instrument fitting and verification protocol. Hearing Review. 2005;12(6):40-46.
5. Bonta R, Smith K. Create a high tech experience. Advance Audiol. 2004; July/August:49-51.