Identifying Quality Improvement Opportunities in a Universal Newborn Hearing Screening Program

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1 QUALITY REPORT Identifying Quality Improvement Opportunities in a Universal Newborn Hearing Screening Program AUTHORS: Kenneth C. Deem, MD, MPH, a Ernesto A. Diaz- Ordaz, MD, a and Brian Shiner, MD, MPH b a Department of Otolaryngology Head and Neck Surgery, University at Buffalo, State University of New York, Buffalo, New York; and b The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire KEY WORDS neonatal screening; hearing loss; early intervention; health care quality, access, and evaluation; quality improvement ABBREVIATIONS AABR automated auditory brainstem response EHDI Early Hearing Detection and Intervention EI early intervention JCIH Joint Committee on Infant Hearing PCHL permanent congenital hearing loss UNHS universal newborn hearing screening doi: /peds Accepted for publication Sep 9, 2011 Address correspondence to Dr Kenneth C. Deem, 1237 Delaware Ave, Buffalo, NY, kcdeem@gmail.com PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2012 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. abstract BACKGROUND AND OBJECTIVES: Hospital-based universal newborn hearing screening (UNHS) programs are encouraged to maintain quality assurance protocols, but many hospitals lack the time and resources to initiate this process. We studied a practical approach to measuring baseline quality indicators and identifying improvement opportunities in UNHS programs. METHODS: We determined screening processes and quality indicators for UNHS programs at 4 hospitals through site visits and a 2-year retrospective review of nursery and audiology records. Nurses, audiologists, and otolaryngologists met for feedback of hospital-specific quality indicators. The sessions identified improvement opportunities and proposed system changes for immediate implementation. RESULTS: Hospitals screened newborns for hearing loss. Screening rates were.99% at all hospitals. Rates of referral and diagnostic testing varied significantly between hospitals. Low referral rates prompted 2 hospitals to adjust screening processes to reduce potential falsenegative screening results. Two other hospitals addressed poor diagnostic follow-up by changing the referral process to include additional family contact information. Hospitals also increased referrals to Early Intervention Child Find services on the basis of our finding that these referrals increased the likelihood of diagnostic follow-up fourfold. We could not fully assess indicators of hearing aid eligibility and enrollment in early intervention services due to insufficient documentation. CONCLUSIONS: Review of nursery and audiology records successfully established most quality indicators for the UNHS programs we studied. Feedback of quality indicators identified multiple improvement opportunities and facilitated endorsement of immediate system changes. This study demonstrates a practical and data-driven approach to quality improvement that can be used by any UNHS program. Pediatrics 2012;129:1 8 PEDIATRICS Volume 129, Number 1, January

2 Effective newborn hearing screening programs significantly improve language outcomes by identifying infants with permanent congenital hearing loss (PCHL) and facilitating early intervention (EI). 1 4 Universal newborn hearing screening (UNHS) programs were developed with guidelines published by the Joint Committee on Infant Hearing (JCIH) and Healthy People These guidelines outlined the framework of UNHS programs and defined outcome measures for quality assessment. Rates of screening, referral, diagnostic testing, hearing aid fitting, and enrollment in Part C EI services function as the primaryqualityindicatorsforunhs programs (Table 1). 5,9 Nationally, UNHS programs consistently achieve JCIH targets for screening and referral, with nearly all newborns screened for hearing loss before discharge and,4% referred for outpatient hearing testing. 5,10 Timely diagnostic follow-up and EI enrollment has proved a greater challenge. State UNHS programs, also known as Early Hearing Detection and Intervention (EHDI) programs, report considerable variation in rates of diagnostic follow-up (15% 95%) and EI enrollment (10% 100%). 11 A survey of EHDI coordinators estimates that one-half of infants with a positive screening test result are lost to follow-up, and one-third with confirmed hearing loss do not initiate EI services. 9 Research suggests many barriers to timely followup and intervention; these barriers could affect the effectiveness of any single UNHS program. 5,11 18 In 2001, New York State mandated UNHS in all birthing hospitals. 9 Hospitals are required to report aggregate hearing screening data to the state EHDI program. However, these data are insufficient for calculation of quality indicators and feedback of performance analyses to individual hospitals. Since then, much emphasishasbeenplacedondevelopment of statewide informatics systems to support data management, infant tracking, and quality assurance. 5,19 New York State recently amended UNHS legislation to support reporting of UNHS data in a statewide tracking system. 20 As this data management system becomes available, hearing screening outcomes will need to be examined in the context of local UNHS systems. The responsibility for local UNHS system evaluation and quality improvement is not well established. State EHDI coordinators have cited a lack of time and resources to engage in systematic evaluation of screening outcomes at individual hospitals. 12 For continued improvements in UNHS outcomes, it is important that hospital-based UNHS programs be prepared to lead quality improvement efforts at the local level. JCIH guidelines recommend that hospital-based UNHS programs maintain a process for outcomes monitoring and continuous quality improvement, but the details of this process are not described. 5 To the best of our knowledge, there are no published reports illustrating a specific approach to quality improvement in UNHS at individual hospitals. There exists a need for a practical approach to quality improvement that can be undertaken by hospital-based UNHS programs. In this study, we initiated an improvement protocol encompassing the UNHS system in Buffalo, New York, and TABLE 1 Quality Indicators and Guidelines for UNHS Programs Timeline Quality Indicator Description a Operational Definition Guideline 1 Month Screening Percentage of infants screened before 1 mo corrected age Screened (n) Births (n).95% b Referral Percentage of infants screened who are referred for diagnostic testing 75 Days Child-Find Services For infants lost to follow-up by 75 d of life, the percentage referred to EI Child-Find services 3 Months Diagnostic testing Percentage of infants completing diagnostic testing by 3 mo corrected age Hearing loss Hearing aid fitting Percentage of infants diagnosed with PCHL For infants with bilateral PCHL who elect amplification, the percentage fit with hearing aids within 1 mo of diagnosis 6 Months Early Intervention Percentage of infants with PCHL who enroll in EI by 6 mo corrected age a Adapted from JCIH guidelines 5 and New York State Department of Health memorandum. 18 b JCIH guideline. 5 c New York State law. 18 Referred (n) Screened (n) Referred to Child-Find Services (n) Lost to follow-up at 75 d (n) Completed Diagnostic Testing (n) Referred for Diagnostic Testing (n) Diagnosed with PCHL (n) Births (n) Fit with hearing aids (n) Eligible for hearing aids (n) Enrolled in EI (n) Diagnosed with PCHL (n),4% b 100% c.90% b 1% 3%.95% b.90% b 2 DEEM et al

3 QUALITY REPORT describe our approach to establishing baseline quality indicators and recommendations for improvement. Buffalo was an ideal choice because it was not part of the New York State UNHS demonstration project in the 1990s, 21 and there were no previous systematic efforts to improve UNHS. Our goal was to assess hearing screening processes and measure quality indicators at each of 4 birthing hospitals. We hypothesized that (1) a 2-year retrospective review of quality indicators would yield sufficient data to compare local quality indicators with JCIH guidelines, and (2) feedback of these data to each hospital and audiology center would identify opportunities for improvement for immediate implementation. METHODS System Overview The UNHS system in Buffalo is composed of 4 hospitals and 2 audiology centers, serving 8 counties in western New York. Each hospital is managed by 1 of 2 nonprofit organizations. Experienced pediatric audiologists performed all diagnostic testing. All hospitals and audiology centers are located within a 9-mile radius. Institutional review boards from both managing organizations approved this study. County public health departments did not permit review of EI records due to lack of signed parental consent. Assessment of Screening Processes We made site visits to each nursery and audiology center. We reviewed hospital policies and forms related to hearing screening and observed hearing screening tests in each nursery. We interviewed staff and discussed hearing screening processes with nurses, nursery supervisors, UNHS coordinators, audiologists, and audiology center directors. FIGURE 1 Buffalo cohort of newborns screened for hearing loss, 2007 to Measurement of Quality Indicators We reviewed nursery records at each birthing hospital and identified infants who failed newborn hearing screening from 2007 to 2008 (Fig 1). For the 300 infants included, we recorded gender, prematurity, insurance status (Medicaid or private), nursery level 22 (I, IIIA, or IIIB), distance from home to audiology center, laterality of suspected deficit (unilateral or bilateral), and presence of PCHL risk factors. 5 For infants with diagnostic follow-up, we recorded timing of testing, diagnosis of hearing loss, and interventions (hearing aid fitting and EI referral). For infants who could not be contacted for follow-up by 75 days of life, we recordedifthere wasareferral toeichild Find services, as required by New York State law. 18 Diagnostic testing included otoacoustic emissions, tympanometry, auditory brainstem response, and visual reinforced audiometry when appropriate. We categorized hearing loss accordingtotype(sensorineuralor conductive), laterality (unilateral or bilateral), and severity (mild/moderate or severe/profound). We considered hearing loss mild/moderate if air or bone conduction thresholds were between 30 and 60 db, was high-frequency only (.2000 Hz), or was of indeterminate severity. We calculated quality indicators for each hospital and compared these with JCIH guidelines (Table 1). We corrected ages to 40 weeks gestational age for all calculations. We compared quality indicators using x 2 analysis. Multivariate logistic regression was used to evaluate factorsassociatedwithcompletionof diagnostic testing. A 2-tailed a of 0.05 was used to determine statistical significance. For pairwise comparisons between hospitals, we used a Bonferroniadjusted P value to control for type I error (0.05/6 = adjustment). We performed statistical analyses using SPSS 16.0 (SPSS Inc, Chicago, IL). PEDIATRICS Volume 129, Number 1, January

4 Feedback of Quality Indicators We arranged multidisciplinary meetings to provide quality indicator data, one for hospitals 1 and 2 and another for hospitals 3 and 4. Meetings included otolaryngologists (Dr Deem and Dr Diaz-Ordaz), nurses (UNHS coordinators and nursery supervisors), and pediatric audiologists. Groups discussed improvementopportunitiesandchangestrategies for each stage of the screening process (screening, diagnostic testing, and early intervention). We encouraged groups to endorse at least 1 intervention for immediate implementation. Groups did not use a testing period before implementation. RESULTS Screening Processes Table 2 displays the characteristics of the screening processes and referrals for each nursery. Nurses performed screening tests with either a 2-step protocol using transient evoked otoacoustic emissions followed by automated auditory brainstem response (AABR) or with AABR alone. AABR alone was used for infants in each level III nursery and was the only screening technology supported at hospitals 3 and 4. UNHS coordinators were responsible for hearing screening protocols, infant tracking, and data reporting to the New York State EHDI program. Audiologists made referrals to county EI programs when they confirmed a diagnosis of PCHL. After 75 days without follow-up, either the hospital UNHS coordinator or an audiologist made referrals to EI Child Find services. Quality Indicators Table 3 presents the UNHS quality indicators at each hospital. Screening rates were at or near 100% and referral rates were,4%. Hospital 1 had higher referral rates than all other hospitals (P,.0001). Hospitals 3 and 4 had much lower referral rates than hospitals 1 and 2 (P,.0001). No hospital achieved.90% diagnostic follow-up by 3 months corrected age. Hospital 1 had the lowest rate of the 3-month follow-up, significantly lower than hospital 2 (P,.0001) and hospital 3 (P =.003). At 3 months corrected age, diagnostic follow-up was completed by 61.3% of infants referred (n = 300). Thereafter, only an additional 12% completed follow-up within the first year of life (Fig 2). Nursery level and insurance status were independently associated with lower rates of follow-up for diagnostic testing at 3 and 6 months corrected age (Table 4). Eighty percent of infants who were late or lost to followup were from hospital 1 (Table 3), which had the only level IIIB nursery and the highest percentage of infants with Medicaid insurance (Table 2). Infants with risk factors for PCHL and infants who failed screening bilaterally were no more likely to undergo follow-up at 3 months compared with infants without these factors (Table 4). We plotted quarterly rates of 3-month follow-up on a control chart and detected no special cause variation during the 2 years studied. By 75 days of life, 91 infants had not presented for diagnostic testing and could not be located by mail or telephone. Sixty of these infants were referred to their county EI Child Find officer as at-risk. Infants referred to EI Child Find services were 4 times more likely to follow-up by 6 months corrected age than infants not referred (26.7% vs. 6.5%, respectively; P =.03). Twenty-four infants were identified with PCHL, representing 0.11% of infants screened, and 10.6% of infants who completed diagnostic follow-up (Fig 1). Eighteen infants had bilateral sensorineural hearing loss, including 9 with severe to profound hearing loss. Twelve infants with PCHL completed diagnostic testing by 3 months corrected age. TABLE 2 Characteristics of Hearing Screening Protocols and Referrals From Each Hospital Hospital Nursery Level Nursery Level Nursery Level Nursery Level I IIIB I I IIIA I Screening protocol TEOAE, AABR AABR TEOAE, AABR AABR AABR AABR Timing of screening 2nd day of life Before discharge 2nd day of life 1st day of life Before discharge 1st day of life No. of screening attempts allowed TEOAE, 2; AABR, 1 AABR, 2 TEOAE, 2; AABR, 1 Unlimited Unlimited Unlimited Referred (n) Medicaid (%) Risk factor (%) a Distance from home to follow-up.25 miles (%) Bilateral (%) b Male (%) TEOAE, transient-evoked otoacoustic emissions. a At least 1 risk factor present for hearing loss. 5 b Failed screening in both ears. 4 DEEM et al

5 QUALITY REPORT TABLE 3 Quality Indicators for UNHS Programs in Buffalo, New York, from 2007 to 2008 Quality Indicator Guideline a Hospital Eight infants with PCHL were fitted with hearing aids, including 6 with bilateral hearing loss. Three infants were fitted by 6 months corrected age and 2 were fitted within 1 month of diagnosis of PCHL. Eligibility for hearing amplification was not always clear from review of audiology records. Six infants with unilateral or mild degrees of hearing loss were not fitted. Severe developmental delays and comorbidities were noted in another 5 infants who were not fitted. Nursery and audiology records did not always indicate when infants received EI referral, evaluation, and enrollment. At least 18 infants with PCHL were referred for county EI services, 6 due to loss to follow-up by 75 days of life, 6 due to diagnosis of PCHL, and 6 due to other developmental delays. We were not granted access to review county EI records to confirm EI evaluation and enrollment. Total n % n % n % n % n % Screened.95% Referred,4% mo follow-up.90% Ever follow-up Diagnosed PCHL 0.1% 0.3% a JCIH guidelines. 5 FIGURE 2 At 3 months corrected age, diagnostic follow-up was completed by 61.3% of infants referred (n = 300). Thereafter, only an additional 12% completed follow-up within the first year of life. Feedback of Quality Indicators Table 5 summarizes results of multidisciplinary meetings to discuss quality indicator data, improvement opportunities, and proposals for change. Hospitals 3and4targetedverylowreferralrates and endorsed a screening-process change to limit potential false-negative results on screening tests. Hospitals 1 and 2 targeted low follow-up rates and endorsed a referral-process change to include additional family contact information. Both groups endorsed tracking-process changes to ensure appropriate EI Child Find referrals after 75 days of life. Additional improvement opportunities included unclear documentation of hearing aid eligibility and inability to confirm EI enrollment. DISCUSSION In confirming our first hypothesis that we could sufficiently measure local quality indicators, we found the Buffalo UNHS system screened 99.9% of newborns, referred 1.4% for diagnostic testing, completed diagnostic testing for 61.3% by 3 months corrected age, and diagnosed PCHL in 1 of every 1000 newborns. Hearing amplification was provided for 8 of 24 infants with PCHL, including 2 infants who received hearing aids within 1 month of diagnosis. We found insufficient documentation to determine the percentage of infants with PCHL who were enrolled in EI services by 6 months corrected age. These data demonstrate that the UNHS system in Buffalo is capable of achieving timely diagnosis and intervention for some infants with PCHL but that significant barriers exist for many others. In confirming our second hypothesis, feedback of quality indicators to multidisciplinary teams of nurses, pediatric audiologists, and otolaryngologists resulted in the identification of multiple improvement opportunities and change ideas. As a result of these meetings, teams endorsed changes targeted at processes of screening, referral, and diagnostic testing for immediate implementation. Proposed changes affecting processes of hearing aid fitting and EI required additional consideration. Effective screening programs successfullyidentifyinfantswithpchl.programs in this study identified 24 infants with PCHL among live births, representing the lower end of the estimated incidence of PCHL of 0.1% to 0.3%. 1 When infants with unilateral and mild bilateral hearing loss are included, the estimated incidence of PCHL reaches 0.6%. 23 In the New York State UNHS demonstration project, the overall incidence of PCHL was 0.19%, nearly twice that observed in our study. 24 Our low rate of PCHL suggests that additional infants with PCHL were missed during the processes of screening and diagnostic follow-up. We observed a very low rate of referral at 2 hospitals using a 1-step screening PEDIATRICS Volume 129, Number 1, January

6 TABLE 4 Risk Factors for Diagnostic Follow-up at 3 and 6 Months Corrected Age Variable Total Follow-Up at 3 Months Follow-up at 6 Months protocol. This finding raised concerns regarding false-negative screening results, as infants who passed after multiple failed screening attempts were not referred for diagnostic testing. The impact of repeated screening attempts could be significant. Johnson et al 25 foundthatupto23%ofinfantswhopass AABR testing after previous failed N % n %N RR 95% CI n %N RR 95% CI Total referred Gender Female Reference Reference Male Nursery level I Reference Reference IIIA IIIB* Insurance status Private Reference Reference Public (Medicaid)* Laterality of referral Unilateral Reference Reference Bilateral Distance from home to follow-up Within 25 miles Reference Reference.25 miles Risk factor for hearing loss No Reference Reference Yes RR, relative risk. *P,.05 at 3 and 6 months. attempts with otoacoustic emissions had PCHL loss at 9 months of age. Screening protocols typically set a limit of 2 screening attempts due to an increasing probability that infants with PCHL will pass by chance alone after repeated attempts. 5 Our efforts resulted in a screening protocol change at these hospitals to require referral for diagnostic testing after 2 failed AABR tests. No hospital achieved.90% follow-up for diagnostic testing by 3 months, as recommended by JCIH guidelines. Our overall rate of 3-month follow-up (61.3%) and range between hospitals (50.5% 80.2%) is consistent with reported rates from UNHS programs nationwide. 10,11 A single hospital (hospital 1) had the majority of referrals, highest proportion of infants with risk factors for hearing loss, and the lowest rates of follow-up for diagnostic testing. This facility had the only level IIIB nursery and the highest proportion of infants with Medicaid, variables associated with loss to follow-up in this study. In feedback sessions, clinical teams identified the inability to contact families after discharge as a contributing factor to loss to follow-up. Problems arose from infant name changes, inactivation of telephone accounts, and lack of a known pediatrician. Establishing reliable contact information and known pediatrician before hospital discharge is cited as a major area for improvement in UNHS programs. 11,26 Two hospitals changed the referral process to include a facsimile of the mother s TABLE 5 Summary of Recommendations From Multidisciplinary Meetings to Discuss Quality Indicators and Improvement Opportunities Quality Indicator Improvement Opportunity Hospitals Problem Identified Change Idea Immediately Actionable? Referral Diagnostic testing Child-Find Services Hearing aid fitting EI Very low rates of referral for diagnostic testing Low rate of follow-up for diagnostic testing Missed referrals to EI Child-Find officer at 75 d of life Unable to determine quality indicators for hearing aid fitting Unable to determine quality indicators for EI enrollment 3 and 4 Potential false-negative screening results 1 and 2 Inability to contact families after discharge due to incomplete or incorrect contact information All All All Inconsistent protocol for making EI Child-Find referrals Unclear records of hearing aid eligibility Lack of signed parental consent to review EI records Limit AABR screening to 2 attempts Include facsimile of both mother s and infant s contact information page with referral for diagnostic testing Clarify responsibility for making EI Child-Find referrals, and standardize tracking protocol Develop clinical pathway with prospective documentation of hearing aid eligibility Prospectively obtain consent to review EI enrollment status at time of EI referral Yes; screening policy changed Yes; referral policy changed to include mother s contact information page with other referral documents Yes; meeting attendees agreed on persons responsible for tracking infants and a protocol for making EI Child-Find referrals No; required more complex system changes and endorsement of others not in attendance at the meeting No; required consultation with multiple county EI officers to clarify necessary consent documentation 6 DEEM et al

7 QUALITY REPORT demographic information along with the infant s demographic information and screening results at the time of referral for outpatient audiological testing. This system change represented a simple low-cost intervention to improve the reliability of contact information. We foundthatthe likelihoodofanyfollowup rapidly diminishes after 3 months of age (Fig 2). We also observed significantly higher rates of follow-up among infants referred to EI Child Find services. EI Child Find referral should be a standard procedure for all infants who cannot be reached for follow-up by 75 days of life. In multidisciplinary discussions, we found that ownership of making EI Child Find referrals was unclear, resulting in inconsistent tracking of newborns who had failed screening. Recognition of this problem led to clarification of processes used at each hospital for infant tracking and referral to EI Child Find services. Infants with risk factors for PCHL and infants who fail screening bilaterally are more likely to have PCHL, 5 yet these infants were no more likely to be followed up than infants without these factors. This finding suggests that an additional opportunity exists to target these infants for improved family education and coordination with the medical home to emphasize timely diagnostic follow-up. Effective UNHS programs also facilitate timely delivery of EI services. JCIH guidelines recommend hearing aid fitting within 1 month of PCHL diagnosis and enrollment in EI services by 6 months of age. 5 Due to lack of documentation, our assessment of quality indicators for hearing aid fitting and EI enrollment was limited. Prospective documentation of hearing aid eligibility and family wishes for hearing amplification will help audiology centers and otolaryngologists better understand when amplification should be aggressively pursued. This study is limited by its retrospective approach to calculation of quality indicators, which was insufficient for determining indicators for EI. A more practical approachwouldinvolvecollectionofunhs data through a statewide data management system, routine analysis of these data by a state EHDI program, and regular feedback of quality indicators to EHDI coordinators at individual hospitals for use in continuous quality improvement. National EHDI goals, developed by the Centers for Disease Control and Prevention, recommend that each state establish a complete EHDI tracking and surveillance system that will minimize loss to follow-up. 27 New York recently passed state legislation to allow linkage of individual newborn hearing screening results to the statewide immunization information system. 20 This process will allow providers to use a central resource to report and track the hearing screening results of individual patients. It also may facilitate UNHS system improvement through feedback of quality indicator data to UNHS team leaders at the local level. Interventions selected for immediate intervention were generally policy changes, which have been criticized as weak interventions. 28 We feel that these policies are likely to be instituted as they were designed by clinical teams responding to their own challenges rather than by external bodies. 29 Our ongoing tracking efforts use established signal detection methods to determine whether these changes in policy result in improvements in clinical practice. 30 As the interventions are simple, endorsed by teams, and will be tracked, our hope is that early successes will engage teams in planning stronger actions. Multidisciplinary meetings did not include several important stakeholders: parents of infants with PCHL, pediatricians, and county EI officers. Inclusion of these groups may reveal additional solutions to challenges uncovered by UNHS quality measurement. The quality indicators and improvement opportunities we report represent the beginning of a quality improvement process. Ongoing measurement of quality indicators is required to determine whether interventions represent an improvement and to ensure that improvements are sustained. Hospitals and audiology centers plan semiannual meetings to review quality indicators and make additional changes. CONCLUSIONS A 2-year retrospective review of UNHS records was sufficient to measure quality indicators for hearing screening, referral, and diagnostic testing but was not adequate to measure quality indicators for EI. Our analysis revealed unwarranted variation in 4 UNHS programs serving the same geographic population. Site visits and our multivariate analysis gave us insight into sources of this variation. Feedback of our observations and quality indicator data identified multiple improvement opportunities and interventions that were endorsed for immediate implementation at each hospital. This study represents a data-driven approach to starting a quality improvement protocol that can be used by any UNHS program. Continued monitoring of quality indicators is needed to determine whether changes result in system improvement and to ensure that improvements are sustained over time. ACKNOWLEDGMENTS The authors thank the Buffalo Hearing and Speech Center, Robert Warner Rehabilitation Center, Kaleida Health System, and Buffalo Catholic Health System for their collaboration with this study. PEDIATRICS Volume 129, Number 1, January

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9 Identifying Quality Improvement Opportunities in a Universal Newborn Hearing Screening Program Kenneth C. Deem, Ernesto A. Diaz-Ordaz and Brian Shiner Pediatrics; originally published online December 12, 2011; DOI: /peds Updated Information & Services Citations Permissions & Licensing Reprints including high resolution figures, can be found at: /content/early/2011/12/07/peds This article has been cited by 2 HighWire-hosted articles: /content/early/2011/12/07/peds #related-urls Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/permissions.xhtml Information about ordering reprints can be found online: /site/misc/reprints.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN:

10 Identifying Quality Improvement Opportunities in a Universal Newborn Hearing Screening Program Kenneth C. Deem, Ernesto A. Diaz-Ordaz and Brian Shiner Pediatrics; originally published online December 12, 2011; DOI: /peds The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/early/2011/12/07/peds PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN: