Improving follow-up after newborn hearing screening An action kit for audiologists

About this Action Kit

This Action Kit is designed to help audiology practices provide reliable follow-up care after newborn hearing screening.  Providers participating in a series of national collaboratives developed the ideas and tested the improvement strategies that have led to the promising practices in this kit.  It is designed to help providers create an efficient and reliable system of diagnosis and referral and ultimately improve outcomes for infants who are deaf or hard of hearing and their families.

Formal research has not yet validated these ideas, and this resource does not represent all possible ideas for improvement within each area. This Action Kit does represent promising improvement strategies that have been shown to be effective in audiology practices throughout the United States.

Download the complete PDF version of the Improving Follow-up after Newborn Hearing Screening action kit

Hearing loss is one of the most frequent birth defects in the United States.  Early diagnosis and intervention improves language, social communication, and academic performance.  The importance of family involvement in supporting the best outcomes cannot be understated.

Every state and territory in the United States has an Early Hearing Detection and Intervention (EHDI) program that is responsible for ensuring that all newborns are screened for hearing loss; that infants who do not pass the hearing screen receive appropriate audiological diagnostic assessment; and that timely and appropriate early intervention services are available for all infants and young children diagnosed as deaf or hard of hearing.  In 2000, the Joint Committee on Infant Hearing (JCIH) set national standards related to EHDI, with the goal of optimizing outcomes for infants who are deaf or hard of hearing.

These standards include: completion of screening before 1 month of age, obtaining a diagnostic evaluation before 3 months of age and beginning early intervention before 6 months of age.  In the past decade, the U.S. has made impressive progress in the first step in this process, with screening rates increasing from 47% in 1999 to 96.6% in 2012.  However, the two critical follow-up steps of diagnosis and entry into early intervention are not happening at the same level of reliability as the initial screening.  The 2013 data from the Centers for Disease Control and Prevention (CDC) indicates that 32% of the babies that “refer” after hearing screening do not have a documented hearing status, and that 37% of babies diagnosed with hearing loss are not documented as having entered intervention services.

The net result is that the majority of babies who do not pass their hearing screening may not be receiving proper follow-up or intervention services.  Implementing timely and reliable systems for these critical follow-up steps will improve providers’ capacity to meet the national standards for early diagnosis and entry into appropriate intervention, and ultimately improve outcomes for children with hearing loss.  Furthermore, improving this system will affect the overall experience for families and infants, ensuring infants get the care they need through a family-centered approach.

Between 2006-2013, the National Institute for Children’s Health Quality (NICHQ) partnered with the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) to engage state EHDI programs in five learning collaboratives designed to help EHDI programs better meet their program goals of screening, diagnosis and intervention by 1, 3 and 6 months, respectively. 

Participating teams, which included 49 states and 3 territories, employed quality improvement (QI) methods to test and implement changes to improve the quality and timeliness of follow-up care to newborns with hearing loss. In 2013, MCHB asked the National Center for Hearing Assessment and Management (NCHAM) to continue to provide technical assistance to states implementing QI methods in an effort to reduce loss to follow-up. NCHAM has contributed funds to put the action kit online and provides support to keep the kit up to date.

The past years of focus on QI in EHDI Programs has identified promising change strategies for system improvement and helped states improve data collection and reporting, engage parents, and reduce loss to follow-up and documentation.


NICHQ (National Institute for Children’s Health Quality) is an independent, nonprofit organization working for nearly two decades to improve children’s health.  NICHQ helps organizations and professionals who share this mission make breakthrough improvements so children and families can live healthier lives.


NCHAM (National Center for Hearing Assessment and Management) serves as the National Resource Center for the implementation and improvement of comprehensive and effective EHDI programs. 

What Is a Learning Collaborative?

A learning collaborative is a quality improvement approach in which teams from diverse organizations come together to accomplish a shared objective – in this case to improve follow-up after newborn hearing screening.  Teams work together over a period of time to learn how to test changes within their system on a small scale.  Each team collects and reports data on a monthly basis throughout the collaborative to track improvement and identify successful change strategies that can then be spread more widely.  Learning is accelerated as the collaborative teams work together and share their experiences through regular calls and in-person meetings.