Inside Sleep

Diagnostic Sleep Lab Accreditation

Simplified Measures Lead to Operational Excellence

• By Sandra Canally
• Jan 01, 2010

For accreditation to truly serve the public good and to be of any particular value to patients and their loved ones, by its very nature it must be comprehensive. However, for accreditation to be readily implemented by any and all provider groups who serve within today’s wide-ranging healthcare delivery sectors, it also needs to be a simplified, straightforward process. I believe that healthcare accreditation can serve as a streamlined continuous quality improvement regime as well as a comprehensive, real-time review of a provider’s overall performance.

Establishing Quality Standards

An accreditation program should provide a comprehensive set of service and product specific quality standards that are written in layman’s terms. In addition, since every business, including hospital and stand-alone sleep labs, is unique in certain ways, a team advisor is especially helpful in guiding each business through the implementation process. Such an advisor, along with access to the accrediting company’s online resources, can preclude the necessity for the business to hire a consultant.

Quality standards for a sleep lab can be divided into a series of categories that include administration, corporate compliance, billing, human resources, quality improvement, risk management, equipment management, patient services, polysomnographic protocols and government regulatory requirements. Administration standards address leadership and ownership responsibilities, confidentiality and financial management as well as business functions specific to a sleep lab’s scope of services.

To receive accreditation, sleep labs should be prepared with a corporate compliance plan. This involves designating a compliance officer and setting in place policies that mirror OIG “fraud and abuse awareness” measures that include specific standards of conduct. Billing standards should mandate that all billing practices comply with Medicare, Medicaid and all private insurers guidelines.

Human resources is a difficult area for most businesses because of the need for continuous compliance. The provider organization must have written human resources policies and procedures that specify a medical director’s qualifications, training and experience as well as his/her continuing education requirements. Such requirements must be consistent with the specialized equipment, items, and services that they and the sleep lab provide to Medicare/Medicaid/private payer beneficiaries. The organization also needs a mechanism in place to monitor the staff’s orientation and ongoing training, in addition to required continuing education credits as it relates to the license or certification of the employee (i.e., CMEs/CECs/CEUs)

Upholding Quality

Quality improvement is a continuous process. Each organization should have a documented “quality improvement plan” that includes yearly goals, monitoring of company measures and a way to process complaints. Patient satisfaction and dissatisfaction are also key factors in quality improvement measurement.

Patient services is a key area in assuring compliance with standards for safety, honesty and caring. Sleep labs should have an organized “admission” process and forms that describe patient preparation for sleep evaluation and study. In addition, Pre Sleep Questionnaires should include Pediatric, Epworth Sleepiness Scale and Beck Scale are used, and Electrode/Sensor Placement.

Patient education is a key component of accreditation requirements. Sleep labs seeking to achieve and maintain accreditationworthy quality need to demonstrate that they provide specific preparatory directions to each patient prior to the sleep study.We suggest a review of the sleep study procedure with each patient prior to the study. Common elements include a review of such things as sleep study protocols; use of PAP Therapy; use of oxygen to include portable monitoring; goals to be achieved with the study; and review of instructional videos.

It is critically important that a provider organization verifies whether their patients understand the sleep study protocols prior to starting the testing phase.We believe that patients who require continued medical management after the study must be offered follow-up consultation by a physician with demonstrated capability and experience in diagnosing and managing a full range of sleep disorders, either directly through the facility or by referral. All other patients should receive a survey to determine the patient’s level of satisfaction with the services provided.

Onsite Evaluations

Onsite evaluations are a crucial part of ensuring that organizations maintain their established standards. When we conduct an onsite evaluation of a sleep lab, we spend a great deal of time on validation of staff competences and patient services policies and procedures, as well as sleep study protocols.

Areas of focus include the physical testing location, security, policies that reference the protocol for set-up, performance, scoring and follow-up for each type of test performed. It also includes emergency management (EM), such as responding to patient emergencies within the facility. Such types of emergencies might include cardiac, neurological (specifically seizure), psychiatric (specifically suicidal ideation), fire, belligerent patients, bomb threat, etc. EM plans need to include a mechanism for contacting emergency services/staff, contacting sleep lab staff and specific responsibilities of technical staff. Equipment management and infection control are evaluated as they relate to the equipment used during the testing.

Government regulatory quality standards focus on licensing as required by the state as well as OSHA requirements regarding blood borne pathogens, tuberculosis, “right to know,” fire safety, proper lifting and emergency preparedness.

This article originally appeared in the Respiratory & Sleep Management January 2010 issue of HME Business.