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Four sleep accreditation questions answered.

Accreditation of your sleep disorders center or laboratory is the gold standard to provide evidence that practice standards are being followed. A successful survey by the American Academy of Sleep Medicine or the JCAHO provides your organization with a patient centered process that fits the needs of your organization while focusing on quality patient care.


I interviewed Kathryn Hansen, Accreditation Specialist, with the Sleep Center Management Institute, who has many years of accreditation experience. Here are the answers to the accreditation questions I am most frequently asked.

Why should I seek accreditation of my program?

There are a number of benefits, which are obtained through completing accreditation of your sleep facility. Successfully completing the survey provides the leverage you need to gain access to managed care contracts. It is a peer review process recognized by insurers and other third parties. It demonstrates to patients that your program meets standards for quality of care of sleep disorders patients and demonstrates to patients that you have gone the extra step to ensure a safe, secure, patient-first environment. Accreditation helps establish credibility in a competitive healthcare market. It provides proof to state and federal agencies that you have met the nation's highest standards for healthcare.

How will accreditation impact reimbursements to the facility?

In 2003, an insurance company in California began offering bonuses to medical groups who met or exceeded targets for clinical and service quality. This type of pay for performance program is designed to reward both performance and improvement through incentive programs that draw on evidence and best practices, which are incorporated into your program. Pay for performance has significant potential to improve the performance of a program and provide bonus payments for quality.

What are some of the changes recently published by the American Academy of Sleep Medicine in accreditation standards?

In June, 2008 revisions in the accreditation standards were adopted by the AASM. It reduced the number of standards to meet and changed the numeric rating of 1 to 5 to a simple "Meets Standards" or "Does Not Meet Standard." Some of the key changes are provided here for review:

* Each center must have as a medical director a doctor with a license valid in the state of the center and in all states in which patients are seen.

* Each center must have a Diplomate of the American Board of Sleep Medicine (D ABSM) on staff, or an individual who has been accepted by the ABSM to sit for its certification exam and must perform duties on site.

* The center must maintain a staff of appropriately trained and supervised technicians working under direct supervision of the Medical Director.

* Technician staffing must be adequate for the safety of the patients working a maximum patient to tech ratio of 2:1 under usual circumstances for attended PSG.

* Referral policies and procedures for effective patient evaluation must be present and information is required from the referral source. For directly referred patients the medical director or designated center staff physician must review clinical information to determine if testing is appropriate.

* Patient testing rooms must provide privacy, safety, and accessibility to allow for effective data acquisition generally having a minimum of 140 square feet and no dimension less than 10 feet. Clean bathrooms must be available and conveniently located within the center. At least one bedroom and bathroom must be handicap accessible.

* The control room must be adequate in size, design, location and comfort to allow for effective function and comfort of technologists.

* The interpreting MD or a D ABSM must review the entire raw data recording for every patient having a sleep study.

* The center demonstrates the ability to manage a full range of sleep disorders and have available, effective treatments for these sleep disorders. Appropriate follow-up for patients who require continued management must be offered. It is important to provide documentation of the follow-up visit defining the outcome of the treatment plan. For terminology and diagnosis the Center must use the most recent diagnostic and classification manual of the AASM.

* The center's professional and technical staff must each participate in an average of 10 CME or CME-equivalent sleep related educational activities over a three year period. This CME must be documented for each staff member.

* The quality assurance program must address inter-scorer reliability with the D ABSM based on epoch comparisons and at least three other quality assurance indicators.

The site visit of a new accreditation and re-accreditation no longer requires an overnight stay and concludes with an exit interview to discuss a summary of findings in the early afternoon. Within three months the final notification usually occurs and accreditation is retroactive to the date of the site visit, if accreditation status is granted.

What standards do I need to address for accreditation with the Joint Commission?

Accreditation by the Joint Commission is divided into two sections: patient-focused functions and organization functions. These standards cover assessment, treatment and follow-up care, medication management use and monitoring for effectiveness, processes in place to reduce the risk of infections, and measures of performance improvement of the environment of care, the clinical process, and clinical outcomes. The initial survey of your program will take two days during which a detail review of quality, environmental, and leadership activities are completed.

For additional information contact the AASM at

by Duane Johnson PhD
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Author:Johnson, Duane
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Article Type:Interview
Date:Jun 22, 2011
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