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.