by Ahnna Parker
Accreditation Advisor
Sound sleep is an imperative in achieving and maintaining good health. Yet, according to the National Sleep Foundation, between 50 and 70 million Americans experience some sort of sleep or wakefulness disorder. Because of these statistics, sleep medicine is a growing specialty area and in high demand. Patient care in this area is not a new service line for hospitals but it is an expanding one.
Preparing your sleep center for accreditation is a significant undertaking, whether it’s hospital-based or independent. In this blog post, we share some guidance to help your sleep center prepare for regulatory and accreditation oversight and improve patient safety and quality outcomes.
Put patient, staff and environmental safety first
Security and emergency measures: Your center should have measures in place for staff to request in-house security assistance for in-hospital sleep centers or police assistance at stand-alone facilities. Ensure staff have access to a lockable safe room where they can retreat to summon help. Stand-alone centers must have emergency management plans customized to their facility. Hospital-based sleep center plans should be included in the hospital emergency management plan. Be sure policies cover protocols for cancelling patients and patient management during emergencies, including weather emergencies, loss of electricity and active shooter. Emergency operations policies should include who makes decisions, how and when they are made.
Environment of care: Ensure your center has patient rooms large enough to accommodate a caregiver for patients who are not independent. Emergency equipment must be available and maintained per state and organizational policy. If your center is stand-alone, it must meet health care occupancy standards and have health care grade equipment. Make sure fire extinguishers are readily available and their tags reflect mandatory annual and monthly checks. Follow all Joint Commission standards related to fire safety and environment of care.
Equipment maintenance: Equipment in the facility should be inventoried to the medical equipment list and have preventive maintenance documented and routine cleaning performed as per manufacturers’ instructions for use. All exits must have battery-powered emergency lights and documentation must show that the exit lights are checked monthly and annually. If oxygen cylinders are used, they should be secured, labeled and stored properly. (Reference Joint Commission Standards in the following chapters: Environment of Care, Emergency Management, and Life Safety (as applicable).
Physician credentialing and privileging
Since 2018, the Centers for Medicare and Medicaid Services (CMS) has required physicians who interpret sleep studies to be board-certified in sleep medicine. Specifically, before granting initial or revised privileges to physicians responsible for interpreting sleep studies, physicians must have at least one of the following qualifications:
- Certification in sleep medicine by the American Board of Sleep Medicine (ABSM) or by a member board of either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
- A completed fellowship in sleep medicine through an Accreditation Council for Graduate Medical Education-accredited program. Following the completed fellowship, certification in sleep medicine must be completed within two examination cycles through the ABSM or a member board of either the ABMS or the AOA.
Staff competency
The organization determines the level of training required for sleep technicians based on state regulations. Ensure up-to-date job descriptions for sleep technicians have been developed and put in place. Additionally, your sleep center should have a comprehensive training and education policy. Cover and document the following topics in each employee’s personnel file:
- General safety and patient management orientation
- Staffing ratios, including amended ratios for special needs patients
- Evidence of training (provided by someone with appropriate education and experience in the field of sleep medicine) in how to administer various tests and follow protocols
- Policies outlining when sleep techs should call the house supervisor, rapid response team and/or physician for real-time guidance in managing clinical emergencies, including EKG arrhythmias
- Education on identifying EKG arrhythmias
- Training on managing other patient medical emergencies
- Training on how and when to report critical value findings
- Ongoing safety, infection control and sleep study education
Infection prevention and control practices
Sleep centers must follow national infection prevention and control guidelines and manufacturer’s instructions for proper cleaning of equipment.
In-lab sleep testing: Follow manufacturer recommendations for cleaning any reusable equipment and CPAP/BiPAP humidifier filter changes.
Ensure policies are in place to guide actions for patients identified as having diseases spread by contact (such as lice or scabies) or open wounds. How are linens and pillows cleaned and stored? How is infection prevention and control surveillance performed and integrated into the organization’s infection control plan?
Home sleep study testing: Your sleep center should have a system for reprocessing home testing equipment after each use and documenting preventive maintenance. Practices must comply with manufacturer recommendations for proper cleaning.
Ongoing performance improvement activities
Your sleep center should develop and integrate performance improvement into the hospital’s organization-wide performance improvement plan. Consider how you will define and communicate critical values, such as dangerous apneic episodes that occur during patient testing. Are phone calls and documentation surrounding critical values monitored and tracked? Are turn-around times of patient reports monitored to ensure compliance with organization policy?
Medical staff should identify and ensure compliance of focused professional practice evaluation (FPPE), such as regular peer reviews etc., and ongoing professional practice evaluation (OPPE) as it applies to physicians interpreting sleep studies. Identify how quality measures, such as the accuracy, completion and timeliness of patient reports, are linked to re-credentialing of these physicians, which is every two years in most states.
Advance preparation for accreditation is key
Going through an accreditation or re-accreditation process is difficult. Sleep centers must have detailed, comprehensive policies and procedures in place for the following areas, including clinical oversight, handling medical emergencies, equipment maintenance and more. Your sleep center must demonstrate compliance with policies and procedures and show that physician and staff credentials are current and complete. You must also have an active quality improvement program.
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