Volume 2024 | No. 2
SURVEYOR
SLEEP
SLC6-1D Overview of the requirement:
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT SLC6-1A
The organization writes a comprehensive annual performance improvement report. Data for the report is obtained from a variety of sources and methods. Surveyors review the annual PI report to assess compliance. Most deficiencies were cited due to incomplete or missing annual summaries.
Overview of the requirement:
The organization develops and maintains an ongoing organization-wide Performance Improvement Program that measures, analyzes, and tracks quality indicators. Analysis of data enables the SLC to assess processes of care, services and operations. PI activities are summarized and shared at least biannually. Compliance is evaluated based on response to interviews and review of policies, procedures, and performance improvement reports. The standard was repeatedly cited due to lack of annual clinical competencies, as well as other missing aspects of measurement.
Comment on deficiencies:
Frequency of citation:
17%
Examples of surveyor findings:
n The organization does have a PI program in place. However, no written annual PI summaries have been completed. n The organization’s written annual summary did not include: Description of the PI activities. ٝ Activity findings. Corrective actions that relate to the care/service provided. n Develop a comprehensive, written annual PI report that describes the selected and required activities, findings, and plans of correction as indicated. n The final annual report is a single document, but improvement activities must be conducted at various times during the year. Use your dedicated monthly/ quarterly PI audits and findings to identify trends and opportunities for further improvement. n Develop an internal plan of correction that includes a process to ensure the written PI summary is completed annually for all indicators. n If using a contracted agency to provide sleep studies or sleep technicians, ensure that services provided by the agency are monitored as part of the PI program and summarized in the annual PI report. Have all parties work together to develop and document the annual written PI report that outlines all PI activities.
Comment on deficiencies:
Frequency of citation:
23%
Examples of surveyor findings:
n The organizations written biannual summary does not include: Annual clinical competency of the personnel administering sleep testing. Satisfaction surveys. Adverse events. Client/patient complaints. Client/patient records. Monitoring of time frames from the time of study to the time the information is sent back to the referring physician. Ongoing monitoring of scoring reliability and consistency (including manual and computer assisted) between the sleep technicians (clinical personnel) and the medical director. At least one important aspect of care/service provided. n Upon interview it was indicated that the governing body does not receive reports regarding the PI Program. n The PI plan did not include descriptions of methods used to collect and review data. n Ensure that the written biannual summary addresses all PI activities required by standard and that the report is provided to the governing body/owner. n Define methods used to collect and review data, including: Current documentation (e.g., review of client/patient records, incident reports, satisfaction surveys). Client/patient care/services. Direct observation in care/service setting. Interviews with clients/patients and/or personnel. n Develop an internal auditing process to ensure ongoing compliance. Avoid unnecessary stress right before the survey and reach out to ACHC throughout your accreditation cycle. Ask your Account Advisor about our PI tools and resources. Remember that performance improvement is more than just a requirement; it’s beneficial to your organization’s growth.
Tips for compliance:
Tips for compliance:
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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