Volume 2024 | No. 2
SURVEYOR
SLEEP FROM THE PROGRAM DIRECTOR
Whether your organization conducts sleep testing in the lab, at home, or both, ACHC is proud to be an active participant in your success. As the industry grows and technology changes, we’re keeping a close eye on the regulatory response. Our standards remain flexible enough to accommodate both LCD requirements and your individual business model, without sacrificing integrity and quality of care. Sleep Results Only two standards were cited at a frequency above 20%, indicating that ACHC-accredited providers have once again raised the bar for excellence. However, a few individual standards have become increasingly noncompliant over time, particularly when it comes to gaps in documentation and recordkeeping. SLC5-1A was most frequently cited at 34%, mostly due to missing elements in the client/patient record. Providers should pay close attention to the requirement for sleep study questionnaires. The easiest, most effective way to combat this deficiency is to institute a checklist, conduct periodic audits, and include measurement of complete records in your Performance Improvement Program. Three of the six highlighted standards have experienced a dramatic increase in findings over the past three years: SLC2-4B was cited at 8% in 2021 and is now at 20%. SLC4-6D has grown from 6% to 15% in frequency. SLC 6-1D was once 9% and is now 17%. While we hope that analysis will always show that fewer than 20% of organizations seeking accreditation for sleep services, this trend is troubling. The cohort surveyed in the period covered by this report includes many organizations that were also surveyed three years ago. That means compliance has declined for these sleep labs. I hope this report will spur all ACHC customers to look again at the requirements and rededicate themselves to meeting the standards.
Surveyor comments repeatedly noted failure to implement consistent recordkeeping practices. At first glance, these look like small errors, but a deeper examination reveals a lack of organizational oversight. The inability to maintain accurate, complete documentation impacts adherence to healthcare regulations and, by extension, patient safety. Many providers correct documentation deficiencies during the survey and follow up by submitting a process to prevent recurrence. However, sustained and ongoing compliance is the real challenge. How are you ensuring compliance throughout your accreditation cycle? Resist the temptation to “quick fix” a systemic issue. Consider that this responsibility lies not just with one person, or one team; prioritize standardized recordkeeping processes at all levels of your organization. A New Chapter As you may know, my tenure as the Program Director of the Sleep Program is drawing to a close. The landscape of sleep testing has grown and changed over the years, but one thing has remained constant – my belief in the power of accreditation. To put it simply, accreditation makes your organization better. If your organization is better, other organizations will follow suit. And before you know it, the entire industry has improved. ACHC continues to evolve and ensure that the cycle continues. It has been my honor to assist organizations from single owner start-ups to corporate entities with hundreds of locations over the past 18 years. While I fully intend to enjoy my retirement, you may still see me from time to time. As always, please don’t hesitate to reach out to your account advisor with any questions.
SLEEP ACCREDITATION
Services
Sleep Lab/Sleep Center Services
Home Sleep Testing
FREQUENT DEFICIENCIES FROM SLEEP SURVEYS
60%
50%
40%
30%
20%
10%
0%
SLC2-4B
SLC3-4A
SLC4-6D
SLC5-1A
SLC6-1A
SLC6-1D
Tim Safley, MBA, RRT, RCP Program Director
Fiscal Management
Program/Service Operations
Human Resource Management
Provision of Care and Record Management
Quality Outcomes/ Performance Improvement
achc.org | (855) 937-2242 | 5
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