Volume 2025 | No. 2
SURVEYOR
SLEEP
■ The PI summary doesn’t document data collection related to complaints, adverse events, or client/ patient records. ■ The organization has not completed a semiannual (twice a year) PI summary in the past two years. ■ The PI summary did reflect ongoing monitoring of scoring reliability and consistency (including manual and computer assisted) between the sleep technicians (clinical personnel) and the medical director. Compliance tips for: Nerd Newbies (understand the requirement) The goal of the standard is for the organization to establish a meaningful Performance Improvement Program that uses data to evaluate the quality of its care, services, and operations. The required elements of the standard provide guidance on specific areas to use for data collection and measurement.
Compliance tips for:
One goal of this standard is to ensure continuity of care. Documentation of initial referrals, medications, Epworth score, testing methodology and device used, technician notes, and the patient’s response to treatment must be complete and traceable at a level of specificity that makes all relevant information accessible to the interpreting physician and to any subsequent provider.
Nerd Newbies (understand the requirement)
■ Audit for complete patient records.
Nerd Apprentices (audit for excellence)
ٝ Check for signatures, credentials, and dates associated with each entry.
■ When audits reveal missing documentation, continue to an analysis. ٝ Are errors specific to a particular required element? If so, create checklists. ٝ To individuals providing care/services? If so, plan focused training sessions. ٝ If your organization uses electronic records, ensure that credentials are automatically associated with electronic provider signatures.
Nerd Trailblazers (prepare the path for others)
■ Audit data collection activities to ensure that each required element is addressed. The intent of the semiannual report is to ensure that an analysis of the data is performed at least twice a year. ■ Build a checklist to support data collection and development of the semiannual PI report. ■ Review past PI reports to establish internal benchmarks. These become your metric to identify opportunities for improvement.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT SLC6-1A Frequency of the citation: 20% Overview of the requirement: Each sleep lab must develop a Performance Improvement (PI) Program that measures, analyzes, and tracks quality indicators to assess its processes and outcomes. Comment on deficiencies: Compliance is assessed through review of policies and procedures, PI reports, and response to interviews. Deficiencies noted that required categories of data are omitted from semiannual summary reports. Examples of ACHC Surveyor findings: ■ The organization does not have a written PI Program. There is no description of the data collected by the organization for self-assessment. ■ The semiannual PI summary did not document data collections for: 1. Annual clinical competency of the personnel administering sleep testing 2. Monitoring the time frames from the study to the time the information is sent to the referring physician.
SLC6-1D Frequency of the citation: 18%
Overview of the requirement: This standard requires an annual PI report that describes the activities, findings, and corrective actions taken to achieve measurable improvement in the sleep services provided. Comment on deficiencies: The annual Performance Improvement Report is the source of evidence for compliance. Deficiencies were cited for failure to develop an annual report. Examples of ACHC Surveyor findings: ■ The PI annual report did not address the improvement activities and corrective actions taken. ■ There were no annual PI reports for the past three years.
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