When embarking on the accreditation process, it’s crucial to select an organization that meets the specific needs of your facility.
By Lori Sichtermann
It goes without saying that every sleep center across the country strives to give patients the best quality in care using the most advanced technology and research capabilities. One of the paths to demonstrate this drive is to acquire accreditation from a board-certified accreditation organization (AO).
Sleep Review polled the leading AOs regarding the process of acquiring certification. Their feedback included tips on where to begin, what to avoid, and the importance of knowing a facility’s limitations. The replies featured seven similarities of theme. Keep these seven tips handy for when you start your search.
1. A facility should accurately evaluate its needs before approaching an AO. According to the leading AOs, the first step to conquer is to do a thorough evaluation of the facility’s actions, capabilities, and specialties.
“Take a close look at what your facility is doing day-to-day and make sure you have the policies and procedures in place that reflect compliance with the AO’s standards,” notes Michael Dye, senior assistant director of The Joint Commission. “Issues such as environment of care, national patient safety goals, performance improvement, medication management, record of care, and treatment services are all areas that sleep centers utilize differently. It’s important to fully understand how your facility works and how that aligns with accreditation standards.”
2. Be aware that the accreditation process takes time…a lot of time. “Too many facilities go into the process thinking they can just submit an application and it’ll be quick and easy; but that’s not really how it works,” comments Melissa Clark, director of accreditation for the American Academy of Sleep Medicine. “Facilities really need to take the time to become familiar with the entire accreditation process and understand that it requires time and effort on their part.”
3. Learn your options: What services are available from the various AOs? “Review the quality standards from all accreditors prior to choosing your AO,” says Sandra Canally, president of The Compliance Team. “Understanding an AO’s standards without needing to hire an interpreter is important. A provider should not need to take more than 4 hours a week to implement the requirements of their accreditation.”
4. Choose an AO that offers clear verbiage regarding costs. “How much is this going to cost is always our number-one question,” Dye says. “This is understandably a top concern for any type of sleep facility—large or small. We have a nice, simple answer, and we are extremely transparent when it comes to pricing. Facilities should consider the transparency of pricing before embarking on the process.”
To this point, Steve DeGenaro, RRT, director of survey services for the Healthcare Quality Association on Accreditation, suggests providers evaluate AOs based on what value-added options are included in the cost. “Accreditation standards should be focused on actual sleep lab processes with the goal of supporting the facility to operationalize the standards in the hopes of continuous improvement,” he says. “One should look at how long the accreditation award is given for and if there are any costs associated within that award period.”
5. You’re going to have questions, so consider the AO’s response to your concerns. “It’s important to know if your facility’s operational model is outside the regularities of what the AO is accustomed to surveying, can the AO adapt?” asks Canally.
She also notes the importance of asking what kind of support the facility is going to receive from the AO during the preparation time. For example, The Compliance Team employs call advisors who walk providers through the standards, one-by-one, throughout a series of orientation conference calls.
6. Gauge the differences in evaluation procedures. According to Dye, a lot of what distinguishes AOs is the way they perform the survey process. “We are very much a boots-on-the-ground organization,” he says. “Roughly 80% of our survey process is walking around the facility, talking with staff, patients, and family members of patients. From the moment we walk in the door to the time we leave, we’re looking to see how the facility operates.”
Whether an AO surveys a sleep study is something to consider as well. “[The Joint Commission] is comprehensive in how we go about its accreditation process,” Dye explains. “Our surveyors arrive early in the afternoon and stay into the evening to observe a sleep study. The surveyors then return early the next morning to observe the discharge of the patient. We see how the patient is managed through the continuum of care.”
7. Budget your resources to accommodate for the commitment. “Each applicant has to know its limits,” Clark says. “Often, a sleep center may not have adequate staff to handle both the implementation of the accreditation requirements and the day-to-day business operations. This is why it is so important to choose an AO that aligns with your business.”
To budget the resources, Dye suggests providers allot 4 to 6 months from the date the application is submitted to the time of the scheduled visit from an AO. “This gives a facility ample enough time to breathe and be prepared for when the surveyor arrives.”
The field of sleep medicine is a progressive industry. And, as it continues to evolve, so will the standards and procedures for becoming accredited. With so many moving parts, the process of becoming accredited may seem overwhelming. But, as Canally explains, when you take a step or two back, the process has a simplistic core: “The Compliance Team’s quality standards focus on three simple ideals: safety, honesty, and caring. If a provider excels in those three ideals, what else really matters?”
As an exclusive to Sleep Review readers, the country’s leading AOs provide insight on questions to ask when deciding on the ideal accreditor. Additionally, click here to learn about the Five Misconceptions About Accreditation.
Lori Sichtermann is associate editor of Sleep Review. She can be reached at [email protected].