Budget cuts and tight deadlines can sometimes lead to cutting corners. Without even knowing it, many sleep labs may be participating in questionable practices when scoring patient studies. While the scoring of sleep studies largely rests in the hands of the scoring technologist, it is important for medical directors and laboratory managers to create processes, hiring and training practices, and documentation standards that promote a culture of responsibility. Evaluating common pitfalls helps lab managers recognize how a lab could potentially loosen its ethics in spite of contrary intentions.
SCORING DATA WHILE PATIENTS SLEEP
It may come as a surprise that sleep labs that permit (or even require) technologists to score while the patient sleeps are placing quality in jeopardy. The collection technologist’s purpose is to carefully oversee and ensure the quality of patient sleep data for the analysis stage and final diagnostic care. Some labs may expect the tech to score on the fly or in real time as the patient sleeps. Night techs who are scheduled for hookup and monitoring activities should focus on patient care and proper monitoring; divided attention is likely to impede both effective collections and subsequent accurate scoring.
The age-old question when it comes to scoring a sleep study is: How long does, or should, it take to complete? Some say an hour; others say no more than two. The reality is that there is no correct answer. A technologist should always score studies to meet current standards. Nuances such as montage, acquisition software, and reason for study can all impact the complexity associated with the time required for reliable outcomes. In light of this, quality scoring should never be rushed. Time restraints make cost-efficiency more of a priority than patient care and send the wrong message to staff members. Sleep scoring is a meticulous and intensive craft. Only ample time given to this important task can ensure accuracy, reliability, and consistency.
SENIORITY OVER SENSIBILITY
Regardless of seniority, quality assurance programs, peer review, and continuing education are key. Interscorer reliability and reviews are a must for any sleep lab. Ignorance about the changes in the industry simply invites bad habits.
Besides ensuring the qualifications of current staff, take care when hiring as well. While a potential candidate’s CV may indicate years of experience, many techs have worked as RPSGTs performing hookups for the majority of their careers without ever thoroughly scoring a sleep study. Training and retraining must become part of your quality assurance culture to maintain consistency across the board. Require potential employees to score a sample sleep study to see if they meet expectations before hiring.
ARTIFICIALLY INFLATED AHI ORDERS
Many sleep labs also operate as durable medical equipment (DME) providers. If a lab that provides DME is engaged in unethical scoring practices, it may encourage technologists to overscore SDB so CPAP can be prescribed. Having clear event definition in policies and procedures (for example, hypopneas versus RERAs) is a must, and in this situation will ensure consistency among a facility’s scoring techs. Should the target AHI not be met for therapeutic purposes, sound policies will provide a solid rationale for scoring outcomes.
Numerous sleep labs create scoring quotas for their technologists to meet on a daily basis. Such organizations likely believe these targets set a standard and provide a basis for employee performance reviews. Quotas for many sleep labs ensure reliable turnaround times of patient sleep studies. It is not unusual for these sleep labs to consider scoring quotas as part of a win-win situation. The technologist wins because they have a full understanding of what is required of them in a full workday. Management wins because they can ensure productivity levels remain measurable and a backlog of sleep studies can be avoided.
While on the surface scoring quotas look like smart business, they risk undermining quality assurance and patient care. Sleep labs that are mandating that a scoring tech score a certain number of tests per day are also forcing techs to score quickly, creating a competitive culture and work environment ripe for mistakes and oversights. This practice places additional stress, causing them to rush the entire process in order to meet their quotas. Sleep labs that use targets eventually risk losing sight of production improvement. Any quota should be backed with an active quality assurance program that tracks reliability and productivity and considers ongoing input for process improvement from techs.
SET AND FORGET: AUTOMATED SCORING
Sleep medicine is still very much a human-centered industry. With over 80 different sleep disorders, nothing comes close to replicating assessments made possible by real-life training and experience. Unfortunately, in some cases, automated scoring is not only the primary but the solitary mode of sleep analysis. These sleep labs are utilizing automatic software in the hopes it will increase productivity and cut costs. However, without appropriate application and use, this tool can lead to sliding skills in their technical team and possible misdiagnoses. Sleep labs need to understand the purpose of technology and ensure their techs are using these tools to complement their decision-making process. Whether as a primary or secondary resource, the keen eye of a registered technologist is essential for an accurate analysis of a patient study.
Like any other professional, a registered polysomnographic technologist takes pride in the letters that follow their name. Tested professionals are highly trained and have the specialized experience to ensure the highest rates of scoring accuracy. There are different credentialing organizations (ABSM, BRPT, NBRC) all requiring completion of continuing education in order to maintain their credentials. With this in mind, labs should consider their stance on mandatory technologist qualifications. Labs with technologists who are not currently registered should implement a skills upgrade program to encourage and facilitate the earning of a technologist’s designation to keep registered staff at the forefront of current knowledge and practices.
RAISING ETHICAL STANDARDS: COMMUNICATE AND TRAIN
Believe it or not, doubt can be a good thing. Educate staff, managers, and technologists alike to openly communicate about both their own and fellow colleagues’ scoring conduct. In a culture where apprehension is met with training and support, a true sense of team can be developed. In other words, ongoing training is necessary not only to upgrade scoring skills, but to habituate staff to voicing their trepidation. Such exercises should not be viewed as grounds for disciplinary action; rather, they should be seen as opportunities to learn from one another’s challenges.
Don’t conceal mistakes; spotlight them. This includes establishing a reporting system as a means of logging errors and wrongdoing. Such data can later inform process reviews and help make improvement to scoring methods an ongoing exercise from which everyone benefits.
Offer incentives for a job well done, speaking up, asking for help, and undergoing additional training. Assistance for further training (training allowance/time off or internal mentorship program) is an option. Monetary rewards are always welcome. If these options are not realistic, offering other incentives such as choosing schedule preferences is a perk that employees appreciate.
MANDATE EXPERIENCE REQUIREMENTS
Some sleep labs resemble luxury resorts with all the amenities you would find at a five-star hotel. But ironically, many leave registered technologists off their list of privileged amenities. Sleep labs both public and private should consider internally mandating that registered techs score sleep studies. Do not wait for someone to mandate that registered techs must score sleep studies; insist on it up front. This business practice will validate a facility and position it as a premier sleep lab that makes quality and reliable patient care their number one priority.
DECIPHER UNETHICAL VERSUS SLOPPY SCORING
A sleep lab must come to realize that oversights and omissions are not desirable, but they are to be expected. No matter how thorough and experienced a technologist is, there are times in one’s career when oversights occur. The key is for laboratories to anticipate it and to structure their policies and practices to ensure such oversights are as far removed from patient diagnoses and care as possible.
With the amendments to the scoring rules by the AASM, many scoring techs must be fully trained or retrained to completely comprehend how removed their scoring may be from the current industry standard. Both hospital-based and private sleep labs must ensure that patient care and quality remain top priority. Hiring staff with little or no sleep or medical background in order to cut costs or deal with labor shortages can be detrimental. There are other business alternatives to be considered before sacrificing quality and patient care.
Natalie Morin, RPSGT, is president and CEO of Sleep Strategies Inc, a provider of professional scoring and consulting services for sleep disorders facilities worldwide. The author can be reached at [email protected]
*CORRECTION: A previous version of this article incorrectly stated the recommended patient to technologist ratio for attended polysomnography according to current American Academy of Sleep Medicine (AASM) Standards for Accreditation of Sleep Disorders Centers. According to the previously published article, “With the recent AASM endorsement to increase patient-to-technologist care from 2:1 to 3:1, technologists may face increased demands to meet patient needs and maintain collection quality.”
According to current revised Standards for Accreditation of Sleep Disorders Centers, “The AASM recommends a patient to technologist ratio of 2:1 under usual circumstances for attended polysomnography.”
The information that stated the incorrect patient to technologist ratio has been removed from the currently posted version of the article.