Accreditation FAQ 2017-09-18T20:23:01+00:00

Accreditation Frequently Asked Questions

  1. What quality assurance measures do we need to use

For Facility Quality Assurance program, facilities must have a QA program that addresses the following indicators:

    1. A process measure for OSA;
    2. An outcome measure for OSA;
    3. An outcome measure for another sleep disorder (e.g. RLS, Insomnia or Narcolepsy); and
    4. Inter-scorer reliability as outlined in Standard F-7.

For HSAT Quality Assurance program, facilities must have a QA program that addresses the following indicators

    1. Two (2) Process measures
    2. One (1) Outcome Measure

For questions on specific measures, please contact the American Academy of Sleep Medicine (AASM) Accreditation Department. For more information regarding Quality Assurance, please review the AASM’s published Quality Measures.

  1. What quality assurance measure can I use for home sleep apnea testing (HSAT)? Can I use the same indicators for both in-center and HSAT?

For HSAT Quality Assurance program, facilities must have a QA program that addresses the following indicators:

    1. Two (2) Process measures
    2. One (1) Outcome Measure

For questions on specific measures, please contact the accreditation department. For more information regarding Quality Assurance, please review the AASM’s published Quality Measures.

The sleep facility can use the same indicators for both in-center and HSAT; however, it must be addressed within the QA policy that the same indicators are being used.

  1. How do I report QA if I haven’t completed 6 months of data using the 2016 Standards required QA measures?

If the facility has not been practicing under the 2016 Standards for the past six months, the facility should submit a QA report addressing the previous standards. When applying, submit the most recent QA report and policy under the 2014 standards as well as a revised policy addressing the new 2016 Standards requirements.

  1. Our clinic and lab are separate. How do I report QA and PAP Assessment if I don’t have access to clinic data?

The AASM Standards allow for the sleep lab and clinic to be in separate physical locations; however, the sleep facility is considered the sleep lab and clinic collectively, even if they are in separate spaces. Regardless of the location of the clinic (i.e. within the center, in a physician’s separate office, etc.), it is still considered part of the sleep facility and must provide information required for the sleep facility as a whole to meet these standards.

The 2016 Standards require that the sleep facility as a whole obtains and maintains all clinical information, including the PAP assessment data specifically required by Standard H-2 for applicable patients, and quality assurance data required by Standards J-1-J-3 for each patient seen or tested in their medical record. The AASM Standards do not specify the location where the medical records must be held (i.e. the clinic vs. the lab) but these records must be maintained and accessible by the sleep facility as a whole.

The sleep facility is not required to have this information for patients that are directly referred for testing only; Standard H-2 only applies to patients who are prescribed PAP by sleep facility staff.

  1. Our clinic and lab are separate, and the lab is unable to retrieve follow-up or PAP assessment from the physician’s clinic in order to complete QA and PAP assessment. How does the facility meet these standards?

The following strategies can be utilized to gain access to data that is needed to meet these standards:

    • The clinic and lab can have a Business Associate Agreement to address the sharing of PHI and share data with the lab accordingly.
    • The clinic can have patients give consent to sharing the data with the lab.
    • The clinic can provide the data needed to measure the QA indicators to the lab de-identified. This would address any HIPAA concerns the clinic may have.
    • The clinic can maintain the QA measures for clinic specific measures and report results to the lab for inclusion in the larger QA report.

It is important that the clinic understands that it is their responsibility, as a clinic of the accredited sleep facility, to ensure that the facility as a whole is able to meet all accreditation standards.

  1. Who can interpret a sleep study and diagnose patients?

The 2016 Standards do not define who can interpret sleep studies. It is at the facility’s discretion to decide who may interpret; however, only licensed physicians, and APRNS in some states, may diagnose a medical condition, and all individuals must practice within the limits of their license or scope of practice. Standard F-8 requires diagnoses made by individuals not board-certified in sleep medicine be reviewed by an individual who is board certified in sleep medicine.

  1. When a non-board certified physician’s diagnosis is reviewed, is a signature by the individual board certified in sleep medicine required?

Yes; it must be indicated on the report that the diagnosis has been reviewed by the individual board certified in sleep medicine.

  1. Our facility doesn’t do HSAT. Do we still have to have P&Ps and equipment for it?

Under the 2016 AASM Standards for Accreditation, all AASM-accredited sleep facilities must have the capability to conduct HSAT as part of their sleep program. This includes developing HSAT policies and procedures, having access to a HSAT device, and having the ability to conduct HSAT when needed. Please note that your sleep facility can rent HSAT equipment or have an arrangement with a separate entity to access a HSAT device when needed.

The sleep facility has the option to contract home sleep apnea testing. Please see standard F-9 – Subcontracting HSAT for additional information.

  1.  We are a pediatrics only facility. Are we required to provide HSAT?

According to the AASM Practice Parameters, only patients 18 years or older should be testing using HSAT. If your facility sees only patients 17 years of age or younger, you will not be required to maintain an HSAT program.

  1. I have only begun my HSAT program. How do I submit a report for QA if I do not have any data?

The facility should submit the HSAT QA policy and a blank HSAT QA report template that includes the process and outcome measures along with the thresholds set for each indicator.

  1. What are my options if I cannot provide HSAT in-house?

If the facility does not provide HSAT in-house, the facility may subcontract home sleep apnea testing. See Standard F-9 for requirements regarding subcontracting HSAT.

  1. Can you recommend an HSAT Subcontractor?

The AASM is not able to provide recommendations for programs that provide HSAT. It is the facility’s decision to choose a subcontracting company, provided that the subcontractor meets all applicable AASM HSAT Standard requirements.

  1. What is required within the application if we subcontract our HSAT program?

Indicate within the application that the facility is subcontracting HSAT. The HSAT contract will not be requested within the application, and you are not required to include subcontracted HSAT staff within the application.  The inclusion of HSAT policies and procedures will be determined based on the elements of HSAT that are subcontracted.  You will be required to submit an HSAT QA report.

  1. Do subcontracted scorers need to be included in the application?

Technologists scoring as part of a subcontracting company should not be listed within the application; however, they must still meet all applicable accreditation requirements as part of the subcontracting agreement.

  1. What is needed in the contract to meet the Accreditation Standards?

Per Standard F-10, the facility is responsible for assessing the performance of the subcontractor in meeting contractual obligations including meeting applicable AASM Accreditation standards for scoring personnel. Therefore, your written agreement with the subcontractor must enumerate the performance expectations of the subcontractor including adherence to application AASM Standards.

  1. Who needs a background check?

Per Standard B-13, each facility shall comply with all background check requirements which may be required by federal, state or local law. In the absence of such requirements, the facility shall conduct criminal background checks of all new employees. The facility shall utilize information obtained in this process only to the extent such information is relevant to the job duties of a particular person. Subcontracted employees who have patient interaction fall under this requirement.

  1. Am I required to have an AED on-site?

Yes. Per Standard I-4, all facilities, at a minimum, must have either an automated external defibrillator (AED) or access to an on-site medical emergency response team (typically available in hospital-based facilities).

  1. I only test patients at my lab but a board-certified sleep specialist interprets all the sleep studies. The patients are treated by their primary care doctors, not the sleep-specialist. Can my lab be accredited?

A sleep facility, as defined by the AASM, is composed of a laboratory (where patients are tested), and a clinic (where patient consultation and management is offered by medical staff members). Under Standard G-1, the facility must demonstrate management of an adequate range of sleep disorders. The AASM does not accredit sleep labs or independent diagnosing testing facilities that only provide testing without availability for patient management (clinical services).

  1. How many Registered Polysomnographic Technologists (RPSGTs) are we required to have on our staff?

At least one member of the technical staff of the sleep facility must be registered by or accepted to sit for a registration examination by the:

      1. American Board of Sleep Medicine (ABSM)
      2. National Board for Respiratory Care (NBRC)
      3. Board of Registered Polysomnographic Technologists (BRPT)
      4. Another organization that offers an equivalent examination accepted by the AASM.

The registry exam must be passed within one year from acceptance to sit for the examination; otherwise, the individual will be considered a non-registered tech. The individual(s) fulfilling this standard must be present at the facility at least 30 hours per week, or 75% of operating hours.

  1. How big should our bedrooms be?

The AASM Standards do not specify a dimension requirement for sleep testing bedrooms. However, each room must be single occupancy, private and comfortable, have hard floor-to-ceiling walls, and a privacy door that opens directly to a corridor or common use area. Patient testing bedrooms must not have any impediments to the delivery of emergency care. The patient testing rooms must be of sufficient size to accommodate emergency personnel access with a minimum of 24 inches of available clear space on three sides of the bed, which must be at least a standard hospital bed.For additional physical space requirements, please reference Standards D-5 through D-10.

  1. One member of my technical staff is a scoring tech who does not interact with patients. Does she need CPR certification?

Yes. All members of the technical staff, regardless of job duties, must be certified in CPR per Standard B-9.

  1. My facility is: relocating, merging, changing ownership, changing facility name, changing primary contacts, or changing facility directors. Am I required to contact the AASM?

Yes. Facilities that are undergoing any one or more of these significant changes, must contact the AASM in writing within one month of the change. Please contact the AASM Accreditation Department for further details or reference the Accreditation Policies and Procedures for specific requirements.

  1. My facility is relocating. Am I required to contact the AASM?

Yes. Facilities that are or have relocated must contact the AASM in writing within one month of the change. For all relocations, a facility must submit formal notification from the facility director and complete a special circumstance application within 90 days of the relocation notification. If centers are relocating within 18 months of their expiration date, they can choose to pursue an early reaccreditation application, which would include a site visit. Continued accreditation at the new location will be contingent on the AASM Board of Directors approval. Please review the Accreditation Policies and Procedures for the full Special Circumstances policy.

  1. My facility is relocating and changing ownership. What does the AASM require in this situation?

If the facility is relocating and changing ownership simultaneously, the facility will be considered a new sleep facility and must submit a new application for accreditation.

  1. My facility staff has changed. Am I required to contact the AASM?

We only request that the sleep facility updates the AASM on a change of facility director or primary contact. All other professional or technical staff members would be updated at the time of reaccreditation. However, these individuals would need to meet all applicable AASM Standards.

The primary contact information can be updated at any point by logging into your facility’s account and editing the “My Account” page.

  1. My main location is accredited. Does this mean that my satellite location is also accredited?

No, AASM accreditation is location specific. Your facility’s accreditation would only apply to the address of the accredited center. For this reason, satellite labs or additional centers would not fall under your accreditation. Each location would need to obtain separate accreditation by submitting a new accreditation application.

  1. My five-year accreditation is expiring this year. What should I do?

You must submit an application for reaccreditation of your sleep facility. Applications for reaccreditation are due 180 days prior to your expiration date. The AASM Accreditation Department will send official notices via mail 10 months and 7 months prior to your upcoming expiration date with information regarding reaccreditation processes. The facility can submit an application after the due date; however, a late fee will apply. If the facility fails to submit a reaccreditation application by the accreditation expiration date, the facility must pursue new accreditation by submitting a brand new online application via the AASM website. Please be aware that no extensions past the expiration date of your accreditation will be available.

  1. What is a direct referral?

The AASM defines a direct referral as a patient that is tested by the facility but is not seen by facility professional staff prior to or after the test for follow-up. For example, if a patient comes to your facility for testing only and returns to their primary physician (not associated with your sleep facility) for follow-up and treatment, the patient would be considered a direct referral.

  1. I see patients in the office of my private practice, not related to the accredited sleep facility. Do they count in the patient volume statistics form?

If a physician’s private practice is not associated with the sleep lab (i.e. not serving as the sleep clinic), these patients would not need to be included in the Patient Volume and Sleep Study Statistics section of the application. However, if the private practice directly refers patients to the sleep facility for testing, they would need to be included in Question 3 of the Patient Volume and Sleep Study Statistics section addressing direct referrals. To address specific situations, contact the AASM Accreditation Department.

  1. I just had my site visit. When will I find out the results?

After the site visit, the sleep facility’s accreditation application and site visit report will be sent to the AASM Board of Directors for review and decision. The AASM makes every effort to notify sleep facilities of the accreditation decision with 45 days of the site visit occurring.

  1. I am a clinic or practice that provides HSAT for my patients, but I do not have a lab to provide overnight testing. How do I apply for accreditation?

Clinics/practices that provide HSAT but do not have a lab where overnight testing is performed qualify for Independent Sleep Practice (ISP) Accreditation.  These ISPs must accept patients with all sleep disorders and provide ongoing patient management and have a relationship with an AASM-accredited sleep facility that can provide overnight testing when needed. See the ISP Standards for Accreditation for more information.

  1. Our entity would like to use our own Business Associate Agreement (BAA). Is this acceptable?

Yes, an entity can utilize their personalized Business Associate Agreement. This would be considered a custom BAA that would need to be reviewed and approved by the AASM Director of Accreditation. This review process can take approximately 1-3 months to complete. The AASM Director of Accreditation will work directly with the facility regarding any information that needs to be included or omitted.

If the facility would like to submit their application prior to having an AASM signature on the custom BAA, we ask that you upload the document without signatures into the Business Associate Agreement section of the application. The AASM will work with your facility while in the application process to complete this agreement. Once the BAA has been approved and signed by both parties, the fully executed document will be uploaded into your application and emailed to the primary contact.

  1. My technologist was hired only one year ago. Do they need to have 30 CECs?

For the accreditation application, all technical staff are required to earn 10 credits in sleep related topics per year averaged over three years (i.e. 30 CECs earned over the last three years [36 months]); however, for a newly hired sleep technologist, the AASM may accept CECs prorated based on the hire date if the facility also submits a continuing education policy. The policy must indicate that the sleep program will prorate CECs based on the date of hire of technical staff and will adhere to Standard B-9 Sleep Technician and Technologist Continuing Education. For example, if a tech has been working at the sleep facility for only one year, the AASM will require 10 sleep-related CECs along with a continuing education policy to meet compliance.

The Continuing Education Policy can be included in your Tech Training Policy required in the Facility tab of the application.

  1. Do you have any example policies and procedures that my facility can utilize when developing our own?

The AASM released the 2016 Standards Accreditation Reference Manual in January 2017. This easy-to-use guide provides concrete examples of policies, procedures, forms and documents that you will need for your manual. These samples are provided for you to customize according to the specific needs of your sleep facility. Tabbed sections enable you to quickly access the information you need most at any moment. Also included are sections containing job descriptions for sleep facility technical staff, sample reports, and reference material.

Purchase your e-book or print copy of the AASM Reference Manual today by visiting the AASM online store. The e-book contains additional easily customizable electronic example policies, procedures, forms and reports.