Professional Staff Responsibilities
Applicable Accreditation Standards
Facilities must appoint a facility director who is board-certified in sleep medicine (as defined in Standard B-2) by the ABSM, a member board of the ABMS or a member board of the AOA and who may be a MD, DO or PhD. See Standards B-1 through B-4 for additional requirements
Facilities must designate a single facility director who is board-certified (as defined in Standard B-2) in sleep medicine by the ABSM, a member board of the ABMS or a member board of the AOA. The facility director must be an unrestricted licensed physician or a PhD. See Standard A-1.
The facility director:
- Is responsible for serving as primary contact or designating a primary contact for the AASM and apprising the AASM of any changes to the facility.
- Is responsible for ensuring there is a process for determining that only licensed health care professionals with prescriptive authority in the state where the patient would be tested can request a HSAT.
- Is responsible for the qualifications of all medical and technical personnel.
- Is responsible for the supervision and oversight of facility professional and technical staff.
- Is responsible for assuring staff complies with the Code of Medical Ethics as well as any institutional ethics requirements.
- Must provide direct and ongoing oversight of the testing protocols and the quality of testing including the proper operation and calibration of the equipment.
- Must review, report, and manage the facility’s quality assurance program on a quarterly basis as mandated in Section J.
- It is recommended that the facility director spend a minimum of 8 hours per month fulfilling the above responsibilities. The facility director may fulfill this requirement by either physical presence in the center, and/or regular conference calls, virtual meetings and webinars with the professional and technical staff.
Inter-scorer reliability (ISR) must be determined between each scorer and the facility director or a medical staff member board-certified (as defined in Standard B-2) in sleep medicine or a corporate-appointed physician or PhD board-certified in sleep medicine; such individual must be an employee of the corporation and serves as the reference sleep specialist. ISR assessment must be conducted for each individual facility. In cases where a corporate appointed individual serves as the reference standard for ISR, the facility director or medical staff member must attest in writing that he/she has reviewed the results of the ISR assessment and will take corrective action when results fall below the facility’s level of acceptable agreement as defined in its quality assurance program.
For comprehensive PSG, the following parameters must be compared: sleep staging epoch-by-epoch agreement, respiratory events, leg movements and arousals. Sleep technologists must be blinded to the scoring of the facility director/medical staff member and to all other scoring technicians. Comparisons between each scorer and the facility director/medical staff member must be made on 200 consecutive 30-second epochs in each of three polysomnograms per quarter, for a total of 12 polysomnograms per year. Comprehensive PSG studies must report agreement between scorer and the facility director/medical staff member as percent concordance defined as the quotient of the total number of epochs of agreement for a given parameter and the total number of epochs in the analysis sample multiplied by 100. Sleep-related breathing event comparisons for laboratory PSG must include analysis by total number of events and by the following event types: obstructive apnea, central apnea and hypopnea. If the facility reports respiratory effort related arousals, this event must be included in the comparison. Use of the AASM Inter-Scorer Reliability program fulfills the requirements of this standard.
The facility must establish minimal thresholds for the quality assurance metrics. Quarterly, the facility director must attest to the effectiveness of quality improvement efforts and address plans for remediation of metrics that do not meet the minimal threshold. Quarterly reports must be signed and dated by the facility director and maintained for at least five years.
Qualifications of Facility Director
- Must be sleep specialist who meets one of the following criteria:
- A Physician or PhD;
- Boarded in sleep by ABSM, AOA, ABMS;
- Physician who completed a 12-month ACGME accredited or AOA accredited fellowship in sleep medicine, and is eligible to sit for and is awaiting first opportunity to apply to sit for the next available sleep board examination;
- Examination must be passed within two examination cycles
Medical Staff Member
Facilities whose facility director is not a licensed physician must have, at minimum, one physician (MD or DO) with a valid, unrestricted license in state where facility is located. Sleep Medical Staff members include, physicians, license psychologists, APRN, (all may or may not be board-certified in sleep medicine) and PAs who hold valid licenses in states where patients are evaluated, diagnosed and treated.
Medical Staff Member Responsibilities Include:
- May review information provided for each direct referral patient & determine if meets criteria for requested test.
- Provides consultation, management, treatment and follow up assessment.
- Provides the diagnosis of a medical condition as a licensed physician or APRN (if acceptable under their scope of practice in certain states).
- Responds to medical emergencies as appropriate.
- Serves as reference sleep specialist for the purpose of ISR assessment, if board certified as defined by standard B-2.
Key Things to Keep In Mind
- Facility is to designate only one individual; MD or PhD who is board certified in sleep by the ABSM, ABMS or AOA as the facility director.
- If facility director is not a licensed physician, there must be one licensed physician on staff that is board certified in sleep medicine.
- On site requirement for the facility director may be met either by physical presence in the facility, teleconferencing, conference calls, virtual meetings and/or webinars with the professional and technical staff members.
- Facility director may conduct educational sessions on sleep medicine topics to sleep technicians to ensure CEC’s are earned.
- Facility director is to ensure all staff are trained regarding HIPAA regulations and that patients are informed of their HIPAA rights.
- Review of the diagnoses made by an individual not boarded in sleep must be completed by a board-certified sleep individual as defined in standard B-2