Professional Staff Fact Sheet

Applicable Accreditation Standards

Entities must appoint a Network Director who is a sleep specialist and meets one of the following requirements:

  1. A physician or PhD who is board-certified in sleep medicine by the ABSM or a physician certified in sleep medicine by either a member board of the ABMS or a member board of the AOA.
  2. A physician who has completed a 12-month ACGME-accredited or AOA-accredited fellowship in sleep medicine, is eligible to sit for the sleep medicine board examination and is awaiting the first available opportunity to apply to an ABMS member board or AOA member board to sit for the sleep medicine examination. To retain accreditation, the ABMS or AOA examination in sleep medicine must be passed within two consecutive cycles.

The entity must appoint one Network Director to oversee services across all locations; individual locations may appoint separate local Site Directors (reference Standard N-3, N-4). The Network Director may also serve as the Site Director.  

  1. Is responsible for serving as or designating a primary contact for the AASM and apprising the AASM of any changes to the accreditation network.
  2. Must review, report, and manage the entity’s quality assurance program on a quarterly basis as mandated in the Sleep Clinic Standards.
  3. Must annually review and provide oversight of all policies and protocols for the accreditation network.
  4. Must review and assess all safety related issues, perform risk analysis, and communicate with stakeholders.
  5. Must have access, as needed, to the information in electronic medical records (EMRs) utilized by each location.
  6. Must be medically licensed in each state of the network, should the network encompass an area larger than a specific state or locale. 
  7. It is recommended that the Network Director spend a minimum of 4 hours per month fulfilling the above responsibilities in larger Networks 2 hours per month per location may be required)The Network Director may fulfill this requirement by either physical presence, and/or regular conference calls, virtual meetings, and webinars with the professional and technical staff.

Entities must appoint a Site Director, who is a sleep specialist, and meets one of the following requirements:

  1. A physician or PhD who is board-certified in sleep medicine by the ABSM or a physician certified in sleep medicine by either a member board or the ABMS or a member board of the AOA. 
  2. A physician who has completed a 12-month ACGME-accredited or AOA-accredited fellowship in sleep medicine, is eligible to sit for the sleep medicine board examination and is awaiting the first available opportunity to apply to an ABMS member board or AOA member board to sit for the sleep medicine examinationTo retain accreditation, the ABMS or AOA examination in sleep medicine must be passed within two consecutive examination cycles

This entity may appoint one Site Director to oversee services across all locations; alternately, each location may appoint separate Site Directors that meet this standardThe Site Director may also serve as the Network Director.

  1. 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 testing.
  2. Is responsible for the qualifications and training of all medical, technical and administrative support personnel. 
  3. Is responsible for the supervision and oversight of entities medical, technical and administrative personnel. 
  4. Is responsible for assuring staff complies with the Code of Medical Ethics as well as any institutional ethics requirements.
  5. Must provide oversight of proper operation and calibration of the equipment mandated in the In-Lab Testing and/or HSAT standards.
  6. It is recommended that the Site Director spend a minimum of 4 hours per month fulfilling the above responsibilities. The Site Director may fulfill this requirement by either physical presence, and/or regular conference calls, virtual meetings, and webinars with the professional and technical staff.

Qualifications of (Network, Site) Directors

  • Must be sleep specialist who meets one of the following criteria:
    • A Physician or PhD.
    • Boarded in sleep by ABSM, AOA, ABMS.
    • A physician who has completed a ACGME-accredited or AOA-accredited fellowship in sleep medicine and is eligible to sit for the sleep medicine board examination through an ABMS member board or AOA member board. The ABMS or AOA examination in sleep medicine must be passed within three consecutive examination cycles from fellowship completion.
      • The examination may not be failed twice consecutively during this period.  

Medical Staff Member

  • Entities whose director is not a licensed physician must have at least one physician (MD or DO) with a valid, unrestricted license. 
  • 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

  1. Review information for each direct referral patient and determine if the patient meets the criteria for the requested test.
  2. Provide consultation, management, treatment, and follow-up assessments.
  3. Diagnose medical conditions as a licensed physician or APRN (if permitted under their scope of practice in certain states).
  4. Respond to medical emergencies as appropriate.
  5. Serve as the reference sleep specialist for ISR assessment, if board-certified, as defined in Standard N-1.

Key Things to Keep In Mind

  • Entities must designate both a Network Director and a Site Director, who must be an MD or PhD board-certified in sleep medicine by the ABSM, ABMS, or AOA.
    • One director may serve in both positions.
  • If the director is not a licensed physician, there must be one licensed physician on staff who is board-certified in sleep medicine.
  • Each director must spend a minimum of 4 hours/month fulfilling their responsibilities.
    • This can be achieved through physical presence, teleconferencing, conference calls, virtual meetings, and/or webinars with professional and technical staff members.
    • If one director fulfills both roles, a total of 8 hours per month is required.
  • Sleep study interpretations made by individuals who are not board-certified in sleep medicine must be reviewed by a board-certified sleep specialist, as defined in Standards N-1 and N-3.