Quality Assurance Program Fact Sheet
Applicable Accreditation Standards
Sleep clinics are required to track three sleep medicine quality measures related to the delivery of patient care and outcomes. A written policy is required that defines the selected quality measures and outlines the methods for data collection, analysis, and reporting.
A QA report is required to summarize and analyze the collected data, offering insights into trends, areas for improvement, and the overall effectiveness of the clinic’s services. Reviewing these quarterly reports allows sleep clinics to identify potential issues, implement corrective actions, and continuously improve the quality of patient care.
Indicator Selection
The three required sleep quality measures must include one process measure and two outcome measures, in addition to ISR.
- Process Measures: Indicate the ACTION taken to improve the health of patients diagnosed with a sleep disorder.
- Outcome Measures: Indicate the IMPACT these actions have had on the health status of these patients.
- Measurement/Methodology: The tool used to support the evidence gathered.
- Process Measures may use medical records or documentation notes (e.g., questionnaires).
- Outcome Measures may use sleep questionnaires such as the SAQLI (Sleep Apnea Quality of Life Inventory) or FOSQ (Functional Outcomes of Sleep Questionnaire).
- Minimum Threshold(s): Defines the lowest acceptable boundary between acceptable and reduced performance, typically expressed as a percentage (e.g., 85%).
- Example: 10 meet a measure ÷ 20 randomly selected medical records = 50%
- Through this evaluation, clinics can improve clinical outcomes and processes by identifying problem areas that result in negative outcomes.
Quarterly Data Collection and Analysis
Data must be collected, tabulated, and analyzed quarterly to determine if the minimum thresholds have been met.
- Formula for calculating measure: # meeting measure ÷ sample size = % who met the measure.
- Example: 10 meet a measure ÷ 20 randomly selected medical records = 50%
Through this evaluation, clinics can improve clinical outcomes and processes by identifying problem areas that result in negative outcomes.
Remediation of Metrics
The Director must develop plans to correct deficiencies identified during the analysis of areas that did not meet the minimum threshold. Clear goals should be set, and plans for improvement should be implemented to meet high-quality standards.
Record-Keeping Requirements
Written quarterly reports must be signed and dated by the Network Director and maintained for at least five years.
QA Practical Recommendations
- The sample size is set by clinic; it is not necessary to do all patients.
- Implement realistic tools that will enable patients to give you data quickly.
- Example Use short questionnaires or surveys that can be completed by patients in the office or by ancillary staff without increasing the workload.
- When setting the minimum threshold, ensure it is specific, measurable, and realistic. Thresholds can be adjusted or increased after each quarter.
Reporting Requirements
Quarterly QA reports should indicate:
- Description of the indicator measured.
- Definition of the percentage (or number) of patients used in the activity.
- Methodology (tool) used to determine the result.
- Minimum threshold hoped to achieve.
- Final percentage achieved.
- Remediation plans if the minimum threshold is not met.
Examples
Clinical Process for OSA: Assessment of Sleepiness | Clinical Outcome for OSA: Improve Quality of Life |
---|---|
20 patients used in activity | 20 patients used in activity |
Methodology: Documentation of sleepiness assessed during the initial evaluation. | Methodology: Use of FOSQ to show any signs of improvement. |
Target goal: 95% | Target goal: 85% |
Key Things to Keep In Mind
- The QA policy should describe two sleep medicine outcome measures and one process measure. The specifics of each metric can be detailed in the QA report to avoid revising the policy whenever a measure is changed.
- Each measure should include a description of the metric, the number/percentage of patients reviewed, the methodology used, and the minimum (target) threshold to be met.
- The Network Director reviews the quarterly report and creates plans for remediation if thresholds are not met.
- A complete QA report must include ISR results and be signed and dated by the Network Director. Refer to the ISR Fact Sheet for more information.
- Annually, the Network Director should evaluate the effectiveness of the QA program and decide if additional indicators are needed for future monitoring.
- Example measures are available at the AASM website.