Quality Assurance Fact Sheet
Quality Assurance Program Development
A complete QA program outlines details of the specific indicators monitored by the facility, including inter-scorer reliability and three other indicators. The QA plan should monitor indicators that measure sleep facility processes and patient outcomes. Indicators should be identified through facility collaboration and may be selected from the AASM published Quality Measures.
When selecting indicators, a facility may develop their own or may be selected from the AASM published Quality Measures. When selecting indicators consider the following:
- Process measures indicate what action the facility does to improve the health of those diagnosed with a specific sleep disorder.
- Outcome measures indicate the impact that these actions have had on the health status of these patients.
- Measurement/Methodology is the tool used to support the evidence gathered.
- Example: Process measures may use the medical record or patient encounter documentation note; questionnaires etc. Outcome measures may use sleep measurement tools such as SAQLI (Sleep Apnea Quality of Life Inventory); FOSQ (Functional Outcome of Sleep Questionnaire);
Some example indicators would be:
|Outcome Measure for Insomnia||Improve Daytime Functioning|
|Outcome Measure for Narcolepsy||Reduce Excessive Daytime Sleepiness|
|Outcome Measure for RLS||Decrease RLS Symptoms Severity|
|Process Measure for OSA||Baseline Assessment of OSA Symptoms|
|Process Measure for OSA||Assessment of Sleepiness|
|Outcome Measure for OSA||Improve Quality of Life|
It is acceptable to utilize the same OSA outcome measure and process measures for both facility and HSAT testing, provided that the data is analyzed from all patients (HSAT and in-center). Reference the Quality Assurance Template for further examples of how to implement quality measures.
Minimal thresholds (Goals) should be established for each indicator. Thresholds are usually expressed as a percent the facility hopes to achieve (e.g. 85%). The facility must review all measures to determine if minimum thresholds have been met. The Facility Director must track the chosen indicators quarterly to determine if expected thresholds have been met and to also identify areas of improvement. Through this evaluation, there is opportunity to improve the process and outcomes of patient care by identifying problem areas resulting in a negative outcome.
Remediation of Metrics
Through evaluation of the established goals, conclusions can be drawn regarding the evaluation of the data. Quarterly, the Facility Director must address plans for remediation for indicator metrics that have not met the minimum threshold (goal) established by the facility. A remediation plan must be created by the Facility Director in addition to the actions implemented. At this time other indicators may be chosen as necessary.
Record Keeping Requirements
Written quarterly reports must be signed and dated by the Facility Director and maintained for at least five years. By signing the report, the Facility Director is attesting to the effectiveness of the quality improvement efforts. The report must address the indicators, minimal thresholds and remediation of metrics if warranted.
QA Practical Recommendations
- When selecting a clinical outcome, remember to choose a sleep disorder that is of interest to the facility.
- Determine what processes you may already have in place that can provide you data to evaluate if the outcome has been achieved.
- Implement realistic tools that will enable patients to give you data quickly.
- Example: Use short questionnaires or surveys that can be completed by either patient’s in the office, or ancillary staff without increasing the work load.
- When determining the minimal threshold expectation; be realistic in defining your goal. Look at where you are now and identify where you would like to be. Thresholds can be modified/increased after each quarter.
Applicable Accreditation Standards
Facilities must have a QA program that addresses the following indicators:
- A process measure for OSA;
- An outcome measure for OSA
- An outcome measure for another sleep disorder (e.g. RLS, Insomnia or Narcolepsy); and
- Inter-scorer reliability as outlined in Standard F-7.
The facility must have a QA program for HSAT that addresses the following indicators:
- Two process measures;
- One outcome measure.
The facility must establish minimal thresholds for the quality assurance metrics. Quarterly, the Facility Director must attest to the effectiveness of quality improvement 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 thresholds. Quarterly reports must be signed and dated by the Facility Director or maintained for at least five years.
Key Things to Keep In Mind
- Sample size is set by the facility. It is not necessary to do all patients. Small facilities may choose a sampling size of 5; while hospital based facilities may choose a larger percent.
- Quarterly the Facility Director must address plans for remediation if thresholds have not been met for each indicator.
- A complete QA report reflects a full quarter (three months) analysis of data compiled.
- A summary of the compiled analysis is to be submitted for each indicator including inter-scorer reliability.
- It is acceptable to utilize the same OSA measures for both in-center and HSAT quality assurance; the QA policy should reflect this.
A complete QA report is signed and dated by the Facility Director. Measures may be chosen from the AASM Quality Measures.