Accreditation surveys for sleep centers are often compared to “open book tests on operating a high-quality sleep center,” says Tim Safley, MBA, the senior program director at the Accreditation Commission for Health Care (ACHC). However, from June 1, 2022, to May 31, 2023, more than 10% of surveyed sleep centers failed to meet nine ACHC standards—a significant decline compared to the previous year when only three standards were commonly unmet.
In its publication, The Surveyor, ACHC outlines these deficiencies, detailing each standard’s intent, compliance assessment methods, specific examples of deficiencies, and tips to help sleep centers avoid these pitfalls. Representatives from ACHC and external accreditation consultants also share insights on why these deficiencies occur and how to excel in accreditation surveys.
Top Sleep Lab Accreditation Deficiencies
The most frequently cited deficiencies in sleep labs from mid-2022 to mid-2023 include:
Client Records: An individual record for each client with current and accurate information was missing in 50% of labs.
ACHC Tip: Ensure timely, comprehensive documentation of evaluations, equipment used, and other relevant information.
Performance Improvement Program: Lacking in 48% of labs.
ACHC Tip: Schedule reminders for semiannual performance improvement summaries.
Annual Performance Improvement Report: 48% of labs were non-compliant.
ACHC Tip: Use data from semiannual summaries and include corrective actions in the annual report.
Grievance/Complaint Information: Absent in 33% of labs.
ACHC Tip: Implement a “patient instruction checklist” and keep a copy in each patient file.
Performance Improvement Activity Documentation: 25% of labs fell short.
ACHC Tip: Document each activity in detail, identify benchmarks, and track corrective actions and remeasurements.
Service Contracts/Agreements: Not properly maintained in 23% of labs.
ACHC Tip: Collect liability coverage certificates and track their expiration dates.
Financial Responsibility Communication: Lacking in 21% of labs.
ACHC Tip: Periodically audit patient files for completeness.
Background Checks: Not adequately documented in 21% of labs.
ACHC Tip: Document any special considerations for hires with criminal backgrounds.
Monthly Education for Personnel: Missing in 21% of labs.
ACHC Tip: Establish monthly training sessions on equipment, policies, procedures, and clinical protocols.
Reasons for Increased Deficiencies
The increase in deficiencies is partly attributed to the rapid return to normalcy post-COVID-19, as many sleep centers had to quickly ramp up operations, leading to oversight of standards. Additionally, more sleep labs sought accreditation during this period.
Smaller facilities often struggle with accreditation due to competing priorities, says Andrea Clark, DBA, MSW, RPSGT, president of Signature Sleep Services LLC. Limited staffing and lack of administrative experience among technologists and physicians also contribute to non-compliance.
The shift from large, hospital-based labs to smaller, out-of-center facilities has left many sleep centers without the necessary resources for compliance. The extended pandemic-related closures and the pivot to home-based tests have further complicated compliance efforts.
Future of Sleep Lab Accreditation
The trend towards home-based assessments could simplify the accreditation process. According to Troy Lair, a principal at Elite Accreditation Consultants, accrediting bodies might move towards more manageable compliance expectations.
Clark suggests that educational materials focused on developing policies and procedures could improve compliance rates. ACHC's approach emphasizes helping sleep facilities improve while meeting accreditation requirements. Their resources include a team of experts, free webinars, and a comprehensive "Guide to Success" workbook.
“Sleep medicine is evolving, with advancements in technology and changing requirements for sleep test coverage,” says Safley. “ACHC remains in touch with both accredited organizations and payors to support the needs of all stakeholders. With the right resources and knowledge, we hope to see a decrease in common deficiencies.”
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