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Sleep Laboratory Accreditation
Sleep Laboratory accreditation is presently a voluntary assessment process that allows a sleep testing facility to meet and follow a number of guidelines for higher standards of operation. In today’s business of sleep it is becoming increasingly important to differentiate your sleep center operation as a center of excellence by achieving laboratory accreditation through a nationally-recognized accrediting organization. Medicare, private payers and regulatory agencies are beginning to require sleep laboratory accreditation for reimbursement. Recently Medicare carriers have released new Local Coverage Determination (LCD) policies that require sleep laboratories and centers to obtain accreditation through the American Academy of Sleep Medicine (AASM) or The Joint Commission.
On May 1, 2009 the Florida Medicare contractor, First Coast Options, released its latest Polysomnography and Sleep Testing LCD. It states that effective June 30, 2009 all sleep testing laboratories and centers including hospital affiliated, physician practices and independent diagnostic testing facilities must be accredited by the AASM or as a sleep laboratory by Joint Commission in order to bill for sleep studies. Similarly, Medicare contractor, Trailblazer Health Enterprises which contracts services for Texas, Colorado, New Mexico and Oklahoma, also released an LCD that states all sleep testing performed by physician practices and independent diagnostic testing facilities must be accredited only by AASM. These are clear indicators that sleep facility accreditation will no longer be a voluntary option as Medicare and private payers will require laboratory certification for reimbursement.
Pursuing Laboratory Accreditation
The only two recognized accreditation agencies for sleep disorder centers are the AASM and The Joint Commission. Although the certification costs are similar, the standards for accreditation are quite different. They both require comprehensive policy and procedures but have key differences that include:
AASM Standards: Apply to all types of sleep testing facilities. The AASM recognizes two accreditation categories: a comprehensive sleep disorder center that can diagnose and treat all aspects of sleep medicine and a sleep-related breathing disorders laboratory that evaluates and treats only sleep disordered breathing. AASM accreditation is more clinically oriented and focuses primarily on the medical director and staff physicians, technical staff, diagnostic equipment, protocols, documentation and quality assurance. The AASM also offers provisional accreditation to new startup laboratories allowing them 6 months to build a history of quality patient care in order to meet all standards required for full accreditation.
Joint Commission Standards: Apply to all types of sleep testing facilities. The Joint Commission also recognizes two accreditation categories that include hospital based sleep laboratories and independent diagnostic testing facilities with its Ambulatory Care pathway. The accreditation process is more facility oriented and focuses primarily on patient safety, infection control, emergency procedures, medication management, human resources and leadership. The Joint Commission does not offer any type of provisional accreditation options.
Lab Accreditation Assistance Program Team
Sleep Management Centers has established a Lab Accreditation Assistance Program (LAAP) that offers a variety of services to assist all types of sleep diagnostic facilities with the accreditation process. This program is managed by two of the most experienced sleep technologists in the country with over 60 years combined experience in sleep medicine. They have served with numerous boards and committees in the sleep field and have accredited a number of hospital based and independent sleep testing facilities. Under their leadership, Sleep Management Centers was accredited by the AASM as a full service center with a perfect, no proviso assessment. It was also accredited by The Joint Commission as an ambulatory care center with an A+ assessment. The company also runs an AASM accredited Sleep Technology Educational Program (A-STEP) and remains the only independent sleep disorders center in Florida with these combined certifications.
Accreditation Assistance Program Services
The Sleep Management Centers LAAP allows you to choose what accreditation option is best for your facility and what timeframe you require accreditation to be completed. This decision depends on a number of factors that will be specific to startups or established operations. Our LAAP service is offered as a 10 step process or by hourly consultation as estimated after each step. The structured path is as follows:
- Initial consultation - An important first step to gain information on lab status, required timelines and the most appropriate accreditation process. (1 to 2 hrs)
- Site evaluation – This step is a detailed evaluation of your sleep facility to establish how it compares to the standards of the selected accrediting agency. A report will be generated providing the recommendations to proceed with accreditation. This step is not required for startup labs that have not advanced beyond the concept phase. (6 to 8 hrs)
- Policies and Procedures – The LAAP team will review your present policies and procedures with recommendations to bring them up to accreditation standards. In startup or early stage cases a P&P manual will be generated. All P&P will be modeled after Sleep Management Centers highly recognized version. (8 to 16 hrs)
- Accreditation application – Very important part of the accreditation process since incomplete or inaccurate applications are the most common reason for delays. This part will move efficiently if all the requested information arrives in a timely fashion and the LAAP team completes the application. (8 to 40 hrs)
- Requested modifications – Although the LAAP team is experienced with this process every application is different and typically requires additional information requests from the accrediting organization. We treat every application with high priority minimizing any delay of the scheduled site visit. (4 to 12 hrs)
- Site visit preparation – Once the application has been accepted the site visit will be scheduled. The LAAP team will inform the sleep lab staff what to expect and how to prepare for the visit. (10 to 20 hrs)
- Accreditation site visit – The most critical phase of the process since the accrediting agency site visitor is the one who recommends to the accrediting agency whether the sleep lab should be certified. A LAAP team member will inspect the site prior to the visit to ensure it is in compliance and coordinate the sleep labs response to the site visitor requests. (8 to 16 hrs)
- Requested provisos - Although there are exceptions, most site visitors will identify provisos (required changes or additions) to the P&P manual in the exit interview. The LAAP team member will assist with the any required provisos and make the appropriate changes, corrections, or additions. (4 to 10 hrs)
- Certification guidelines – After accreditation has been granted a LAAP team member will discuss with the sleep lab how the standards must be followed, preparation for possible unannounced site visits and the regulations regarding the use of accreditation logos for marketing purposes. (1 to 2 hrs)
- Marketing accreditation – This is an optional session where the Director of Marketing from Sleep Management Centers will suggest a number of ways to market and sell your new sleep lab certification into the local medical community. Our marketing director has 20 years experience in the sleep field and these marketing tips are based on a number of trial and error experiences. (1 to 2 hrs)
Note: Hourly rates for each step are estimations and can vary due to a number of factors.
For more information how the LAAP team can help with your accreditation needs call 866-469-2021 or click on
Frequently Asked Questions
Q: What is accreditation?
Sleep laboratory accreditation is presently a voluntary assessment process that requires your facility to meet and follow a number a guidelines for higher standards of operation.
Q: Why is it required?
Medicare and an increasing number of third party payers are requiring sleep laboratories to obtain accreditation as a precondition for reimbursement.
Q: What accrediting agencies are there?
The only two recognized accrediting agencies for sleep laboratories are the American Academy of Sleep Medicine (AASM) and The Joint Commission (TJC).
Q: How are they different?
The AASM concentrates more on the sleep testing component and physician leadership as compared to TJC which is focused more on patient safety and management personnel.
Q: What accreditations does AASM offer?
The AASM provides facility accreditation to either a full sleep disorders center or a laboratory for sleep related breathing disorders.
Q: What is the difference between the two?
Both facilities must be able to diagnose the full spectrum of sleep disorders and provide follow-up with the center dealing in all sleep disorders and the laboratory dealing with just sleep-disordered breathing.
Q: What is AASM provisional accreditation?
The AASM can provide provisional accreditation to new facilities for 6 months allowing them to build a history of quality patient care in order to meet all standards required for full accreditation.
Q: What facilities qualify for provisional accreditation?
Only new start-up centers and laboratories or new facilities opened up by an existing accredited sleep center or laboratory.
Q: What accreditations does TJC offer?
The TJC accreditation process differs on whether the facility is hospital-based or an independent ambulatory care center.
Q: Which one is the most appropriate?
It depends on several factors including facility type, established or startup, staff experience in sleep, local insurance payer requirements and time.
Q: What is the process?
Typically broken down to multistep approach that includes comparing your sleep laboratory service to the required accreditation standards, completing the application, generating policies and procedures and entertaining the site visit.
Q: How much time does it take?
That also depends on several factors including site visit backlogs but anyone inexperienced in the accreditation process should plan to spend several hundred hours over a 6 month time frame.
Q: Can this timeframe be decreased?
Yes considerably if you are able to get assistance from someone experienced in the accreditation process or hire a reputable consulting service that can verify past accreditations.
Q: How much does it cost?
Not including consulting services the 2009 application fee for either AASM accreditations is $3,800.00 and for $3,375 for TJC Ambulatory Care accreditation.
Q: Where do I start?
Visit the following website links for details on the different accreditation standards and process requirements at www.aasmnet.org and www.jointcommission.com.
Q: How does LAAP compare to other accreditation services?
The LAAP team has a perfect record of accrediting sleep labs since 1985 with a very low proviso rate offered at affordable costs. |
