Sleep Medicine Certification and Accreditation

Brian W Carlin MD FAARC

Introduction Certification and Credentialing of Individuals Certification of Polysomnographic Technologists Certification of Respiratory Therapists Certification of Physicians Accreditation of Sleep Facilities American Academy of Sleep Medicine Joint Commission Accreditation Commission for Health Care Summary

Sleep-disorders medicine is undergoing substantial evolution in terms of testing and therapy. In order to ensure that the providers of care for patients with sleep disorders provide quality and safe care, various types of individual certification and sleep-disorders-center accreditation programs have been developed. These programs should help to ensure optimal patient care. Key words: certification; accreditation; registered polysomnographic technologist; RPSGT; sleep disorders specialist; CRT-SDS; RRT-SDS. [Respir Care 2010;55(10):1377–1385. © 2010 Daedalus Enterprises]

Introduction ics.1 Sleep-disorders medicine is a rapidly evolving field. The evolution in terms of newer diagnostic techniques and The Committee on the Health Professions, from the informatic and therapeutic technology will dictate the need Institute of Medicine of the National Academies, devel- for increased educational and clinical experience. This ex- oped a vision for clinical education in the health profes- perience will ultimately need to be translated to patient sions, recommending that all health professionals should care. Mechanisms to determine that optimal patient care is be educated to deliver patient-centered care as members of being delivered will need to be developed. an interdisciplinary team, emphasizing evidence-based A key component in the evolution of technology and practice, quality-improvement approaches, and informat- education is the certification of practitioners and accreditation of sleep-disorders centers. In order to ensure that professionals have developed the basic skills necessary to Brian W Carlin MD FAARC is affiliated with Allegheny General Hos- provide quality care, assessment of the knowledge, skills, pital, Drexel University School of Medicine, Pittsburgh, Pennsylvania. and attributes of a healthcare provider in the field of sleep- disorders medicine is essential. In order to make certain Dr Carlin presented a version of this paper at the 45th RESPIRATORY CARE Journal Conference, “Sleep Disorders: Diagnosis and Treatment,” held that sleep-disorders centers are providing quality and safe December 10-12, 2009, in San Antonio, Texas. care, assessment of various standards of practice is also Dr Carlin has disclosed a relationship with the National Board for Re- essential. In a Web-based survey, accreditation or certifi- spiratory Care. cation of sleep centers and physicians was associated with better indexes of clinical management for patients who Correspondence: Pulmonary and Critical Care, Allegheny General Hos- 2 pital, 490 East North Avenue, Suite 300, Pittsburgh PA 15212. E-mail: have obstructive sleep apnea. This discussion will center [email protected]. on the mechanisms available for individual certification of

RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 1377 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION healthcare providers of sleep services, as well as the mech- mate of the percentage of minimally knowledgeable can- anisms available for sleep-disorder center accreditation. didates who would answer each question correctly. After collecting data from the panelists, the minimally accept- Certification and Credentialing of Individuals able score is calculated by examining the estimates for each question and deleting the outliers and then averaging the panelist’s estimates and determining the number of Certification refers to the confirmation of certain char- questions that corresponded to the statistic obtained. The acteristics of an object, person, or organization. This con- panelists were then able to recommend a cut score for the firmation is often provided by some form of external re- examination. The final passing score was then based on view, education, or assessment. A common type of this pooled judgment and included a statistical adjustment certification is professional certification, where a person is for testing error. The BRPT was ultimately responsible for certified as being able to competently complete a job or the final decision regarding the passing point. task, usually by passing an examination. The RPSGT examination consists of 200 multiple-choice Credentialing is the process of establishing the qualifi- single-best-answer questions. One hundred fifty of these cations of organizational members or organizations, and questions compose the actual test and count toward the assessing their background and legitimacy. This process candidate’s score, while the other 50 questions are “pre- helps to ensure that the provider meets a minimum stan- test” items and do not count toward the final score. These dard for the provision of a particular service. Through “pre-test” items are evaluated and, if acceptable, are then credentialing it is hoped that a patient who is receiving a banked to potentially be included in newer versions of the particular service will subsequently be provided that care examination. by a qualified person. There are several pathways, based upon the level of Currently there are 2 types of certification processes training and experience that a candidate may use to be- available for professionals who provide care for patients come eligible for the examination. Regardless of the path- with sleep disorders. These include certification of tech- way used for eligibility, candidates must hold certification nologists and therapists through the Board of Registered in basic cardiac life support or the equivalent, including a Polysomnographic Technologists (BRPT) and the National hands-on practical training evaluation segment. In addi- Board for Respiratory Care (NBRC), as well as certification, candidates must follow the BRPT standards of con- tion of physicians and PhDs through the American Board duct and policies and procedures.4 of Sleep Medicine (ABSM) and the American Board of Medical Specialties (ABMS). Pathway 1-A The candidate must complete a minimum of 18 months of paid clinical experience, where at least Certification of Polysomnographic Technologists 21 hours per week per calendar year on the job duties performed are direct patient recording of polysomnogra- The BRPT administers a certification program that leads phy and/or scoring (during a 3-year period prior to the to the Registered Polysomnographic Technologist examination). The candidate must also have completed the (RPSGT) credential, based on practices that measure the AASM A-STEP (Accredited Sleep Technologist Educa- knowledge, skills, and abilities of technologists in the field tion Program) self-study (online) modules, or a BRPT- of sleep-disorders medicine. This certification is based upon designated equivalent education program. The candidate successful completion of a computer-based examination. must also have completed secondary education. The examination is based upon a job analysis that reflects current practice. This job analysis is performed every 5 years Pathway 2-A The candidate must complete a minimum to maintain currency with the practice of sleep-disorders of 6 months of paid clinical experience where at least testing and treatment. Based upon this job analysis, a new 21 hours per week per calendar year of on the job duties version of the examination is developed. performed are direct patient recording of polysomnogra- The current version of the BRPT examination was de- phy and/or scoring (during a 3-year period prior to the veloped in 2005. This examination was designed to assess examination). Each candidate must hold a credential in minimally acceptable knowledge in the duties performed one of the following allied health fields: nursing, respira- by an RPSGT. The modified Angoff technique was used to tory care, electroneurodiagnostics, physician assistant, determine a recommended cut score.3 A panel of 13 reg- medical doctor, or emergency medical technician- istered polysomnographic technologists representative of paramedic. the profession in North America were trained by experts in the standard setting method for establishing a recommended Pathway 3-A The candidate must successfully complete passing score. Following training, the panelists reviewed a program in polysomnographic technology accredited by each question on the examination and recorded their esti- the Commission on Accreditation of Allied Health Edu-

1378 RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION cation Programs (CAAHEP). This program may be a stand- Table 1. RPSGT 2010 Examination Blueprint Domains alone program or attached to a program in respiratory or electroneurodiagnostics. Currently in the United States Domain %* there are 12 respiratory therapy advanced level programs Pre-study procedures 15 with a polysomnogram concentration component of train- Study performance 25 ing, 12 neurodiagnostic technologist programs with poly- Therapeutic intervention 25 somnogram concentration component of training, and 24 Post-study procedures 10 stand-alone polysomnogram training programs. Scoring and data analysis 25

* These percentages reflect the number of questions in that particular domain that are on the Pathway 4-A The candidate must successfully complete examination. ϭ a minimum of 9 months of paid clinical experience where RPSGT Registered Polysomnographic Technologist at least 21 hours per week per calendar year of on the job duties performed are direct patient polysomnography recording and/or scoring (completed within a 3-year period with the exam content based on introductory-level topics, prior to the examination). The candidate must complete with an examination blueprint mirroring the RPGST ex- the A-STEP introductory course as well as the A-STEP amination.7 self-study (online) modules or a BRPT-designated alter- nate education program. Certification of Respiratory Therapists

The examination is based on a content outline that is The NBRC developed the Sleep Disorders Specialist based on the job analysis. Five domains of questions are (SDS) examination for certified respiratory therapists included on the examination “blueprint.” These include (CRTs) and registered respiratory therapists (RRTs), to questions on pre-study procedures, study performance, ther- assess the knowledge-based competency for those thera- apeutic intervention, post-study procedures, and scoring pists practicing in the field of sleep-disorders medicine.8 and data analysis. The percentages of overall test questions The examination was developed using similar means to from each domain are shown in Table 1. those of the RPSGT examination. A 5-step process was There are nearly 14,000 RPSGT-credentialed sleep tech- used, which included a viability study, a personnel study, nologists worldwide, and this number has doubled in the a job-analysis study, test-specification development, and a past 4 years and can be expected to continue to increase. criterion-related validation study. The purpose of the NBRC Various regulatory requirements currently exist regarding credential is to document that a candidate has met a min- RPSGT practitioners. The Centers for Medicare and Med- imum achievement standard while performing the job of a icaid Services require that polysomnogram testing be mon- sleep-disorders specialist. A process similar to the RPSGT itored by a credentialed technologist (RPSGT) when per- examination was used for the determination of the passing formed in an independent diagnostic testing facility.5 In (“cut score”) score. addition, the AASM facility accreditation guidelines re- The SDS examination program is designed specifically quire at least one RPSGT be on staff and that all other for a respiratory therapist who has an NBRC respiratory technologists be enrolled in an education program leading care credential and experience or education in the field of to RPSGT examination eligibility.6 sleep-disorders medicine. Depending upon the baseline cre- In March 2010, the BRPT began offering a new certif- dential attained by the candidate, successful completion of icate level examination. This examination is designated as this examination will enable the candidate to declare cer- the Certified Polysomnographic Technologist (CPSGT) ex- tification as either a CRT-SDS or RRT-SDS. Candidates amination. This is the first step in establishing a tiered for the examination have already demonstrated their min- credentialing system in sleep technology by the BRPT. imal competence (through attainment of the CRT or RRT This certificate will not be a prerequisite for sitting for the credential) in some of the areas used when diagnosing and RPSGT examination but rather an entry-level certificate treating patients with sleep disorders, and are thus not for those entering the sleep technology profession. A can- retested on those particular areas of content. The SDS didate will be able to sit for the examination with a min- examination focuses on competencies that are unique to imum of 3 months of full-time experience in sleep and the diagnosis and treatment of patients with sleep disor- hold a high school diploma or the equivalent, a current ders and does not include content about general respiratory cardiopulmonary resuscitation/basic life support certifica- care. tion, and verification of completion of a designated subset Candidates may gain entry to the examination through a of the American Academy of Sleep Medicine (AASM) variety of means, based upon their previous NBRC certi- A-STEP self-study online modules. The examination con- fication status, clinical experience, and education. These sists of 75 multiple-choice single-best-answer questions, pathways include:

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Pathway 1-A The candidate must be a CRT or RRT Table 2. SDS 2010 Examination Blueprint Domains having completed a CAAHEP-accredited respiratory therapist program that included a sleep add-on track. Domain %* Pre-testing 12 Pathway 2-A The candidate must be a CRT with 6 months Sleep disorders testing 30 of full-time clinical experience following certification in a Study analysis 31 sleep diagnostics and treatment setting under medical su- Administrative functions 9 pervision (MD, DO, or PhD). Full-time clinical experience Treatment plan 18 is defined as a minimum of 21 hours per week per calendar * These percentages reflect the number of questions in that particular domain that are on the year. examination. SDS ϭ Sleep Disorders Specialist Pathway 3-A The candidate must be an RRT with 3 months of full-time clinical experience following certification in a sleep diagnostics and treatment setting under examination has an emphasis on not only sleep-disorders medical supervision. testing but also management of patients with sleep-disor- dered breathing. This examination can be taken throughout The examination was first offered in December 2008. It the year on most days, with the results provided to the consists of 180 multiple-choice single-best-answer ques- candidate at the immediate conclusion of the test. tions. Twenty of the questions are “pre-test” questions and Competency testing for the credentialing of individuals do not count as part of the final score. A total of 4 hours ensures the knowledge level of technologists/therapists in is allowed for completion of the examination. The exam- the field. The National Commission for Certifying Agen- ination is scheduled at a computer-based testing agency cies (NCCA) is the accreditation body of the Institute for and can be taken at any time during the year, based upon Credentialing Excellence (formerly known as the National such scheduling. Organization for Competency Assurance). This agency es- Five major content areas are contained within the ex- tablishes standards for credentialing agencies that help to amination, including: pre-testing, sleep-disorders testing, ensure that a particular organization has developed the study analysis, administrative functions, and treatment plan. appropriate standards and processes upon which to base The percentages of questions in each content area are listed credentialing “best practices.” Both the BRPT and the in Table 2. Each content area is tested using a variety of NBRC are NCCA-accredited organizations. The RPSGT cognitive levels of knowledge, including recall, applica- examination has been validated and reviewed by the NCCA. tion, and analysis. Candidates who earn the SDS credential The SDS examination has recently undergone validation are required to demonstrate continued competence through and has been submitted to the NCCA for review. the NBRC’s continuing competency program every 5 years. While both examinations (RPSGT and SDS) have un- Certification of Physicians dergone a similar development process, there are some differences between the examinations. The RPSGT exam- Certification for physicians is also available. Beginning ination is offered to a wide variety of medical personnel in 1978, the AASM developed and began administration and tests both basic and advanced concepts regarding sleep- of a competency examination for physicians in the field of disorders testing. Prior to June 2010 this examination was sleep disorders. In 1991 the ABSM was created and as- offered only during various times (known as windows) sumed responsibility of the examination until 2006. Over through the year. The results of the test were then distrib- a 28-year period, 3,445 individuals earned the credential uted within several weeks following the end of that par- of Diplomate of the ABSM. The examination evolved over ticular testing window. As of June 2010, the examination the years, beginning with both written true/false questions, is offered via an “on-demand” basis. The candidate applies along with an oral examination, to a 2-part examination for acceptance to the examination, and once approved for consisting of multiple-choice questions and essay response- the examination the candidate is then able to schedule a based questions to, most recently, a computer-based ex- time to take the examination. Each test is administered in amination consisting only of multiple-choice questions. a computer-based testing center over a 4-hour period. The The last ABSM examination was administered in 2006. results are then forwarded to the candidate following com- The ABSM certificate is time-unlimited, meaning that can- pletion of the examination. didates who successfully complete the examination are The SDS examination is offered only to respiratory ther- certified by the ABSM for life. apists who have previously earned the CRT or RRT cre- Beginning in 2007, a certification examination in sleep dential and consists of testing concepts that are in addition medicine was administered under co-sponsorship of 5 to those tested at the level of the respiratory therapist. This ABMS member boards: the American Board of Internal

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Medicine (http://www.abim.org), the American Board of a means to measure the internal processes, organizational Family Practice (https://www.theabfm.org), the American management, patient safety practices, and treatment and Board of Otolaryngology (http://www.aboto.org), the service outcomes. The process helps to ensure that the American Board of Pediatrics (http://www.abp.org), and healthcare facility is providing competent testing and care the American Board of Psychiatry and Neurology (http:// and helps to certify to third parties that the facility is www.abpn.com). The examination is a computer-based behaving in an ethical manner and employing suitable qual- test consisting of multiple-choice questions, and is admin- ity-assurance measures. In most instances (and certainly in istered every other year. Candidates who successfully pass the instance of sleep-disorders testing), this is a peer- the examination are given a credential that is valid for developed and reviewed process that is provided through a 10 years, following which recertification is required. nonprofit organization. This structure has established higher The same examination is administered to candidates from standards than state or federal requirements. Accreditation each of the 5 member boards. The exam is designed to of a sleep-disorders center is a voluntary process and cur- evaluate the extent of a candidate’s knowledge and clinical rently is provided by one of 3 organizations: the AASM, judgment in the field of sleep-disorders medicine. A spe- the Joint Commission, and the Accreditation Commission cific pre-established blueprint of content has been devel- for Healthcare (ACHC). oped and is used as a guide in developing the examination. Content areas include normal sleep and variants, organ American Academy of Sleep Medicine system physiology in sleep, sleep evaluation, pharmacol- ogy, disorders related to sleep-wake timing, insomnia, hy- The AASM has been accrediting sleep laboratories and persomnolence, parasomnias, sleep-related movement dis- sleep-disorders centers since 1977. The AASM is a pro- orders, sleep-related breathing disorders, and childhood fessional medical organization representing those profes- sleep disorders. sionals who practice sleep medicine and sleep research. Eligibility for candidates to take the examination de- The accreditation process of the AASM is based upon the pends upon the candidate’s particular area of prior certi- organization’s Standards for Accreditation,6 which were fication (eg, internal medicine, family practice, otolaryn- developed to ensure that the highest level and quality of gology, pediatrics, or neurology/psychiatry). A physician care is delivered to patients with sleep disorders. They who is certified by the ABIM as an internist has 2 path- describe the required structural, professional, and human ways (practice and training) by which to become eligible resources; clinical and technical standards; and emergency for the examination. Practice pathway A is open to can- and quality-assurance methods required for accreditation. didates who have been practicing sleep medicine for a In addition, accredited facilities must follow the standards minimum of 12 months accumulated over a maximum of of the AASM’s practice parameters, which cover a variety 5 years prior to the application and involving a minimum of topics and were developed through a rigorous evidence- experience of evaluating 400 individual patients, as well as based methodology. A list of the accreditation standard interpreting and reviewing the complete raw data of 200 topics is shown in Table 3. polysomnograms and 25 multiple sleep latency tests. Prac- The facility must have a single medical director who is tice pathway B is open to candidates who are currently a licensed physician within the state where the facility is certified by the ABSM. The Training pathway requires the located. The medical director is responsible for the direct candidate to complete 12 months of clinical sleep medi- and ongoing oversight of testing and is responsible for the cine fellowship training in a program that is certified by qualifications of all medical and testing personnel. He/she the Accreditation Council on Graduate Medical Education. must be present within the facility for at least 8 hours per Each of the other member boards has specific policies for entry to the examination. The various pathways for eligibility for certification can be found at the individual ABMS Table 3. AASM Standards for Accreditation boards’ Web sites. Recently the member board of the Amer- Personnel ican Osteopathic Association approved new practice path- Patient policies ways for eligibility for a sleep-medicine examination pro- Facilities and equipment vided by the American Osteopathic Board of Internal Policies and procedures Medicine.9 Data acquisition, scoring, and reporting Patient evaluation and care Accreditation of Sleep Facilities Patient records Emergency procedures The quality of healthcare facilities differs from one site Quality assurance to another. Accreditation is a process in which certification AASM ϭ American Academy of Sleep Medicine of competency, authority, or credibility is presented. It is

RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 1381 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION month and can serve as the medical director of no more the facility. A plan for equipment maintenance is also than 3 sleep facilities, regardless of their accreditation sta- necessary. tus. All data acquisition and storage must comply with the Each facility must designate a single professional who AASM standards. All reports and scoring must also com- is either board certified by the ABSM or by a member ply with these standards. All raw data from the study must board of the ABMS as the medical director. This profes- be reviewed by the physician interpreting the study. The sional could also be accepted by the ABMS-approved board center’s physicians must demonstrate the ability to man- to sit for the next examination in sleep medicine or who age patients with a wide variety of sleep disorders. The has completed a 12-month fellowship in sleep medicine ongoing evaluation and management of such patients must and is awaiting the next available examination. The board- be documented, including follow-up of treatment with pos- certified sleep specialist must provide direct and ongoing itive airway pressure. A cumulative database of the pa- oversight of the testing and quality of testing, as well as tient’s final diagnosis (including any procedures performed) facilitate the quality-assurance program of the facility. must be maintained by the facility. Accredited sleep facilities must maintain appropriately A written emergency plan must also be available that trained and supervised technologists, with a staffing ratio describes the details for contacting emergency personnel of patients to technologists not greater than 2:1. A mini- under a wide variety of medical and nonmedical condi- mum of one sleep technologist must be certified by the tions. At a minimum, the policies must include procedures BRPT (or accepted to sit for the BRPT examination) or an for cardiac, neurologic, psychiatric, and environmental equivalent examination accepted by the AASM. All tech- emergencies. All appropriate emergency equipment that is nologists and technicians who are not certified by the BRPT described within these policies must be readily available at must be enrolled in or have completed the AASM’s A- the facility. STEP self-study modules, or must be enrolled in or have A quality-assurance program that addresses several qual- completed a CAAHEP-accredited sleep-technology train- ity indicators must performed by the facility. Inter-scorer ing program, or an electroneurodiagnostic program, or a reliability monitoring, along with 3 other quality indicators respiratory-therapy add-on track for sleep technology. All (eg, testing turnaround time, positive-airway-pressure com- medical personnel, physicians, and technologists must pliance rates, technologist study performance, patient sat- maintain active participation in continuing medical educa- isfaction) must be performed and reviewed by the medical tion. director or center’s board-certified sleep specialist at least The facility must have a written acceptance policy for quarterly. patients to receive care at the center. At least 20% of the An application for accreditation is completed and filed patients must be seen in consultation by a sleep facility staff, either prior to or within 3 months following a sleep along with an accreditation fee of $3,800. The AASM study. All other patients must have their records reviewed national office will review the application and will deter- by a sleep facility staff physician to determine if the pro- mine whether the facility is eligible for a site visit. If posed evaluation conforms with the established AASM deemed not acceptable, the AASM will notify the facility practice parameters. Each patient who is accepted for test- of the requirements that the center must meet in order to ing must undergo such testing in compliance with the Prac- become eligible for such a visit. The facility will then have tice Parameters for the Indications for Polysomnography the opportunity to address the deficiencies, and the AASM and Related Procedures10 and the Clinical Guidelines for will then again consider whether the facility is eligible for the Use of Portable Monitoring in OSA (obstructive sleep a site visit. apnea).11 Once the facility is eligible, the AASM will coordinate Standards addressing the space requirements, including a site visit with the facility and the site visitor, who will provisions to provide emergency care within such space, if then visit the laboratory, with the review typically taking necessary, are also included. The facility must maintain place during a 6-hour period, beginning in the morning. equipment as described in the AASM Manual for the Scor- The site visitor will speak with the center’s administrative ing of Sleep and Associated Events: Rules, Terminology, staff, physician staff (medical director and physicians who and Technical Specifications,12 and must maintain equip- interpret studies or see patients in the center), and tech- ment for the delivery of positive-airway-pressure therapy. nologist staff. He/she will review all pertinent information Written protocols (paper or electronic forms) must be and several patient records, including evaluation, manage- maintained by the facility. These include policies and pro- ment, and testing records. All site visitors are board-cer- cedures for standard sleep-disorders testing (eg, polysom- tified sleep specialists and are current or previous medical nography, multiple sleep latency testing, maintenance of directors or directors of AASM accredited centers. A re- wakefulness testing, and positive-airway-pressure titra- view of the site visitor’s findings is provided at the end of tion), as well as any other types of testing provided within the site visit.

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Following the visit, the site visitor will prepare a de- agement, provision of care, performance improvement, tailed report that will be forwarded to the AASM board of record of care, treatment and services, rights and respon- directors. The board will then decide on one of 3 recom- sibilities of the individual, and waived testing. mendations: full accreditation, accreditation with provisos, Web-based tools are used to assist with the process, and or accreditation denied. If granted accreditation with pro- an on-site survey assists with evaluation of direct patient visos, the center will need to meet those stipulations that care and the role of the staff.13 Emphasis for the process is were noted by the board within a specified deadline in on the organization’s systems of the provision of care and order to obtain accreditation. If the center does not meet ongoing improvement and tailoring of standards. A “tracer” the stipulations within 3 months from the date of the de- system is used to track a patient’s movement through the cision letter, the review process is terminated by the AASM system. Few formal interviews are conducted, with more and the application for accreditation is withdrawn. attention being paid to the staff and direct patient care. The The option to undergo accreditation by the Joint Com- process focuses on the execution of the delivery of care mission exists, as certain payers accept this accreditation and services. This system will trace up to 4 patients through as an alternative to the AASM accreditation. The accred- the care process and the facility, and uses the patient chart itation is often completed by hospitals during the overall as the “road map.” Dialogue on the use of various forms of Joint Commission hospital accreditation process. Some data and infection prevention is contained within the re- payers may not consider the hospital-wide accreditation view. The process seeks to help an organization identify acceptable and require a more specific sleep-laboratory and correct problems, with the ultimate desire to improve accreditation site visit. the safety and quality of the care and services provided. The on-site process is designed to accommodate a sleep Joint Commission center’s normal operational systems and schedules. Typi- cally, a 2-day survey is scheduled for the first survey, and The Joint Commission recently developed an accredi- includes observation of an overnight sleep study. The cen- tation process for sleep-disorders centers. The Joint Com- ter will receive a summary of the findings at the conclu- mission is a non-governmental, not-for-profit organization sion of the site visit, with a preliminary decision obtained that was constructed in 1951 to act as an independent within 48 hours. If there are requirements necessary for accrediting body for healthcare organizations worldwide. improvement, the center may submit further evidence for Beginning in 1975, the Joint Commission established the compliance with the standards within 60 days. The final Ambulatory Health Care Accreditation Program to encour- accreditation decision is then processed. age high-quality patient care in the settings of a non-hos- The Joint Commission uses “employee” surveyors that pital-based care program (eg, freestanding ambulatory are ambulatory professionals who work part-time for the healthcare facilities).13 A total of over 15,000 organiza- Joint Commission. Each surveyor undergoes initial and tions are accredited by the Joint Commission. It offers a yearly training and must pass a certification examination comprehensive package of services that can be used as a to help ensure consistency in the survey process. Defined, management tool to enhance quality of care and service, fixed pricing fees are posted on the Web site and are billed patient and staff safety, organizational risk management, over a 3-year period.13 All accreditation decisions are valid and continuous performance improvement. Any healthcare for a 3-year period. organization may apply for Joint Commission accreditation, provided all of the following requirements are met: Accreditation Commission for Health Care the organization assesses and improves the quality of its services; the organization identifies the services it pro- The ACHC has been involved in the accreditation of vides; the organization provides services addressed by the various types of healthcare organization since 1986. More Joint Commission’s Ambulatory Care standards; and the than 10,000 locations have been accredited worldwide. organization is in the United States or one of its territories. Primarily involved in the accreditation of home healthcare Sleep-disorders centers fall under this type of accreditation companies, durable medical equipment suppliers, and hos- program. pice, the ACHC began in 2009 to design an accreditation The accreditation process for sleep-disorders centers is program for facilities that provide sleep diagnostic testing. similar to the process used by the Joint Commission for The program focuses on patient care and outcomes of the other ambulatory care centers. Standards of care must be sleep testing process. met and address patient-focused requirements. These stan- The program includes a preliminary evidence report that dards are organized around functions and processes, and is a compilation of the facility’s policies and procedures, include environment of care, emergency management, hu- matched to ACHC’s accreditation standards. The ACHC man resources, infection prevention and control, informa- standards include business operations and administration, tion management, leadership, life safety, medication man- financial management, human-resource management, con-

RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 1383 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION sumer services/records, quality improvement and out- Summary comes, and equipment and patient safety. Following review of the report, recommendations for The practice of sleep-disorders medicine is constantly changes to the policies and procedures are made to the evolving. This evolution includes diagnostic testing, ther- facility, and a site visit is then scheduled. Actual observa- apeutic management, and credentialing and accreditation tion of patient care is then performed at the time of the site processes. Certification of individuals practicing sleep-dis- visit. Some third-party payers have recognized the ACHC orders medicine can be attained through a variety of means process for accreditation in regard to reimbursement for for technologists, respiratory therapists, and physicians. testing services provided. Further details regarding the ap- Such certification helps to ensure a minimum level of plication process as well as the fees involved can be ob- competency of the practitioner. Accreditation of sleep- 14 tained through the ACHC. disorders centers can be obtained through the AASM, the While the process for accreditation differs somewhat Joint Commission, or the ACHC. Accreditation helps to among these 3 accrediting agencies, there are certain sim- ensure that the center maintains a standard of care and ilar characteristics. Sleep-specific criteria for accreditation quality processes that will ultimately ensure optimal test- are included in each process. In addition, a certified phy- ing and patient safety. Currently certification and accred- sician must also be included as part of the process. itation are intimately involved in reimbursement for the Accreditation of sleep facilities has many benefits. In provision of services in many areas throughout the coun- addition to being recognized as a benchmark for quality try. review and achievement, it demonstrates that the facility’s Both certification of individuals and accreditation of staff has met defined education standards. Accreditation sleep centers will continue to evolve in the coming years. gives each staff member a sense of accomplishment in The measures currently being used to ensure competency meeting standards that have been benchmarked and en- for individuals will probably undergo further changes in ables staff members to have an increased sense of pride order to ensure that practitioners are up to date on the when providing patient care. Accreditation demonstrates practice of sleep medicine. Accreditation will probably be to third-party payers that the center has met a defined set expanded, given the increasing requirements that sleep- of standards. Accreditation may help to secure reimburse- disorders centers have accreditation in order to be pro- ment and help to expand market opportunities and increase vided reimbursement. All of these changes will help to patient evaluation and testing services. Some payers actu- ensure that those patients who are undergoing sleep-dis- ally require accreditation, although this varies from one orders testing and treatment receive the best care possible. area of the country to another and from one third-party payer to another. Certification and accreditation are becoming much more REFERENCES important, particularly in terms of reimbursement by third- party payers. The Centers for Medicare and Medicaid Ser- 1. Greiner AC, Knebel E, editors. Health professions education: a bridge vices currently recognize the accreditation of the AASM to quality. Washington, DC: National Academies Press; 2003. http:// ϭ and the Joint Commission, but not the ACHC. Certified www.nap.edu/openbook.php?record_id 10681. Accessed August 6, 2010. technologists (eg, currently the RPSGT) must perform the 2. Parthasarathy S, Haynes PL, Budhiraja R, Habib MP, Quan SF. A sleep-disorders testing in independent diagnostic testing national survey of the effect of sleep medicine specialists and Amer- facilities. Coverage of continuous-positive-airway-pressure ican Academy of Sleep Medicine accreditation on management of devices is allowed, based on the diagnosis of obstructive obstructive sleep apnea. J Clin Sleep Med 2006;2(2):133-142. sleep apnea, based on portable-monitor testing. Interpre- 3. Angoff WH. Scales, norms, and equivalent scores. In: Thorndike RL, editor. Educational measurement, 2nd edition. Washington, DC: tation of portable-monitoring results in this situation must American Council on Education; 1971:508-600. be performed by a board-certified sleep physician or a 4. Board of Registered Polysomnographic Technologists. BRPT can- physician who is a member of the staff of an accredited didate handbook, 2010 edition. Registered polysomnographic tech- sleep-disorders center. Local coverage determinations for nologist. http://www.brpt.org/exam_info/brpt_handbook.pdf. Ac- various Medicare administrative contractors have been is- cessed August 6, 2010. 5. US Department of Health & Human Services, Centers for Medi- sued that require independent diagnostic testing facilities care & Medicaid Services. http://www.cms.gov. Accessed August and all other non-hospital-based facilities where sleep stud- 6, 2010. ies are performed to have evidence on file that they are 6. American Academy of Sleep Medicine. Standards for accreditation fully or provisionally certified by the AASM as a sleep- of sleep disorders centers. http://www.aasmnet.org/resources/pdf/ disorders center. Information regarding coverage issues dec2008centerstandards.pdf. Accessed August 6, 2010. 7. Board of Registered Polysomnographic Technologists. BRPT can- for a particular region of the country can be found at the didate handbook, 2010 edition. Certified polysomnographic technol- Centers for Medicare and Medicaid Services and Medicare ogist. http://www.brpt.org/exam_info/cpsgt-handbook.pdf. Accessed administrative contractors Web sites.15-17 August 6, 2010.

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8. NBRC. Sleep Disorders Specialty Examination. https://www.nbrc. 13. The Joint Commission. How to become accredited. http:// org/examinations/sds/tabid/92/default.aspx. Accessed August 6, 2010. www.jointcommission.org/accreditationprograms/ambulatorycare/ 9. American College of Osteopathic Internists. http://www.acoi.org. Ac- htba/ahc_accreditation. Accessed August 6, 2010. cessed August 6, 2010. 14. Accreditation Commission for Health Care. Accreditation pro- 10. Kushida CA, Littner MA, Morgenthaler T, Alessi CA, Bailey D, cess. http://achc.org/accreditation_process.php. Accessed August Coleman J, et al. Practice parameters for the indications for poly- 6, 2010. somnography and related procedures: an update for 2005. Sleep 15. Centers for Medicare & Medicaid Services. Part A/Part B Medicare 2005;28(4):499-519. administrative contractor. http://www.cms.gov/medicarecontracting 11. Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, reform/07_partaandpartbmedicareadministrativecontractor.asp. Ac- Gottlieb DJ, et al. Clinical guidelines for the use of unattended cessed August 6, 2010 portable monitors in the diagnosis of obstructive sleep apnea in adult . patients. J Clin Sleep Med 2007;3(7):737-747. 16. American Academy of Sleep Medicine. Portable monitoring. http://www. 12. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM manual aasmnet.org/portablemonitoring.aspx. Accessed August 6, 2010. for the scoring of sleep and associated events: rules, terminology, 17. Trailblazer Health Enterprises. Local coverage determinations. http:// and technical specifications. American Academy of Sleep Medicine; www.trailblazerhealth.com/tools/lcds.aspx?domainidϭ1. Accessed 2007. August 6, 2010.

Discussion tries. The examination development Carlin: Not yet. Once the examina- was through the AMP [Applied Mea- tion has undergone the validation part Minkley:* The RPSGT [Registered surement Professionals Incorporated], of the process, the NBRC will then Polysomnographic Technologist] cre- which is the NBRC’s exam develop- apply to the NCCA [National Com- dential has a progression of development arm, so it was the same rigorous mission for Certifying Agencies] for ment very similar to the RRT [Regis- development as the respiratory care recognition of the SDS as a validated tered Respiratory Therapist] and CRT credentials. examination. Once that happens, I sus- [Certified Respiratory Therapist] cre- In regards to lab accreditation for pect discussions with CMS [Centers dentials. hospital-based labs, hospital-based for Medicare and Medicaid Services] The same job task analysis and that labs may get a visit from the tracker will occur regarding allowing RTs same 5-step process used for respira- from the Joint Commission. They with the SDS credential to care for a tory care credentials was followed for don’t separately accredit them, but be- Medicare patient in the same manner its development and maintenance. The cause they’re within the hospital the that an RPSGT does. In addition, dis- maturation of the RPSGT credential Joint Commission often comes cussion with the AASM will probably and addition of the CPSGT [Certified through and their tracker will ask to Polysomnographic Technologist] by occur to allow recognition of the SDS track a patient, mainly looking at credential as part of the sleep labora- the BRPT [Board of Registered Poly- proper documentation and that they tory accreditation process. somnographic Technologists] is not adhere to national patient safety goals. unlike that of the NBRC [National It’s not a separate accreditation, but Board for Respiratory Care] and RRT because they occupy the same loca- Quan: So if someone wanted to take credential some 30 years ago. The tion, they get a site visit. an exam who didn’t have a certificate, BRPT started with a written exam with it wouldn’t make sense to take the orals, and then we went to a standard- Carlin: Yes, and then they are ac- newer exam now, when they may not ized validated exam—that same pro- credited under the umbrella of the hos- be able to be hired at an accredited cess. I chaired the committee that de- pital. lab. veloped the RPSGT exam. The interesting thing with the RPSGT is Minkley: Of that hospital, yes. But that the job task analysis is re-certi- it’s not a separate sleep accreditation; Carlin: Yes. That is one of the ben- fied or validated every 5 years, or it’s just saying that the sleep center is efits of the RPSGT credential at sooner if growth in the field necessi- operating within the hospital, so they present. tates it. It also is validated as an in- need to meet the same standards. ternational credential, which is unique Malhotra: What’s the deal in Cal- in allied health credentialing; people Quan: If you study a Medicare pa- ifornia? I heard that there was some can go back and forth between coun- tient in your laboratory, you need to bill that Schwarzenegger didn’t sign, have an RPSGT do the study. Does but there was a mandate that there has to be an RT there to give noninvasive * Pamela Minkley RRT RPSGT CPFT, Home Medicare recognize the new SDS Healthcare Solutions, Philips Respironics, Mon- [Sleep Disorder Specialist] certifica- ventilation or something—some weird roeville, Pennsylvania. tion? thing that’s the opposite of Medicare.

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Carlin: In California there have is a minimum standard for certifica- ulum. Oftentimes the RTs are taking been discussions on proposed legisla- tion of technologists and RTs practic- the sleep components in addition to tion. ing sleep medicine, and that there are their respiratory curriculum, so they’re now 2 testing processes that can be coming out eligible for dual creden- Minkley: That is actually the result used in that certification determina- tials: sleep and respiratory. The same of a state licensure issue—a growth tion. for neurodiagnostic schools. It’s a win- issue in the sleep field, with RTs be- win situation all the way around. ing licensed and sleep technologists Minkley: It’s an interesting chal- not, so there was an issue with scope lenge. Sleep is a new profession and Malhotra: Hopefully, this is not a of practice. This is a good thing for it’s grown up in the internet age and radical suggestion, but would it make this group to discuss, for us to say that the age of direct consumer advertis- any sense for us to include in this dis- we’re all in this to keep our patients ing, where the demand for sleep med- cussion that there was general agree- safe; let’s stop this craziness. icine and technology services comes ment that we should work together? much more quickly than it did for re- Malhotra: What would it take for spiratory care. I think if the field had Parthasarathy: Yes, I think that’s us to all apply the same standards? It grown up in an earlier age, as did re- a great idea. It appears that there are seems like we’re all fighting each spiratory therapy, we wouldn’t be hav- many sleep societies and then we also other. ing these issues. But the demand is so have all the official state societies, so high, we should be working together what struck me is that the side-by- Minkley: It doesn’t make sense. If to make sure qualified people are not side comparisons of standards that you nursing had had the same stick-to- only with our patients in the sleep cen- showed for the SDS and the RPSGT itiveness with challenging respiratory ters but all the other places RTs need are very comparable. What’s wrong care in the beginning, the field be where there’s a demand for them with joining forces? wouldn’t be what it is today. But now that can’t be met. Forcing sleep cen- respiratory care seems to want to chal- ters to require RRTs without specific Malhotra: I’m not sure that we lenge the sleep folks, who are behind training in all the aspects of sleep med- should necessarily draw that conclu- them in the development, but are de- icine and technology other than ven- sion, just based on this, but the gen- veloping quickly, responsibly, and tilation where they don’t have exper- eral concept is that we should all work similarly to respiratory care itself. We tise is irresponsible for sleep center together for the health of our patients. should work together and make it work patients and creates a shortage in other for our patients, because we’re both areas where RRTs are needed. Minkley: Absolutely. In Michigan wasting resources. The sleep field is developing edu- the respiratory groups have been cation pathways just like respiratory around longer and we have stronger Carlin: From what I understand, care did; the processes are the same, state organizations to help lobby conversations have occurred at the the evolution is the same. Certificate within the state legislature for the highest levels of both the AARC and degree schools are coming online needs of our patients. We joined forces. [American Association for Respira- at a fast pace. A curriculum has been It makes more sense economically. We tory Care] and the AASM to try to developed by the AAST [American have our meetings together, we mix work out something reasonable and Association of Sleep Technologists], together, and we’re trying to get the fair for everyone. which used to be the APT [Associa- EEG folks in as well so that we don’t tion of Polysomnographic Technolo- lose the richness that came from the Malhotra: I understand that they gists]. The curriculum is available and original development of the field weren’t even talking for a long time, developed the same way and through through the EEG folks, which we lose though. the same process as our respiratory a lot of when we focus only on sleep curriculum. It’s being offered in apnea. That’s another group of people Carlin: In September 2009 the lead- schools, and many times it’s paired we don’t want to forget, because ership of AARC and AASM met in with an associate degree in either re- they’re important to sleep medicine. Chicago to discuss the various issues spiratory care or an EEG [electroen- related to the practice of sleep medi- cephalography] program to make it Parthasarathy: Stuart, do you have cine, as far as both societies go. The easier for the schools to implement a sense of the academy’s sentiments? meetings apparently went well, and on- those that are already running. You I know you don’t speak for them, but… going discussions will be held to help combine the students within those pro- further define the issues. I think what grams for basics and then separate Quan: I don’t know. But I do have everyone needs to realize is that there them for the sleep part of the curric- a question. With the future of poly-

1386 RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION somnography being increasingly respiratory and sleep support the va- by either the ABSM [American Board driven toward ambulatory testing, it lidity of the credentials and believe in of Sleep Medicine] or the ABMS raises the question of what will be the the value of education, but it’s when [American Board of Medical Special- job description and need for polysom- the political writers get involved and ties] in the sleep subspecialty programs nographic technicians? As long as start putting in exclusionary clauses that started to be offered in 2007. The there’s testing, obviously you will need or saying, “This credential is better stipulation is that if you’re not board- some people to do the testing. I won- than the other,” that we start digging certified, you must be a staff member der whether the field might evolve to trenches and fighting. All of us in this of an AASM accredited facility. a more educational type thing or just room are tired of this and wish it would My point is that the exact same stan- focused on treatment rather than the go away, because we just want to take dards for the eligibility for interpret- testing aspect? care of our patients. ing a Medicare-reimbursed sleep test With that said, I always want to en- go into effect in January 2010 for all Carlin: I think that’s one of the rea- courage everyone who is working in in-lab sleep testing as well. I would sons the NBRC developed the SDS that arena to think about their prac- like the physicians to comment on how exam, on which there is a higher per- tices and what they hope to see for they’re going to respond to that. A lot centage of questions regarding treat- their patients, and to never forget the of physicians who do testing or are ment options and patient-education op- need for the education of the practi- involved in sleep are not board-certi- tions. Every 5 years both the NBRC tioners from physicians down to the fied. We need to regulate ourselves, and the BRPT conduct a job analysis technicians. The education of the peo- or someone else will be regulating us. of the field so that the examinations ple giving this care is really impor- will reflect what is current in the field. tant. Stuart had a great point when he Gay: I was involved in a lot of the As things change over the years to talked about how the job of taking portable monitoring dialogue, and I’ve come, the job analysis will reflect those care of these patients from the non- spent many hours on this. Ultimately, changes, and then subsequent changes physician level will change as our tech- it was not as much trying to regulate to the examination will be made. nology changes, and I think the cre- the physicians doing the home stud- dential and the testing for professional ies, but CMS was fearful that the ven- Minkley: It’s every 5 years or sooner credentials at that level is going to dors would get involved. In fact, when if there are significant changes. If prac- evolve from the technology of “How vendors heard that portable monitor- tice changes, the job task analysis will do I do a study?” to “I’ve diagnosed ing was an inevitability, at that point reflect that. That’s why an exam is this person and how can I take care of they were coming to physicians and standardized and validated, because them? How do we manage their dis- asking, “How do you want to partner you’re referencing it to actual prac- ease?” with us so that we can get this pro- tice—not what we think they should That’s what I do. I love the testing, gram going?” I was approached, as do, we’re testing them on what they I love the diagnosis, but really my job were other physicians I know across actually do. is about how I take care of the patients the country. in a wellness setting. How can I in- CMS immediately became aware Bollig: I’d like to discuss the licen- fluence people who don’t have sleep that the vendors thought that there was sure issues that are going on nation- disorders but are at risk of having sleep potential to really market portable wide. I think the important thing to problems due to lifestyle decisions? I monitoring themselves. That’s where remember is that oftentimes it’s not think that there is going to be a defi- CMS said, “We don’t want the fox the actual credentials that are being nite change in what the credential is anywhere close to the chicken coop,” questioned. I don’t think the validity going to be an example of in the fu- and it became more about how to reg- of the RPSGT credential is being ques- ture. ulate DME vendors than us. This is tioned, and I don’t think that in the Some CMS standards require cre- also when the huge follow-up docu- future the validity of the SDS creden- dentialing of sleep staff to get reim- mentation burden was laid primarily tial will be questioned either, because bursed for sleep testing. All 4 of the on the HME community. I believe they’re both valid creden- DME MACs [durable medical equip- tialing exams for people working in ment Medicare administrative contrac- Parthasarathy: I agree. I think phy- sleep medicine. tors] put into place physician guide- sician certification is an important I think what happens at the political lines for the interpretation of home piece of this, and I share your senti- level, and often happens in politics, is sleep testing and portable monitoring, ment regarding us regulating our- that it’s the way the proposed licen- and that includes that the physician selves. The Institute of Medicine puts sure laws are written. I believe that who reads the portable-monitoring test out a report on healthcare quality1 ev- the professional organizations for both results must be board-certified in sleep ery few years, but they don’t always

RESPIRATORY CARE • OCTOBER 2010 VOL 55 NO 10 1387 SLEEP MEDICINE CERTIFICATION AND ACCREDITATION seem to be acted upon. It talks about if I was a young technician with a but there was no pressure to take how even credentialing/accreditation limited amount of money to put into boards. My mentor, Benjamin Bur- should involve other pieces in terms exams and I found out that a particu- rows, was a well recognized pulmo- of self-evaluation modules. lar lab can’t hire me because I took nary physician who never took the pul- I’m due to take the boards, and we the wrong exam—I think that’s a trag- monary boards, although I think he have these different set modules where edy for that individual. gave the exam. it involves sending out questionnaires We should put our political wran- But nowadays, not just in sleep, if to our patients to ask them to rate us gling aside and find out how we can you don’t pass your subspecialty ex- on how we’re doing. Part of that could join hands. I’m not asking that the so- amination, it’s very difficult for you qualify as a module, or being involved cieties merge, but I think there should to actually practice medicine. The fact in the hospital with quality-assurance be common boards between the two. that Medicare requires sleep tests to in reducing VAP [ventilator- be interpreted by board-certified phy- associated pneumonia] or something 1. Institute of Medicine of the National Acad- sicians is just the train going down the emies; Greiner AC and Knebel E, editors. like that. Soon some of these recom- Health professions education: a bridge to track. Pretty soon hospitals won’t let mendations are going to be adopted quality. Washington, DC: National Acade- surgeons operate unless they have a and taken more seriously. The board mies Press; 2003. http://books.nap.edu/ certificate from the American Board ϭ examination is part of that process, openbook.php?record_id 10681. Ac- of Surgery within a couple years of cessed June 25, 2010. and it’s here to stay, and we’ll live finishing their residency, and it’ll be and die by it, and I think it will be Malhotra: Home sleep testing is the same for pulmonary and critical better for patient quality of care and an opportunity in a sense, because care doctors and neurologists. I don’t benchmarks around the country; I we’re going to have to redefine what see that as a departure from where think it’s a good thing. an RPSGT is and does. Same with we’ve been going. I think all these benchmarks are the RTs involved in sleep. This is an comparable. I think the common theme opportunity for us to all come to the Parthasarathy: I’d voice the same should be that everybody should join same table and write down criteria sentiment. But I don’t think politicians hands, rather than forming little cot- that everybody agrees are useful for should be mediating these societies. I tage-industry entities with a narrow whatever kind of sleep technician in think they’re the worst mediators, see- view. I have written down all the let- 2015. ing what’s happened. So going to our ters of the alphabet twice over, and I legislatures and trying to push some- still don’t have it all right in my head, Quan: With respect to Suzanne’s thing I think only puts up further road- and I’m thinking, there are going to [Bollig] question, as far as accredita- blocks to getting people to agree with be young people trying to pick which tion of physicians goes, I think before each other. So I’m just going to sum- exam, and it wasn’t until Stuart asked I was born the board exams were com- marize everything with a nice quote whether the SDS is recognized by pletely voluntary. Passing the board for Rajiv: Why can’t we all just get Medicare that I realized it was not. So exams was a recognition of excellence, along?

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