Understanding the accreditation process from application through the site visit is key to a timely and desired result. In many states, Medicare is requiring freestanding sleep centers to become accredited within certain timeframes. If accreditation is not obtained, Medicare reimbursement will cease. More than two dozen states are either mandating accreditation or on their way to doing so. Sleep centers would be wise to start preparing for accreditation now as the process can take a significant amount of time.


The first item you need is a comprehensive and detailed policy and procedure manual. This manual must address all aspects of your business including clinical, operational, financial, and human resources procedures.

The clinical policies must address key accreditation standards such as interscorer reliability, detailed step-by-step procedures for polysomnography, CPAP/bilevel titration, and multiple sleep latency testing (MSLT)/multiple wake testing (MWT).

The operational policies must address safety procedures, including fire, natural disaster, and patient instability. Other operational policies must address procedures on patient acceptance, insurance authorization, and the scheduling and staffing of sleep center personnel.

The financial policies must address everything from budgeting to the handling of cash by sleep center personnel. Human resources policies and procedures must range from employee performance reviews to the company dress code.

The more detailed all these policies are, the better the “blueprint” of your business operations. Once you have your policy and procedure manual complete, you must implement all these systems.


Staff training is the most lengthy and most important step of all. The best way to accomplish training of staff is to incorporate the introduction of new policies and procedures into staff meetings. The meetings can be held more often while preparing for accreditation to expedite the training process. Pre- and post-tests about specific subjects presented are a good way to assess the training process and gauge competency.


The third step involves assuring proper documentation of the training process. This should be available within meeting minutes and in employee-specific documentation within the personnel record.

Preparing for the accreditation process will cost an organization additional time and money initially. The key is to minimize this and design efficient systems to meet accreditation standards. A comprehensive data management system that handles patient scheduling, clinical data management, and medical billing is an optimal solution. The key is not to add personnel to accommodate accreditation requirements on an ongoing basis.


Ramp-up time for your accreditation survey can take up to a full year depending on how prepared a sleep center already is. New sleep centers often have an advantage. Starting from square one can be easier than “cleaning up” or changing existing systems and habits.

It is always a good idea to consult a professional for guidance if needed. Being accredited used to be an option, now it is becoming a requirement. The accreditation process can be daunting and lengthy if you have not been through it, but it is good business and supports best business and clinical practices.

Dan Helmchen is chief executive officer of Sleep Logistics, Las Vegas. He can be reached at .