Key Accreditation Standards
Network Director Requirements (Category I)
Every accredited network must designate a Network Director who specializes in sleep medicine. To qualify, the director must be either:
- A physician or PhD holding board certification in sleep medicine, recognized by the ABSM or other relevant boards.
- A physician who has completed a 12-month accredited fellowship in sleep medicine and is eligible to take the board examination. It’s important to note that they must pass this exam within two consecutive cycles to maintain accreditation.
The Network Director oversees services across multiple locations, although individual sites may also have their own Site Directors (refer to Standards N-3 and N-4). The same individual can serve as both Network and Site Director.
Responsibilities of the Network Director (N-2)
The Network Director has several critical duties, including:
- Acting as the primary contact for the accreditation body and updating them on any changes within the network.
- Monitoring the quality assurance program quarterly, as required by the Sleep Clinic Standards.
- Conducting an annual review of all policies and protocols for the network.
- Assessing safety issues and performing risk analyses, followed by communication with stakeholders.
- Having access to electronic medical records (EMRs) as necessary.
- Maintaining a valid medical license in each state where the network operates.
For larger networks, the director should dedicate at least 4 hours each month to these responsibilities, while smaller setups may require just 2 hours per month per location. This can be achieved through in-person visits, conference calls, or virtual meetings with the staff.
Site Director Requirements (Category I)
Each entity must appoint a Site Director, also a sleep specialist, who meets the same qualifications as the Network Director. This individual can manage services across different locations or each location can have its own Site Director.
Responsibilities of the Site Director (N-4)
The Site Director is tasked with:
- Ensuring that only licensed healthcare professionals with prescriptive authority can request patient testing.
- Overseeing the qualifications and training of all medical and technical staff.
- Monitoring compliance with medical ethics codes and institutional standards.
- Ensuring the proper operation of required testing equipment.
It’s recommended that the Site Director also invest at least 4 hours each month in these duties, which can be fulfilled through various means of communication with the staff.
Qualifications for Directors
Both the Network and Site Directors must be sleep specialists who meet one of these criteria:
- A physician or PhD.
- Board certification in sleep medicine from ABSM, AOA, or ABMS.
- A physician who has completed an accredited fellowship in sleep medicine and is eligible for the board examination, which must be passed within three consecutive attempts.
Medical Staff Members
If the director is not a licensed physician, there must be at least one physician (MD or DO) on the team. The medical staff may also include licensed psychologists, APRNs, and PAs, all of whom are qualified to evaluate, diagnose, and treat patients.
Medical Staff Responsibilities
Medical staff members are responsible for:
- Reviewing each referral to determine patient eligibility for testing.
- Providing consultations, management, treatment, and follow-up assessments.
- Diagnosing medical conditions as permitted within their scope of practice.
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