Sleep Center Policies and Procedures

LEARNING OBJECTIVES

On completion of this chapter, the reader should be able to:

1. Recognize the regulatory bodies that require policies and procedures.
2. Define the difference between a policy and a procedure.
3. Describe an alignment continuum.
4. Identify core processes.
5. Determine the number of policy and procedure manuals needed and the relative content material.
6. Utilize guidelines for when a policy needs to be written.
7. Recognize the value of policies and procedures.

Policies and procedures are essential to management and are fundamental to the operation of a sleep center. They are the handbook of operations for managers and employees. They convey the correct work processes for a sleep center that lead to quality services. Everyone needs to know what to do and how to do it. Policies and procedures provide this knowledge for all members of the staff. They include a wide array of applications and vary in degree of specificity. Applications may range from acquisition of supplies to following emergency protocols. Good policies and procedures provide insight into what management believes is important. They define expectations of employees, purpose of these expectations, and consequences of failure to abide by them (1). Consequently, they are used as a measure of employee performance.

Policies and procedures are critical to the evaluation of regulatory compliance because regulatory standards and subsequent levels of compliance are often measured against policies and procedures. The American Academy of Sleep Medicine (AASM) requires specific policies and procedures to be in place for accreditation as do other accrediting organizations such as the Joint Commission (JC) and the Accreditation Commission for Health Care. These organizations set standards for operations and assess compliance for accreditation. When a sleep center is accredited by one of these health care agencies, it is because they have met or exceeded standards of quality imposed upon them by these organizations. Reimbursement for services rendered by sleep centers also depends upon accreditation, especially Medicare.

There is a difference between policies and procedures, but they go hand in hand. Policies define the standards employed for the strategic direction of operations in order to reach goals. They state management’s position on a situation, action, or behavior. They are a set of guidelines and rules. Procedures are the specific processes employed to express policies in action for day-to-day operations and to achieve the standards of an organization, resulting in the highest quality of patient care (2). For the most part, a procedure will serve as an adjunct to policy; however, not every policy will require a written procedure. These documents provide direction, guidance, and accountability and are a reflection of the organization’s culture. By utilizing policies and procedures, the sleep center will operate with greater efficiency and staff members will have a defined sense of purpose.

ALIGNMENT CONTINUUM

Every organization has a reason for its existence, a sense of purpose. When such a purpose is put on paper, it is iterated as a mission statement. Because goals and objectives progress naturally from the knowledge of why an organization exists, a mission statement provides a sense of direction. In the absence of this direction,
decisions and their consequences can drive an organization down the road to failure.

A mission statement is the beginning of a policy and procedure manual and serves as a reference to determine the core processes within the written policy. It is the essence of an organization’s vision, values, and strategic goals. Writing effective policies and procedures can be challenging if these elements of business have not been defined because the direction of the organization is vague and subsequent management expectations are undefined. The mission of the American Association of Sleep Technologists (AAST), “AAST provides education, resources and advocacy, and leads sleep-care professionals to be the most knowledgeable in the field resulting in the highest quality of care for patients,” illustrates this nicely.

Alignment continuum is a term used to describe the relationship between the mission, vision, values, and strategic goals and subsequent core processes. The individual(s) responsible for developing the policy and procedure documents should work to understand the elements of the alignment continuum to ensure continuity with the policies and procedures.

The purpose of the vision is to determine whether the direction of the sleep center and its current scope of practice accurately reflect the direction of the organization. The vision captures an organization’s purpose and values and embodies the future of the organization. The vision of the AAST, “AAST will play a key role in setting the standard for professional excellence in the evolving practice of sleep healthcare,” illustrates this focus on direction.

The strategic plan outlines the goals and priorities of the sleep center and assures they are consistent with the direction and focus of the organization. The strategic plan is the road map to accomplish the vision.

Core processes are essential business functions for the organization. There are two types of core processes: operational and clinical. In a sleep center, operational processes establish rules for running the center. Clinical processes regulate patient care. Core processes require a definite course of action or policy. Policies and procedures support these processes and provide a framework for planning, action, and decision making for management and employees. Many core processes for sleep centers have already been identified, so much so that defined supporting policies and procedures are required for accreditation. For instances where there is no precedent, the process of identifying core processes or essential business functions is necessary.

DEVELOPING POLICY AND PROCEDURE MANUALS

Essential business functions can be determined from areas of management that are included in an organizational chart. The manual title represents one of the organization’s essential functions (e.g., human resources). If the sleep center is a hospital-based facility, the sleep professional may only need to be concerned with the development of a single manual specific to the operations and core processes of the department. Conversely, a freestanding sleep center typically operates independently and the sleep professional will need to ensure that manuals for all the essential business functions are developed. Careful consideration needs to be given to the number of business functions identified. The fewer manuals that exist, the easier it will be to manage the set of policies and procedures developed to create a desired outcome. The process of development begins the moment a policy topic is selected and is complete only after the document has been distributed and employees have been trained.

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