We spoke to the team that conducted the first assessment for the ASA/NATA Sleep Disorders Services accreditation program regarding what the program entailed, the challenges faced, and the outcomes achieved.
Who was the team on the assessment?
Sue Harry was the NATA Lead Assessor for the assessment of the RAH sleep service and Professor John Wheatley and Brett Duce were the technical assessors.
All assessment team members were involved in the establishment of the ASA/NATA Sleep Disorders Services accreditation program against a revised ASA Standard for Sleep Disorders Services.
What did the team hope to achieve with this foundation assessment?
The inclusion of the principles of the ISO 15189 Standard, especially the quality system aspects, in the ASA Standard for Sleep Disorders Services (SDS) was new and there were many questions with respect to how it would work. This was the first of a couple of assessments planned as ‘pilots’ to evaluate ‘proof-of-concept’ for the accreditation program before making it more widely available.
Overall, we hoped to determine if the approach for the assessment was suitable, including program (time allocations), documentation, role of each of the assessors (sleep physician and sleep scientist) and the Standard.
What challenges did the team face?
The approach used for this accreditation program was unlike NATA’s other accreditation programs; this program is the first one for NATA where patient set-up for sleep studies is observed in the evening and the assessment completed the following morning. As we had no previous experience in this type of assessment, one of our key challenges was to ensure that the required outcomes were achievable through this new approach.
For the technical assessors, other challenges included adapting to a new ‘system-based’ mindset as well as having a third assessor in the process. The previous system used two assessors – one medical and one scientific, with both assessors reviewing all of the facility’s documents. With the ASA/NATA program, the technical assessors focus on the clinical and technical documents, whilst the NATA assessor focuses on the quality system documents. Professor John Wheatley commented that he felt ill-prepared coming into the assessment without reading all of the documentation, however, this being said, it ended up being a benefit to have a NATA assessor guide the new process.
What were the steps and how long did the process / assessment take?
A letter confirming the assessment program and assessment team was sent to the facility a few weeks prior to the assessment. Also, the assessment program and briefing documentation was sent to the technical assessors so that they could prepare for the assessment.
Professor John Wheatley and Brett Duce reviewed the documents in detail prior to the site visit. The process was made easier as they had worked together on previous accreditations.
As part of the process, they discussed the positives and negatives of the documents. They trusted each other’s judgement and shared the review workload. It was a considerable benefit that RAH was well prepared for the assessment.
The assessment occurred over 2-days, commencing at midday on the first day. The activities included a team briefing followed by a preliminary meeting with senior staff, an inspection of the facility, review of documentation, interviewing senior staff, and discussing the sleep services offered.
The review also included the witnessing of patient set-up. The assessment finished at midday on the second day after an interview with the Director, preparation of the assessment report and an exit meeting where the assessment findings were presented.
Was the RAH sleep service receptive to the findings of the assessment?
The RAH’s Lung Function Laboratory was already accredited under NATA’s pathology program for blood gas analysers to the ISO 15189 Standard. Consequently, some staff were familiar with the NATA laboratory assessment processes as both facilities were in the same department within the hospital. Hence, the findings were ‘as expected’ by the sleep service and ‘typical of any NATA assessment’.
Supporting this, Dr Andrew Thornton, who at the time of the assessment was the Chief Scientist of the Sleep Service, was instrumental in the revision of the ASA Standard for Sleep Disorders Services, along with Professor Nick Antic, and had been through the ISO 15189 assessment process before.
How well has the program operated over the past 10-years?
The ASA/NATA program has operated extremely well. The previous accreditation program appeared to be driven by large tertiary sleep laboratories in public hospitals and regardless of size, any laboratory was perceived to be operating at the same standard of service. Smaller, private sleep laboratories were hesitant in seeking accreditation.
The ASA/NATA program has successfully encouraged numerous private sleep services to become accredited as well. We believe this is due to the accreditation program being more focused on the specific service and its system establishing who they are, what demographic they are servicing, and how they best serve their patients and clinicians involved in the patient’s care.
Any other comments?
Brett Duce acknowledged the initial hard work of Sue Harry, Tracy Fleming, and Janet Copland in the NATA team for the ASA/NATA Sleep Disorders Services accreditation program.
The assessment team all acknowledged the skills, hard work and humour of the late Professor Nick Antic and wished he were here to see the successful system that he helped create.
For additional information on sleep assessment and accreditation, visit https://nata.com.au/accreditation/sleep-disorders-services-asa-standards/
Or contact Tracy Fleming at: firstname.lastname@example.org