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Blog Feature

By: Tamara Sellman on June 21st, 2016

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Are All Policy And Procedure Manuals Created Equal?

Sleep Technology Trends


Are All Policy And Procedure Manuals Created Equal?

This article originally appeared in the Volume 25 Number 1 A2zzz issue.


Sleep center policy and procedure manuals (P&Ps) are a workplace mainstay. Or at least they should be. It might be surprising to learn that, in some sleep centers, no such manual exists, or if it does, it is grossly out of date, hard to access, or literally falling apart at the seams.

Just because we, as sleep technologists, work in the dark doesn’t mean we should be kept in the dark regarding policies and procedures.

WHY HAVE A P & P Manual?

The P & P is the single best resource for ensuring all employees are “on the same page” regarding workplace protocols and the shared goals of a sleep center: to provide quality diagnostics and therapeutics for patients with sleep disorders. The P & P not only provides guidance but offers users a measure of legal protection; after all, the first course of legal action in a situation involving staff or protocol is to consult the P & P.

It is also consulted during regulatory compliance audits and is required for American Academy of Sleep Medicine (AASM) accreditation.

However, the P & P isn’t just a bureaucratic compilation meant only for administrators. It provides sleep technologists with real- world, hands-on guidance—like recipes in a cookbook, if you will—for addressing variations in protocols while on the job.

A typical P & P manual is a large ring-bound file housing the sleep center’s core policies (“the rules”) and procedures (the “how to” of “the rules”). Today’s sleep centers may also use electronic formats residing on dedicated computers or a network for quick access.


P & P documents could include:

  • Detailed flowsheets for specific tests
  • The latest AASM practice parameters and clinical/”best practice” guidelines
  • Sleep center safety rules 
  • Key phone number lists for after-hours calls
  • Codes of ethics and the sleep technologist “Scope of Practice”
  • Master copies of shareable patient form blanks and education media
  • Manufacturer manuals, data sheets, charts, diagrams
  • Emergency procedures
  • Equipment cleaning and maintenance instructions
  • Human resources FAQs and administrative documents
  • Electronic health record (EHR) instructions
  • HIPAA  requirements
  • Legal documents

Influential policies and procedures also come from outside the sleep center—The Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and affiliate hospitals—and should be included.

When started at ground zero, most P & P manuals are generated by customizing a generic template, such as one offered by the AAST, to the specific language and priorities of the medical director. Some P&Ps are written entirely in original language, while others are a collage of referenced sources, or a combination of both.

Reviews should be a yearly undertaking, led by the medical director or sleep center manager, with updates made in a timely fashion following changes in protocol or AASM parameters. All changes must be made in writing, added to the P & P directly, approved by the medical director, and promptly disseminated to all users as photocopies or via email links.


They are equal in that they ideally provide guidance, protection, and clarity for the sleep center staff.  But they are always imperfect “works in progress.”  While most sleep centers typically follow AASM practice parameters, even these offer wiggle room for customizing protocols. By their very nature, P & Ps will vary because their focus and content reflect the perspectives and priorities of individual medical directors.

For example, one sleep center’s split-night protocol might require 2.5 hours of recording time before switching from nocturnal polysomnography (NPSG) to titration, while another may require only 2 hours.

This doesn’t mean the P & P is wrong, but it does mean sleep technologists need to know what their P & P requires.

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