Accreditation Standards

Preparing for a Successful Survey

Preparing for your survey doesn’t have to be stressful. QUAD A provides a Standards and Checklist manual, which is used for your initial survey, self-surveys, and resurvey to facilities to ready themselves for their upcoming survey. This ensures that there will be no surprises during the onsite survey.

Your facility will work with your dedicated accreditation specialist to prepare for the onsite survey. You will receive an individualized description of the specific events that will lead you up to the onsite survey. You will also receive an outline of the survey to help you understand the process, who to have available, and the information that must be ready for the onsite visit.

We suggest your facility actively participates in the onsite survey and prepares with operational discipline, attention to detail and a focus on the patient. Facilities that are engaged in the survey process from start to finish tend to be better prepared. Patient safety was paramount in the mindset of the QUAD A founding members and continues to be the beacon that guides the organization today.

After the Survey

Following the conclusion of the survey, your facility will receive a formal report identifying any areas that require improvement. Identified areas must be addressed by a written Plan of Correction. There will be a set time frame to submit evidence showing that the identified deficiency are now in full compliance with the corresponding standards. We communicate the final decision of all surveys to any appropriate state or federal agencies to facilitate official recognition.

It’s important that your facility maintains 100% compliance on an ongoing basis. QUAD A accreditation is a continuous process that requires facilities to remain in compliance with all standards at all times between onsite surveys.

Celebrate - Let Your Patients Know the Good News AdobeStock_300397652-1 B

Publicize your achievement of QUAD A accreditation by notifying patients, the public, the local media, third-party payers and referral sources.

We will provide you with marketing materials to use in your facility, on your website and social media channels.

Take Advantage of Facility Consultants

Consultants help outpatient health care facilities prepare for accreditation

Consultants can be helpful assets to facilities as they prepare for accreditation, however, not all facilities need a consultant’s services. Whether or not to engage a consultant depends entirely on the facility’s needs.

There are consultants who have worked with QUAD A in the past helping facilities navigate the accreditation process. While QUAD A does not endorse or make any representation regarding consultants or their services, for your convenience a list of consultants may be obtained by contacting us.

View our Accreditation Consultancies here >

To learn more about becoming a consultant, contact marketing@quada.org.

Outpatient Office-Based Surgery

The following information is required for the Office-Based Surgery program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Anesthesia Validation Form
HIPAA Business Associate Agreement
Copy of each physician/surgeon's State Medical License
Copy of each physician/surgeon's Board Certificate or letter of admissibility by the certifying board
Copy of each physician/surgeon's delineation of Hospital Privileges (approved list of procedures from the hospital)
A floor plan or diagram of the facility clearly labeling rooms, including Operating Room, Prep/Scrub area, clean room/area, Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and dimensions)
Copy of Certificate of Incorporation (Required for applicants in the State of New York only)
New York OBS Addendum (New York OBS only)

Additional accreditation information:

Outpatient Office-Based Procedural

The following information is required for the Office-Based Procedural program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Anesthesia Validation Form
HIPAA Business Associate Agreement
Copy of each physician/surgeon's State Medical License
Copy of each physician/surgeon's Board Certificate or letter of admissibility by the certifying board
Copy of each physician/surgeon's delineation of Hospital Privileges (approved list of procedures from the hospital)
A floor plan or diagram of the facility clearly labeling rooms, including Operating Room, Prep/Scrub area, clean room/area, Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and dimensions)
Copy of Certificate of Incorporation (Required for applicants in the State of New York only)
New York OBS Addendum (New York OBS only)

Additional accreditation information:

Outpatient Oral Maxillofacial Surgery

The following information is required for the Oral Maxillofacial Surgery program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

HIPAA Business Associate Agreement
Anesthesia Validation Form
A floor plan or diagram of the facility clearly labeling rooms, including Operating Room, Prep/Scrub area, clean room/area, Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and dimensions)
Copy of each physician/surgeon's State Medical License
Copy of each physician/surgeon's Board Certificate or letter of admissibility by the certifying board (not required for facilities outside of the USA)
Copy of each physician/surgeon's delineation of Hospital Privileges (approved list of procedures from the hospital)
Copy of Certificate of Incorporation (Required for applicants in the State of New York only)
New York OBS Addendum (New York OBS only)

Additional accreditation information:

Outpatient Pediatric Dentistry

The following information is required for the Pediatric Dentistry program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

HIPAA Business Associate Agreement
Anesthesia Validation Form
A floor plan or diagram of the facility clearly labeling rooms, including Operating Room, Prep/Scrub area, clean room/area, Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and dimensions)
Copy of each dentist/physician/surgeon's State Medical License
Copy of each dentist/physician/surgeon's Board Certificate or letter of admissibility by the certifying board (not required for facilities outside of the USA)
Copy of each dentist/physician/surgeon's delineation of Hospital Privileges (approved list of procedures from the hospital)

Additional accreditation information:

Medicare Ambulatory Surgery Centers

The following information is required for the Ambulatory Surgery Centers program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Proof that the 855B form has been processed by the carrier
Anesthesia Validation Form
HIPAA Business Associate Agreement
Copy of each physician/surgeon's State Medical License
Copy of each physician/surgeon's Board Certificate or letter of admissibility by the certifying board
Copy of each physician/surgeon's delineation of Hospital Privileges (approved list of procedures from the hospital)
Equipment List
A floor plan or diagram of the facility clearly labeling rooms, including Operating Room, Prep/Scrub area, clean room/area, Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and dimensions)

Additional accreditation information:

Medicare Rural Health Clinics

The following information is required for the Rural Health Clinics program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Proof that your 855 Application has been processed by the Carrier.
Validation of current Health Professional Shortage Area Designation (HPSA) or Medically Underserved Area (MUA) letter or web posting
Validation of non-urbanized area by the U.S. Census Bureau
Accreditation Agreement
HIPAA Business Associate Agreement
Copy of professional licenses for each physician and midlevel practitioner.
30 Day Schedule for each Physician, Physician Assistant, Nurse Midwife, and Nurse Practitioner
Floor plan of clinic
Clinic State License Certificate (if in a state that requires licensure)

Additional accreditation information:

Medicare Rural Health Clinic (RHC) Accreditation Standards Manual V3.4
- Medicare Rural Health Clinic (RHC) Accreditation Standards Manual Change Log

Medicare Outpatient Physical Therapy

The following information is required for the Outpatient Physical Therapy program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Proof that your 855A has been processed by the Carrier
Accreditation Agreement
HIPAA Business Associate Agreement
Clinic Administrator's professional license or resume
Copy of professional state license for each practitioner on staff
Floor plan of each site (primary and all extensions)
Ten random unique patient charts are available for review at the Primary as well as the Extension(s)

Additional accreditation information:

International Surgery

The following information is required for the International Surgery program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Anesthesia Validation Form
A Floor plan of the facility (label: Procedure, Recovery, Clean/Dirty, and Prep/Scrub area
Copy of each physician's medical license
Certificate of Training or a document equivalent to Board Certification for all physicians listed on the application
Hospital Privileges for each physician on staff or an Agreement between the Hospital and Surgery Center

Additional accreditation information:

International Dentistry

The following information is required for the International Dentistry program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

Anesthesia Validation Form
Anesthesiologist Attestation Form
A Floor plan of the facility (label: Procedure, Recovery, Clean/Dirty, and Prep/Scrub area
Copy of each physician’s medical license
Certificate of Training or a document equivalent to Board Certification for all physicians listed on the application
Hospital Privileges for each physician on staff or an Agreement between the Hospital and Surgery Center

Additional accreditation information:

International Physical Therapy

The following information is required for the International Physical Therapy program:

To be completed in the QUAD A Portal:

To be uploaded into the QUAD A Portal:

A Floor plan of the site
Copy of professional license for each practitioner on staff
Clinic Administrator's professional license or resume
Ten random unique patient charts are available for review at the primary, as well as any extension(s)
International Physical Therapy Standards Manual

How do I change or add my Patient Safety Data Reporting Administrator? The Medical Director must complete the “Patient Safety Data Reporting Administrator Authorization Form” located on the QUAD A website under Patient Safety Data Reporting Documents. The completed form should be emailed to helpdesk@QUADA.org.

What if I don’t remember my facility password? Simply click the Forgot your password? link on the Patient Safety Data Reporting login screen. You will then be prompted to enter your email address. Be sure to use the designated facility administrator’s password. You will then receive an email from support@QUADA.org with a link to reset the facility password. Call the help desk at 224-643-7704 if you need further assistance.

Do we have to enter the data for the first case of every month for each surgeon/proceduralist? Yes, QUAD A standards require providers to submit Patient Safety Data Reporting information for the first case of every month for each surgeon.

What if a surgeon/proceduralist didn’t perform any cases in one of the months? If a surgeon/proceduralist has not performed at least one case per month, cases from other months in the period may be selected for a total of three reported cases per period.

What if a surgeon/proceduralist performs fewer than three cases during the period? If a physician using the facility has performed fewer than three cases during a reporting period, that information must be reported to the QUAD A office using the Exemption form. All cases that were performed during that period must be reported through the online system.

My practice doesn’t routinely use CPT Codes. How do I find a procedure’s CPT Code? QUAD A utilizes the CPT codes created and maintained by the American Medical Association (AMA). The AMA website offers a variety of CPT code resources.

How do I enter PSDR for a case that included several procedures? If you are entering a case that included several procedures, like a “mommy makeover,” you would enter each individual procedure as a line item within the random case submission. A breast lift, liposuction, and tummy tuck would be entered as Mastopexy (breast lift), Suction assisted lipectomy, and Excision of excessive skin and subcutaneous tissue.

We’ve created a helpful list of common procedures and their associated CPT codes.

You can find documentation here.

How does Peer Review differ from Patient Safety Data Reporting?

What QUAD A previously called Peer Review is a separate and distinct process from what many physicians are familiar with as a full clinical peer review process, which is performed at a physician-to-physician level. The objective data elements required during the quarterly Patient Safety Data Reporting, as part of the accreditation process, is specifically intended for medical study and the evaluation and improvement of quality care and reduction of morbidity and mortality. Such data can be entered prior to the facility conducting its peer review meetings. Revised standards manuals will be published soon and will use more distinct language to demonstrate the difference.

As we fully transition from referring to this process as Peer Review to Patient Safety Data Reporting, be aware that our online reporting portal may continue to reflect the term Peer Review for a time until all our vendors have completed updates to the systems they administer on our behalf.

How do I know if my facility has to submit PSDR data? Facilities participating in QUAD A’s Office-Based Surgical, Office-Based Procedural, Oral Maxillofacial Surgery, Pediatric Dentistry, International Surgical, or Medicare ASC program must submit Patient Safety Data Reporting (PSDR) information for the added provider(s) from the first day the new provider(s) began working in the facility.

QUAD A Programs and Standards Manuals

It's your chance to weigh in!

Our Program Standards are evolving, and your input matters.

Current Standards Manuals

ASC

Ambulatory Surgical Center Medicare

Accreditation Standards Manual V8.3

Effective August 5, 2024

OBS

Office-Based Surgery

Accreditation Standards Manual V8.3

Effective February 1, 2023

OBP

Office-Based Procedural

Accreditation Standards Manual V15.2

Effective February 1, 2023

OMS

Oral Maxillofacial Surgery

Accreditation Standards Manual V3.2

Effective February 1, 2023

RHC

Rural Health Clinic - Medicare

Accreditation Standards Manual V3.4

Effective OCTOBER 14, 2024

OPT

Outpatient Physical Therapy - Medicare

Accreditation Standards Manual V8.3

Effective August 5, 2024

PD

Pediatric Dentistry Program Standards

Accreditation Standards Manual V 2.2

Effective February 1, 2023

International

International Surgery & Dentistry Program Standards

Accreditation Standards Manual V 4.2

Effective February 1, 2023

Interested In Accreditation?

Accreditation Application Materials

The following information is required for the Office-Based Surgery program:

The following information is required for the Office-Based Procedural program:

The following information is required for the Oral Maxillofacial Surgery program:

The following information is required for the Pediatric Dentistry program:

The following information is required for the Ambulatory Surgery Centers program:

Medicare Ambulatory Surgical Center (ASC) Accreditation Standards Manual V8.3

The following information is required for the Rural Health Clinics program:

The following information is required for the Outpatient Physical Therapy program:

The following information is required for the International Surgery program:

The following information is required for the International Dentistry program:

The following information is required for the International Physical Therapy program:

Accreditation Resources

Accreditation Frequently Asked Questions