Requirements for Personnel Files in Facilities Accredited by QUAD A

In facilities accredited by QUAD A, questions often arise regarding what needs to be included in personnel files. In the context of QUAD A accreditation, personnel refer to all clinical staff, including physicians and anesthesia providers, regardless of their employment status. Accreditation from QUAD A requires compliance with certain requirements for both directly employed and contracted employees. These requirements encompass various aspects, including personnel records, training, credentialing, and privileging. This newsletter article aims to outline the specific requirements related to personnel files as stated in SECTION 11: PERSONNEL of the QUAD A standards manual. Creating a checklist for each personnel file will help track that all items are present when the facility is surveyed. Documentation of immunizations, inoculations or declinations required for health care workers per Federal or State requirements and facility policy and procedure is also required in the personnel file. Please verify your state requirements and include those records in the personnel file. 

In the context of QUAD A accreditation, personnel refer to all clinical staff, including physicians and anesthesia providers, regardless of their employment status. 

Personnel Records

• The accredited facility is responsible for ensuring that all personnel files are accurate and up to date. 
• The following information must be included in personnel records: 

-  Date of employment 

-  Description of Duties 

-  Certifications and licensure, including BLS/ACLS    

-  A resume of training and experience

-  Immunizations and Inoculations:   

1) Hepatitis B (required)

2) State-required immunizations (e.g. TB, MMR, Tetanus, etc.) 

3) Hazardous health conditions 

The facility must have a process in place that requires staff to inform their employer of any health conditions that may have the potential to put other staff or patients at risk.  Each staff including any contract staff, must have such a record stating whether or not they have any hazardous health problems in their personnel file. Hazardous health problems and the plan of action or special precautions documentation must be reviewed and updated annually.   

Training and Credentialing

• This may include continuing education, annual training and in-services. 
• The accredited facility must ensure that all personnel meet the necessary training and credentialing requirements. 
• Copies of training records, certifications, and licenses must be maintained in the personnel file. 
• Credentialing and privileging files for both the facility and hospital must also be maintained by the accredited facility. 

 These files may include: 

- Professional certifications 

- Privileges that have been requested, reviewed, granted, and denied for specific procedures 

- QUAD A mandatory annual training:  

1) Fire Safety  

2) Universal Precautions  

3) Bloodborne Pathogens 

4) Hazard Safety   

5) Malignant Hyperthermia, if applicable 

6) Anesthetic Gas Exposure, if applicable. 

7) Emergency Preparedness (Medicare facilities) 

Maintenance of Personnel Files: 

• Personnel files must be maintained in a secure and confidential manner.
• Regular review and updating of personnel records is necessary to ensure compliance with accreditation requirements. 

The maintenance of accurate and up-to-date personnel files is crucial for facilities accredited by QUAD A. By adhering to the requirements outlined in the standards manual, organizations can ensure that all necessary information is on file for all clinical staff, including physicians and anesthesia providers. Regular review and updating of personnel records are necessary to maintain compliance with accreditation standards and safeguard the quality of care provided.

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.