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5 min read

Defining Personnel in Accredited Facilities

In every QUAD A accredited facility, the term "personnel" plays a crucial role in defining the structure and functioning of the entity. But who exactly falls under this category, and why is it significant to understand this distinction? This newsletter delves into the concept of personnel, exploring its various dimensions, implications, and the critical role it plays within a facility.

Personnel, in its broadest sense, encompasses all individuals who work for a facility or are associated with it in a capacity that contributes to its operations and objectives. This includes full-time and part-time employees, contracted staff, agency staff, and sometimes volunteers. For instance, in QUAD A facilities, personnel include doctors, surgeons, anesthesia providers, nurses, scrub technicians, administrative staff, medical assistants, physical therapists, physical therapist assistants, occupational therapists, occupational therapist assistants, speech-language pathologists, social workers, etc. The definition of job titles of personnel may vary slightly depending on the context and the specific policies of a facility, but it fundamentally refers to the human resources that are instrumental in the functioning of an entity. However, employment status (owner, employee, contractor, etc.) is not a factor in defining who is included as personnel.

Understanding who is considered personnel is not just a matter of words; it's a key that unlocks the doors to effective management, a healthy organizational culture, and legal and accreditation compliance. From a management perspective, recognizing all categories of personnel ensures that effective strategies are in place for recruitment, training, development, maintenance of personnel files, and retention. It's about acknowledging the value of every individual associated with the organization, regardless of their employment status, in achieving its objectives and investing in their professional growth. 

Additionally, having the understanding of who is considered personnel in your facility is pivotal in your success in complying with QUAD A standards related to personnel, and the contents of a personnel file. As stated above, employment status does not play a role in determining which personnel need to have a personnel file in your facility. For example, if your facility offers surgical services and you contract anesthesia services from an outside company or agency, those anesthesia providers are considered personnel from an accreditation perspective. Upon survey, the surveyor will review 50% of all clinical personnel files. Additionally, during ASC and RHC surveys, surveyors will review 100% of all clinical personnel records of those individuals who are required to be licensed under State or local laws or regulations for verification of appropriate documentation and current licensure. 

In conclusion, the question of who is considered personnel is more than just a matter of classification; it touches upon every aspect of organizational life, from management and culture to legal and accreditation compliance and workforce dynamics. As the nature of work continues to evolve, facilities must adapt their understanding and management of personnel to stay relevant, competitive, and compliant. By understanding the definition of personnel, facilities can create a supportive and dynamic environment that leverages the full potential of all associated individuals, ultimately driving facility success in the accreditation process. 

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.