Demystifying Clinical Personnel Training: A QUAD A Compliance Guide

Clinical personnel training is a crucial element in delivering safe and high-quality healthcare. QUAD A’s comprehensive accreditation standards include verification of continuous training for all personnel in the facilities we accredit. QUAD A standards include positional competency, site-specific training, and safety protocol proficiency, and require facilities to provide and maintain documented proof of up-to-date training. These standards provide patients with the peace of mind that those entrusted with their well-being are adept at caring for them during their procedures.

According to QUAD A, the definition for “Clinical Personnel” encompasses the entire surgical and procedural team, including surgeons, proceduralists, anesthesia providers, nurses, and scrub techs, etc. It is important to note that employment status (e.g., owner, employee, contractor) is not a factor in this definition, which can be found in the general glossary at the end of each standards manual. 

All training must be documented in each personnel file as outlined in the QUAD A manual under Section 11, Sub-section I. Core training must include: 

• Bloodborne Pathogens 
• Hazard Safety 
• Standard Precautions 
• Emergency Procedures 
• Facility-specific training (e.g., laser safety) is also mandatory where applicable.  Training can be delivered through various methods (in-person training, meetings, e-learning modules, interactive activities, etc.), but must be accessible, relevant, and provided to all staff, regardless of their role, level of experience, or employment status. 

Breaking Down Annual Hazard Safety Training 

This training educates staff on potential risks that may affect them or the patients and typically includes: 

• Hazard Communication 
• Ergonomics 
• Electrical Safety 
• Personal Protective Equipment (PPE) 
• Hazardous Materials 
• Emergency Procedures

Training must also address facility-specific safety concerns. For example, if a facility performs laser procedures, laser safety training is required. During a survey, staff must be able to clearly describe the facility’s laser safety policies and procedures and demonstrate adherence to them.

Documentation & Key Clarifications 

Training records must be retained for at least three (3) years; if the state requires a longer retention period, the stricter requirements prevail. The facility must ensure that every staff member understands the safety protocols.  If the provider or staff member has privileges at multiple locations, they must receive site-specific training at each site. The requirement is not for physicians or staff members to be trained 10 times on the same topic.

Facilities often ask if a standalone general attestation is an acceptable form of evidence of required training. A general attestation alone is not proof of training. The facility must be able to provide evidence of the training provided for the signed attestation.

Note: The hands-on drill component for Operative/Structural Fire Safety must be conducted in-house. Not all staff may be working on the day of the actual drill, but training and education must be provided to everyone.

In summary, QUAD A compliance hinges on documented, site-specific training for all clinical personnel. All staff training must be documented in individual personnel files and must be retained for at least three (3) years. Remember that a signed attestation alone is not a substitute for proof of training.  

By following these guidelines, your facility can implement patient safety measures and meet our accreditation standards. We hope this newsletter helped provide clarity and understanding for QUAD A’s training requirements for Clinical Personnel.  

Thank you for your continued dedication to safety and excellence. Should you have any questions about the facility safety manual, please email  standards@quada.org.  

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.