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Frequently Asked Questions

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General Questions

What Is Accreditation

Accreditation is a formal process that evaluates whether a healthcare facility meets established standards for patient safety, quality of care, and operational practices. Facilities accredited by QUAD A are assessed against rigorous, evidence-informed standards and must demonstrate compliance across all areas of operation.

Accreditation provides a structured framework to support consistent operations, reduce risk, and strengthen patient safety. It also demonstrates to patients, regulators, and partners that your facility has been independently evaluated against recognized standards.

To achieve QUAD A accreditation, facilities must meet 100% of the applicable standards across all categories. The process requires an on-site survey conducted by a qualified QUAD A surveyor, which includes: observation of care processes; assessment of the environment; staff interviews; documentation review; and verification that documented policies align with practice.

If any deficiencies are identified during this process, facilities have the opportunity to address them through a structured Plan of Correction before accreditation is granted.

Most facilities complete the accreditation process within 90 to 150 days after submitting a complete application. Survey scheduling typically occurs within 30 days once documentation and floor plans are approved. For those requesting an immediate survey in a non-Medicare program, we may be able to accommodate but an additional fee would apply.

Facilities must:

  • Complete an annual self-assessment
  • Undergo an onsite survey every three years
  • Maintain ongoing compliance with all standards
  • Submit PSDR data for applicable programs

This approach supports continuous readiness rather than one-time preparation.

Prices vary based on program, class, facility size, and number of specialists. Consult our fee schedule for more information.

PSDR is a required component of QUAD A surgical programs. Facilities submit data quarterly, including selected cases and any unanticipated outcomes, to support analysis of trends and improve patient safety across the industry. Learn more about PSDR.

PSDR supports ongoing monitoring and helps identify patterns that may impact patient outcomes. This data informs future updates to standards and promotes continuous improvement across accredited facilities.

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 provide more distinct language to demonstrate the difference.

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.

Program Eligibility

Is my facility eligible ror the CMS ASC Program?
  • An ASC must be certified and approved to enter into a written agreement with CMS. Participation as an ASC is limited to any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.
  • The regulatory definition of an ASC does not allow the ASC and another entity, such as an adjacent physician’s office, to mix functions and operations in a common space during concurrent or overlapping hours of operations. CMS does permit two different Medicare-participating ASCs to use the same physical space, provided they are temporally separated. The two facilities must have entirely separate operations, records, etc., and may not be open at the same time.

A Rural Health Clinic (RHC) is a clinic located in a rural, underserved area with a shortage of primary care providers, personal health services, or both. Currently, there are about 4,500 RHCs nationwide providing primary care and preventive health services in underserved rural areas.

RHCs provide:

  • Primary care and preventive services
  • Services and supplies provided as part of care from RHC practitioners, such as blood pressure checks or vaccinations
  • Homebound visiting nurse services in CMS-certified home health agency shortages
  • Some care management services
  • Some virtual communication services, such as communications-based technology and remote evaluation services

An RHC must:

  • Be in an area defined by the U.S. Census Bureau as non-urbanized
  • Be in an area currently designated by the Health Resources and Services Administration (HRSA) within the last 4 years as 1 of the following:
    • Primary Care Geographic Health Professional Shortage Area
    • Primary Care Population-Group Health Professional Shortage Area
    • Medically Underserved Area
    • Governor-designated and Secretary of Health and Human Services-certified

An RHC must:

  • Employ an NP or PA (RHCs may contract with NPs, PAs, CNMs, CPs, and CSWs when the RHC employs at least 1 NP or PA)
  • Have an NP, PA, or CNM on duty at least 50% of the time during operational hours
  • Post operation days and hours

Health Care Services Requirements:

  • Directly provide routine diagnostic and lab services
  • Have arrangements with 1 or more hospitals to provide medically necessary services unavailable at the RHC
  • Have drugs and biologicals available to treat emergencies
  • Provide the following lab tests on site:
    • Stick or tablet chemical urine exam or both
    • Hemoglobin or hematocrit
    • Blood sugar
    • Occult blood stool specimens exam
    • Pregnancy tests
  • Primary culturing to be sent to a certified lab
  • Not be primarily a mental disease treatment facility or a rehabilitation agency
  • Not be a Federally Qualified Health Center (FQHC)
  • The primary purpose of a rehabilitation agency is to improve or rehabilitate an injury or disability, and to tailor a rehabilitation program that meets the specific rehabilitation needs of each patient referred to the agency. A rehabilitation agency must provide, at a minimum, physical therapy and/or speech language pathology services to address patients’ needs.
  • The rehabilitation agency must be able to provide therapeutic procedures as well as the modalities of heat, cold, water and electricity for physical therapy treatments for the patients under its care for service at any of its practice locations. The rehabilitation agency must also be able to provide any equipment required by the speech-language pathologist to treat patients accepted for such services.
  • Occupational therapy is an optional service and cannot be substituted for either of the previously stated services. It may be provided in addition to physical therapy and/or speech-language pathology services.
  • The extension location and the primary location must have the same:
  • Governing body,
    • Administration; and
    • Policies and procedures (e.g., housekeeping, infection control).
      • Evacuation plans must be specific to the location where the services are provided.

Most facilities complete the accreditation process within 90 to 150 days after submitting a complete application. Survey scheduling typically occurs within 30 days once documentation and floor plans are approved. For those requesting an immediate survey in a non-Medicare program, we may be able to accommodate but an additional fee would apply.

Getting Started

What happens after I apply?

Once your application and documentation are complete:

  • QUAD A reviews your materials
  • A survey is scheduled
  • Your facility undergoes evaluation
  • You complete the Plan of Correction process for any deficiencies
  • Accreditation is awarded upon full compliance

Yes. Many facilities begin by reviewing standards, assessing current operations, and identifying gaps through a self-survey. QUAD A resources and educational materials can help guide this process.

If I have questions not listed here, how can I get the answer?
Contact us to speak with one of our accreditation specialists, who will be happy to assist.