The Truth About Med Spa Safety Standards with Tom Terranova of QUAD A

26:12Completely outside of aesthetic medicine, they'll tell you, we don't have any clear distinction in our training that says, this is what you do. So if you're not even seeing that in critical care, you're definitely not going to see it in aesthetic medicine where there's no hospital oversight going on at all. Yeah, and often emergency preparedness, emergency response is a team game, right? Usually there's a few people involved in whatever, whether it's ACLS. Because often you have, if it's, not to get too technical, but if you're responding to like lidocaine toxicity, people have different roles.

26:45And so just having a nurse, one nurse, even if they're great at it, usually there's some, they need interaction with other people. You have a team. Always working in a team. Even surgeons, when you go into a surgery, when you're performing a surgery, you have colleagues in there with you. There are multiple professionals in there with you. So it doesn't even logically make sense from the medical framework. framework, international medical framework, to have any kind of a facility where you are just going in seeing one person who's going to inject you with whatever it is that you're getting, and then that's it.

27:16You get it done, you go home. That doesn't make any sense. Also, one of my big questions for you is also this. What about things like wait times? Because I know oftentimes, as you know, with a lot of procedures, even if they're non-invasive procedures, you have to wait. So when you're going home or when you're, who's picking you up and all of these little things come in so do you guys account for stuff like that as well and kind of provide guidance on those protocols or is that kind of out of scope for this there's a lot there's a lot that has to do with sort of um uh various protocols within the practice right and then it there's sort of two different ways that we handle them philosophically that is one there are standards, there are protocols that we say you must do this.

28:03There's a few of those. And then there's protocols that we say you must come up with a protocol to do this because it might vary greatly depending on the services that you're providing or the types of care or the types of patients you see even. Patient acuity becomes really important. And so often what we're doing is forcing the leadership of the center to make a clear and conscientious choice and document that so that everyone on the team, again, team, is on the same page. So we may say, in whatever case, aesthetics probably doesn't apply, but it's always the one that jumps to my mind. What's your policy for treating pediatrics?

28:47And they say, well, it's aesthetic. We don't treat pediatrics. Okay. Who's a pediatric? Well, I'm not sure. Well, the question is, you define a pediatric. Is it prepubescent? Will you treat a 16-year-old who's already gone through puberty? Is that a pediatric or is it 18 or is it height and weight? You determine it because of your service line and what you're doing, but put it out there so everyone knows, right? And then make sure you have equipment that can treat them. So I want to distinguish between kind of how we push the envelope on the facilities. So we do have a few things. There's some issues around depending on the services.

29:25I'm just, if you're seeing me look off to the side, it's because I'm referencing. So we do have reporting for any adverse event as we talk that happens within 48 hours of discharge. So we do talk about discharge in terms of sort of post-operative or post-procedural discharge. Like you want to be checking in with the patient to make sure that things are going accordingly. And then there is discharge instructions and what I'm looking for right now because I want to make sure that in the new program there is some discussion around criteria in some of our programs but I don't think the specific discharge criteria actually having established discharge criteria comes up in this program because no one's going under sedation.

30:15When they call it a sedation you want to make sure they hit a discharge criteria but you do want to make sure that people are leaving sort of with our full faculties, right? And so there's an element there of that, of coordinating. There's a point, though, that I want to make sure that we talk about here that you asked about earlier, and it's about, like, the team, and it's about the headlines. And we talked about it with nurses, physician training, emergency response training, all of that. One of the biggest areas that I think most jurisdictions struggle with is the medical directorship of a med spa.

30:53Yes. Because most, not all states, require a medical director. Most, not all states, set some sort of criteria of that being a physician. In some states, there's independent nurse practitioner or advanced practice nurse practices. But by and large, let's just say you need a medical director. Yeah. One of the big issues that many states struggle with is people who are an empty seat, who are a medical director by name. I hear horror stories. I can't speak to any firsthand, but of medical directors who are medical director of dozens and dozens and dozens of facilities in states they've never been to, right?

31:32And they've never stepped foot in the facility. You could see news reports of an adverse event and they contact the medical director and they talk to the staff and they say, yeah, the medical director comes here once or twice a year. That's one of the biggest issues, right? The medical director and part of this program is the medical director, whoever's named, needs to be actively involved in the administration office of care in the facility. They need to know the services. Again, they might have different training, but they need to train up on the services being provided. And they need to know how to respond, what are the likely adverse events, and they need to be overseeing the care.

32:02That's the job of being the medical director. You direct. That's exactly right. That's exactly right. There is no purpose in being a medical director that gets a salary to basically not show up and be an MTC and just collect a passive salary. I mean, one, it's unethical, in my opinion. And two, all you're doing is opening yourself up as a medical director to a lawsuit or to a malpractice. I mean, that malpractice is probably on your malpractice insurance as a physician and you're not there. So you don't know what's going on. So as a protective measure for yourself as a physician, as a professional, from the ownership perspective of the facility and from the practitioners living there, you know, living and working there every day, you want to make sure you have an ecosystem that supports you, that is educational, that is optimizing, that is looking for quality and safety and is reducing risk.

32:57I think we talk about this from a safety standpoint for the patient, which is super important. When you talk about it from a facility standpoint too, like no facility wants to have adverse effects. The risk is complete all the way around from reputation to financial to legal to just on your own conscience, right? So the whole effort is to be self-protective. Yeah. I mean, it's a very, very, you know, you bring up such important points here because, you know, first thing that comes to my mind is when it comes to being a medical director, I mean, this is for all, I think every reputable doctor I know would never put their name on anything if they couldn't physically see what's going on.

33:38Because yes, there's a lot of risk, but more importantly, what is like, I mean, what is the point of that? You know, at the end of the day, how much money could you possibly be making that you're going to just risk all of that? Because if you get sued and if there's any kind of legal action taking place, you're losing all of that. So it doesn't even make logical sense to put yourself in that position. So if there is somebody doing that, I don't even see what the, you know, the gains versus loss, like what that scenarios like for them because it doesn't make sense. And more importantly, when you look at other facilities like nursing homes, for example, right, or like step-down centers, you have to physically be there as a physician.

34:14Like every morning, if you're working at a step-down center as the main medical person that's there checking who's been admitted that day, you have to physically sign off. So why is that same model not being applied to an aesthetics practice or a med spa? It should absolutely be the same. So it's not that we don't have these parameters, right? It's not that we don't have the blueprint of doing this as a medical community. It's just that for some reason we're saying, aesthetic medicine, hands up in the air, whatever. You know what I mean? Let's just not even think about it. I don't know why it's like that.

34:46That's crazy. You know, my operating theory there is that it is that same paradigm perception that it is no risk. And low risk is not no risk, right? And I think that's the subtlety there, right? Like, clearly, clearly, clearly, I don't want to misrepresent this to patients or physicians or practitioners out there. Clearly, the med spa space is less risky than the acute care hospital. It clearly is less risky than the surgery center, than nursing, than step down. You know, generally, you have healthy patients coming in. Generally, they're coming in for something very, very small. Clearly, it is less invasive.

35:21It is less intense. That's why this program in and of itself doesn't look like a surgical program. It's very different because clearly the risk profile is lower and it has a different risk profile. But it doesn't mean there's no risk. And I think that's where we get caught. We're like, nothing's going to happen there. And I will tell you, I have heard, again, I won't name names. I was at a, this is maybe two, three years ago as we were starting this process. I was at a conference of regulators. It's actually the same one where the guy talked about the bridge people. I was at a conference of regulators and they had someone who does some training in the med spa space for injectors or people like that.

35:58And he has this really comprehensive program, at least as it was told to me. I'm not super familiar firsthand. But the person lectured quite a bit for... It's a three-day conference. I'm pretty prominently throughout the three days. And the thing that really threw me off was really comprehensive training, really comprehensive protocols, really comprehensive documentation. And then at the end of the conference, when people were kind of talking about how to put protections in place, I don't know if it was trying to make people feel better or what, but basically said, look, you can't do any real harm here.

36:31And you can't do any lasting harm here. And I basically felt obligated to get up and say, you know, basically, unfortunately, everything you've said for the last three days is now moot because you've just undermined entirely that this is a no risk situation and not a low risk situation. And while we should all recognize it's low risk, we should not discount the fact that it is and delude ourselves to thinking that it is no risk. And the data very clearly shows otherwise. And we went back to the statistics on necrosis and occlusions and blindness and even mortality. And that, I think, is the misperception that causes people to say, well, heck, I can take a passive income and I'll operate on volume and I'll get 40 centers or I'll operate through a corporate and I'll be the medical the director of all 40 of our sectors because there's no risk there really and that's that's i think misguided well that's incredibly misguided but more importantly i think it's also very very scary to me right from the medical standpoint of we're even letting this happen because in my i don't know about any other doctor listening in but when i went to medical school and i went through my training it was hammered into my brain that there is no such thing as low risk.

37:41Like this low risk concept doesn't even make sense to like, I mean, it's like risk is risk. If you don't acknowledge it, you're getting sued and you're going to lose your license. That's, that was it. You know what I mean? And so I, that's why I was appraising a minor procedure is a procedure on someone else. Absolutely. Absolutely. And it's like, you know, it's not even about procedures, it's medications. It's how you administer those medications, how you monitor things like drips. Do you record outputs? And do you put that in the file? All of this is monitored in any kind of a hospital setting.

38:12So again, the same question is circulating in my mind where it's like, where did this conversation even begin of saying, oh, this is low risk. We don't have to worry about it. Of course you have to worry about it. You know, like, it's about the appropriate level of worry, right? Like, you don't want to treat it like a cardiac case, but you want to treat it with the appropriate level of care. And I think right now we're under because it is patient driven. We are under an environment where people are trying to go to independent practice because they are frankly sick of being strangled by by oversight and regulation in the more acute care environments in hospital.

38:48Yeah, trying to go more and more independent. And we've gotten to a point where we're extremely independent. And what we want to make sure that we're doing is put the appropriate guardrails around it, not extreme and extraordinary guardrails. I think it's art more than science to really thread the needle of rigor and reasonableness, right? Like you can't treat injectables practice, a wellness practice, the same as you would treat the intensive care unit at a tertiary hospital. Of course, you should treat it like something. And let's figure out what that is and say, this is the rigor that we need to make sure that you're operating in a way that cares for all of your patients on a daily basis in the appropriate way.

39:31And that doesn't strangle the industry. That's really the art of this is to say, strong enough, not too strong. You know, we really want the Goldilocks approach. Well, no, I completely agree with you. I think that's a brilliant way to think about it. And also, you know, I don't want to be too negative. I really do want to add the positivity in here for all the people that are doing it right. You know, I have such, I have great friends, some, you know, prior guests that have come on the show that they run med spas, they run these beautiful centers and, you know, they're doing everything by the book, everything right.

40:02You're going the extra mile. It might cost a little bit more for them, you know, on the business side, but they don't take any risks, you know? And so a program such as this is incredible for those people out there that are like, I don't want to take risks. I want to do it right. I might not know, you know, because if you don't know, if you don't know what are the things I should look out for or like what should I go through to be truly like, you know, validated by a third party entity, you don't know what to do and then you don't do it. So I think your program is so phenomenal in that way that it's giving access more than anything to professionals who are like maybe lost, you know, in that sense of like, well, what else can I do?

40:40You know, what else can I really do to validate what I'm doing and make sure that it's checking all the boxes and, you know, all of that stuff. So I think this is phenomenal from that. I'll take it a step further because some of those people who are the cream of the crop, they're already doing it. They might have minimal or no changes to what they're doing, but it's a validation. And I think the real critical key there is you may even know, right? your top 1 % or 10 % or whatever the percentage is of med spa operators out there may already look at our manual and go, piece of cake, right? I got to buy one piece of equipment.

41:14I got to rewrite one policy. I have to do one training that I sort of didn't think of. But by and large, we got this covered, right? And I think the top tier is going to have no problem. The big thing is that patients don't know because that assumption level. And I think we're in a crowded market, obviously. And you and I talked about this before. It is a market that is exploding in growth. People are flocking to it for the financial benefit. And that's okay. There's nothing inherently wrong with that. But as we talked about, the market, some best estimates that I've heard are that we're about 10 % saturated.

41:51So if we think there's a lot of med spas now, wait five years, right? It's going to be a really crowded market. And without some differentiation that a patient can tangentially hold on or tangibly hold on to and really grasp and understand as to what makes practitioner A different than practitioner B. The only thing they have to go on is sort of style. Instagram, right? They can go on, you know, how many followers do you have? Which is not helpful at all because it's just, you know, I hired a marketing company that got a million and a half bots to follow me. Great. My engagement was huge. It makes me look like a superstar.

42:29or, you know, price. And what you don't want is a raise to the bottom on price because that's where you get adulterated products, you get product bought from, you know, unreputable third parties, you get people cutting corners on, again, wasting product that's too old that needs to be wasted. You know, what we find is even good practitioners, now, I'm sort of leveraging my history with surgery, even well-trained, even great practitioners, ethical practitioners face human problems. economic problems. And so you have to justify this fancy new machine you bought. You have to justify your costs. You try to stretch a product.

43:07So in a crowded market where patients have no clue who to pick because they can't tell the difference between you, you, and you, what we need to do is say, I am Volvo. I am Mercedes. I am the luxury brand. And that's why you want to pay 5 % more for me because that 5 % is your safety. That 5 % is your comfort, your trust, and our ability to respond to an emergency for you. It's okay that that person up the street is 10 % cheaper than me. I really hope you'll consider the fact that you are buying, you are paying for me to do things the right way, to have an extra staff member who's looking out for my infection prevention, right, my emergency preparedness, my whatever it is, you might be paying for that patient, whoever, make a rational choice.

43:55Now, you as a patient can choose to go one way or the other. But as of right now, there's really nothing other than social media, bedside manner, style of the facility, maybe language. I think that's an important one, right? Like we see a lot of patients who are treated in not their native language. And so people will seek out, people will seek out someone who can care for them in a way that they can communicate. I think that's very good. It's very appropriate. But even within that community, you have people, unfortunately, that can also sometimes weaponize that. Now, again, I don't want to make things, I don't want to go to the negative, but I want to make sure if you're the patient who's treating whatever, the Chinese community in Chinatown in New York, right, that they can tell the difference if English is a second language in there, a recent arrival, but they want these services, that they're able to communicate and find the practitioners who are safe in their community and not necessarily just somebody who's going off a price.

44:50And it could be the Bronx, it could be Chinatown, it could be Miami, it could be, you know, little, little, I don't know, right? But that's the point, right? Like in every environment, there's the cost driver and there's the people who are going to keep me safe driver. And I think that's what we want those people to be able to stand out. Absolutely. No, this is so, so, so important. I love that you brought up, like, you know, I think just international kind of experiences that people have, you know, if you, because that's human nature. You know, you're going to go to somebody that looks like you, that can speak your language, that you can understand.

45:23But I still think, and I don't know if this is part of the program or if anything exists right now, but I still think that documentation is a very real thing. And everything in the United States in an English-speaking country needs to be documented in English as well as any other foreign language. And those kind of things should also be thought about, you know? Like, you can explain something. You know, in hospitals, this happens as well. If you speak, like, I speak Hindi. I've spoken to patients in Hindi before, but at the same time, I'm still writing things in English and Epic, you know, at the end of the day.

45:51So you have to have this like duality there. And I think there is a way for it to go forward where you don't compromise your, you know, as a med spa or a facility, you're not compromising your uniqueness. You're just making sure that whatever you're doing is by the book. And no matter who you treat, it's going to be by the book every single time, you know. And so I think this is incredible. And I really urge everyone listening. We have so many patients that listen in. And we get a lot of questions about these things as well as far as like vetting spas and vetting facilities. So I think, you know, how does a patient understand, like, what do they look for to make sure that a facility has gone through your program?

46:30Like, is there a seal to look for? What do we look for? Yeah, you can see if there's video, you can see the seal directly over my left shoulder. but you will see our logo, Quad A, probably accredited by Quad A. Any facility that's accredited should carry a certificate. That certificate, we require them to place in a publicly viewable place. So usually it's the waiting room, the door, whatever. Their actual, their certificate is actually digitally distributed and it's like sort of a blockchain type of deal. So actually we encourage most facilities to embed that in their website and on their social media so that you can click it because it is click-through and it will go to the separate platform that houses their accreditation certificate.

47:15So separate from their own website, it's a third party, explains the program, explains the level of risk stratification that they are in. Are they a green facility, a yellow facility, an orange facility? Not just that they're accredited because we want to make sure that they're providing the appropriate care and what it means to be accredited. I think that's the first thing. We have a directory that unfortunately is down right now for renewal and for redesign. That'll be coming up shortly. So in the future, patients, facilities, they can go to www.quad.org, Q-U-A-D.O-R-G, and look for accredited facilities.

47:53There's a section for patients. You click on that, you go to accredited facilities, and there's a directory. Again, that it's down right now for refurbishment, but it will be back up. But look for all of those indicators. I have no doubt that other people will come into this space to do what we're doing. We obviously recognize the need and wanted to move very quickly to put a product out there. There's other people. What you want to make sure that you're doing as a patient is understanding what accreditation means and what accreditation of facility carries. You know, there are organizations that exist in the world that call themselves board certifying that are not ABMS recognized boards.

48:32And what that means is someone could take some training, they could take an exam, they can pass, maybe they get certified, whereas others might require a certain time in residency, a certain time of training, a certain number of cases to be done, an oral exam, an arachnid exam. So not all certifications are created equal. And that's the same with accreditation. You don't want a desk review. You don't want someone just submitting some papers and saying, I, you know, looked at this facility. I promised that my facility is going to operate in a great way. And here's my training. You know, what we do is we put eyes on site, which I think is incredibly important.

49:07Even most referral sources don't ever do that. You refer to another doctor because you know that doctor and their reputation, but you don't meet their nurses and their techs. That's what we do. And any accreditor that you value should be putting eyes on site and looking at the staff top to bottom and the records top to bottom. So in our case, any patient can go to our website and download the standards and see exactly what we require of the facility. And you can see how comprehensive it is. And I encourage all patients to vote with their wallet, to walk into a facility and say, are you accredited and by whom?

49:43Right now, as far as I'm concerned, we're the only people that are doing this in a comprehensive on-site way. So ask, are you quality accredited? And if not, leave. Go somewhere else. Say, I'm not coming back here until you're quality accredited because I want to know everything you're doing top to bottom is that you've demonstrated the ability to comply with some standards. Because I don't know what to ask, but I believe that they do, right? And to a practitioner out there, this would be one of our standards. They're going to evolve. In our Surgery Worldwide version 16.8, right? They change. Medical technology changes.

50:18we're going to learn a lot in this first six months of this new program. And we're going to refine and tweak and zero in. And in two years, the technology and the services are going to change. We're going to refine and tweak again. It's a living document. It's a living program. But what it is, is a partnership to always push safety forward, to push safety first for the patient. And as a patient, you have to be aware of that. I love that. I love that so much. And for everyone listening, I'm going to be linking everything, the show notes of this episode. So make sure you are scrolling down and going to the website, checking out all the things that Tom is talking about.

50:51And I could not agree more with you, Tom. I think it's so important and so amazing that you guys have put this transparency, both obviously on the side of like any practitioner that wants to get accredited, but then also for the patients themselves, you know, that can go through this as a patient and understand like, wow, they really do look at everything, you know, and this is very, very important. And I love what you're doing. And, you know, I'm I just I don't know. I don't have enough good words to to praise it. So thank you so much. I do have one question for you, though, before we go. And I think this is important for everyone to understand.

51:22Where is the government in all of this? Like, I know we talk about the FDA a lot. You know, I've brought them up a lot. But what is their role in all of these things? Like, you know, yeah, it's a good question. And frankly, some of the best places that we work in some of the best environments we work as an accrediting organization is in. as a supplement to the government. We don't replace government. That's never our intention. I think for even practitioners, but especially patients, it's very interesting to understand how healthcare in the U.S. and abroad works, right? I'll zero in on the U.S.

51:57because it is essentially 100 different countries. So in the U.S., when you talk about, we'll start with surgery home about, but only because it actually applies to meds. In the U.S., there is the Department of Health in most states that deals with essentially institutions, right? Your hospitals, your nursing homes, your step-downs, as you talked about, your ambulatory surgery centers. Those are licensed entities that the government sort of recognizes as an institution, and the staff can come and go from that institution, and they are essentially interchangeable, but that institution is licensed and verified by the government.

52:35In every state, there is also a medical board, a pharmacy board, a nursing board that licenses the professionals. So when you get down out of the institutions to a private practice, so if you're an office surgery setting or a private practice that does gastroenterology, the Department of Health in most cases is no longer looking at that center. the medical board is looking at that center and it is tied to that medical director who's owning and operating that facility or maybe maybe there's a practice right yeah and those people and that medical board are judging everything that's happening and they are basically holding that physician's license in the balance and that's how they're saying if things go wrong or right it will be your medical license that is what's on the line, right?

53:26And so only about half the U.S. states have a strong mandate for office surgery accreditation. That might shock a lot of patients. Only about half the states have that. And even states that do have varying degrees of monitoring and enforcement. I will say we have a really good relationship with the state of New York. The state of New York says to their facilities, to their offices, go out, find an approved accreditor. here's the list of who they are, get accredited. And there's about 11 or 1200 accredited office surgeries in New York. We do about 800 of them. It's so big, we're the market leader.

53:58I love New York. I love it. New York is always on point with this stuff. Yeah, that's amazing. But the state can go out to 1200 facilities. And I'll be honest with you, not every office surgery that should be accredited in New York is. They still struggle with modern reinforcement, even though they have a public facing website that lists every accredited clinic by county. and they encourage patients, if you go to a clinic, look it up. And if it's not accredited, report that, right? So that's where we are in the continuum of surgery. Where most states are right now with MedSpot is looking at who's doing the procedures themselves, who's allowed to.

54:34In some states, I believe Florida has some rules around the medical director. Each state is going to have to decide how and when they want to regulate this space and how they want to approach it. I think their first problem is deciding where it falls. Many states struggle with, is this medicine? Is this pharmacy? Is this nursing? Is it dentistry? Is it something else? Is it our Department of State? Who exactly should regulate this? I think that's even a first struggle for them. I think, if I'm not mistaken, Florida had a proposal on the books to regulate MedSpa under the Board of Pharmacy. I think some other states are working on it under the Board of Medicine.

55:14but it's a moving target. What we're proposing to some states, and we don't actually advocate, it's very much like a technical advising. If they can't keep up with office surgeries because there's too many locations and they don't have the personnel or financial resources to do that, they've worked with us in many cases for 30 plus years. They can do the same thing they do in surgery. And they can say, go out, here's a list of approved accreditors and get it done. and then push the states to do it. That would be, in our mind, that's the way it works well. It allows the state to focus on complaints, on adverse events, on sort of the for-cause stuff.

55:54And they coordinate with us. Like when we work on an investigation with the state of New York, they coordinate with us and they see what we're finding. They communicate with us and they sort of use us as an extension of the state and then they take their actions. So they act independently, but they utilize our resources. Yeah, that's smart. They should do that. That's how every state should do it. I mean, that's ideal for me. I think it works well. Yeah, because they don't have enough people. So, sorry, go ahead. Honestly, we do it abroad too. We have a great relationship with DHA, which is the Dubai Health Authority.

56:26Obviously, they're going under some, they have a lot more high priorities right now. But we accredit like 75 % of the ambulatory surgeries in Dubai. And we're working with them on subsurgical as well now. And if there is a for-cause issue, they communicate with us very, very openly, and they rely on our findings. They communicate with our surveyors. They may send in surveyors with our surveyors for collaborations. It becomes an issue where we can extend the government without smothering the industry because it tends to, the pendulum tends to swing very, very hard if it becomes legislation. So one of the easiest things and one of the best things to do is to say, here is a responsible organization that we know that we have confidence in, that's been doing this for 45 years, that sets the bar in that right space.

57:20And we'll work with them. If we have a few points of emphasis, like Florida has points of emphasis that they really like, that they really want to make sure that we're looking at that's a little bit unique to their state, they may say, okay, use your program, but also make sure you're looking at these four or five other things. and that's a good partnership that puts it on the right, you know, kind of acuity so that it's not killing the industry and treating it like cardiac care, but not just letting it be kind of free form. Right. That's wonderful. I'm glad that there are, you know, states that are utilizing you guys the right way.

57:54I think that's very, very important, especially if you want to implement this, you know, across the country and obviously internationally. But, I mean, I really urge people, you know, If you guys are going to any kind of spa, anything, any clinic, and you're not seeing the things you should see, right? A lot of the things Tom has mentioned here, say something. Bring it up. Bring it up to the med spa owner. I would. I would be like, hey, listen, I'm not trying to be mean, but can you give me some proof of what you do? What are your normal practices? And it might make them think because I don't think that people open businesses with ill intent.

58:29I think sometimes there's a lot of miseducation and undereducation on a lot of regulatory stuff. And so this is also very, very important from that stance is that like you're putting it in the forefront. So if someone wants to understand this and they own a business such as this, they can go and opt in, you know, and I think that's very important. And I think it also falls on the patients. You know, as patients, we think everything should be just taken care of. Well, this is a new space. It's developed. Like you said, only 10 percent saturation has happened right now. So as it evolves, I talk to every day, Tom, on the show, I have regenerative medicine specialists coming on, skincare brands that are trying to move into the, you know, if you expect things like exosomes to start being legal in the United States for injectables and stuff and regenerative medicine, then this kind of regulation is absolutely paramount.

59:18Like you have to have this level first and then we can talk about all the other stuff, you know, because this is the baseline. This is the the standing point, you know, for everything. And so I really urge all the any patient listening, any consumer listening, like you guys got to speak up to, you know, it can't just be always on. Oh, well, they didn't know. Sometimes they don't know. They might not know. Yeah, you said it right. Like we assume people know no one starts a business. No one takes on care with ill intent or maybe a few people do. And when we talk about this, the conversation tends to go to the people that are up to no good, because that's who you really want to get rid of.

59:52Honestly, you want to weed out the people that are up to no good. But the reality is, you know, there's some percentage of folks that are at the top tier. There's some percentage that are up to no good. And there's a lot of folks in the middle who don't know what they don't know, who are too busy to know what they don't know, who are just trying to do the best they can and trying to scale and can't quite figure it out. And they're struggling with consistency. And that's where this stuff really makes a difference. At the top notch, are we going to make a huge difference? It's going to be an incremental difference.

1:00:18I look at it like grading scales. If I got an A student, I'm trying to get them to an A plus, is it really going to make that, are we going to make them that much better from a 97 % to a 99 %? It's great for them, but it's on the margin. If I could take a C student and make them an A student, that's real difference, and it makes a real difference to the patient. Some of those F students are going to stay F students, and it's up to the market to weed them out by saying, why are you not doing this thing that's really approachable and reasonable? I'm not sure I feel good about you. And the way to do that, as you said, is to educate yourself, go to the website.

1:00:53I wanted to say this, follow us on social media, not because I love, I'm not a big social media person. Personally, I do it a lot for the business. But if you follow Quad A now, Instagram, Twitter, LinkedIn, Facebook, I guess it's X now. The reason I say that, most of what we do is business to business. so it's not going to really relate to the patient. But what will relate to the patient is when we profile facilities and centers that become accredited. And we amplify their pride in becoming accredited, passing their survey, and being able to show you as a patient that they are doing everything that they can to keep you safe.

1:01:32We are doing the best we can to amplify their voice and let you identify them more readily. And so if you follow all of that on social media, when they announce their accreditation, they tell their badges, they go to our learning sessions to learn better practices and better techniques to keep you safe. The more your eyes are on that and more you're able to speak intelligently to them about that, the more you're going to validate and reaffirm that commitment. That's right. I love that. And I will be linking, by the way, guys, make sure if you watch our stories or anything on our socials, you're going to see there, we're going to pop Quad A Socials up there as well.

1:02:09So check that out. And I've loved this chat, Tom. Thank you so much. We've learned so much. I mean, I've learned so much. I didn't know this was the case. And I know a lot of people out there, we don't know these things. So it's very, very important to highlight. So I can't thank you enough for your time and for all the education. It's been wonderful. Thank you for giving me an outlet for all the energy and passion I have for this. So I hope it makes a difference for some of the practitioners listening and for the patients out there. And I can't thank you enough for giving us this platform. No, of course.

1:02:37I'm so glad you're passionate about it. We need passionate people to do this, you know, rather than someone who doesn't care. So thank you so much.