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INTERNATIONAL AIR AMBULANCE ACCREDITATION ROUND TABLE
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INTERNATIONAL AIR AMBULANCE ACCREDITATION ROUND TABLE BUSINESS FORUM SESSION 001
C-Level International Air Ambulance Accreditation Round Table
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CONTENTS 18|
Q1
WHAT ACCREDITATION PROGRAMS EXIST FOR MEDICAL TRANSPORTATION PROVIDERS?
20|
Q2
HOW DO VOLUNTARY ACCREDITATION PROGRAMS DIFFER FROM STATE REQUIREMENTS?
26 |
Q3
WHAT BENEFITS DO PATIENTS SEE FROM AN ACCREDITED MEDICAL TRANSPORT COMPANY?
27 |
Q4
HOW FEASIBLE IS 1 WORLDWIDE STANDARD FOR AIR AND GROUND AMBULANCE COMPANIES?
30 |
Q5
HOW CAN WE MANAGE AND MEASURE THE QUALITY OF AIR AND GROUND AMBULANCE BROKERS?
31 |
Q6
HOW CAN YOU ENSURE THE QUALITY OF YOUR AIR AMBULANCE PARTNERS?
C-Level International Air Ambulance Accreditation Round Table
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34 |
Q7
WHAT HAPPENS IF AN ACCREDITED AIR AMBULANCE COMPANY HAS AN ACCIDENT?
35 |
Q8
WHO MEASURES THE QUALITY AND REGULATES MEDICAL TRANSPORTATION ACCREDITATION PROGRAMS?
36 |
Q9
DO ASSISTANCE AND INSURANCE COMPANIES PREFER TO CONTRACT ACCREDITED COMPANIES?
37 |
HOW DOES YOUR BUSINESS MEASURE AND MANAGE QUALITY?
38 |
Q11
WHAT MAY BE IMPROVED IN THE ACCREDITATION PROCESS?
39 |
Q12
HOW CAN WE MEASURE THE QUALITY OF MEDICAL ESCORTS ON COMMERCIAL AIRLINES?
BONUS READER QUESTIONS CAN SMALLER AIR AMBULANCE COMPANIES, GAIN ACCREDITATION? WHAT DOES THE FUTURE HOLD FOR MEDICAL TRANSPORTATION ACCREDITATION?
Roundtable
Q10
Roundtable
14 |
ARRIVALS
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
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ROUND TABLE DELEGATES AIRMED JANE TOPLISS
Jane Topliss joined AirMed in 2003 as a line pilot, since then she has gained approximately 4,500hrs of air ambulance flight experience. Jane currently looks after all of the business development and marketing at AirMed and in 2011 became a Company Director and Board Member. On a daily basis she is involved in client liaison, contract negotiations, company training programmes and regulatory discussions.
Eileen Frazer is the Executive Director of CAMTS. CAMTS is an organization of non-profit organizations dedicated to improving the quality and safety of medical transport services, with 21 current member organizations each of which sends one representative to the CAMTS Board of Directors. Originally developed 1991, the Accreditation Standards address issues of patient care and safety in fixed and rotary wing services.
EURAMI LAURENT TAYMANS
Laurent Taymans is President of the Board of EURAMI. Elected as President to lead several significant reforms that include the modernization of the statutes, revising standards and reviewing and improving the self assessment questionnaire. These achievements were made possible due to the intense and effective collaboration between the EURAMI board and members.
Roundtable
CAMTS EILEEN FRAZER
T
. e m o h e m e k a
24-HOur EmErgEnCy SEr viCE
+43 512 22422-100 taa@taa.at
More than medical care and ambulance services: • 3000 patients returned home every year • Cost-effective double and multiple transport facilities • Worldwide operations - experts in long-haul flights • Shuttles with shared capacities on a weekly basis • Online tracking of free capacities at www.taa.at • Own fleet of seven aircraft
www.taa.at Platinum Safety of Flight Award 2013 | ERA member | EBAA member | EHAC member | EURAMI certified
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
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ROUND TABLE DELEGATES FAI VOLKER LEMKE
Volker Lemke is the Director Sales & Marketing (CSO) at FAI Air Ambulance. After learning about the basics of aviation and emergency medical care in a long career as a road and helicopter ambulance paramedic, Volker built on this experience to become a trainer and teacher and then a sales manager. In 2004 Volker brought his talent and enthusiasm, as well as his extensive market knowledge to FAI.
IAAA GARY ANDREWS
Gary is the President of the International Air Ambulance Alliance - fixed wing. The IAAA is a global not for profit organization that holds air ambulance members accountable for professonal standards of opertion and delivers collective membership benefits. It is an advocate for air ambulance industry change and works with other professional organizations who share the same goals and mission.
TYROL EVA KLUGE
Eva Kluge is Head of Sales and Marketing at Tyrol Air Ambulance in Austria (winner of the 2013 ITIJ Industry Award “Air Ambulance Provider of the Year�). Eva is an expert in healthcare, medical assistance and cost containment. For the past 17 years she has worked in executive roles for renown players in the market (Europ Assistance, Munich Re). She holds a degree in Healthcare and Social Management and speaks fluently 5 languages, among them Arabic.
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Roundtable
Q1
WHAT ACCREDITATION PROGRAMS EXIST FOR MEDICAL TRANSPORTATION PROVIDERS?
EVA KLUGE: For Air ambulance providers: EURAMI, CAMTS, NAAMTA. JANE TOPLISS: I am aware of 3 accreditation programs for air ambulance providers – CAMTS, EURAMI and the IAAA. At present CAMTS is more recognised and accepted within the US market with EURAMI initially being very European focused, however it now has a very global membership and accredited provider list. CAMTS and EURAMI are now being cited within tender documentation as being a requirement for providers tendering for the contracts with the United Nations and the Canadian Government. The IAAA is a fairly new organisation and I am unfamiliar with their accreditation standards and process. EILEEN FRAZER: CAMTS was the first accreditation available to air medical services with an initial focus on rotor wing and fixed wing in North America but available world-wide. The CAMTS Accreditation Standards are also recognized worldwide – first published in 1991 and widely emulated by other organizations, States and other accreditation bodies. VOLKER LEMKE: Accreditation programs of interest to the air ambulance industry can be classified in three complementary categories: Aviation accreditation, air ambulance accreditation and individual provider accreditation. The first one is well entrenched as it has existed for decades, is compulsory on a national basis and in some areas like Europe, also subjected to supra-national standards. There are in addition well established international organizations such as ICAO and IATA that act as umbrella organizations for all aircraft operators including air ambulances. On the contrary specific accreditation of air ambulances is more recent. It exists nationally for public sector emergency systems (particularly helicopter
EMS) but does not extend to privately owned and operated international air ambulance providers. This led to the recent development of volunteer accreditation schemes such as the well-established EURAMI or CAMTS, or newer initiatives such as IAAA. The accreditation of providers is both done at the national level for each profession individually and subject to well-accepted international transversal standards such as ATLS or ACLS. LAURENT TAYMANS: There are several programs; CAMTS, EHAC, EURAMI and NAAMTA. EURAMI has been in existence since 1992, a little after CAMTS. As CAMTS had a largely North American focus at the time, EURAMI filled a gap in the European sector. Although EURAMI took another approach, the objective was the same, allow companies to validate their level of quality of medical services. Over time we progressed past the European borders and we are now present on all continents. The feedback that we have received from the companies that underwent accreditation was that our European approach was more flexible in addressing the regional differences in aeromedical medicine. It is important to note that we are predominantly medically driven, bringing to the standards our knowledge and experience. GARY ANDREWS: The two larger accreditation programs are CAMTS and EURAMI. However, the IAAA/ NAAMTA partnership is expeditiously becoming a contender due to the company’s service-based approach to accreditation as well as their efforts at increasing transparency throughout the air ambulance industry. NAAMTA offers procedures that include guidelines for developing a quality management system focusing on transport safety, patient care, and continuous improvement. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
One of AirMed's Learjet35As at Glasgow Airport. Picture courtesy of Iain MacKenzie
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FAI holds an Air Operator Certificate (AOC) issued by the German Federal Ministry of Transport
Roundtable
FAI’s current fleet includes 2 Lear 35A, 5 Lear 55, 1 Lear 40XR, 5 Lear 60/60XR, 3 Challenger 604, 3 Global Express and 1 Falcon 7X
20 |
Roundtable
Q2
HOW DO VOLUNTARY ACCREDITATION PROGRAMS LIKE EURAMI DIFFER FROM STATE REQUIREMENTS PUT IN PLACE BY AGENCIES LIKE THE CAA OR FAA?
EVA KLUGE: State requirements are even stricter and less focused on the practical aspects of air medical transfer. JANE TOPLISS: The voluntary accreditation programs differ significantly from state requirements. The CAA remit is specifically on the operation of the aircraft, the training of the flight crew, aircraft equipment requirements, flight crew duty and so on, however it has no input whatsoever on what is happening medically in the cabin. The voluntary programmes seek to close that gap, are medically led and focussed on the medical aspects of air ambulance operations. The accreditation programmes also provide some form of cross over between medical provision and aircraft suitability by stating what is required in terms of cabin environmental conditions like noise, light, vibration and pressurisation; something which is not stipulated in CAA requirements. In the UK, and more specifically England, all ambulance providers, including air ambulances, based in England need to be registered with the UK healthcare regulatory authority, the Care Quality Commission. This has been the case since April 2011. There are different levels of registration depending on the different regulated healthcare activities you provide on board. The theory behind this healthcare regulation requirement is to ensure that all providers of care, be it in a hospital environment, care home or during patient transport, are delivering the same essential standards of quality and safety. Unfortunately whilst the theory is fairly simple, the reality is extremely complicated due to various exemptions within the legislation. See the report in Waypoint “The Curious Case of the CQC”, click here, which gives a little more background information. In addition to the CAA and the CQC in England, there are also the British and European Standards which need to be taken into account. See BS EN 13718 – 1:2008 and BS EN 13718 2:2008 –
Medical vehicles and their Equipment – Air Ambulances. Unfortunately these Standards are rarely recognised and are not taken into consideration by any of the regulating bodies when they are carrying out their audits and approval/registration processes. There are very specific requirements within these Standards which pertain to both the medical equipment and the type of aircraft used. Extracts of which are below: l 4.2.1 A heating system shall be provided capable of raising the temperature in the patient compartment from 0 °C to + 18 °C within 20 min, when the outside air temperature is 0 °C. l 4.2.3 Lighting: Type
Illuminance Ix, Minimum
Patient Area Surrounding Area
200 ª 50
ªMeans shall be provided to switch the lighting down to 10 Ix
4.3 The patient compartment shall have available a minimum of four 12 V DC outlets. Optionally one additional outlet may be supplied by a separate battery, dedicated to medical devices. The outlets shall be available for medical equipment and located in the area of storage and/or use of the medical device. l 4.6 Mechanical vibration shall be kept to a minimum. l 4.9.2 For manual loading and unloading, a maximum lifting or lowering height not exceeding 1 200 mm with a loading angle of 16° between the patient’s sagital axis and the horizontal position will take care of this provision. l 5.4.1 Fixed wing air ambulances shall have more than one engine and a pressurised cabin. l 5.4.1 The choice of aircraft should be based on the capacity of the aircraft to: l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
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AirMed neonatal consultant Dr Catherine Convery on a transfer from South America
Roundtable
On the runway with FAI, a leading Global air ambulance owner operator
FAI’s fleet of dedicated air ambulances can be activated at any time, 24 hours a day, 7 days a week
iPMI Magazine | Air Ambulance Accreditation Round Table
a) minimize the time taken for entire flight; b) limit the number of ground stops; c) ensure comfort for patient, crew and escort l 5 . 4 . 2 T h e p a t i e n t compartment shall be large enough to provide free space for the patient on a stretcher, the minimum dimensions being: height: 1 200 mm; width: 1 300 mm; length: 2 650 mm.
specific to a practice in a certain country, the standard will be stated followed by “or international regulation”. All accreditation bodies award accreditation based on “substantial compliance” since it is almost impossible to be in 100% compliance. The CAMTS Board of Directors is made up of very experienced air and ground transport professionals and this is important because accreditation decisions are based on the collective wisdom of the Board. A service with easily correctable contingencies will be awarded accreditation as long as patient care and safety are not compromised. LAURENT TAYMANS: CAA and FAA issue regulatory requirements that are mandatory. As such they are heavily aviation centric. EURAMI has taken a holistic approach that evaluates not only the aviation component but also the medical and structural component. We also look at quality management in medicine and more specifically in the aviation environment. EURAMI accreditation is not mandatory and is performed on a voluntary basis. VOLKER LEMKE: Air transport regulation bodies cover only the aviation and technical components. Medical components such as criteria for equipment or medical crew qualifications are typically not included, and it is better that way, since these bodies lack the qualifications to establish those. Conversely, voluntary accreditation organizations such as EURAMI use international experts with a demonstrated knowledge of the practice of aviation medicine to audit candidates for accreditation.
C
Roundtable
It is AirMed’s understanding that the EURAMI Accreditation Standards are substantially based on the European Standards. However in order to attain Accreditation with any of the voluntary accreditation bodies, you only need to show substantial compliance and so under that definition there are occasions when accredited members may still be operating while being noncompliant with the totality of the published standards. EILEEN FRAZER: Accreditation processes are voluntary. Government and aviation authorities are regulatory, meaning there is no choice but to meet their rules. In the U.S, there are currently 9 States and 2 counties that require CAMTS accreditation. These States are beginning to change their regulations, as suggested by CAMTS, to recognize accreditation as “deemed status” so that if a program is accredited it already exceeds State rules and regulations which are usually minimal in nature. CAMTS Accreditation Standards address all of the above and more in Section 02.05.00 Medical Configuration. If a standard is
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A star for long-range transports within the TAA fleet: Gulfstream 100
iPMI Magazine | Air Ambulance Accreditation Round Table
TO ACCOMPLISH THIS, BOTH ORGANIZATIONS COMMIT TO THE FOLLOWING: Provide accreditation standards built on industry best practices, state and federal regulations, and other regulatory agency guidelines relating to transport safety and quality of patient care. l Incorporate quality management system practices that help organizations monitor and evaluate their own processes for continuous improvement. l Deliver tools and services that aid organizations to acquire and maintain accreditation. l Fair and consistent auditing processes. l Provide an open forum for best practices and updates on the changing regulatory landscape for medical transport services. l
ENFORCEMENT OF STANDARDS Individual accreditation organizations like NAAMTA truly differ from entities like the CAA or FAA in the methods of enforcement. These federal bodies lack the resources to regularly monitor EMS compliance. Individually-run organizations like NAAMTA possess the measures needed to ensure air ambulance providers remain compliant with requirements set at state and federal levels. l
Photo: Courtesy of Tyrol
Roundtable
GARY ANDREWS: The standards set forth by state and federal entities establish a foundation of performance for air ambulance organizations. Companies seeking accreditation set themselves apart in the industry by attaining an additional level of performance. Accreditation programs are built upon a foundation of best practices on a global level, meaning any organization that achieves accreditation is part of an elite group of professionals capable of competing internationally. The IAAA/NAAMTA partnership establishes an underlying value system whereby standards are developed, defined, monitored, and enforced as part of the service of accreditation.
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Roundtable
Q3
WHAT BENEFITS DO PATIENTS SEE FROM AN ACCREDITED MEDICAL TRANSPORT COMPANY?
EVA KLUGE: Safety, quality, peace of mind, clear procedures with a scientific emphasis. This is also helpful in case there ever would arise a liability issue. Likewise, a patient is not at the mercy of some ruthless individuals exploiting his/ her situation. Adequate technical equipment, adequate medical treatment and well experienced medical staff (doctors as well as nurses) based on state of the art established therapies. JANE TOPLISS: There are almost certainly air ambulance providers around the globe who deliver an excellent patient centred service who are not accredited. However, patients (and clients) can be assured of a certain minimum standard of care by an accredited provider as they have had to go through a rigorous audit program covering all aspects of their operation in order to attain accreditation. The providers are then continually assessed. CAMTS delivers continual monitoring based on evidence provided by the operator throughout their accredited period to ensure continued compliance with their standards. EILEEN FRAZER: It depends on the accrediting organization. Standards are important but the process is equally important. Do the auditors have the appropriate and specific expertise and experience. None of the CAMTS site surveyors have less than 10 years current experience in air or ground transport and we match the site surveyors’ experience to the specific needs of the service. In addition, our Board of Directors is made up of experts from every discipline involved in medical transport. CAMTS is not only proud of this level of expertise but we are transparent. The CAMTS website provides all of this information by posting our current policies and a current list of our member organizations and representatives, many are familiar and published researchers in the field of air medical transport. The Mission of CAMTS has always been to improve patient care and transport safety. We
rely on our Mission and Values (Fair, Ethical, Consistent, Accountable and Patient and Safety Focused) to meet our Vision - that all patients are transported safely by qualified personnel using the appropriate mode of transport. LAURENT TAYMANS: Accredited companies show commitment and vision, providing sustainable aero medical care. Overall patient care quality is better and more consistent and as such outcomes are often better. “Professionalism means consistency in quality” which is what an accredited company delivers, consistent quality medical care. By undergoing EURAMI accreditation companies show and more importantly live that commitment on a daily basis. VOLKER LEMKE: Patients have the guarantee that at the very least the certified provider will meet minimal standards, and that it will usually meet much more than minimal standards. This therefore guarantees better medical management. GARY ANDREWS: The standards set as part of the IAAA/NAAMTA accreditation program are intended to improve the functions of the EMS organization and the overall patient experience. Patients will notice the following attributes of accredited organizations: Adequately-trained air ambulance professionals capable of ensuring patient safety and recovery l Well-maintained and equipped vehicles for safe and speedy transport l Measurably higher level of quality in service and safety l Increased levels of accountability from the air ambulance provider in giving details about the transport to the insurance provider l Compliance with the standards of accreditation will ultimately lead to more positive patient feedback and additional business opportunities. l l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q4
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HOW FEASIBLE IS 1 WORLDWIDE STANDARD FOR AIR AND GROUND AMBULANCE COMPANIES? implement, not only on the political but also a practical level. An excellent analogy would be the ILCOR (International Liaison Committee on Resuscitation) guidelines that are the basis of our management of cardiac arrest. If we look at it’s history, we understand that even in something as vital as the management of cardiac arrest, a worldwide standard is a lifetime achievement at best. I do however believe strongly that it would be of great benefit to the patient if it were to be implemented. VOLKER LEMKE: Horizontal integration of accreditation standards to include air, water and ground ambulances under a single umbrella may be attractive intellectually, and clearly some standards regarding equipment and clinical staff qualifications and clinical and operational protocols are similar. However each of the three transport environments has very distinct characteristics and it is difficult to realistically envisage more than a loose information and standard sharing association.. GARY ANDREWS: Establishing a single, global set of standards for air ambulance organizations creates myriad benefits from a technological, economical, and societal standpoint. Effectively achieving a worldwide standard requires multiple elements to work in tandem. Everything from global education requirements to standard flight rules would become necessary and managed by governments. IAAA believes such an initiative must begin with a group of well-organized stakeholders that are interested in designing and laying the foundation of global acceptance. No one global standard yet exists, though with NAAMTA’s forward thinking business model to augment efforts, we strive to aid in establishing international medical transport standards based on ISO processes. l
Roundtable
JANE TOPLISS: There should be no reason why this cannot be achieved, however homogenising local laws and regulatory requirements into a single set of legally enforceable standards would be a hugely complex task requiring a real will to succeed across all of the regulatory bodies involved. Local differences will still need to be accounted for e.g. environmental operating conditions need to be taken into account including aircraft performance requirements for short and rough runways, extremely hot conditions where some form of additional air conditioning may be required on the ground for the patient and the converse in very cold climates. Ground ambulances differ markedly around the world making a process of standardisation extremely difficult. Many countries supply little more than an adapted van and, in terms of the personnel on board, a paramedic may have very different training and responsibilities in different countries. EVA KLUGE: Rather unlikely, the number of accreditations is rather on the increase. Clearly, there is also an economical aspect for accrediting bodies. In technical terms, one worldwide accreditation is not too realistic from a short to mid term perspective as standards of training, geography etc. differ substantially from country to country. EILEEN FRAZER: World-wide standards are achievable but standards must be flexible to allow for differences in culture, topography, differing regulations and available resources. Recognizing the uniqueness of each air medical and ground service, standards must be applied in the context of the program’s mission statement and scope of care with certain core elements such as: aircraft and ambulance configuration, Communications, legal and ethical practices, medical direction, qualified personnel in all disciplines and quality and utilization management. LAURENT TAYMANS: Although a fantastic ideal, a worldwide standard would be difficult to
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Roundtable
Q5
HOW CAN WE MANAGE AND MEASURE THE QUALITY OF AIR AND GROUND AMBULANCE BROKERS?
JANE TOPLISS: I think this question should actually be widened to include an air ambulances entire client base. If we can get all air ambulances working to a certain standard through the accreditation process, then the only way for the provision of care to continually improve is for the relationships between the providers and their clients to be more open and with better communication. There are many instances throughout the industry, including brokers and assistance companies, where the level of information which is provided to the air ambulance company is extremely poor. By having a minimum standard of medical and operational information provided to the operators, the risks carried by all parties will start to reduce. Whilst it is known that the company who is providing the care during the transfer, usually the air ambulance operator, is the one carrying the medical risk, there is a considerable amount of work done prior to the operator becoming involved. Should there be an incident of any kind during a transfer, then all aspects will be looked at including the medical information the air ambulance operator was given. Bear in mind that we will base our staffing and care decisions on the medical notes provided to us. In many instances it is this transmission of accurate and pertinent information that is found lacking. Taking the above information in mind, there should be an accreditation standard available for non-operators, which is something we have already suggested to one of the voluntary accreditation bodies. Accreditation of air ambulance providers only ensures quality in one aspect of the overall care package a patient receives. EILEEN FRAZER: One way for brokers to ensure quality is to reach out only to transport services that have achieved accreditation. This does not guarantee quality but it does ensure that a
comprehensive audit was completed in a reasonable time frame (at least every 3 years). Checklists should be developed by brokers that require certain evidences of quality (can be based on accreditation standards) be submitted before contracting with a service in the event an accredited service is not available. CAMTS is working on accreditation for Assist companies so that an internal auditing practice encompasses all the important critical elements as discussed above. LAURENT TAYMANS: This is not possible outside of a specific legal and regulatory framework. Last year EURAMI implemented minimum medical and operational requirements when applying for accreditation. This was designed to exclude companies that broker flights. VOLKER LEMKE: This is a good question, the answer to which I do not know ... it is one of the greatest challenges in our industry. As a minimum requirement brokers should be called on requesting proper documentation like AOC, airworthiness and insurance certificates etc. of each operator they use and clients should insist on getting the credentials from the broker to be protected against providers they do not wish to do business with. GARY ANDREWS: IAAA and NAAMTA deal exclusively with air and ground ambulance organizations and do not offer membership options or accreditation standards for brokers. While the role of the broker is important in some circumstances, we feel that the services rendered by air ambulance operators are where the focus should currently be placed. As we come to better understand brokers, we will evaluate the creation of broker standards to manage and measure their quality as a contributing entity to pre-hospital care. EVA KLUGE: They should be obliged or to cooperate with accredited companies only where available as otherwise there is no control. At least they should be obliged to inform their clients about the various choices. They should be supervised by well-known experts. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q6
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WHEN AIR AMBULANCE COMPANIES WORK TOGETHER ON A CASE OR PIGGY BACK, HOW CAN YOU ENSURE THE QUALITY OF YOUR PARTNERS?
TAA Dornier 328 equipped for a shared capacity transport
as well as the qualifications of the medical crew and the equipment list. GARY ANDREWS: The purpose of the IAAA/ NAAMTA partnership is to create and foster relationships between air ambulance companies. We refer to this relationship as the “alliance.” One of our goals is to give our alliance members a conduit to conduct business with companies of similar standards of performance and levels of transparency. When an air ambulance operator needs to work with another to complete a transport assignment, they need to rest assured that whomever they partner with will provide the same level of detail and safety for their patient. We actively encourage our Alliance members to work together for partner projects simply due to these major benefits: Keeps patients with accredited members Ensures higher quality patient care and monitoring l Greater transparency to patients and insurance payers l l
By keeping patients with air ambulance organizations who have received IAAA/NAAMTA membership, both the patients and the insurance payers can expect to receive a higher level of service. l Photos: Courtesy of Tyrol
Roundtable
JANE TOPLISS: You can only ensure the quality of your partners by undertaking thorough due diligence. A great starting point is the voluntary accreditation system, but nothing beats close communication, audits and site visits. EILEEN FRAZER: Communications and preplanning are essential and made easier if the companies are accredited because they are meeting compliance with similar standards of care and safety. EVA KLUGE: By previous audit and cooperation agreement. It is risky to pick an air ambulance company somewhere not knowing what standards you can expect. LAURENT TAYMANS: Working with accredited companies, adequately ensured, with a valid AOC is probably the only way to ensure that your partners are providing quality medical care. Although we encourage EURAMI accredited companies to work with each other we also strongly encourage our accredited providers to seek out the best quality aeromedical services possible if there is no other alternative. This avoids “lock in” and takes into consideration the patient’s health and safety first. VOLKER LEMKE: As a rule we use only EURAMI accredited providers. Should it be necessary in an emergency situation to use a non-certified or an unknown partner, we would at the very least verify the aircraft’s certification and insurance,
Tyrol Air Ambulance medical team inside the Dornier 328
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Roundtable
Q7
WHAT HAPPENS IF AN ACCREDITED AIR AMBULANCE COMPANY HAS AN ACCIDENT?
JANE TOPLISS: I am unsure of the procedures within CAMTS and EURAMI when one of their accredited providers has an accident. Every accident is fully investigated by the Aviation Regulator. Accreditation should not be revoked until investigation results are known. EILEEN FRAZER: CAMTS has a policy that all accidents that involve injury and/or substantial damage must be reported within 30 days. A service that has a fatal accident is so designated on the list of accredited services on the CAMTS website as “Under review”. The service must submit follow-up reports, NTSB reports and a Root Cause analysis. Within 6 months, a supplemental visit is performed and findings are reviewed by the Board. A decision to change the accreditation status or withdraw accreditation is always an option but the important goal is that the service is following its own internal processes to ensure safe practice. LAURENT TAYMANS: Aviation related accidents have a strict regulatory framework with a formal investigative process which EURAMI will not and cannot interfere. We are not a regulatory body. Medical accidents/incidents happen and must be addressed in a “no blame” manner. As with any serious adverse event there is a voluntary reporting procedure as well as an investigation. Findings are communicated confidentially as well as any recommendations to avoid this incident. If the issue is structural and is not addressed by the program or clearly against the EURAMI standards, the board may vote to withdraw their accreditation. This process is designed to ensure a maximum amount of objectivity and to allow all parties to be heard. VOLKER LEMKE: The regular accident investigation by the industry’s national authorities takes place the same way as it would for any accident involving aircraft. After completion of the
investigation recommendations may be made that accreditation bodies would have to take into account. GARY ANDREWS: The IAAA nor NAAMTA are accident investigation organizations, but both organizations must be involved in the discovery process for uncovering the cause of the accident. Incidents are commonly indicative of inadequate training, poor vehicle maintenance, or simple human error; we must identify the problem point for an accreditation status assessment. Reporting accidents and incidents enables us to evaluate the event and implement corrective actions for future transports. 1. The affected organization should contact IAAA/NAAMTA within 10 days of alerting the proper authorities, i.e. the EASA, FAA, CAA, and transportation safety boards. 2. IAAA/NAAMTA will follow the event evaluation of the regulatory agency. NOTE: The air ambulance organization’s membership and accreditation status will remain in full effect pending the results of the evaluation. 3. Once a determination is established by the regulatory agency, we will review the ruling and assess a course of action for the organization’s accreditation status. The IAAA and NAAMTA reserve the right to examine NTSB, FAA, or local authority’s rulings as to the cause of the accident. Accreditation and membership status will be reviewed after analysing cause of accident. A supplemental audit may be required to continue accreditation. EVA KLUGE: That depends entirely on the circumstances of the accident and issues like intent, gross negligence etc. A well-established Air Ambulance should be familiar and well approved with critical resource management. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q8
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WHO MEASURES THE QUALITY AND REGULATES VOLUNTARY MEDICAL TRANSPORTATION ACCREDITATION PROGRAMS? demonstrates to the companies they audit, attributes the IAAA similarly wishes to convey. ISO 9001 certification helps set NAAMTA apart from other accreditation organizations as one that can prove true program transparency as well as guarantee a dedication to its own expected standards of performance. It not only makes NAAMTA accountable for its processes, but also benefits our members. The phrase, “Say what you do, and do what you say,” best describes ISO 9001 certification. The most compelling benefit of ISO 9001 certification for an accrediting organization is that any company can reap the rewards offered through this higher standard of performance, much like the organizations that seek accreditation through NAAMTA. The ISO 9001:2008 certification eliminates variances to the levels of service provided and the processes followed as an accreditation organization. Each process pertaining to the accreditation in its entirety is thus documented, allowing NAAMTA to guarantee the same standard of service to each organization it audits, regardless of prior accreditations. Accountability and reliability are necessary attributes to any air ambulance accreditation program, and NAAMTA is no different in its delivery. By receiving the ISO 9001:2008 QMS certification, they have the resources and processes necessary to obtain and demonstrate a higher standard of performance throughout the auditing phase as well as between audits. NAAMTA isn’t just a form of accreditation; like the IAAA, they’re a resource for the betterment of the industry and your organization through learning centre resources, air ambulance reporting tools, and daily support. l
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JANE TOPLISS: This is something that is industry wide discussions between operators and service users take place with the standards and quality levels constantly monitored and updated as modern practices evolve. EILEEN FRAZER: Communications and preplanning are essential and made easier if the companies are accredited because they are meeting compliance with similar standards of care and safety. LAURENT TAYMANS: There is no regulatory body for voluntary accreditation programs. Quality measurement is provided through internal review and evolution that we’ve been refining over the past year since the present board has been in office. Understand that outside measurements and audits can measure the accreditation program’s internal processes ie what & how it collects and evaluates information. It does not ensure that the questions asked nor the findings of the auditors are pertinent, as they do not hold “knowledge” of the industry. VOLKER LEMKE: The air ambulance provider itself should measure performance as part of its quality orientation. It is in the provider’s own interest to maintain high performance targets to improve its market position. After each audit feedback from EURAMI will allow the organization to reach even higher targets. EVA KLUGE: Players from various fields in the travel insurance/ assistance industry with excellent experience in aero-medical transport. GARY ANDREWS: This is one of many areas that set NAAMTA apart as a unique accreditation organization. Whereas other companies might be regulated solely by a board of directors or a similarly-internal body, NAAMTA’s accountability is also regulated by the International Organization for Standardization (ISO). In March of 2012, they became an ISO 9001:2008 certified Quality Management System (QMS) company. NAAMTA pursued this certification due to the structure, transparency, and continuity it
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Q9
DO ASSISTANCE AND INSURANCE COMPANIES PREFER TO CONTRACT ACCREDITED COMPANIES?
JANE TOPLISS: In AirMed’s experience, there is a preference within the assistance industry to use providers who are accredited. However their use is not, in our opinion, used often enough and cost is still the driving factor in many decisions, not the quality. Saying that I do know of some assistance companies who will only use those providers who have some form of accreditation. EILEEN FRAZER: Some CAMTS accredited programs have found that being accredited helps with achieving contracts but it is very inconsistent and contracts are at times awarded to the lowest bid, regardless of accreditation status. LAURENT TAYMANS: The general tendency is yes. EURAMI is a requirement for several assistance companies and recently by the Canadian armed forces. VOLKER LEMKE: Some do, others don’t. Unfortunately the number of companies belonging to the second category is still too high. Perhaps a stronger more unified accreditation with some official sanction by an international organization could contribute to changing this state of affairs. EVA KLUGE: Western Europe and the US: mostly yes, but occasionally they do their own audits. Price is a major driver, but so is safety. GARY ANDREWS: Knowing that an air ambulance provider meets the highest standards in medical transport gives added reassurance and comfort
to insurance companies. We find NAAMTA’s standards exceed those of local and state EMS regulatory bodies, which means a reduced risk for insurance providers and thus more of a cost savings. NAAMTA standards ensure that patients receive the highest quality of care due to our rigorous standards. As a resulting impact of NAAMTA’s standards combined with IAAA’s commitment to service excellence, our air ambulance alliance members are much more responsible, accountable, and transparent in their dealings. Not only are these air ambulance professionals well-trained and credentialed, but vehicles are adequately maintained and stocked with the resources needed for patient care. The organizations we accredit and associate with have detailed record keeping and thus improved claims processing and reimbursement procedures, resulting in a lower insurance liability. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q10
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HOW DOES YOUR BUSINESS MEASURE AND MANAGE QUALITY? staff to improve processes and individual performance. Audits and ramp checks ensure compliance with established procedures. EVA KLUGE: Process is before-during-after: Before: Selection of staff with the appropriate education, regular trainings for various requirements (inc. soft skills of staff), standardized procedures and structured manual for air ambulance missions; simulation trainings also for the medical staff. During: Applying the defined rules. After: Customer satisfaction survey, follow up of medical outcome in clinic. GARY ANDREWS: Both NAAMTA and IAAA are founded upon the principles of quality management. Quality and utilization management reinforce our unofficial motto of “continuous improvement.� Due to NAAMTA being an ISO 9001:2008 certified QMS, our partnership has enabled us to establish criteria as part of the certification process that enable us to measure and manage quality efforts. The concept behind effective quality management is planning, doing, checking, and acting. This effectively creates a cyclical process of improvement of always observing its own efficiency and improving upon it actively in some of the following ways: l They document all processes to establish a correct method of completing a task or using an internal document and tracking all changes that occur. l As part of their efforts to maintain ISO 9001:2008 compliance and manage internal efficiency, we perform quarterly internal audits to identify inefficiencies and improve upon them. l Their web tools allow them to track and monitor data trends and file usage to analyse opportunities for improvement. l
Roundtable
JANE TOPLISS: AirMed manages quality in many different ways and we put it at the forefront of everything we do. If you are high quality then you will be safe, both in terms of aircraft operation and patient care. We have a company wide Safety Management System (SMS) which looks at all of the processes within the company by assessing previous incidents and potential foreseeable risks. This is a continuous and ongoing process across all departments, covering the provision of care, flight operations and maintenance. We are also assessed from a qualitative (and quantitative) sense on a regular basis by our regulatory authorities, the CAA and CQC as well as our voluntary accreditation body, EURAMI. In addition to this, AirMed is ISO 9001 compliant and many of our clients have their own additional audit process. EILEEN FRAZER: The pillars of CAMTS are Education, Safety and Quality. We assess education through benchmarks in training and certifications and in patient outcomes. Safety Management Systems are required and components such as non-punitive reporting are especially stressed and most often found to be a problem when we see the results of our Safety Culture Survey. This is an anonymous survey that is emailed to each employee prior to a site visit. Specific survey questions can be found on our website. Quality management is addressed in section 01.12.00 of the standards and a service must demonstrate an emphasis on QM on a continuing basis with constant attention to improving patient care and safety. Outcome studies are required. VOLKER LEMKE: The aviation and technical components of course have their own quality management program with its integrated audit process. On the medical side outcomes are systematically verified through examination of patient data, regular quality improvement meetings with the
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Roundtable
Q11
WHAT MAY BE IMPROVED IN THE AIR AMBULANCE ACCREDITATION PROCESS?
JANE TOPLISS: AirMed is currently accredited by EURAMI and so we are most familiar with their processes. As has been publicised in the industry press over the past 12-18 months, EURAMI has experienced considerable difficulties leading to firstly an interim board followed by a newly elected board. The new board are developing new standards and systems which will, hopefully, lead to much greater transparency. Great steps have been made by EURAMI to raise the standards of their accredited members with better auditing procedures being put in place, however it is still very early days. Accreditation bodies need to ensure they consult widely with the expert services they accredit which could promote an extremely robust set of standards. The accreditation process needs to be extremely robust in terms of adherence to the published Standards and the accrediting bodies need to be more proactive in ensuring continued compliance. Independent auditors should be carrying out the audit process which will help with concerns about commercial sensitivity and intellectual property ownership within the providers. There also needs to be greater interaction with the users of air ambulance services and promotion of communicaton and better working relationships between the operator and user. The air ambulance company can only do their job to the best of their abilities if the user (client) gives them the information they require to do the patient transfer safely and with minimal risk to the patient. AirMed has recommended to the accreditation bodies that an accreditation standard is available to the assistance/insurance industry with the aim to educate and raise standards on information provision. EILEEN FRAZER: Services who apply for accreditation must be aware of the experience and expertise of the accrediting agency. Standards can be emulated by other accrediting
bodies but for the medical transport services to learn and grow by the journey through the accreditation process, the accreditation agency must be credible and have expert auditors and Board members who make the accreditation decisions. LAURENT TAYMANS: Streamlining the self assessment and audit process to improve review and bring to the program essential items that could influence its daily operations. Other improvements are being evaluated at the board level. VOLKER LEMKE: Essentially nothing since it is very rigorous as is. A step-up of the auditing process remains something to be aimed at, as would be worldwide agreement on unified compulsory standards. GARY ANDREWS: The IAAA/NAAMTA partnership reflects a recent improvement on accreditation. In addition to auditing organizations, the extended service through web-based tools and maintaining a very flexible model of growth to suit the needs of IAAA members has never been implemented or offered to customers. A few ways in which the IAAA/NAAMTA improves on the original accreditation business model include: l Staying current in practice and procedures. l Maintaining membership and participation in industry organizations and events allows NAAMTA to be structured to change or modify standards as new skills and technology emerge for EMS and patient needs. l Obtaining operator buy-in. NAAMTA strives to help EMS organizations realize the value of accreditation in terms of business opportunities and added services. l Creating added value for EMS organizations. Accreditation programs must strive to help operators remain current in their education and business needs which means offering services that extend beyond accreditation. EVA KLUGE: EURAMI just was reorganized. Some delays in reaccreditation occurred. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q12
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HOW CAN WE MEASURE THE QUALITY OF MEDICAL ESCORTS ON COMMERCIAL AIRLINES?
TAA operating out from the heart of the Alps around the Globe
medical escort services have already been accredited and there are several more applicants. VOLKER LEMKE: While escorts on air ambulances are performed by relatively few and easy to identify operators, who have been, for the larger and / or best known of them, seeking a means of demonstrating their quality through some form of certification, the same is not true of medical escorts on commercial aircraft. These are provided by almost all assistance companies and in addition performed informally by lots of providers, including hospitals. No standards exist in this respect although these would definitely be required. The easiest source would definitely be an organization like IATA asking all its members to abide by common rules. GARY ANDREWS: IAAA views the role of medical escorts as equally important to that of air ambulance organizations. As such, we hold these professionals to the same standard of excellence as the rest of the industry. While the environment in which they operate may be different than a standard medical transport, the same educational, equipment, and reporting requirements of quality management apply. EVA KLUGE: Agreed upon, training standards, customer survey, complaint ratio, medical outcome during/ after transport, types of missions and experience. l
Roundtable
JANE TOPLISS: AirMed is not involved in the provision of medical escorts on commercial airlines and so my knowledge on this particular area of the market is limited, however I do understand that CAMTS is shortly (if not already) bringing out an accreditation specifically for commercial medical escorts. I can only see this as a good thing as it will lay out minimum requirements in terms of medical qualifications, training, equipment and rest periods. Anything which helps to ensure a good level of patient care has to be encouraged and seen as a positive step. LAURENT TAYMANS: Measuring the quality of an individual does not make sense. We believe that it is better to measure the quality of the framework in which that person works. For example ensuring that a person is current in training and clinical skills thanks to access to periodic training and evaluation in their work. We also believe in the importance of a medical director, as there oversight and third party review. EILEEN FRAZER: CAMTS developed specific standards for medical escort services by convening a special fixed wing and medical escort committee a few years ago. Drafts were revised based on public and peer commentary and finally published in 2012 as a separate accreditation process. Two
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One of AirMed’s Learjet 35As at Glasgow Airport
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
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Photo: Courtesy of Iain MacKenzie
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Q13
CAN SMALLER AIR AMBULANCE COMPANIES GAIN ACCREDITATION?
EVA KLUGE: As long as they have their own part 135/145 + valid AOC and the required criteria for eligibility this should be fine. Probably there could be different price models, e.g a progressive scale. LAURENT TAYMANS: We implemented minimum criteria last year as well as approval by the board for new applications. These criteria include a minimum number of missions and time of operations. EILEEN FRAZER: CAMTS has a requirement of a minimum of 12 transports per year to be eligible to apply for accreditation. JANE TOPLISS: AirMed believes that ALL companies that carry out ANY air ambulance Transfers need to be regulated from a healthcare perspectiveas well as an aviation one. Accreditation is one form of ensuring these Standards. The companies who do not specialise in air ambulance provision and carry out only a few transfers per annum, need to be regulated and audited more rigorously. This is due to their experience being limited and so they are less likely to understand or see the risks involved in patient transportation. The new EURAMI eligibility criteria will only allow those companies who have experience in patient transfers to apply and whilst this shows that experience is extremely important, this combined with a lack of integrated healthcare and aviation regulatory oversight, does leave the gap of inexperienced small air
ambulance companies undertaking missions which undoubtedly carry higher risks. VOLKER LEMKE: It is clearly possible to develop and maintain a high quality infrastructure even without having a high volume of activity. And this can certainly then also be accredited. All criteria of excellence have to be met by each air ambulance and its team for each mission, and this is not volume dependent. However clearly the larger a company the more comprehensive a program can be and the lesser the marginal cost of quality related investments. GARY ANDREWS: Accreditation isn’t an exclusive club intended only for larger and higher-revenue businesses. We believe organizations of all sizes stand to benefit from IAAA membership and the accreditation offered by NAAMTA, because every transport company affects the air ambulance industry as a whole. Small air ambulance companies find themselves competing with larger and moreestablished EMS organizations, which means they need to level the playing field by pursuing accreditation. When standardization is outlined, easily accessible, and monitored, any organization is able to compete for business no matter their size. NAAMTA’s model of accreditation works for all sizes of operation because the same standard of excellence is needed globally. l
iPMI Magazine | C-Level International Air Ambulance Accreditation Round Table
Q14
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WHAT DOES THE FUTURE HOLD FOR MEDICAL TRANSPORTATION ACCREDITATION? entitled Levels of Care – one component we will completely revise in 2015. VOLKER LEMKE: If one were able to have a dream it would be to have an international standard accreditation that would be vetted formally by an international aviation organization such as ICAO or more likely IATA, or alternatively (and less desirably) by an internationally accepted health care provider accreditation organization. EVA KLUGE: It should become more unified, but for the time being it seems that more accreditation bodies arise as it is an interesting business model. That can be observed on the various industry events. We have to focus on the medical necessities. GARY ANDREWS: Simply stated, we seek to prompt the winds of change and raise the platform of accreditation. Through the IAAA/ NAAMTA partnership, we are capable of helping organizations succeed in many ways; we anticipate our vision becoming the industry expectation when seeking for ways to implement quality patient care, transport safety, and continuous improvement. External accountability is an increasingly-important attribute of any business. It validates a level of integrity in the relationship needed between patient, insurance, and operator. The same can be said of transparency for the accrediting organization. Through NAAMTA’s ISO 9001:2008 certification, they provide an unmatched level of transparency to the companies they audit. IAAA likewise furthers the establishment of transparency through its members. For example, when an IAAA member insurance provider requests information from us about a recent air ambulance transport by one of our air operator members, we work with the operator to identify the information needed to address the insurance payer’s request. We believe the value NAAMTA offers extends beyond auditing and will continue to be such. As organizations come to experience the additional tools and resources offered through this partnership, they’ll begin to expect the same level of service from all accreditors. l
Roundtable
JANE TOPLISS: I believe that there is a greater role that the voluntary accreditation bodies can play in lifting the standards of medical transportation. Wider education programmes could be provided, educating all of the service users and newcomers to the industry on topics like; what the risks are, the complexities involved in patient transport, regional variations and the importance of good client/provider relationships. They should also have a greater involvement in the drafting of Standards and legislation and work alongside providers and the Regulatory Authorities in finding the best ways to ensure standards are raised and maintained across the industry. I hope that the requirement for holding an Accreditation will become a requirement for all medical transportation providers in the future and that only those operators who have some form of accreditation are allowed to provide a service. International standards may be also best served by the establishment of a requirement for an air ambulance AOC, taking into account both the aviation and complex medical requirements for international repatriation and retrieval by air. LAURENT TAYMANS: Aeromedical transport standards will hopefully be one day legislated and regulated by an international body. In the meantime, we will do our best to continue to improve our standards and raise awareness as well as support those programs who have undergone accreditation. EILEEN FRAZER: Standards are dynamic and CAMTS is constantly revising standards to stay abreast of current practice and technological advances. A key component of revising standards is to solicit input from peers and medical transport professionals. Our standards usually go through 3 drafts which are subsequently posted on the CAMTS website for comment before they are approved and published in the next edition. We are currently working on the 10th Edition and encourage all to view a draft on our website
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AirMed Learjet 35A departing from Oxford Airport
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