Ensuring transparency in international air ambulance accreditation

There were two groups for this debate — one side represented the accreditation bodies of CAMTS, EURAMI and IAAA/NAAMTA, while on the other side were James Paul Wallis, Andy Lee, and Alberto Carson. The session was moderated by Ian Cameron.

The media and operators:
Alberto Carson - COO, AirEvac International
Andy Lee - Managing director, Medair International
James Paul Wallis - Editor, Waypoint AirMed & Rescue

The accreditation panel:
Eileen Frazer - Executive director, CAMTS
Dr Laurent Taymans - President, EURAMI
Gary Andrews - President, Red Consulting/IAAA

James: How do people know what standards accredited providers have met?

The questioner pointed out that CAMTS and NAAMTA standards are available online, whereas the EURAMI standards aren’t publicly available. He also highlighted the wording on a EURAMI accreditation certificate which shows that providers have to show only ‘substantial compliance’ with the standards — how, he asked, can payers be sure where providers are and aren’t compliant with standards?
Eileen asserted that the CAMTS standards are publicly available because it is important that people can see what providers are expected to do. She explained that all accreditation bodies use the phrase ‘substantial compliance’ because no company can be 100-per-cent compliant in every way, but it is the outcome that is important.
The new EURAMI 4.0 standards are coming out soon, and will be available from the website after acceptance of terms and conditions, said Laurent. He also made the point that companies can’t always achieve 100-per-cent compliance.
The standards are online, said Gary, but the IAAA/NAAMTA works on the basis of continuous improvement as well — it is not simple accreditation after three years. Once accreditation is completed, that organisation is tested randomly on a quarterly basis, which enables the body to understand how the accreditation is working and ensuring that it is adding value to that service, giving payers and fixed-wing operators peace of mind.

Andy: What are the thoughts about operators being honest and transparent throughout the audit process?

This is a concern, said Gary, as we are talking about trust, integrity and professionalism. The IAAA/NAAMTA process obtains all relevant information possible during the accreditation process, and the quarterly audit allows NAAMTA to check up on what people have said. Accreditation is only available to providers that are owner-operators of aircraft or that have an exclusive lease and can demonstrate having operational and economic control of the aircraft. This criterion automatically excludes the accredition of brokers, he explained. The process of monitoring with ISO 9001-2008 standards enables the IAAA accreditation process to be fully transparent to all, including the opportunity for the IAAA accreditation to be available to scrutiny as well — no other accrediting organisation can match this, he said.
CAMTS has in place the ability to perform supplemental and monitoring visits at any time, and can react to information as they are told, Eileen explained. There is also annual verification. Furthermore, she explained that the websites and marketing materials of air ambulance companies are thoroughly checked to ensure that the promises they make in these materials are being kept.
Laurent commented that before an audit takes place, there are extensive background checks carried out by EURAMI. The new standards also require a lot more information to be given, said Laurent, and research is going to be a lot more in depth concerning the operations of each company. Laurent said that although the process used to be based solely on trust, it was recognised that people were stretching the truth in the audit process. It has been a learning process. EURAMI has also recently restricted the selection of its auditors so they are more thorough and impartial.

Alberto: Over the past few years, Internet quoting tools have become popular with assistance companies, creating an auction of a very critical service. With missions being flown below cost in many cases, how do these bodies ensure their guidelines are being followed with regards to safety?

CAMTS has self-assessment standards and also looks at specific operations — such as historical records of accidents — as well as what analysis is being performed by a company to ensure safety in the future, said Eileen. Accidents don’t mean immediate revocation of accreditation — companies are given a chance to put things right if there was something wrong.
Laurent agreed that Internet tools are driving down prices, but he added that insurers are not helping this situation. Companies that are bigger and can work on a volume basis will keep on pushing prices down, he reflected, adding that he thinks that there is a fair price to be paid for such services — a meet-in-the-middle of the amount the insurers want to pay and what the air ambulances want to charge in order to offer the best possible services. He said that there will be a code of conduct and ethics in the new EURAMI standards which will help to fuel improvement programmes.
IAAA/NAAMTA has continuous improvement processes in place, Gary explained. Most fixed-wing operators will say that insurers will go for the cheapest option, supporting the assertion that insurers are driving down prices. Thus, the IAAA has invited insurers and assistance companies onto its board to get them involved so they understand more about the business and how expensive it is to operate in, and to contribute to industry improvements. Gary cautioned that brokers don’t always add value — they can just add cost, confusion and additional risk — but added that there are good brokers out there.

The panel then moved on to the topic of brokers:

The US Department of Transport is making a new category in its evaluation criteria called ‘air charter brokers’, said Eileen. Brokers advertising as air ambulance companies are a problem, and this new category seeks to address this issue and requires companies to disclose the difference between brokers and operators, she added.
Considering the issue of EURAMI members brokering a flight to non-members, Laurent explained that there are ground rules in place — as long as the operator tells the client that they are sharing a flight with a non-EURAMI member, that gives the client the choice of whether to accept this option. There are minimum requirements, so brokers can’t apply for accreditation, he explained. There needs to be a legal framework that will protect EURAMI members, but it is a difficult problem.
Accreditation bodies can’t influence payers, said Gary, but they are educating and supporting the payers so that insurers understand the difference between brokers and operators. He agreed that transparency in this particular issue is still a problem — for example when an operator brokers to another operator.

James: How does your accrediting body make it clear who is accredited?

The audience was shown examples of operators’ websites not matching with an accreditation body’s online list of accredited providers (an operator showing a CAMTS logo on its site on 29 October, where the CAMTS site said their accreditation had expired 12 days previously; an operator that had a NAAMTA logo on its website on 17 October, but was not shown on the NAAMTA online list; and an operator whose EURAMI accreditation expired at the start of October, that was still present on the online list weeks later).
There are certificates for operators that have gained accreditation, said Laurent, and EURAMI has worked hard over the last 12 months to try and enforce good use of the logo, although he added that some errors remain. Laurent explained that the organisation works hard to ensure that website information is current and transparent. Any company in doubt can call up EURAMI and check a provider’s accreditation status, he said.
For CAMTS, said Eileen, there is a due process procedure. If the company is in the process of re-accrediting, then there is a 30 day process where there is a time lapse, which would explain some differences between websites.
Gary said that the example given by James was an accreditation done only two weeks previously, but accepted that the companies could have worked together to release the information at the same time.

Andy: Do auditors have an equal level of knowledge of aviation and medical policies and procedures?

NAAMTA accreditation auditors are independent, said Gary, and there are no competitors going to accredit other providers. To ensure consistency on both aviation and medical sides, ISO 9001-2008 standards are employed and observed.
Eileen stated that CAMTS employs 62 site surveyors, and they are either aviation or medical personnel. There could be a medical manager visiting a programme of a large competitor, but the auditor would not be involved in the operator’s business region. If possible, both aviation and medical experts are sent to sites.
All of EURAMI’s auditors are physicians, said Laurent. For the aviation aspect, they have knowledge and experience in the industry, but he admitted that they are not aviation experts and there is not an equal level of knowledge. The medical element is vital, and there is a degree of trust given to the operator that they comply with local government standards with regards to the aviation side of operations.

With companies having a long track record of accidents, how does a programme maintain accreditation status?

When an accredited programme has an accident, said Eileen, CAMTS asks for an accident report within 30 days, and performs a root cause analysis. There is also a database that records accidents and incidents and can analyse whether or not there is trend developing. This is often difficult to spot, and Eileen made the point that accidents happen — there isn’t always a trend. A company can be put under special review if it has had several fatal accidents in a short period of time — this means an independent safety auditor is brought in. Companies undergoing this process are shown on the CAMTS website. CAMTS, though, is essentially reliant on the National Transportation Safety Board to analyse accidents, said Eileen, as this is not the role that CAMTS was created to perform. The Commission gives the company a chance to deal with the aftermath of an accident, and discretion is needed. CAMTS has required its members to implement a safety management system (SMS) since 2008, and accredited providers that suffer incidents and accidents must report them to CAMTS.
Laurent explained that when an audit is performed, there is always a background check on aircraft accident data performed. There is also a self-reporting system in place. Laurent said that he was not aware of there having been any fatal accidents suffered by EURAMI providers. With regards to updates and changes to a company’s status, the website will state whether a company is undergoing a review. Incidents are dealt with on a case-by-case basis, because it could be very damaging for the company if a malicious or damaging report were to be prematurely released. SMS is in the EURAMI standards, and the new version clarifies this further, said Laurent. There are different SMS versions, and some involve patients and some don’t — it is evolving over time. Self-reporting, he said, is not supposed to be punitive, it is a chance to learn.
Civil aviation authorities and the US Federal Aviation Administration require disclosure of accidents, noted Gary. NAAMTA/IAAA asks for disclosure and works with operators to discover the root cause of the accident. As the body is dedicated to the fixed-wing air ambulance industry, there is not a high frequency of accident claims, so there is a lack of experience in this field, he said. In NAAMTA, explained Gary, it depends on the incident as to whether or not a company will be placed under review. SMS is a compulsory requirement for NAAMTA accreditation. Gary was keen to point out: “You shouldn’t fear an audit, it should be a chance to create a culture of continuous development and improvement.”

James: How do the bodies deal with conflict of interest to ensure fair decisions?

Examples of conflicts of interest given included members of accredited air ambulance providers being on the boards of accrediting bodies.
CAMTS has strict rules with regards to conflict of interest — inspectors do not represent their employer while working for CAMTS, said Eileen. Companies seeking accreditation are referred to by number, not name, in meetings. Inspectors are also asked to sign a conflict of interest form and if there is a conflict, then the person is asked to leave the room while their employer or competitor is being discussed.
All EURAMI board members sign a conflict of interest form, Laurent explained. Any decision that could be affected by a potential conflict of interest means that that member has to leave the room. If there is a competitor being discussed, then a member can also be asked to leave the room. Laurent made the point that it is a very small industry, and the pool of expertise is therefore somewhat limited.
Gary (pictured above) commented that NAAMTA wouldn’t employ a company’s competitor to perform an audit. There are board advisors who are given bare facts, with no company names, to make decisions. Every board member has to comply with confidential agreements — it is a legal obligation, he said.

Andy: If there is no policing or punishment of offenders, is there any point in accreditation?

Accreditation organisations are not regulatory bodies, noted Eileen. CAMTS does the best it can in terms of policing and making sure companies are following through on their process. There are sanctions (suspension and withdrawal) in place, but CAMTS is not there to punish operators — it wants to help operators better themselves, not punish them for being bad, she said.
Gary agreed that it is important that companies are held to account if they are not complying with requirements, asking: what is the point of signing up to standards if they are not going to be kept to? IAAA/NAAMTA, he added, aims to help companies to raise their standards, but if non-compliance is factually evident, then action will be taken. Punishments are based on the seriousness of the failure, and accreditation can be terminated if necessary. But, said Gary, there need to be facts to work with, not just rumour or perception.
EURAMI’s sanctions are withdrawal and cancellation of accreditation. Laurent echoed Eileen’s comment that accreditors are not regulators.
This session proved to be very popular with air ambulance operators and the insurance companies that make use of their services. The questions from the audience demonstrated a high level of interest in the topic from the industry, showing that this was a debate that could have continued for some time and has yet to be settled.