Is accreditation worth it?

For some air ambulance operators, accreditation equals an improved business – a way of showing insurers that they are at the top of their game. But there are others who are just as successful, but not accredited, perhaps finding the process too costly or time consuming. Is there a right answer to the question: is accreditation worth it? Femke van Iperen asks industry experts for their opinions

Denise Treadwell is President of AirMed International LLC, which is accredited by both US-based CAMTS (the Commission on Accreditation of Medical Transport Systems) and EURAMI (the European Aero-Medical Institute) in order to ‘stay up to date with standards across both the US and Europe’, said Treadwell. She testifies that in both markets, there has been what she refers to as ‘an increased accreditation value within the air medical community’. Many air ambulance operators consider accreditation a wise business move, which Treadwell believes is due to the emphasis placed by accreditation bodies on quality improvement and outcomes. 

Some would say that accreditation is more important now than it has ever been, with Dr Laurent Taymans, President of EURAMI, arguing that being accredited is becoming a requirement when working with certain clients, rather than just being ‘nice to have’. He added: “As we see more and more programmes become increasingly more professional, many large organisations require some sort of accreditation for air ambulance providers and will not work (except in certain exceptional circumstances) with non-accredited providers.” The increasing popularity of EURAMI, he believes, is testimony to the fact that more air ambulance companies recognise the benefits that accreditation can provide.

Changes in accreditation

Accreditation bodies have to keep up with developments in air ambulance equipment, aircraft, personnel training, treatment modalities, and safety requirements. Thus, the standards to which they hold their accredited providers have evolved, and now extend to all aspects of patient transport, including commercial medical escort services. CAMTS, for example, made changes to its 10th Edition Standards of 2015, in which the Advanced Life Support (ALS) and critical care transport standards included ‘more detail for expectations in clinical education, certifications and competencies, as well as equipment and interventions’, as Eileen Frazer, Executive Director of CAMTS explained.

auditors are not just looking for policies to satisfy or ‘check the box’ for SMS requirements

Accreditation processes must ‘evolve to meet the growing need of global markets’, according to Roylen ‘Griff’ Griffin, Executive Director and Founder of the US-based National Accreditation Alliance of Medical Transport Applications (NAAMTA). He explained: “Specifically, aligning the intent of the standard to correspond to the broader geographical differences. Equating the prescribed skills set and educational requirements with the licensure of a country. For example, NAAMTA will research a country’s licensure requirements and identify the parallel skills to ensure medical staff meet compliance to the standards.” CAMTS, which has recently registered CAMTS EU in Zurich to address the needs of services beyond North America, has also developed an accreditation process that is specific to Special Operations, covering providers that offer medical services for large sporting and entertainment events. Special Operations accreditation is also available for tactical rescue services that operate in some of the more undesirable locations of the world, Frazer explained. One of the most significant evolutions in the world of accreditation has been an added focus on Safety Management Systems (SMS), with an integration of organisational culture, noted Emma Roberts, Director of Safety for Florida-based REVA, Inc. According to Roberts: “As carriers become more mature in such systems, auditors are not just looking for policies to satisfy or ‘check the box’ for SMS requirements, they are looking for specific examples of how SMS are critical parts of our business process, and are interviewing all levels of employees to ensure the culture is present throughout.” 

Current appetites

There are companies that consider accreditation to be not only imperative for their own company’s success, but also a win-win situation for everyone involved. David Ewing, Executive Vice President of Global Markets for Canada’s Skyservice Air Ambulance International, told ITIJ: “We strongly believe in the process; it’s good for us, it’s good for the insurers, it’s good for our patients, and it’s good for the industry.” He has a point, according to Dr Cai Glushak, International Medical Director of AXA Partners, who said: “We have made accreditation for air ambulances a top priority. It is critical, reputationally, for liability purposes as well as to extend our capacity, to rely on in-depth audits done by real experts.” Skyservice Air Ambulance International itself is accredited by EURAMI, chosen for its ‘quality of auditors and proven industry experts on the board of directors’, as well as by ARGUS International through its certificate holder, Skyservice Business Aviation, to ‘receive further suggestions for improvement to remain on the top of our game’.       Dr Taymans believes that ‘many ambulance providers have a desire to codify the minimum level of quality of care required’: “Patients will benefit whenever there is an increase in quality, and larger organisations also benefit through the reduced risk of serious adverse events and their reputational and financial liabilities.”  Accreditation is often hailed as being stimulating for a company, keeping it on its toes to meet stringent requirements in safety and clinical standards, said Roberts: “An outside auditor provides a third-party perspective that challenges the ‘how it’s always been’ mentality, and requires companies to really look at their processes.” REVA is accredited by ARGUS Platinum, NAAMTA and EURAMI, as well as pending recommendation from IS-BAO, all of which were chosen for ‘industry reputation and operational relevance’. The company also looks for oversight and validation by other regulatory bodies and insurance providers, in order to ‘provide another set of standards, best practices, and a second set of eyes with different objectives’. For Treadwell, it is beneficial for a company to be routinely checked against industry standards, also indicating that the company is seeking to improve on its current offering: “Accreditation doesn’t mean that you get it right every time or that you are ‘the best’,” she said, “but rather that you have a desire to obtain critical feedback and strive to improve.”  Accreditation within the international air ambulance sector remains voluntary, and there are providers who feel that the time and expense it takes to become and remain accredited is not worth the resources needed. Even those who are accredited recognise that the work a company has to put in before it can be accredited can be daunting. Roberts noted: “There is a very large workload prior to an auditor’s onsite visit. Whether it’s pulling records, reviewing manuals, providing references, or even just co-ordinating with required personnel, each audit is an enormous effort from the entire management team.” Frazer of CAMTS understands that the additional cost can also be a contributory factor in the decision-making process: “Air medical services are expensive to operate, so adding in costs for accreditation is a decision managers often make based on the bottom line in their budget, because accreditation is not required.” However, she added: “Most companies that apply for accreditation see the value in having an outside audit to continue to improve the quality of the service they offer.”

consumer awareness and education are paramount 

There are operators who are concerned that an auditing processes may cause them to be ‘shut down or seen as less than top-notch’, noted Griffin: “Accreditation criteria sets an expectation for operators, hospitals, patients, and payers of insurance. There are fear factors associated with each of these populations that I personally would like to eliminate! If the industry saw accreditation as a support to their services, the return on investment would be readily evidenced.” Although Roberts believes implementing change is generally a positive thing for an organisation, she also explained that with each new policy, process change, requirement for communication or training for front-line employees, there ‘can be some risk to the operation’. She cited a recent example of a new accreditor policy that required mechanics to wear gloves, which in fact turned out to be too bulky for the mechanics, who were unable to handle some of the smaller aircraft parts.

Areas of improvement

Treadwell believes that promotion of the value that accreditation can bring is key to improving how accreditation is seen by the sector. “Like anything, there is always room for improvement, and consumer awareness and education are paramount. As an industry, we must continue to press forward with ensuring our customers understand why accreditation is important and take every step possible to put accreditation at the forefront.”  Comparing the situation with the US nursing sector, where nurses can use their licences in participating ‘compact states’ without having to obtain new or additional ones, Treadwell would also value ‘more cross pollination of the accreditation services’, as it would ‘allow for a more universal set of standards’.  Ewing would call for an additional focus on details, as well as the introduction of a reporting process, he told ITIJ: “More stringent verification of aircraft maintenance and of patient care provided in the air and on the ground as well as an anonymous reporting process by insurers and assistance companies in terms of accidents, incidents, and patient deaths.”  Other changes that could be on the horizon in the future include an increased focus on cross-industry understanding. CAMTS, for example, is working with assistance companies to, as Frazer described it, ‘demonstrate that recognising accredited services ensures a true level of quality’, foregoing the need for assistance company staff to ‘spend considerable time and effort to understand a non-accredited company’.  For Griffin, it is key for payers of insurance to have confidence in accreditation: “They need to understand accreditation criteria, processes, and steps toward quality and continuous improvement that comes with the accreditation process.” Rather than looking to attract more business, he said, a medical transport company should use accreditation ‘to make its processes more robust, to hire the people that allow better patient outcomes, and to use data to make better decisions’. All in all, he said, “The best we can accomplish right now is: for the industry to trust accreditation.”