Over the years, a number of people in the industry have worked to instil greater transparency in the fixed-wing air ambulance sector. In 1993, I personally invited underwriters and assistance companies to come and visit the air ambulance base at which I worked so they could see the aircraft their patients would be transported on, see the medical equipment being used, and meet the flight and medical crews involved; plus, they were allowed to inspect documentation, licenses, and so forth – an early audit process, as it were. Unfortunately, some competitors felt this constituted ‘buying business’. I was never sure – and I am still not – just how proposing an open-door policy with complete transparency would constitute buying business. However, it soon became apparent that the word transparency was not a word much liked in some quarters. Over the years, the world has become a smaller place and is now more accessible for travellers, which has created an even greater need to know that air ambulance operators are applying global standards to their business operations – with complete transparency. This situation is certainly improving, but there are still those that continue to smoke screen their operations.
Hiding behind accreditation
From the early 1990s, transparency became a more prominent marketing tool as accreditation bodies CAMTS (Commission on Medical Transport Systems) and EURAMI (European Aero-Medical Institute) were created. Quite rightly, operators should be proud of the accreditation process they have been through, and should use it appropriately to encourage clients to use their service. However, accreditation and transparency don’t always go hand in hand, and some issues surround the way a small number of operators approach the audit process. Unfortunately, some less scrupulous operators are known to be somewhat ‘creative’ in their approach to an audit, and what is presented to the auditors is not always a true reflection of an operator’s service or true commitment to the industry and indeed to transparency. Thus, during an audit, such operators have been known to rent in or borrow medical equipment specifically for the purpose of attaining a required accreditation. Other items that are known to have been fabricated for an audit’s reporting requirements include case studies, health and safety committees and aircraft safety drills. Furthermore, at some air ambulance companies, ongoing training for staff is not often as vigilant and continuous as accreditation programmes require. These issues are difficult for an auditor to uncover and they are not talked about openly within the air ambulance industry for two reasons: it devalues the programmes for those who have complied in a right and proper fashion, and there is currently no regulating body that can administer penalties for providing such false or misleading information.
Eileen Frazer, executive director of CAMTS, was open about the accreditation process undertaken by CAMTS and confirmed that the organisation checks air medical providers thoroughly, including specifically addressing the veracity of information with which it is provided. She explained that CAMTS has an Integrity of Information policy that lists examples of programmes interfering in the accreditation process, and that any falsification or omission of information can disqualify an applicant or be the grounds for withdrawal of previously awarded accreditation. Frazer continued: “There are also agreements that must be signed by the manager indicating they have reviewed all the information being submitted and the submission is current and accurate.” She cited cases of fraudulent applications that had been uncovered, such as dates of ACLS cards being changed, and one case where a ventilator had been loaned to the applicant solely for the purposes of accreditation, but none of the crew members could use it. “These,” though, “are rare events,” said Frazer.
From the early 1990s, transparency became a more prominent marketing tool
Dr Laurent Taymans, president of EURAMI, commented: “No-one has ever informed us that providers were taking a ‘creative’ approach to the accreditation practice. In our experience, the providers do their best to show an open and honest view of their company.” If there were to be an allegation of malpractice in the accreditation process, EURAMI has a ‘clear procedure’ that allows both parties to present their version of events, and can also send an auditor to the site to review any allegations and report back to the board on them. EURAMI’s audit process involves listing the medical equipment a company has and reviewing that kit on future audits.
For those air ambulance operators that approach the audit process with complete honesty and transparency, what still counts is the day after an audit, and the operator’s continuing commitment to maintain their standards. The responsibility is with the operator to maintain or improve the elements that allowed them to attain their accredited status. Most of our operator colleagues do exactly that and more besides, but the loophole nevertheless exists for those that have deceived through the audit, to continue to do so during the three years that follow before revalidation.
Such loopholes are difficult to control – as Eileen Frazer states: “There is always a possibility that accredited services fall behind until the next site visit.” Measures taken by CAMTS to limit such problems include supplemental site visits if anything has changed at the company that could affect its accreditation, while unannounced visits can be made if CAMTS is alerted to a report of non-compliance. On an annual basis, Verification of Information forms are sent to providers that reaffirms they are following the standards and policies set down by CAMTS and that the provider has notified the accreditor within 30 days of any relevant change to the fleet, equipment or crew.
Dr Taymans said that following a recent survey, EURAMI is confident that their members feel that re-accreditation every three years is an adequate interval between audits. If there is a problem with an operator in the interim – for example, if a complaint is made – then EURAMI can send an auditor to investigate the complaint and ascertain its veracity. “Revoking accreditation has happened in the past on several occasions,” said Taymans, “but in a fair and measured approach.”
More serious problems exist when operators misuse their accreditation to bring a false sense of comfort to clients. For instance, an accredited air ambulance company may claim to operate ‘worldwide’, when in fact their reach is much more limited than potential clients may be led to believe. Accrediting organisations should take responsibility for ensuring air ambulance providers do not ‘over market’ themselves in this way, and are rather more honest and transparent in their proclamations of global reach and operational capabilities.
The websites and marketing materials of those operators accredited by CAMTS are evaluated by the organisation, and if found to contain misleading information, a corrected version of the media will be requested, according to Eileen Frazer. She added: “Interestingly, we will also find programmes that are not CAMTS accredited but have the logo on their website or even state they are CAMTS accredited when they are not. We take this very seriously and have in the past contacted the State Attorney General’s office if it is not corrected immediately.”
EURAMI also takes a serious approach to such actions, and thus is in the process of implementing a new approach to its standards, according to Dr Taymans: “[This approach] will identify the aviation capacity of the company, for example, [if it has] transcontinental or regional fixed-wing operations, helicopter emergency medical services or search-and-rescue rotary-wing operations. We will also endorse the medical capacity of the company.” The intent of these new standards will also be to identify, on the operator’s accreditation certificate, the company’s capacity to perform neonatal, paediatric, or high-risk adult critical care transfers, with the eventual result that ‘all companies certified by EURAMI are able to perform critical care transports of adult patients’.
operators should be proud of the accreditation process they have been through, and should use it appropriately to encourage clients to use their service
Another practice, which some operators are less than transparent with, is brokering aircraft or flights to others. This essentially nullifies the operator’s accreditation in such cases. For example, a turboprop operator may well have legitimately gained their accreditation, but they then proceed to broker jet flights without being transparent to the client. In such cases, operators sometimes justify what they are doing by saying ‘I put my medical teams on the plane,’ but that is not the service that was accredited.
Some operators also use the lack of knowledge that some assistance company staff have regarding aircraft capabilities to mislead them into using their services – by offering their accreditation as a badge of guaranteed quality even though the trip they are supplying may be completely outside the status of the accreditation. This is very unfair on the genuine owner/operators who have invested in their fleet, training programmes, equipment, insurance indemnities and accreditation to offer a truly transparent operation.
An effective method that would go some way to preventing such issues might be for the accrediting organisations to more readily identify air ambulance providers’ level of operating ability. This would make it much easier for clients to understand the operator’s capabilities and would limit exaggerated ‘global reach’ claims dramatically. This could be achieved by providing a simple accreditation ID coding for an operator’s aircraft, areas of operation and medical capabilities, which would be incorporated within their certificate and logo on achieving accreditation.
Leading by example
Looking at the current accrediting bodies, over the years since the early 1990s, CAMTS and EURAMI have developed their programmes by revising the audit processes and addressing issues of transparency. For example, in the past, CAMTS has used site surveyors who are medical flight crew from competitors to carry out audits. Is this fair, and what is done to ensure that surveyors are impartial? “CAMTS has always been very strict about conflicts of interest,” said Frazer. In order to overcome issues of impartiality, the programme being accredited, as well as the site surveyors, sign conflict of interest forms. The site surveyors are also sent outside of their operating area to minimise the potential of representatives of geographically close companies surveying each other. As Frazer points out, though, in such a niche industry, it is difficult to control completely: “In this small community of air medical transport, it is not possible that a surveyor may not have heard of a particular programme, but they must disclose if they ever worked for that company, know personnel at the company or have pre-conceived opinions about a company.”
As part of EURAMI’s new approach to its standards, one of the changes being made is the implementation of a legal relationship with its auditors, which it is hoped will benefit the air ambulance operators, auditors and EURAMI itself.
And EURAMI has made an open declaration to itself to be more transparent. Dr Taymans made a statement to members on 9 November 2012, following the creation of a new Board after the previous Board resigned en masse citing a ‘lack of faith in the leadership’. The statement included the following: “We recognise that the times ahead for us are crucial in gaining your confidence. By striving for transparency and implementing change we hope that we will win your trust.” Efforts to improve the transparency of the organisation include a new website user section, a Facebook page, semi-public availability of EURAMI’s new standards – after signing up to the new website – and a general newsletter for educating the public about the work of EURAMI.
Transparency and accountability are some of the key reasons I began working on the concept now known as the International Air Ambulance Alliance (IAAA). This body is solely for fixed-wing air ambulance owners and operators, and its purpose is to separate fixed-wing from the rotorcraft industry and its associated problems. More importantly, its aim has been to develop levels of service and accountability for the global fixed-wing air ambulance industry by requiring operators to provide documentary evidence of the validity of their business, with a complete open-book transparency. Thus, a strong membership criteria forces out the brokers and operators who use a smoke and mirrors approach to mislead and deceive. The owner and operator of an aircraft is sometimes one and the same thing. What needs to be transparent to the client/payer is whether the operator is actually just a flight booker/broker. Bona-fide operators can show they have complete knowledge of the aircraft, including its tail number and airworthiness, that its crew is appropriately qualified, trained, and has a current medical certificate, and that it meets duty, flight and rest provisions.
Every part of the process of engaging an air ambulance should be available to clients, including costs
My association with the IAAA ceased when I left the US in 2011. Gary Andrews, current president of the IAAA, had this to say about the organisation’s efforts to maintain a transparent and professional standard for their members: “As an alliance, we have controls in place as part of the IAAA registration to initially determine an owner operator of a fixed-wing aircraft from others who claim to be. Further, IAAA members need to display their legal/accreditation documentation on their website to validate the status as owner operators, which is open to public viewing.” The IAAA is also able to track, in real time, some of its operators to check the aircraft they are flying and monitor the patient evacuation process, allowing it to liaise with payers as and when it is deemed necessary. Andrews explained that the hope is that this process can be improved and simplified in the future as more and better technology comes online. As a final check on their members, the IAAA (with the payer’s permission) will liaise with the patient or family as appropriate regarding the service and experience that was provided, and are building a global database of operators and their performance and other characteristics.
Onus on operators
Every part of the process of engaging an air ambulance should be available to clients, including costs. Some operators invoice for ‘extras’ that have previously not been mentioned to the client. Linen, consumables, and waiting time are just some such items, which the client often assumes would be included.
However, there are sometimes genuine unforeseen costs that occur both for medical and logistical reasons. In such situations, a more robust pre-flight agreement would certainly help and could prevent misunderstandings with regards to cost allocation. Some operators and some clients do have provider agreements that are comprehensive in their detail, but they are not the norm. Many air ambulance operators send in a quote, which is accepted, and on production of a schedule, an order to fly is given. This is fine when nothing goes wrong, but when aborting a flight – due either to the patient’s condition, a technical fault with the aircraft, or some other logistical issue – wrangling over areas of responsibility and cost can begin when no comprehensive pre-flight agreement is in place. A clear and transparent provider that works to create a pre-flight agreement covering all potential issues gives comfort to their client and protects themselves at the same time.
I also believe that levels of communication could improve between the operators and assistance companies – pre, during and post-flight. You can never over-communicate. If we report and inform every aspect of a flight, preferably by email, this creates an audit trail, and at the same time we will enhance our assistance partners’ understanding of our operations, and such reporting will become an expected task. Good reporting will add to creating another level of transparency.
Operators need to continue to raise their game when it comes to transparency. Genuine and transparent operators should take the responsibility to inform, educate and persuade the payers to understand what makes a good air ambulance operator – i.e. one that is transparent about its operation and costs. We must be honest about our capabilities, and stop facilitating the smoke-screen operators. The reason we are still talking about transparency and accreditation is not because of the operators in our industry who are doing great things day in and day out, by continuing to invest in their businesses to give high-quality standards of service. It is because of the existence of maverick operators, who are prepared to cut corners, fabricate the truth, and misrepresent themselves and the wider air ambulance community. Eileen Frazer of CAMTS concluded: “Lack of truthfulness or omitting certain factors that play a significant role in providing a service are always found out eventually. In the case of air medical transport, this could dramatically affect a patient’s outcome and the patient should always be the primary concern of any medical transport service.”
These issues need to remain at the top of the discussion pile. True transparency does exist, and more and more operators continue to recognise and respond to the need for open-book policies. My ethos has always been ‘go the extra mile’ and the client will respond with their patronage and trust. Working in an open fashion using honesty and integrity will, in my experience, help forge a reciprocal transparency with your clients.