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CAMTS: A Question of Credibility, Part 1 of 2

How does a well-meaning organization, dedicated to improving medical transport safety and patient care, become so controversial? Guy Maher reports on the Commission on Accreditation of Medical Transport Services in this article from the Fall 2009 issue of Vertical 911, which will be published online in two installments.

It was the alarm clock heard 'round the helicopter emergency medical service (HEMS) world. In October 2008, with little warning or consultation, CAMTS — pronounced “caimz,” the Commission on Accreditation of Medical Transport Services — proposed amendments to its accreditation standards that would have limited naps for HEMS pilots on 12-hour duty shifts to no more than 20 minutes. (The amendments would have also limited medical crews, who commonly work 24-hour shifts, to no more than 14 hours of duty time in a 24-hour period.)

The proposed amendments shot through the HEMS pilot world like a torpedo. Online aviation forums were quickly pages deep with comments — overwhelmingly negative. HEMS operators also pushed back heavily, as did NEMPSA, the National EMS Pilots Association. Meanwhile, pilots of a few CAMTS-accredited programs were telling me that their program directors were already re-designing pilot quarters for their bases, eliminating beds and reducing space.

Conversely, the program director at the HEMS operation at which I work (which is not CAMTS-accredited) stated: “It's not my job, nor my crews' job, to go knocking on pilots' doors to make sure they only nap for 20 minutes.” The lead pilot at our program, who had 19 years of HEMS experience at that time, had no problem getting to the point: “Where the hell does a private organization with a nursing agenda get off telling aviation companies with our own set of regulations how to conduct our operation? And how did they get this much power?”

Indeed. So, I decided to find out.

In researching this story, what became evident was that many programs believe in the outside evaluations, standardization and accreditation CAMTS provides. But, what was also evident, and surprising, were the number of HEMS industry professionals — many in high-level positions with solid credibility — who refused to talk to me, literally out of fear for their job, the potential retribution of the loss of accreditation from CAMTS, or both. It was as if I were asking them to testify in a RICO (Racketeer Influenced and Corrupt Organizations) case against Tony Soprano.

The Organization
CAMTS, by its own mission statement, “is a peer review organization dedicated to improving patient care and transport safety by providing a dynamic accreditation process through the development of standards, education, and services that support our vision.” Formed in 1990 as a non-profit 501(c) corporation, CAMTS actually began as CAAMS: Commission on Accreditation of Air Medical Services. The organization changed to CAMTS when its accreditation began including ground transport services as well.

CAAMS was started with a loan of $78,000 US from ASHBEAMS, now AAMS, the Association of Air Medical Services. Executive director Eileen Frazer was instrumental in its inception. As the safety committee chairperson for ASHBEAMS, she spearheaded the development of a separate (to avoid conflicts of interest) accreditation body to address the slew of HEMS accidents that occurred from the mid- to late 1980s. As she explained: “That [loan] took us through at least five years, actually. We ran the program out of my home and so we didn't really have office expenses. We did the best we could with that $78,000, because, as you know, it takes a while to get marketed and advertised, and then for people to actually apply for accreditation when it's not required is a task.”
That is not the case anymore. CAMTS now has 146 accredited programs, covering 46 states in the U.S., and three other regions: Canada, South Africa and Hong Kong. That strength and growth meant that, by the year 2000, CAMTS's loan from AAMS was fully paid off — and the organization remains debt-free.

CAMTS is not required in Canada, but two programs (Ornge in Ontario and STARS in Alberta) currently have accreditation. (One program in each of Hong Kong and South Africa also have accreditation.) In the United States meanwhile, CAMTS accreditation is required by eight states (Colorado, Maryland, Massachusetts, New Hampshire, New Mexico, Oklahoma, Utah and Washington) and, for all practical purposes, in Arizona through a “deemed status” basis. Accreditation is also required by specific counties in Nevada and California, and by organizations such as the United States Department of Defense and the Indian Health Service.

CAMTS is run by a board of directors representing 19 separate member organizations. There are also two ad hoc board members from the public: currently a cardiothoracic surgeon (who is also an airplane pilot), and a JCAHO (formerly Joint Commission on the Accreditation of Healthcare Organizations, now just The Joint Commission) site surveyor, who is also fixed-wing rated. Both have voting rights. And, there are two non-voting advisors from the International Helicopter Safety Team. There is no term limit for CAMTS board members: they are rotated at the discretion of the respective member organization or at their own wish.

CAMTS also has an executive board whose members are elected every two years, though that does not necessarily mean they are replaced at that time. Consequently, the executive board can comprise many people who are entrenched in the organization.

The member organizations are heavily represented on the clinical side. For HEMS pilots, though, the only direct representation comes from NEMSPA's seat. The National Air Transportation Association has a seat, currently vacant, but it is aimed more at the fixed-wing side. The Air Medical Operators Association is also represented, as is AAMS (which has no ownership of or parent relationship to CAMTS, and whose seat is equal to all others).

The Accreditation Process
Briefly, here's how the CAMTS accreditation process works. A program starts the process by submitting an initial application, along with a $750 non-refundable application fee. CAMTS will then send a program information form (PIF): a 100-page document directly related to the standards, which essentially asks you to show how you meet each of the standards. This is a time-consuming, labor-intensive process that can easily take three to six months to complete. CAMTS allows up to one year to complete the PIF. Once completed, it is submitted, along with all requested supporting documents and the accreditation fee. The basic fee is $6,500 and that allows up to five bases. For every base over five, there is an additional
$650 charge.
Once CAMTS receives the PIF submission, it schedules a site visit, usually within four to six weeks. Two site surveyors spend a minimum of two days at the program to inspect the operation, conduct interviews, and, through completion of a workbook, verify the PIF responses are as stated, relative to the standards.

The cost for the surveyors is $500 per day for each surveyor, plus travel expenses. They are essentially information gatherers and can come from medical, pilot or mechanic disciplines. Training to become a surveyor takes place over the course of just one long weekend, with annual education occurring during AAMS' yearly Air Medical Transport Conference.

Said Frazer: “We don't always have an aviation person, it could be a pilot or a mechanic, but we always have a medical management-type person. The aviation person is always sent if it's a new service that we've never looked at. So, our aviation site surveyors are not as plentiful as the medical management type. But they are there and available. All of our site surveyors have at least 10 to 15 years of experience, some have more, in the air medical transport or ground field. . . . Before the site surveyors leave, they present their list of findings and it's the same list they're going to give to the board of directors, or to the board member who is reviewing that service.”

Life Flight of Maine is a big believer in external assessment, and executive director Tom Judge
even thinks that CAMTS accreditation should be more rigorous. However, he’d also like
to see more aviation expertise at both the field and board levels of CAMTS. Mike Reyno Photo
We asked Chaleece Caldwell, a registered nurse, former critical care manager with Omniflight ( which is an operation that, as we'll soon see, has had its share of issues with CAMTS), and now newly minted CAMTS surveyor about the process. “The questions asked at the survey are not from the surveyor, they are written for you,” she explained. “It's not that I'm an expert in NVG [night vision goggles], I just have to write yes or no. I don't need to be a pilot to read a question or write an answer. However, CAMTS does make a concerted effort to have a surveyor from each discipline to cover the not-so-black-and-white questions. Our biggest concern is being timely
and complete.”

The surveyors prepare a report that is given to one board member, for programs undergoing re-accreditation; or, for new accreditations, to two board members. These board members are the only people at CAMTS who know the identity of the program in question. They review all the submitted information, and call and talk to the site surveyors if they have any questions. This is all done prior to a board meeting. CAMTS clears the board member(s) with conflict of interest forms, too, before they are permitted to do a review.

The designated board member or members then make a formal presentation of the program to the full board, which meets four times per year. There's no mention of who an operator is. Items of concern and deficiency, along with excellences and acknowledgements, are addressed, and this is followed by a board decision vote. Board members are excused from the room for those specific deliberations where there is a conflict of interest (e.g., previous employment by a program).

Full accreditation or renewal runs for a period of three years. Probationary accreditations run for two years. Other results of the board vote can include supplemental visits (with a $2,000 fee plus surveyor costs) and periodic reports required to address deficiencies.

LifeFlight of Maine is a CAMTS-accredited program that is soon to go through the three-year accreditation renewal. LifeFlight executive director Tom Judge, explained: “For our first time, the surveyors were a pilot and a nurse. The second time we had a respiratory therapist and a nurse. This time, we'll have two nurses. We did note on the conflict of interest form that the organizations that the [original] surveyors worked for are against our stand on issues in Washington. I still respected the surveyors, but Eileen [Frazer] pulled them anyway.” He continued, “I, as well as our program, are big believers in external assessment. No matter how good your Q and A [quality assurance] is, you still need that outside evaluation. CAMTS needs to become more rigorous — the ante needs to go up.”

As I listened to Judge utter that last statement, all I could think was: “Man, that's going to send shivers down many spines when that's read.” Because, one thing that rang loud and clear from my research was that many in our industry do not share Judge's opinion.

Concerns with CAMTS
Roger Baker of Safety Focus Group LLC, an aviation auditing company, offered one perspective as to why CAMTS has mixed support in the industry: “In my experience in outside auditing a number of EMS flight operations, I can say that the programs are certainly very nervous about the CAMTS accreditation process, even though they are certain they are operating to those standards. CAMTS is a non-regulated, non-governmental organization that has great power over their livelihood. They are unsure that they will be properly evaluated and are aware of the potential cost to their business.”
Others in the industry also have concerns about CAMTS' impartiality, even with the safeguards the organization has tried to put in place. “Tim,” a clinical manager of a CAMTS-accredited program who asked not to be identified, said: “They may have good intentions, but they are not impartial all of the time. It's hard to be a self-supported yet separate organization. Everybody strives for this accreditation because it's the ‘standard of the industry,' yet there is no real validation. Their process is inherently flawed — everybody is affiliated with a program. Would Bell invite Eurocopter over to pore through their operations? I don't think so. If we didn't have to have the accreditation, we wouldn't have gotten it. But we'd still meet the standards.”

And therein lies the rub for many programs and personnel: CAMTS is required in many instances, even though that was never the organization's intention.

Frazer told me: “We do not want states to require accreditation. We have never encouraged that. We encourage deemed status, so that if you went the extra mile and did CAMTS accreditation you don't have to jump through all the licensing hoops in that state. That we do encourage, but not requiring. I'll give you a reason why. We were sued, and you probably know that, back in 2003, and it wasn't because states required accreditation, it was because Indian Health Services required it.”

Indeed, CAMTS was sued and it was messy. The conflict was with Eagle Air Med, which is headquartered in Utah, and has bases in Arizona, New Mexico and Colorado. (Eagle's ownership also operates Hawaii Air Ambulance and Guardian Flight in Alaska, which were acquired in 2006 and 2008 respectively.) Eagle Air Med has been in operation since 1979, guided by essentially the same management family.

Cheryl Bowers, Eagle Air's executive vice-president and program director explained, “The reason for the lawsuit was because CAMTS made a phone call to us and said that our accreditation was immediately suspended. They would not tell us why, wouldn't discuss the action, but said we would receive a letter. They did not give us proper due process or a chance to respond to any of the issues before suspending us and removing us from the CAMTS accredited programs list.”

Eagle's accreditation was suspended in 2003. CAMTS ultimately prevailed in the primary case against it in 2004, which denied Eagle recovery for lost revenues as a result of the accreditation removal and affirmed the removal. However, as Bowers explained, “Shortly after the ruling, we got a letter from CAMTS stating that they were withdrawing our accreditation for five years. We asked the judge to rule on this and he issued a second ruling that CAMTS had testified that we could re-apply immediately and he amended his order to say that they had to allow us to re-apply immediately.” Eagle Air Med did re-apply.

Subsequently, in 2007, Eagle suffered its first-ever fatal accident. It was a controlled-flight-into-terrain crash in Colorado. Said Bowers, “CAMTS showed up for a surprise inspection literally even before the funerals were over. I do not feel that their actions are directed at trying to make our company better, but, more realistically, the executive board is seeking opportunities to withdraw our accreditation, which is why I was very reluctant to share with you any of our experiences.”

CAMTS also asked Eagle to undergo both aviation and medical outside audits. As Bowers lamented, “Even though we came through those audits with very favorable results, we were still put on probation and will be undergoing another supplemental inspection.”

Interestingly, Baker's Safety Focus Group was one of the auditing companies who performed a five-day audit on Eagle. He and his firm reported that, “This EMS operation is in the top ten percent of the many EMS operations (both the largest and several single-aircraft operations) that I have audited in the last seven years. I have audited over thirty-five different EMS bases and the two largest EMS operators in the United States.”

Bowers continued, “We've undergone eight site surveys with three surprise surveys in the past five years. In addition, CAMTS has reported that they will come out for yet another supplemental inspection in January 2010. We will then have our re-accreditation inspection in May 2011, which means we will have been through 10 inspections in six years.”

Since April 2004, Eagle has paid $58,778.73 directly to CAMTS, and $35,000 for the outside safety audits CAMTS requested in 2008. In addition, Eagle estimates it spends approximately $75,000 per year on CAMTS-related items and the amount of personnel hours required to complete and respond to CAMTS-related issues.

CAMTS didn't come out of the case against it undamaged either. As Frazer explained, “That lawsuit cost $750,000. Had we not had insurance, we wouldn't be in business today. But, not only that, our insurance premium for the MPL [medical professional liability] insurance at that time was only $7,000 per year. Guess what it is now — $32,000.”

Of course, Eagle also paid $750,000 for the lawsuit. As Bowers stated, “We didn't have insurance, so it all came out of our own pocket, because we believed in what we were fighting for and hoped that it would create better due process for other companies.”

Not Alone
Eagle Air Med is far from being the only operation with CAMTS-related administrative burdens, though, as the aforementioned Tim explained: “I spend a lot of time at my job to appease redundant questioning, numerous phone calls, disgruntled employees, responding to accusations — all silliness each time and it's sure hard to move forward when you're so heavily distracted.”
Eagle isn't the only company who has experienced legal battles with CAMTS either. Native American Air (NAA), before it was acquired by Omniflight Helicopters, also took CAMTS to court.

Native American Air, now a part of Omniflight Helicopters, has had its share of
run-ins with CAMTS. It requires accreditation in order to provide
service to the Indian Health Service, and to qualify for deemed status in Arizona.
Dan Megna Photo
Tony Young, who was Native's director of clinical services at the time, and is now in private practice, said: “Three days after I took the job with NAA in April 2001, the letter from CAMTS showed up saying that our accreditation was lost. Normally, you will get a report and a list with the problem areas. This time it was due to a lack of progress from the previous survey done in the fall of 2000 and based on a report in January 2001. There was successful court action to stay the revocation, allow us to present the facts and allowed for a return visit. My impression was that there was hearsay and innuendo taken as fact that wasn't true, yet resulted in punitive treatment from CAMTS. Although our services to IHS [Indian Health Service] were interrupted [and ironically covered by a non-accredited competitor], IHS was interested in us getting due process and they were very supportive of NAA.”

One could argue that, with 146 accredited programs, the potential for conflict is going to be there — more numbers means more exposure. As NEMSPA's representative board member Pat Williams emphasized: “The board does try to address questions of lack of impartiality. The process can be emotionally charged. If a lot of people could meet the board and see the process, they'd feel a lot better about how it works and its fairness.”

But, this is serious business. Many in the HEMS industry want clearly defined best-practice standards, however, they also want a say in determining those standards. As a quasi-regulatory agency, CAMTS has enormous influence on state and federal rule makers, but does not necessarily represent the opinions of the industry at large. It also operates without independent oversight. What if a program fails accreditation, especially in a small town? What might the impact be on that program, the hospital, the town, the community? These are the issues that scare the living daylights out of many operators and programs.

John, who could not be identified due to contractual obligations, is a HEMS industry consultant with 20 years experience in everything from line flying to high-level management. When asked about CAMTS, John replied: “While I'm a firm believer in CAMTS and the external assessment concept, I've always had some concerns around the auditing process, and the potential impact it can have on a program, some of whom are first class businesses. They [CAMTS] have a lot of power to impact a program. And it's always been slightly worrisome to me that an accreditation process can be used as a marketing tool to differentiate programs when the non-accredited programs can be just as safe or safer.”

Organizations that don't want to spend money on CAMTS accreditation can, indeed, be at a marketing disadvantage compared to those that do. Ironically, approximately two-thirds of the accredited programs are in locations where accreditation is not required. So, clearly, these programs — along with many in the “required” group — see value in the accreditation beyond the requirement. And, many who are quick to complain about some of the nuances of CAMTS are just as quick to fire out that press release the minute their accreditation is approved.

Beyond the marketing aspect of accreditation, some operators do see the safety value in having CAMTS oversee their operations. As Walter Heneghan, safety systems manager at Canadian Helicopters EMS division (Canada's largest HEMS operator) stated, “The most beneficial argument for a program to pursue the CAMTS accreditation, in our view, is that the accreditation process acts as a type of checklist to ensure certain policies and procedures are in place.” He cautioned, though, that it seems the benefit is more for newer operations: “We have been running EMS operations for over 30 years, well in advance of the CAMTS accreditation process and we feel that the manner in which we have structured our helicopter EMS program provides a very robust system; integrating the company-wide safety management system with well-developed SOPs [standard operating procedures] and a strong safety culture. If we were just starting out in EMS, then the CAMTS process is probably a worthwhile tool; but for mature programs it can be a real drain on resources.” Nevertheless, he said two of Canadian Helicopters' clients have chosen to follow the CAMTS route and that the company supports them in that process.

To be continued…

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