The Case for CAAS

There are thousands of ambulance services across the country-some private and some public. Most regulation comes from state or local government; however, some agencies are self-regulated.

     Meredith Hellestrae, executive director of the Commission on Accreditation of Ambulance Services (CAAS), says all of this inconsistency works against emergency medical transport agencies.

     "EMS is still fairly young," Hellestrae says. "There's a great disparity in the quality of organizations."

     According to Hellestrae, CAAS was created in 1990 to accredit agencies that agree to uphold better-than-minimum standards that had been identified by industry leaders.

     "It's a voluntary process," she says, "designed to help an ambulance agency of any kind." CAAS, she says, is limited only to transport agencies, public or private. All services are welcome, as long as the agency is willing to do the work. Voluntary or not, Hellestrae warns, accreditation is not simply a rubber stamp. The process has five steps:

Step 1: Self-study
     "When an agency decides that they want to be accredited, they order the standards and assess themselves," Hellestrae explains. During this step, agencies should address each of the standards identified by CAAS. "We cover everything from A to Z," she says. "The agency has to provide documentation, and there have to be policies that cover everything."

Step 2: Application
     When an agency feels it has met all the standards and has documentation to prove it, it can submit an application and pay a fee. The agency bears all of the costs of the accreditation process.

Step 3: Evaluation
     "We do an offsite review and issue them a report," says Hellestrae. Often, agencies will have deficiencies or CAAS will require additional information. Hellestrae describes the process as an active discussion. "The agency is allowed to address any questions we have."

     Once the offsite portion of the evaluation is complete, CAAS sends a team of reviewers to visit the agency. "Onsite review is conducted by a physician and one or two paramedics," says Hellestrae. "They kick the tires of the machinery for at least two days."

     According to Hellestrae, the teams also talk to agency employees during site visits. She describes the process as friendly rather than menacing, as the goal is to improve EMS. "There's a lot of tutoring, mentoring and questions answered," she says.

Step 4: Deliberation
     Once the onsite visit is finished and reviewers file the final report, a panel of three independent commissioners, all with an EMS background, looks at the application and decides whether to accredit the agency. The commissioners, who represent healthcare, law and business aspects of EMS, have the final say. The panel meets quarterly and reviews several applications at a time.

Step 5: Accreditation
     Once an agency has been accredited, it can use the CAAS logo on its ambulances and all advertising. Fees are based on the number of transports an agency does each year and ranges from $3,500 to $10,000 for a three-year accreditation, after which the agency must reapply and go through the entire process again.

     "There are no breaks for redoing it consecutive times," Hellestrae says of the accreditation process. "It keeps this quality mission in front of them and keeps it fresh."

     The CAAS board of directors sets the standards that agencies must follow. Representatives of some of the most influential EMS bodies sit on the board, including the American Ambulance Association, American College of Emergency Physicians, International Association of Fire Chiefs, National Association of EMS Physicians, National Association of EMTs and National Association of State EMS Directors, as well as a liaison from the National Highway Traffic Safety Administration.

     There are several reasons to become accredited, says Hellestrae, most of which involve marketing. "Six states in the U.S. recognize it in their licensure process," she says. "There are areas of the country where accreditation is required to do business or bid on contracts."

     CAAS sends accredited agencies a survey in January of each year to evaluate changes. Significant changes go to the panel for review and may result in more inspections or fees.

     Agencies must diligently maintain accreditation. "If a complaint is made, investigated and found valid, and if it is proven to be a violation of the standards, they could lose their accreditation," says Hellestrae.

     The accreditation process is a commitment, she adds. Many larger agencies dedicate a committee to address standards. "On average, an agency should be able to complete the accreditation process in about a year, if they're diligent and stick with it." Hellestrae cautions that agencies needing to write policies can take as long as five or six years. A handful are accredited in as little as six months.

     Despite the effort involved, Hellestrae says smaller agencies should not be afraid to seek accreditation. "We've accredited small agencies where a husband and wife do all the work."

     CAAS tries to work with agencies as much as possible during the process, especially to ensure independent evaluation. Someone from Michigan can't evaluate a Michigan agency, and Rural/Metro doesn't want someone from AMR. The agency has the right of approval for the team.

     According to Hellestrae, 109 agencies are accredited through CAAS, and more than 200 are currently in the process. For agencies interested in seeking accreditation, Hellestrae recommends attending one of the commission's seminars. "We like to do them in various places across the U.S. and in conjunction with other meetings," she says. CAAS holds about four seminars per year.

     For more information, visit www.caas.org.

Rod Brouhard is a paramedic for American Medical Response in Modesto, CA, and former director of the EMS program at Modesto Junior College.