CAAS: The View From the Inside

As the plane banked sharply out of Newark Airport, I was filled with a feeling that was part excitement and part trepidation and, for once, it wasn’t due to my fear of flying. This time it was because I was traveling all the way across the continent to examine and evaluate someone else’s EMS system as part of my first site review for the Commission on Accreditation of Ambulance Services (CAAS).

What It Is and How It Works

CAAS is one of the oldest and most respected EMS accrediting bodies in the nation. It is an independent, not-for-profit commission governed by a board of representatives from the American College of Emergency Physicians, the American Ambulance Association, the National Association of Emergency Medical Services Physicians, the National Association of Emergency Medical Technicians, the International Association of Fire Chiefs, the National Association of State EMS Directors and a liaison from the National Highway Traffic Safety Administration.

In order for an agency to receive CAAS accreditation, it must go through a lengthy process, which includes these steps:

• Self-assessment, in which the agency considering accreditation evaluates all facets of its operation against established CAAS standards;

• Completion of the application, in which the agency documents its compliance with all the CAAS standards;

• An off-site review of the agency’s documentation by CAAS staff to ensure that the application is as complete as possible; and

• An on-site review by a team of EMS professionals comprised of an EMS physician and two other medics or nurses with significant experience in managerial, clinical, operational and/or other aspects of EMS.

CAAS standards encompass everything that is integral to providing quality prehospital care: the EMS agency’s overall organization, management structure, financial management, clinical standards, equipment and facilities, safe operations and risk management, communications/dispatch, interagency interaction, human resources/personnel, and community relations/public information. Sections concerning medical input and clinical standards are always assigned to the physician reviewer, while the rest of the team divides up the other sections based upon their qualifications, specialties and experience within EMS.

On the Scene

When I landed at the airport, I met up with the rest of the team: Dave Dabell, an ED physician out of Seattle, WA, and Will Chapleau, a fire chief from Chicago Heights, IL. They are both experienced CAAS site reviewers and have been around the proverbial EMS block many times.

On the first day, we arrived on site to find everything and everyone well prepared. As team leader, Will opened the meeting with a brief presentation to agency management regarding the history of CAAS. He explained several critical points, including the composition of the organization and how EMS experts from across the country had developed the CAAS standards for various areas of operation through consensus and peer review. He put the company management at ease and made it clear that the CAAS review team was not there to try and “fail” the agency, but rather to be fair, objective and helpful in its evaluation. In return, the agency made a presentation to the reviewers about their organization.

The remainder of the two days on site was spent trying to establish whether the agency was, in fact, practicing all of the policies and procedures that they had submitted to CAAS. All CAAS site reviewers sign confidentiality agreements, so an agency should not fear public dispersal of private information.

Over the two days, we were given unrestricted access to the entire organization. We spoke to all types of employees—from management and supervisors to dispatchers, billing personnel and field personnel. One or the other of the three reviewers spoke to each and every one. This not only helped us to ascertain that the submitted policiesprocedures, etc., were known and utilized, but also helped us to get a feel for the agency—where it had been, where it saw itself going, and what it was like to work there from multiple perspectives.

It was interesting to examine the operations of a different system from my own and to consider how aspects of it might be adapted to my workplace. For example, one of the unique things I observed at this agency was the utilization of a global positioning system (GPS) with interactive capability. Every vehicle in the fleet—management cars included—had GPS on it. The interactive capability was an exceptional way of communicating when cell or radio wasn’t feasible.

Case in point: Some of my site reviews ran long and we were able to message over to HQ that I was running behind and would meet up with the rest of the team later than expected.

The fact that every car has a GPS means that everyone is on the same page with the push of a button. An obvious advantage in regard to operations, emergency or non-emergency missions, marketing and so on, this technology would be beneficial to countless other systems throughout the industry.

Next Steps

After all elements of the review process are completed, including the on-site review, an objective Panel of Commissioners makes the final accreditation determination. The Panel is made up of three individuals from EMS business, medicine and law, and they are some of the most knowledgeable EMS experts in the U.S. They are not just separate from the reviewers; they are totally separate from the rest of the CAAS organization, allowing for complete objectivity.

How long the CAAS accreditation process takes depends on the agency’s level of preparation prior to applying. Once the agency has all of its written policies, procedures, protocols and required record-keeping systems in place and submits documentation to CAAS, the process takes about six months for off-site, on-site and panel review to complete. There are no time requirements for agency preparation of documentation but, on average, an agency will take about one year from ordering the application to submission of the necessary documentation.

The Benefits of Accreditation

At this point, you may be asking what CAAS accreditation can do for your agency. Agencies that have received accreditation—or have even attempted the process—report significant increases in the overall quality of their operations, especially in organizational efficiency and improved patient care. The CAAS standards represent one of the few sets of comprehensive standards that are currently available for EMS. The importance of this fact, and the integrity of the process, cannot be overstated.

There are also some intangible returns associated with CAAS accreditation, including peer and governmental recognition of the effort that goes into it; risk management rewards (the potential for lower insurance rates, for example, and some measure of insulation from lawsuits); as well as potential marketing and/or contracting benefits.

Questions often arise about the cost of CAAS accreditation. Some agencies say the cost of the process prevents them from attempting it, but my bet is the more common reason is a lack of knowledge or fear of the process.

The actual cost is comprised of three fees: the application fee, the accreditation fee and reviewer fees/expenses. The first-time application fee is $100. Application packages thereafter are complimentary to reaccrediting agencies.

The accreditation fee is based on the agency’s annual medical transports (not total call volume). For agencies doing 1–4,999 annual medical transports, the fee is $3,500. Agencies with 5,000–19,999 transports are charged $7,500; and for those with more than 20,000 medical transports per year, the fee is $10,000. This three-tier fee schedule accommodates small, midsized and larger ambulance agencies of all types, and there are no interim fees to be paid between accreditation cycles.

Reviewer expenses usually cost between $5,000 and $6,000. These include reviewers’ travel, meals, hotel, one car rental for the team and honoraria.

CAAS does all it can to keep the costs of accreditation down. It works with the agency to choose the hotel; and in some cases, particularly with reaccreditations, site inspections can be done with two, rather than three reviewers. Any unused portion of the reviewer deposit is returned to the agency. Staff time, photocopying and the like will also add some expense to the process.

Making the Decision

Do you need CAAS accreditation? There are many questions that need to be answered before an agency is ready to become CAAS- accredited. Does your EMS agency have well-researched policies, procedures and protocols, as well as solid educational and QI processes in place? The process is a lot of hard work for everyone involved, but as those who have achieved or even simply attempted accreditation, as well as the reviewers and others who participate in the process, can tell you, there are plenty of benefits that go with the CAAS seal of approval.

To learn more about CAAS or how to become a CAAS-accredited agency, visit www.caas.org or call Meredith Hellestrae at 847/657-6828, ext. 3014.

The author would like to thank Meredith Hellestrae, executive director of CAAS, for assistance with this article.