Accreditation decisions

Article Outline

• Full accreditation
• Provisional action
• Withhold accreditation
• Deferral action
• Copyright

We at the Commission on Accreditation for Medical Transport Systems (CAMTS) are frequently asked, “How many services achieve accreditation the first time they are reviewed?” This percentage has remained fairly consistent at 65%. In our most recent tabulation, that figure is down to 63%, but it is important to understand the various accreditation decisions and actions that make up the 37% of services that are not accredited the first time.

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Full accreditation 

All services strive for full accreditation, and we find most services that achieve full accreditation the first time are very prepared and have a good understanding of the accreditation standards. Full accreditation is granted for 3 years and is awarded when the medical transport service is in substantial compliance, demonstrating an overall quality of service consistent with the core elements (listed in the preamble of the sixth edition of the accreditation standards) of the accreditation standards in the professional judgment of the board. Although awarded full accreditation, substantial compliance does not mean that each and every standard is met, so most services that achieve full accreditation have some contingencies that must be addressed and reported back to the Board in the form of a progress report.

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Provisional action 

A service may not advertise as being accredited when awarded a provisional action. This is awarded when the medical transport service has applied for the first time and has deficiencies that are, in the judgment of the Board, correctable within a 6-month timeframe but prevent the service from being in substantial compliance.

Provisional actions always require a progress report to address the contingencies cited for each specific standard, and occasionally the board will require a supplemental visit to verify progress on the contingencies. Of the 21% that are awarded a provisional action, only 1% have failed to achieve full accreditation after submitting a progress report or undergoing a supplemental visit.

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Withhold accreditation 

Accreditation is withheld when the board determines that a program applying for the first time does not substantially comply with the accreditation standards. The program may not reapply for accreditation for 6 months. In our recent calculations, 11% of services have been withheld from accreditation. A decision to withhold accreditation is usually made when the board determines that there are major safety or patient care issues that cannot be easily resolved within a 6-month period.

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Deferral action 

The board may defer an accreditation decision when a lack of sufficient information about specific issues precludes an informed and reasonable decision. Only 5% of the services applying for accreditation for the first time result in a deferred decision, and this is usually due to recent changes affecting the service at the time of the site visit. The board does not make hasty decisions, and a deferred action does not negate accreditation; it merely provides time to clarify any issues in question. Usually the service is reviewed at the next board meeting, and 95% of deferred actions result in full accreditation.

Ultimately, accreditation decisions are the result of a great deal of coordination and hard work by the service. It is not the goal of CAMTS to be punitive. Our main goal is to educate and assist in improving the services we review. The board strongly believes that the real value of accreditation is in striving to meet the standards and the process of preparing for accreditation.

In the next issue, we will review the decisions that can result when a service applies for reaccreditation.