All programs have problems. The successful ones identify them, implement changes and evaluate the effectiveness of the changes. The unsuccessful ones continue to have, well, problems.
When an outside, or third party, is evaluating your program against a set of measured standards, your natural instinct may be to achieve 100%.
Why?
We all want to look great in front of others and do not want to learn that we are not as good as we think we are.
Let’s discuss why this is causing you undue stress and is the opposite of what auditors want to see.
When seeking accreditation, the expectation of the auditor(s) is not that your program is perfect; it is that you are not perfect.
Every transport program has its own problems. While some may be unique to the program, most afflict multiple programs. Your problems are likely not unique to you.
Looking at it from a high level, a successful Quality Management (QM) program will identify problems and implement corrective actions to improve those problems. At the end of the cycle, the effectiveness of the changes are evaluated.
With this system in place prior to your audit, the accrediting body will recognize that you have identified problems, implemented changes and are monitoring the effectiveness of those changes. Evidence of this may be requested for their review. These paper trails can be in the form of QM Meeting minutes, corrective action documentation, change in policies, etc.
Again, every transport program has issues. The auditors are expecting to see your problems and how your QM program has identified, corrected and evaluated them.
Look at it this way: the outside auditor is functioning as your quality management system. They will identify problems (i.e., below standard deficiencies) and ask you to submit corrective actions with evaluation as proof of compliance.
The important thing about this concept: when the auditor presents deficiencies to you, they are monitoring how you respond. How you respond indicates the level of departmental integration and future success in growing your QM program.
How to turn a finding into evidence of a healthy program
When a mock audit or internal review uncovers a problem, resist the urge to quietly fix it and move on. Auditors are far more impressed by a documented cycle than by a clean slate: what was found, why it happened, what changed, and whether the change worked.
- Define the problem clearly. State what happened and how you know, using data where possible.
- Find the cause, not the culprit. Ask why the process allowed the issue, which points to fixes that last.
- Implement a specific change. Update a policy, add a checklist, adjust staffing, or add training, and record the date.
- Measure the result. Track the related indicator for several months and note the outcome, even if it is a partial improvement.
Why this mindset matters
Programs that hide problems tend to repeat them, and staff learn that speaking up is risky. Programs that surface problems early build trust, catch small issues before they become safety events, and arrive at accreditation with a real story to tell. Free tools such as the IHI quality improvement toolkit can help structure that cycle if you do not already have a method.
You may also want to read internal quality standards in air medical transport. If your program is preparing for accreditation, learn how we help with CAMTS accreditation consulting.
Further reading
- AHRQ Patient Safety and Quality Improvement program
- CAMTS: Commission on Accreditation of Medical Transport Systems
Frequently Asked Questions
Why are accreditation survey deficiencies not necessarily a bad outcome?
Deficiencies identified during a survey represent opportunities for genuine improvement — they highlight gaps that, if left unaddressed, could affect patient safety or operational effectiveness. Surveyors recognize that no program is perfect, and a thoughtful corrective action plan demonstrates organizational maturity.
How should medical transport programs respond to accreditation findings?
Programs should treat findings as learning opportunities, develop specific and measurable corrective action plans, implement changes systematically, and verify effectiveness through follow-up data review. Accreditation bodies expect demonstrated improvement, not just promised improvement.
What is a corrective action plan in the context of CAMTS or NAAMTA accreditation?
A corrective action plan (CAP) is a formal response to accreditation findings that identifies the root cause of each deficiency, the specific actions taken to correct it, the responsible party, and the timeline for implementation. A well-written CAP demonstrates that a program understands and is committed to fixing the underlying issue.
How do accreditation bodies view programs that acknowledge areas for improvement?
Accreditation bodies view transparency and self-awareness as indicators of a healthy safety culture. Programs that proactively identify weaknesses, report safety events honestly, and demonstrate genuine commitment to improvement are viewed more favorably than those that appear to be concealing problems.