(Policies & Procedures + Quality Management) ÷ Education & Training = √ Accreditation
They aren’t just binders and long documents that everybody loathes. Establishing Policies & Procedures (P&P) that are in-line with an agency-defined Quality Management (QM) and Education & Training (E&T) Programs is quite simple — they work in concert with one another.
While there will always be static policies in place like dress code/uniform, infection control, etc., your program’s vision, mission statement and scope of practice will direct many other P&P, including medical protocols, QM and E&T.
Some programs may choose to have separate “Administrative” and “Clinical/Operational” policies in place. Others may choose to combine them into one manual. Regardless of preference, some policies will be dictated by local, state and national/federal laws and will require cohesiveness with the program’s scope and mission.
Policy updates may derive from your QM Program. For example, if a medication error is discovered, a policy update may require documentation of all crew members verifying the medication to be given.
An agency’s policies will ultimately support and be intertwined with its QM and E&T programs. These polices and programs, which are designed and established by leadership, are dictated by the vision, mission statement and scope of the company’s practice.
The most vital part to maintaining a robust series of P&P is compliance.
The Circle in Action: A Medication Error Example
Here is how the loop works in practice. Your quality management program identifies a medication error. The review finds that the dose was not independently verified. Your policy is revised to require verification by a second crew member and documentation of that check. Education and training rolls the change out to every crew member. Compliance monitoring confirms the new step is being followed. Quality management then watches whether similar errors recur. If they do, the cycle starts again.
Each step feeds the next, which is why treating policies, quality management and education as separate projects creates gaps.
A Quick Policy Review Checklist
For each policy in your manual, you should be able to answer yes to the following:
- Is there a named owner responsible for keeping it current?
- Does it show an effective date, a last-reviewed date and a version history?
- Is it tied to the standard, regulation or program requirement that drives it?
- Has every affected crew member been trained on the current version, with documentation?
- Is there a quality metric or audit that shows whether the policy is being followed?
If the answer to any of these is no, that policy is a likely survey finding. Learn how to keep compliance on track between surveys.
You may also want to read how to stay accreditation compliant. If your program is preparing for accreditation, learn how we help with CAMTS accreditation consulting.
Further reading
- CAMTS: Commission on Accreditation of Medical Transport Systems
- AHRQ Patient Safety and Quality Improvement program
- EURAMI: European Aeromedical Institute accreditation
- NAAMTA: North American Air & Medical Transport Accreditation
Frequently Asked Questions
Why are clinical policies and procedures described as circular in medical transport?
Clinical policies and procedures are circular because they are not static documents — they must be continuously reviewed, updated based on quality improvement data and outcome trends, retrained, and then reviewed again. This iterative cycle ensures that policies reflect current best practice and actual operational realities.
How do clinical policies and procedures support accreditation compliance?
Accreditation bodies require that programs have written, current, and consistently practiced clinical policies and procedures. These documents are the backbone of survey readiness — surveyors will review them for currency, accuracy, and evidence that staff are actually following them.
How often should air ambulance programs review and update clinical policies?
Clinical policies should be formally reviewed at minimum annually, with immediate updates triggered by new evidence, regulatory changes, accreditation standard revisions, or quality improvement findings. Programs should document each review cycle to demonstrate compliance.
What happens if clinical policies are outdated during an accreditation survey?
Outdated policies are a common and significant survey finding. They suggest that a program’s practice may not reflect current standards of care and that the quality improvement cycle is not functioning effectively. This can result in conditional accreditation or required corrective action.