(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.
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.