Joint Commission International Accreditation Standards for Medical Transport Organizations

Effective 1 July 2015 Joint Commission International Accreditation Standards for Medical Transport Organizations English 2nd Edition

Contents General Eligibility Requirements... 1 Section II: International Patient Safety Goals... 3 International Patient Safety Goals (IPSG)... 5 Section III: Health Care Organization Management Standards.... 13 Governance, Leadership, and Direction (GLD).... 15 Quality Improvement and Patient Safety (QPS).... 25 Exposure to and Transmission of Biologic and Chemical Agents (BCA).... 33 Facility Management and Safety (FMS).... 41 Staff Qualifications and Education (SQE).... 49 Management of Information (MOI).... 57 Section IV: Patient-Centered Standards.... 67 Access to Care and Continuity of Care (ACC).... 69 Patient and Family Rights (PFR).... 79 Assessment of Patients (AOP).... 87 Care of Patients (COP).... 95

General Eligibility Requirements General criteria for eligibility for Joint Commission International accreditation are as follows: 1) The medical transport organization is located outside of the United States and its territories. 2) The medical transport organization is currently in operation as a transport organization and is licensed to operate by the appropriate authorities (if required) and is in compliance with relevant laws and regulations. 3) The medical transport organization assumes, or is willing to assume, responsibility for improving the quality of its care or services. 4) The medical transport organization provides services addressed by the standards in this 2nd Edition. 5) The medical transport organization agrees to meet the conditions described in the Accreditation Participation Requirements found in this manual. Additional requirements are the following: 6) The medical transport organization provides transportation to a) at-risk individuals with needs for medical rescue and/or monitoring, support and potential medical intervention during transportation; and/or to b) individuals who are not at-risk who require transportation from one care setting to another or between care settings and noncare settings such as the individuals residence. 7) The medical transport organization is either a public or private entity, and provides services under contract with a health care organization or public agency, on a fee-for-service basis, or a mixture of arrangements for obtaining and paying for the transport services.

Section II: International Patient Safety Goals

International Patient Safety Goals (IPSG) Changes to the IPSG Chapter Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Goals, Standards, Intents, and Measurable Elements Goal 1: Identify Patients Correctly Standard IPSG.1 The transport organization develops and implements a process to improve accuracy of patient identifications. Intent of IPSG.1 The identification process used throughout the transport organization requires at least two ways in which to identify a patient, such as the patient s name, identification number, birth date, a bar-coded wristband, or other

ways. To ensure that the right individual is transported safely to the right destination, two different patient identifiers are required for any type of transport. For example, patients are identified before transporting from one health care organization to another, or from a health care organization to home or from home to a health care organization. When an individual is comatose or unable to communicate, the transport organization seeks others who can identify the individual to be transported. Measurable Elements of IPSG.1 1. Patients are identified using two patient identifiers prior to transport. 2. Patients are identified before discharge to a receiving individual or organization. 3. The patient identification process is carried out by the individual providing the transportation. Goal 2: Improve Effective Communication Standard IPSG.2 The transport organization develops and implements a process to improve the effectiveness of verbal and/or telephone communication. Standard IPSG.2.1 The transport organization develops and implements a process for handover communication. Intent of IPSG.2 and IPSG.2.1 Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety. Communication can be electronic, verbal, or written. Patient transport circumstances that can be critically impacted by poor communication include verbal or telephone patient transport orders, verbal or telephone communication of critical information such as the patient s clinical status, and handover communications at the beginning and end of transport. Handover communications can also be referred to as handoff communications. The most error-prone communications are transport orders given verbally and those given over the telephone, when permitted under local laws and regulations. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order being given. For example, a transport driver may not verify the address or location of the individual requiring transport or understand the name and correct spelling of the individual to be transported.. In addition to accents and dialects, background noise, interruptions, and unfamiliar names and terminology often compound the problem. Once received, a verbal order must be transcribed as a written order. Verbal and telephone orders for transport are entered into a log, journal or electronic system for review and verification. Breakdowns in communication can occur during any handover of patients and patient care information. For example, if the driver did not receive the communication that the patient being transported from one organization to another was thought to have an infectious disease, the driver would not take appropriate precautions or properly clean the vehicle after transport. Standardized, critical content for communication between the driver and the sending or receiving organization, the patient, family, caregivers, and health care providers can significantly improve the outcomes related to handovers of patient care. 3 6 Measurable Elements of IPSG.2 1. The complete verbal transport order is documented and read back by the receiver and confirmed by the individual giving the order. 2. The complete telephone transport order is documented and read back by the receiver and confirmed by the individual giving the order. 3. The transport organization develops and implements a process to improve the effectiveness of verbal and/or telephone communication.

Measurable Elements of IPSG.2.1 1. Standardized critical content is communicated between health care provider organizations and transport workers during handovers. 2. Standardized forms, tools, and methods support a consistent and complete handover process. 3. Data from handover communications are tracked and used to improve approaches to safe handover communication. Goal 3: Improve the Safety of High-Alert Medications Standard IPSG.3 The transport organization develops and implements a process to improve the safety of high-alert medications including concentrated electrolytes. Intent of IPSG.3 When medications are used during the patient transport process, appropriate management is critical to ensuring patient safety. Any medication, even those that can be purchased without a prescription, if used improperly can cause injury. However, high-alert medications cause harm more frequently, and the harm they produce is likely to be more serious when they are given in error. This can lead to increased patient suffering and potentially additional costs associated with caring for these patients. High-alert medications include medications that are involved in a high percentage of errors and/or sentinel events, such as insulin, heparin, or chemotherapeutics; and medications whose names, packaging and labeling, or clinical use, look alike and/or sound alike, such as Xanax and Zantac or hydralazine and hydroxyzine There are many medication names that sound or look like other medication names. Confusing names is a common cause of medication errors throughout the world. Contributing to this confusion are incomplete knowledge of drug names; newly available products; similar packaging or labeling; similar clinical use; similar strengths, dosage forms, and frequency of administration; and illegible prescriptions or misunderstanding during issuing of verbal orders. Lists of high-alert medications and look-alike/sound-alike medications are available from organizations such as the World Health Organization (WHO) and the Institute for Safe Medication Practices (ISMP), as well as in the literature. A frequently cited medication safety issue is the incorrect or unintentional administration of concentrated electrolytes (for example, potassium chloride [equal to or greater than 2 meq/ml concentration], potassium phosphate [equal to or greater than 3 mmol/ml concentration], sodium chloride [greater than 0.9% concentration], and magnesium sulfate [equal to or greater than 50% concentration]). Errors can occur when transport staff are not properly oriented to the transport vehicle when contract or new transport workers have not been properly oriented, or during emergency transport. The most effective means to reduce or to eliminate these occurrences is to develop a process for managing high-alert medications that includes removing them from vehicles when not required or proper secure storage on the vehicle. The transport organization that provides medical services and interventions during transport makes a list of all medications that pose a significant risk to patients. The list includes medications identified as high risk for

adverse outcomes as well as those at risk for look-alike/sound-alike confusion. Information from the literature and/or Ministry of Health may also be useful in helping to identify which medications should be included. 7 9 These medications are stored in a way that reduces the likelihood of inadvertent administration or ideally provides directions on the proper use of the medication. Strategies to improve the safety of high-alert medications may be tailored to the specific risk of each medication and should include consideration of prescribing, preparation, administration, and monitoring processes, in addition to safe storage strategies. 10 14 The transport organization also identifies any areas and/or vehicles where concentrated electrolytes may be clinically necessary depending on the need of transport patients. Measurable Elements of IPSG.3 1. The transport organization has a list of all high-alert medications, including look-alike/sound-alike medications and concentrated electrolytes that are available for use during transport. 2. The transport organization has a process that prevents inadvertent administration of concentrated electrolytes during transport. 3. The transport organization implements strategies to improve the safety of high-alert medications, which may include specific storage, prescribing, preparation, administration, or monitoring processes. 4. The location, labeling, and storage of high-alert medications, including look-alike/sound-alike medications, is uniform throughout the transport organization and vehicles used to meet the medical needs of transport patients. Goal 4: Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery Standard IPSG.4 Not applicable to medical transport organizations Goal 5: Reduce the Risk of Health Care Associated Infections Standard IPSG.5 The transport organization adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health care associated infections. Intent of IPSG.5 Infection prevention and control are challenging in most health care settings including transport organizations, and rising rates of health care associated infections are a major concern for patients, health care practitioners, and transport workers. For example, transport workers assist patients into and out of transport vehicles as well as handle wheelchairs, walkers and other assistive devices, all of which are potentially contaminated. Central to the elimination of these and other infections is proper hand hygiene. Internationally acceptable hand-hygiene guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC), and various other national and international organizations. The transport organization adopts and implements currently published evidence-based hand-hygiene guidelines. Hand-hygiene guidelines are posted in appropriate staff areas, and staff are educated in proper

hand-washing and hand-disinfection procedures. Soap, disinfectants, and towels or other means of drying are located in those areas where hand-washing and hand-disinfecting procedures are required. Measurable Elements of IPSG.5 1. The transport organization has adopted currently published, evidence-based hand-hygiene guidelines. 2. The transport organization implements an effective hand-hygiene program. 3. Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the transport organization. Goal 6: Reduce the Risk of Patient Harm Resulting from Falls Standard IPSG.6 The transport organization develops and implements a process to reduce the risk of patient harm resulting from falls. Intent of IPSG.6 Many injuries to patients are a result of falls. The risk for falls is related to the patient, the situation, and/or the location. Risks associated with patients might include patient history of falls, medications use, alcohol consumption, gait or balance disturbances, visual impairments, altered mental status, and the like. Patients who have been initially assessed to be at low risk for falls may suddenly become at high risk. Reasons include, but are not limited to, surgery and/or anesthesia, sudden changes in patient condition, and adjustment in medications. Patients transported from home to hospital or to home following discharge from the hospital may be at risk for falls. Thus, the transport organization uses a checklist or criteria to identify the types of patients who are considered at high risk for falls. An example of a situational risk is the patient who arrives at the outpatient department from a long term care facility via medical transport for a radiologic examination. The patient may be at risk for falls in that situation when transferring from transport vehicle cart to exam table, or when changing positions while lying on the narrow exam table. Specific locations may present higher fall risks because of the services provided. For example, a patient transported from home to a hospital physical therapy department may be at risk for falls from muscle fatigue from using specialized equipment such as parallel bars, freestanding staircases, and exercise equipment. In the context of the populations it serves, the type of transport services it provides, and its transport vehicles, the transport organization has a process and criteria to identify patients at risk for falls, and take action to reduce the risk of falling.. A fall reduction program may include the communication of known fall risk information prior to transport such as in a hospital discharge summary, or information from the patient s family when transporting patients from their home or a long-term care setting. The transport organization has a responsibility use criteria that identify the locations (such as the physical therapy department), situations (patient transfers from wheelchairs or carts, or the use of patient-lifting devices), and types of patients (such as patients with gait or balance disturbances, visual impairments, altered mental status, and the like) who may be at high risk for falls. The transport organization establishes a fall-risk reduction program based on appropriate staff training, support for patients at known risk, and use installation of hand rails, seat belts and other support aids in the air, land or water transport vehicles.

Measurable Elements of IPSG.6 1. The transport organization implements a process to identify all patients whose condition, diagnosis, situation, or location identifies them as at high risk for falls. 2. The transport organization trains staff to use criteria to identify patients at risk for falls. 3. Measures are implemented to reduce transport related fall risk for those identified patients, situations, and locations assessed to be at risk. Goal 7: Reduce the Risk of Vehicle-Related Accidents and Injuries Standard IPSG.7 The transport organization develops and implements policies and processes to reduce the risks of vehicle accidents and risks related to vehicle operation that can result in injuries. Intent of IPSG.7 Vehicle accidents can be the result of multiple factors from poorly maintained equipment to adverse driving conditions to operator fatigue. This is equally true for land, air and water transport. The prevention of accidents is a high priority for transport organizations to protect patients, operators and staff on the transport vehicle. Poor weather is a major contributor to accidents for land, water and air transport. It is important to be aware of weather risks with accurate and timely weather information and it is equally important for the transport vehicle operator to be guided by policies, procedures and training how to interpret the risks and take risk mitigation actions. Weather risks can vary widely from sand storms in arid regions to monsoons in tropical regions to volcano ash impeding vision to high rough seas. Transport vehicles need to be in safe operating condition in accordance with vehicle/vendor manufacturer recommendations, organization policy, and applicable country laws and regulations. In addition, good communication and information systems and alert operators are necessary to manage road, air, and water risks when they arise, with or without advance warning. Measurable Elements of IPSG.7 1. The transport organization is aware of the known and likely weather and other road, air and water risks to vehicle operation in their area of operation. 2. The transport organization trains operators on how to manage weather and other risk during vehicle operation and uses trained, rested operators when adverse conditions exist at the time of transport. 3. The transport organization ensures that vehicles are in safe operating condition to manage transport risks when they arise. 4. The transport organization maintains records on all vehicle accidents and uses to information to develop risk reduction strategies. References 1. Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011 Jun;37(6):274 284. 2. Rabøl LI, et al. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf. 2011 Mar;20(3):268 274. 3. Craig R, et al. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth. 2012 Apr;22(4):393 399. 4. Drachsler H, et al. The Handover Toolbox: A knowledge exchange and training platform for improving patient care. BMJ Qual Saf. 2012 Dec;21 Suppl 1:i114 120.

5. Johnson M, Jefferies D, Nicholls D. Developing a minimum data set for electronic nursing handover. J Clin Nurs. 2012 Feb;21(3 4):331 343. 6. Segall N, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012 Jul;115(1):102 115. 7. Institute for Safe Medication Practices. Medication Safety Tools and Resources. Accessed Jun 20, 2013. https://www.ismp.org/tools/. 8. Khoo AL, et al. A multicenter, multidisciplinary, highalert medication collaborative to improve patient safety: The Singapore experience. Jt Comm J Qual Patient Saf. 2013 May;39(5):205 212. 9. Shaw KN, et al.; Pediatric Emergency Care Applied Research Network. Reported medication events in a paediatric emergency research network: Sharing to improve patient safety. Emerg Med J. Epub 2012 Oct 31. 10. Ching JM, et al. Using lean to improve medication administration safety: In search of the perfect dose. Jt Comm J Qual Patient Saf. 2013 May;39(5):195 204. 11. Darker IT, et al. The influence of Tall Man lettering on errors of visual perception in the recognition of written drug names. Ergonomics. 2011 Jan;54(1):21 33. 12. Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Harm from High-Alert Medications. Cambridge, MA: IHI, 2012. Accessed Jun 20, 2013. http://www.ihi.org/knowledge/pages/tools/howto GuidePreventHarmfromHighAlertMedications.aspx. 13. Ostini R, et al. Quality use of medicines Medication safety issues in naming; look-alike, sound-alike medicine names. Int J Pharm Pract. 2012 Dec;20(6):349 357. 14. Agency for Healthcare Research and Quality. Patient Safety Primers: Medication Errors. 2012. (Updated: Oct 2012.) Accessed Aug 14, 2013. http://psnet.ahrq.gov/ primer.aspx?primerid-23. 15. Boushon B, et al. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement, 2012. Accessed Jun 20, 2013. http://www.ihi.org/knowledge/pages/tools/tcab HowToGuideReducingPatientInjuriesfromFalls.aspx. 16. Dykes PC, et al. Fall prevention in acute care hospitals: A randomized trial. JAMA. 2010 Nov 3;304(17): 1912 1918. 17. Francis DL, et al. Quality improvement project eliminates falls in recovery area of high volume endoscopy unit. BMJ Qual Saf. 2011 Feb;20(2):170 173. 18. Johnson M, George A, Tran DT. Analysis of falls incidents: Nurse and patient preventive behaviours. Int J Nurs Pract. 2011 Feb;17(1):60 66. 19. Miake-Lye IM, et al. Inpatient fall prevention programs as a patient safety strategy: A systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):390 396.

Section III: Health Care Organization Management Standards

Governance, Leadership, and Direction (GLD) Changes to the GLD Chapter Note: The chapter overview provides definitions for the levels of leadership referred to in the standards. Standard Change Explanation Note: This table lists changes to requirements in this chapter only. Requirements that were in this chapter in the 1st edition of this manual and are now contained either in their entirety or in part in another chapter of this 2nd edition are listed in that chapter s Changes table. The following standards appeared in this chapter of the 1st edition standards but were deleted from this edition (listed with 1st edition numbers): Overview Providing excellent medical transport services requires effective leadership. Leadership comes from many sources in an organization, including governing leaders, clinical leaders and managerial leaders, and others who hold positions of leadership, responsibility, accountability, and trust. These individuals must be identified and involved in ensuring that the organization is an effective, efficient resource for the community and its patients.

In particular, these leaders must define the organization s mission and make sure that it has the resources needed to fulfill its mission. For many organizations, this does not mean adding new resources but using current resources more efficiently, even when they are scarce. Also, leaders must work together well to coordinate and integrate all the transport organization s activities, including those land, water and air services when part of the mission. Effective leadership begins with understanding the roles, responsibilities, interaction, and authority- ty of individuals in the organization and how these individuals work together. Those who govern, manage, and lead an organization have both authority and responsibility. Collectively and individually, they are responsible for complying with law and regulation, and for meeting the organization s responsibility to the patient population served. Note: In all GLD standards, the term leaders is used to indicate that one or more individuals are accountable for the expectation(s) found in the standard. Leadership is used to indicate that a group of leaders is collectively accountable for the expectation(s) found in the standard. 1 3 Standards, Intents, and Measurable Elements Mission of the Organization Standard GLD.1 The medical transport organization defines its mission and makes it known to the community it serves. Intent of GLD.1 Defining the mission of an organization helps focus its resources and activities and makes it clear to the community which patients should seek services from the organization and what service the organization provides. A mission statement describes the a) goals of the organization, b) types of transport services provided, for example, emergency medical transport and/or nonemergency transport, c) catchment/service areas, and d) population served, including any designation of public/private payment. Measurable Elements of GLD.1 1. The organization has defined its mission. 2. The mission addresses elements a) through d) in the intent. 3. The mission statement is made known to the community. Governance/Ownership of the Organization Standard GLD.2 Governance/ownership structure is described in written documents, such as bylaws, policies and procedures, or articles of incorporation.

Standard GLD.2.1 Governance/ownership responsibilities and accountabilities are described in written documents. Intent of GLD.2 and GLD.2.1 There is an entity (for example, a ministry of health), an owner(s), or a group of identified individuals (for example, a board or governing body) responsible for overseeing the operation of the organization and accountable for providing quality services to its community. The responsibilities and accountabilities of governance are described in a document that identifies how they are to be assigned and carried out. The organization s governance and management structure is presented in an organizational chart or other document. Lines of authority and accountability are shown in this chart. The individuals represented on the chart are identified by title or name. Measurable Elements of GLD.2 1. The organization s current governance/ownership structure is described in written documents. 2. There is an organizational chart or document. 3. Those responsible are identified by title or name. 4. The documents are available to staff and the community. Measurable Elements of GLD.2.1 1. Governance/ownership approves the organization s mission statement. 2. Governance/ownership approves the policies and plans to operate the organization. 3. Governance/ownership approves the budget and allocates the resources required to meet the organization s mission. 4. Governance/ownership appoints the organization s senior manager(s) or director(s). Standard GLD.2.2 Governance/ownership supports and promotes quality management and improvement efforts. Intent of GLD.2.2 The titles or location of the governance/ownership structure are not as important as are the responsibilities that must be carried out for the organization to have clear leadership, operate efficiently, and provide quality services. An area of high importance is the continuous involvement of governance/ownership in shaping and promoting the organization s quality program. This includes approving the quality plan and receiving regular reports on the achievements of the quality program. The identification of individuals in a single organizational chart does not ensure good communication and cooperation between those who govern and those who manage the organization. This is particularly true when the governance/ownership structure is separate from the organization, such as a distant owner or a national or regional health authority. Thus, those responsible for governance/ownership develop a process for communication and cooperation with the organization s managers and other leaders in carrying out the organization s mission and plans. Measurable Elements of GLD.2.2 1. Governance/ownership approves the quality plan and supports quality management and improvement efforts within the organization. 2. Governance/ownership minutes document the review and any actions taken on quarterly reports on the quality and patients safety program including adverse and sentinel events.

3. Governance/ownership develops an effective, collaborative communication processes with management. 4. Governance/ownership and management at least annually evaluate the effectiveness of the communication processes. Standard GLD.2.3 The transport organization provides all services within business, financial, ethical, and legal norms that protect patients and their rights. Intent of GLD.2.3 The transport organization has ethical and legal responsibilities to the individuals and populations it serves. The leaders understand these responsibilities as they apply to the organization s business and clinical activities. The leaders create guiding documents, such as the organization s mission, to provide a consistent framework to carry out these responsibilities. The organization operates within this framework to honestly portray its services to the individuals and populations it serves; provide clear policies on the selection of receiving organizations for emergency transport patients; monitor the accuracy of bills; and to resolve conflicts such as those involving financial incentives and payment arrangements. Measurable Elements of GLD.2.3 1. The transport organization s leaders establish a framework for the ethical management of the organization including the ethical and legal norms that protect patients and their rights. 2. The transport organization honestly portrays its services to the individuals and populations it serves. 3. The transport organization provides clear policies on the selection of receiving organizations for emergency transport patients. 4. The transport organization monitors the accuracy of bills. 5. The transport organization resolves conflicts such as those involving financial incentives, payment arrangements, and ethical conflicts. Standard GLD.2.4 There is full disclosure of the ownership of the transport organization. Intent of GLD.2.4 The transport organization makes available to the public documents describing the details of its ownership in full, including whether the organization is a unit of government, an independent organization, a subsidiary of another organization, or another legal organization; all business and other licenses held, and whether they are current; any contractual, business, or financial relationship with another transport organization, health care organization, or business or individual; and all names under which the organization operates or is commonly known by within its community. Measurable Elements of GLD.2.4 1. The organization has a document explaining the details of its ownership and licensure including a) through d) in the intent. 2. The document is accessible to the public from the organization s web site or by other means.. 3. The document is kept current.

Organization Leadership Standard GLD.3 A senior manager or director is responsible for operating the organization and for complying with applicable laws and regulations. Intent of GLD.3 Effective leadership is essential for an organization to operate efficiently and fulfill its mission. Leadership is what individuals provide together and individually to the organization and can be carried out by any number of individuals. The senior manager or director is responsible for the overall, day-to-day operation of the organization. This includes the procurement and inventory of essential supplies, maintenance of any physical facility, maintenance of transport vehicles and transport equipment, financial management, quality management, and other responsibilities. The individual selected or appointed by the governing body/owner to carry out these functions has the education and experience to do so. This senior manager or director cooperates with the organization s leaders to define the organization s mission and plan the policies, procedures, and clinical and non-clinical services related to that mission. Once approved by the governing body, the senior manager or director is responsible for implementing all policies. The senior manager or director is responsible for the organization s; compliance with applicable law and regulation, response to any reports from inspecting and regulatory agencies, and processes to manage and control human, financial, and other resources. Measurable Elements of GLD.3 1. The senior manager or director manages the day-to-day operation of the organization including human, physical, financial and other resources and the carries out approved policies. 2. The senior manager or director has the education and experience to carry out his or her responsibilities. 3. The senior manager or director recommends policies to the governing body. 4. The senior manager or director ensures compliance with applicable laws and regulations and responds to any reports from inspecting and regulatory agencies. Standard GLD.4 Clinical leadership and/or supervision is consistent with the clinical needs of patients and the services provided by the transport organization. Intent of GLD.4 When the mission and services of the transport organization include the transport of emergency patients and those who require treatment and medical services during transport, there is a physician or other qualified individual who plans and monitors the provision of the medical services. The individual s role includes a) the development, implementation, and monitoring of clinical dispatch functions; b) the development, implementation, and monitoring of all patient care and transport protocols; c) the training/education and performance monitoring of employees that provide medical care; and d) the medical component of the organization s quality monitoring and improvement program

When the mission and services of the transport organization do not include the transport of emergency patients, there is an individual with clinical knowledge who participates in the planning and monitoring of the transport services. Important considerations include the resuscitation training of transport staff, infection control issues, and the criteria for determining the deterioration of a patient s condition for which urgent care is needed and how to access that care. This individual s role includes e) the development, implementation, and monitoring of the dispatch functions; f) the development, implementation, and monitoring of the transport functions; g) the training/education and performance monitoring of employees that provide the transport; and h) the transport component of the organizations quality monitoring and improvement program. To accomplish these responsibilities, the individual must have training and experience related to the types of transport services provided by the organization. When required by law or regulation, the individual is a qualified health care practitioner with training and experience related to the transport services provided. Measurable Elements of GLD.4 1. There is an appropriately licensed and trained individual who is accountable for the planning and monitoring of the clinical component of all transport activities of the organization consistent with the mission and services of the transport organization. 2. For emergency medical transport services there is a physician accountable for a) through d) in the intent, and for nonemergency transport services there is an individual accountable for e) through h) in the intent. 3. The individual has relevant clinical training and experience consistent with the mission and services of the transport organization. Standard GLD.5 The organization s medical and managerial leaders are identified and are collectively responsible for defining the organization s mission and creating the plans and policies needed to fulfill the mission. Intent of GLD.5 The leaders of an organization arise from many sources. The governing body/owner names the senior manager or director. The senior manager or director may name other leaders accountable for services provided by the transport organization, for example, a medical leader when emergency transport is provided. It is important that all leaders of an organization are recognized and brought into the process of defining the organization s mission. Based on that mission, the leaders work collaboratively to develop the plans and policies needed to fulfill the mission. When owners or agencies outside the organization set the mission and policy framework, the leaders work collaboratively to carry them out. Measurable Elements of GLD.5 1. The leaders of the organization are identified. 2. The leaders are collectively responsible for defining the organization s mission. 3. The leaders are collectively responsible for creating the policies and procedures necessary to carry out the mission. 4. The leaders work jointly to carry out the organization s mission and policies. Standard GLD.5.1 Organization leaders plan with community leaders and the leaders of other organizations to meet the community s emergency and medical transport system needs.

Intent of GLD.5.1 An organization s mission commonly reflects the needs of its community. The needs of communities usually change over time. Sudden changes, such as natural disasters and outbreaks of infectious diseases, and mass disasters will precipitate rapid change. The transport organization needs to plan to respond quickly and effectively to an emergency, disaster, or epidemic in the community (for example, floods, earthquakes, worker injuries from a factory explosion, flu outbreaks). The transport organization has an identified role in the disaster plan, such as the transport of patients from one hospital to another, or the transport and treatment of injured individuals or the transport of materials and supplies. The organization tests its identified role at least once a year to ensure readiness. Thus, it is important for the leaders of a health care organization to meet with, and plan with, recognized community leaders as well as the leaders of other transport and medical care provider organizations in the community. For example, relationships with nursing home associations, fire brigades, directors of hospital trauma units and others should be considered. Measurable Elements of GLD.5.1 1. The organization plans its response to likely community emergencies, epidemics, and natural or other disasters. 2. The transport organization s leaders plan for meeting the community needs with community organizations and the leaders of other transport, social care and medical care provider organizations, including public safety agencies and government and private organizations in its community. 3. The organization tests its role in the disaster plan once a year and includes resources associated with disaster response. 4. At the conclusion of every test, a debriefing of the test is conducted and the results are communicated to participating staff. Standard GLD.6 The organization s clinical and/or nonclinical leaders implement measures to monitor and improve the transport program. Intent of GLD.6 One of the most important responsibilities of a leader, clinical or managerial, is to implement the organization s quality management and improvement program (see GLD.4, intent items d and h), in particular, the organization s monitoring and improvement priorities. Directors are responsible for ensuring that the monitoring activities provide the opportunity for the evaluation of staff as well as the processes of transport and any clinical care provided. The leaders of the transport organization develop a quality plan for the organization and seek approval of the annual plan by the governance/ownership of the organization. A primary responsibility of leaders is to set priorities. Organizations typically find more opportunities for quality monitoring and improvement than they have human and other resources to accomplish. Therefore, the leaders provide focus for the transport organization s quality monitoring and improvement activities. The leaders use available data and information to identify priority areas. Many improvements require technological and other support to carry out. The leaders understand this and make resources available for priority improvements. Measurable Elements of GLD.6 1. Leaders of the transport organization develop a written quality plan for the organization. 2. Leaders present the improvement priorities to governance/ownership on an annual basis for approval.

3. Leaders select and implement quality monitors that address the priority improvements identified for transport and clinical services provided by the organization. 4. Quality monitors include measures related to staff performance. 5. Leaders provide resources to carry out the improvement activities. Standard GLD.7 The transport organization s leaders provide management of contracts for services. Intent of GLD.7 Transport organizations have the option to either provide services directly or arrange for such services through referral, consultation, contractual arrangements, or other agreements. Such services may range from the lease of its transport vehicles, the employment of drivers or emergency medical technician from an agency, or possibly contracts with a hospital for medications or medical equipment, to the provision of financial accounting services. In all cases, there is leadership oversight for such contracts or other arrangements to ensure that the services meet patient needs and the organization s needs. All contracts are monitored as part of the organization s quality management and improvement activities and to identify contracts that should or should not be renewed. Measurable Elements of GLD.7 1. There is a process for leadership selection and monitoring of contracts. 2. Services provided under contracts and other arrangements meet patient needs. 3. Contracts and other arrangements are monitored as part of the organization s quality management and improvement program. Standard GLD.8 Leaders create and support a culture of safety program throughout the transport organization. Standard GLD.8.1 Leaders implement, monitor, and takes action to improve the program for a culture of safety throughout the transport organization. Intent of GLD.8 and GLD.8.1 A culture of safety has been defined as follows: "The safety culture is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, [a transport organization s] health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures." 7 Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the organization. Leaders demonstrate their commitment to a culture of safety and set expectations for those who work in the organization. Behaviors that are not consistent with a safe culture or that intimidate others and affect morale or staff turnover can be harmful to patient care. Key features of a program for a culture of safety include acknowledgment of the risks of providing transport activities and the determination to achieve consistently safe operations; an environment in which individuals are able to report errors or near misses without fear of reprimand or punishment; encouragement of collaboration across ranks and disciplines to seek solutions to safety problems; and

organizational commitment of resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns. 2,8 16 Health care continues to have a culture of individual blame, which impairs the advancement of a safety culture. There are instances in which individuals should not be blamed for an error; for example, when there is poor communication between patient and staff, when there is a need for medical support during transport and nontransport is provided, or when roads are slick resulting in an accident. However, certain errors are the result of reckless behavior and do require accountability. Examples of reckless behavior include failure to follow hand-hygiene guidelines when transporting infectious patients, not slowing down when after being warned of hazardous driving conditions. A culture of safety includes identifying and addressing issues related to systems that lead to unsafe behaviors. At the same time, though, transport organizations must maintain accountability by establishing zero tolerance for reckless behavior. Accountability distinguishes between human error (such as a mix-up), at-risk behavior (for example, taking shortcuts), and reckless behavior (such as ignoring required safety steps). Leaders evaluate the culture on a regular basis using a variety of methods, such as formal surveys, focus groups, staff interviews, and data analysis. Leaders encourage teamwork and creates structures, processes, and programs that allow this positive culture to flourish. Leaders must address undesirable behaviors of individuals working at all levels of the organization, including management, clinical and management staff, and governing body members. Measurable Elements of GLD.8 1. Leaders establish and support an organizational culture that promotes accountability and transparency. 2. Leaders develop and document a code of conduct and identifies and corrects behaviors that are unacceptable. 3. Leaders provide education and information (such as literature and advisories) relevant to the organization s culture of safety to all individuals who work in the organization. 4. Leaders define how issues related to a culture of safety within the organization are identified and managed. 5. Leaders provide resources to promote and support the culture of safety within the organization. Measurable Elements of GLD.8.1 1. Leaders provide a simple, accessible, and confidential system for reporting issues relevant to a culture of safety in the organization. 2. Leaders ensure that all reports are investigated in a timely manner. 3. Leaders use measures to evaluate and monitor and improve the safety culture within the organization. 4. Leaders implement a process to prevent retribution against individuals who report issues related to the culture of safety. References 1. Kovner AR, Fine DJ, D Aquila R. Evidence-Based Management in Healthcare. Chicago: Health Administration Press, 2009. 2. The Joint Commission. From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd ed. Oak Brook, IL: Joint Commission Resources, 2011. 3. National Collaborating Centre for Methods and Tools. Informed Decisions Toolbox: Tools for Knowledge Transfer and Performance Improvement. Randall T, et al. 2010. (Updated: Sep 23, 2011.) Accessed Jun 24, 2013. http://www.nccmt.ca/registry/ view/eng/46.html. 4. IMPACT: International Medical Products Anti- Counterfeiting Taskforce. Facts, Activities, Documents: The Handbook. Rome: Agenzia Italiana del Farmaco, 2011. Accessed Jun 24, 2013. http://www.who.int/entity/impact/handbook_ impact.pdf.4.

5. Gostin LO, Buckley GJ, Kelley PW. Stemming the global trade in falsified and substandard medicines. JAMA. 2013 Apr 24;309(16):1693 1694. 6. World Health Professions Alliance. WHPA Joint Statement on Counterfeiting of Medical Products. Mar 2010. Accessed Jun 24, 2013. http://www.wma.net/ en/20activities/30publichealth/50counterfeits/ WHPA_Joint_Statement_on_Counterfeiting.pdf. 7. Health and Safety Commission (HSE), Committee on the Safety of Nuclear Installations. Organising for Safety: Third Report of the ACSNI Study Group on Human Factors. Sudbury, England: HSE Books, 1993. 8. Agency for Healthcare Research and Quality. International Use of the Surveys on Patient Safety Culture. Mar 2012. Accessed Jun 24, 2013. http://www.ahrq.gov/legacy/qual/ patientsafetyculture/pscintusers.htm. 9. Agency for Healthcare Research and Quality. Patient Safety Primers: Safety Culture. Sep 2012. (Updated: Oct 2012.) Accessed Jun 24, 2013. http://psnet.ahrq.gov/primer.aspx?primerid=5. 10. Agency for Healthcare Research and Quality. TeamSTEPPS : National Implantation: About TeamSTEPPS. Accessed Jun 24, 2013. http://teamstepps.ahrq.gov/about-2cl_3.htm. 11. El-Jardali F, et al. Predictors and outcomes of patient safety culture in hospitals. BMC Health Serv Res. 2011 Feb 24;11:45. 12. Sorra J, et al. Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. Rockville, MD: Agency for Healthcare Research and Quality, Jan 2012. Accessed Jun 24, 2013. http://www.ahrq.gov/qual/hospsurvey12/index.html. 13. Thomas L, Galla C. Building a culture of safety through team training and engagement. BMJ Qual Saf. 2013 May;22(5):425 434. 14. Wagner C, et al. Assessing patient safety culture in hospitals across countries. Int J Qual Health Care. 2013 Jul;25(3):213 221. 15. Weaver SJ, et al. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):369 374. 16. World Health Organization (WHO). Human Factors in Patient Safety: Review of Topics and Tools. Geneva: WHO, Apr 2009. Accessed Jun 24, 2013. http://www.who.int/patientsafety/research/ methods_measures/human_factors/human_factors_ review.pdf.