hems industry risk profile

8/9/2019 HEMS Industry Risk Profile

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Helicopter Emergency Medical Services (HEMS)

Industry Risk Prole

PRIL 2009


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About the HEMS Industry Risk Profile An industry risk prole (IRP) presents a strategic risk picture of the key risk issues that face a nomi-nated sector within an industry at a given point in time. An IRP contains the denition of the contextof the industry and the context of the risk prole, identication of risk issues, their associated impacts,the risk rating and presents proposed high level treatment strategies the associated residual risk and therisk ranking. An IRP provides the platform for industry to develop a detailed risk reduction plan, outlin-ing the agreed risk reduction measures, timelines for implementation and accountabilities.

About the Flight Safety Foundation

www.ightsafety.org

Flight Safety Foundation is an independent, nonprot, international organizationengaged in research, auditing, education, advocacy and publishing to improveaviation safety.

The Foundation’s mission is to pursue the continuous improvement of global aviationsafety and the prevention of accidents.

The Foundation’s objectives are to:

- Pursue the active involvement and participation of thediverse elements of global professional aviation;

- Anticipate, identify and analyze global aviation safety issues and set priorities;- Communicate effectively about aviation safety; and,- Be a catalyst for action and the adoption of best aviation safety practices.

About Aerosafe Risk Management

www.aerosafe.com.au

The Aerosafe Group is a global aviation safety and risk management company, whichprovides risk management services, support and tailored solutions to aviation compa-nies around the world. With ofces in North America, Australia, India, China and NewZealand, Aerosafe is recognized as an international leader in this important eld. The Aerosafe Group has been invited to set standards with aviation regulators, industry

groups and companies alike and operates at the operational, enterprise, sector andindustry levels in the application of modern risk management practices.

About the Foundation of Air Medical Research & Education

www.fareonline.org

The Foundation for Air Medical Research & Education (FARE) was established in 2001to support charitable, scientic and educational programs and other initiatives, includ-ing outreach to the public, for the air medical and critical care medical transport com-munity. Everything we do is for the patients we serve. The Foundation for Air-MedicalResearch & Education (FARE) is a non prot 501 (c) (3) charity serving the internationalair-medical community through:

- supporting essential air-medical and critical-care transport research andeducation initiatives;- sponsoring educational opportunities and scholarships for air medical professionals;- advancing patient and aviation safety;- funding grants that result in important clinical, safety and operational research;- publishing award-winning public policy literature that helps air-medical practitioners

keep abreast of cutting-edge research and technologies;- providing nancial support to families in crisis after an air medical accident;- informing the public about air medical and critical-care transport;- convening worldwide forums for industry leaders to discuss the global initiatives,

challenges and opportunities for air-medical and critical care transport systems.

FOUNDATION FOR AIR-MEDICAL RESEARCH & EDUCATION


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APRIL 2009

Published by: Flight Safety Foundation

Developed by: Aerosafe Risk Management

Developed for: HEMS Industry, United States of America

Printed & Distributed by: Foundation of Air Medical Research & Education

Helicopter Emergency Medical Services (HEMS)

Industry Risk Prole


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© Copyright Aerosafe Risk Management Inc, April 2009

This document has been developed by Aerosafe Risk Management Inc (Aerosafe) in response to aspecic body of work that was commissioned and funded by industry. The background intellectualproperty expressed through the methodologies, models, copyright, patent and trade secrets used to

produce the Industry Risk Prole remains the property of Aerosafe. Aerosafe grants the Flight Safety Foundation an exclusive, world-wide, royalty-free licence to publish,release and distribute the IRP to industry. This licence includes the ability for Flight Safety Foundationto sub-licence printing and distribution of hard copy prints of the IRP. The intellectual property ex-pressed in this copyright information is governed by the contract between Aerosafe and Bell HelicopterTextron and the subsequent licensing agreement with the Flight Safety Foundation.

While the author and publisher have taken reasonable precaution and have made reasonable efforts toensure accuracy of material contained in this report, Aerosafe does not guarantee that this publication is without aw of any kind. The authors and publisher makes no warranties, express or implied, with respectto any of the material contained herein and therefore disclaims all liability and responsibility for errors, loss,damage or other consequences which may arise from relying on information in this publication.


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INTRODUCTION: Managing Risk in the HEMS Industry

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

How to use the HEMS Industry Risk Profi le (IRP) . . . . . . . . . . . . .8

Next steps: Completing the risk management process. . . . . . . . . . 9

PART 1: Context of the Industry Risk Profile . . . . . . . . . . . . . . . . 11

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Risk Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Depth of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Methodology: Risk Management Process . . . . . . . . . . . . . . . . . . . 19

Methodology: Industry Risk Profile Model . . . . . . . . . . . . . . . . . . 20

PART 2: Summation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Summation of results risk profile . . . . . . . . . . . . . . . . . . . . . . . . . 24

Risk reduction plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

PART 3: Industry Risk Profile Tabulated Data . . . . . . . . . . . . . . . 31

PART 4: Supporting Appendices . . . . . . . . . . . . . . . . . . . . . . . . . 58

A. HEMS IRP stakeholder and distribution list . . . . . . . . . . . . . . . 59

B. Supporting documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

C. Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

D. Project contact details and project acknowledgements . . . . . . 62

Table of Contents


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INTRODUCTION


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The Helicopter Emergency Medical Services (HEMS) industry is to be congratulated for taking aleadership role in developing an industry approach to the management of risk in the vital area of airmedical transportation.

Aviation has a long and proud history of addressing and managing risk, but the very nature of HEMScalls for new and innovative ways of ensuring that risk, in all its forms, is subjected to a rigorousprocess for the management of risk at all levels of the industry.

Risk is all about understanding the effect of uncertainty on organizational or in the case of the HEMSindustry, the industry’s objectives. This Industry Risk Prole is the starting point on the journey ofaddressing the objectives of HEMS participants, large and small, and the risks that they must manage

in order to maximize their opportunities whilst minimizing threats.

The risk management process utilized in the HEMS Industry Risk Prole has many years of practicalapplication throughout the world by all manner of industries including the full gamut of mil itaryand civilian aviation organizations. The adoption of the process set out in ISO FDIS 31000, which isderived from the long standing and well tested process of AS/NZS 4360:2004 is to be applauded.

Having received this Industry Risk Prole the challenge for the HEMS industry is to take the next stepof developing their own unique risk framework to integrate the process into the management systemsat all levels of the industry. This will allow those governing and leading the industry to fully under-stand the risks that must be effectively and efciently managed if all the objectives of the industry areto be achieved.

This document is an excellent starting point and I congratulate those who commissioned this inde-

pendent assessment, the authors, those who participated in its development and revision and theFlight Safety Foundation for their unwavering commitment to safety and the willingness to take onthe role of custodian of the HEMS Industry Risk Prole.

Kevin W Knight AMCPRM, Hon FRMIA, FIR M (UK), LMRMIA

ChairmanInternational Standards Organiz ation (ISO) Working Group on Risk Management

Foreword


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How to use the HEMS Industry Risk ProfileThe HEMS IRP was developed for use at the national level by industry leaders, standard setters, industryassociations, industry bodies and groups that have the ability to develop, resource and implement voluntary industry wide change initiatives to reduce the risk prole of the HEMS industry. The risk

information presented in the HEMS IRP presents and assesses the identied risks and highlightsappropriate performance based risk treatments or risk reduction measures.

Many of the treatments transcend the sphere of inuence of any one individual organization such as anindividual Air Medical Program or Operator and must therefore be managed across traditional divides. While the actions proposed are largely voluntary, it is accepted that some issues raised in the IRP mayonly be resolved by regulatory or mandated action by the customers that engage or utilize HEMS.

The HEMS IRP does not identify the risks of any particular individual or group of Air Medical companiesrather it presents the systematic risks inherent in the entire industry landscape that ultimately have thepotential to induce risk at many levels of the industry.

Developing Risk Reduction Plan

This prole is based upon the assumption that there are four key ways of bringing change to the industry;

- Legislative change by Congress

- Regulatory change by the aviation, medical or state regulators

- Mandated change driven by the Customers

- Voluntary change by the industry

The HEMS IRP predominately focuses on the voluntary change that can be made by industry, yet the IRP rec-ognizes the intersection of the other three areas and can be used as an evidence based tool to inform changein these areas as well.

The true value of an industry level risk prole is not gained until an action plan is derived and commit-ted. The Industry groups listed at Annex A, upon receiving the HEMS IRP, also receive an open invita-

tion to participate in an industry wide effort to develop and implement the Risk Reduction Plan.The HEMS Industry Risk Reduction Action Plan will outline the detailed actions, tasks and activitiesdesigned to reduce risk. Each individual strategy will vary in its effectiveness, however when combined,the cumulative effect will be an overall reduction in the industry prole. The responsibility for themanagement and implementation of each treatment is assigned to an entity, association or organization.This accountability or responsibility for implementation is also indicated on the HEMS Industry RiskReduction Action Plan.

The HEMS IRP will change over timeRisk management is an iterative process. It is acknowledged that the HEMS IRP is dynamic and willchange over time to reect risk changes in the industry. This IRP provides a snapshot of the risk

prole of the HEMS industry at the time of development (January – April 2009) based upon ananalysis of the information available and accessed. As further data or information becomes availablethe risk prole can be updated. In addition to this, as risk reduction measures are completed the riskprole will reduce and the residual risk rating will be realized. It is anticipated that the HEMS IRP will be revisited every six months specically with the intent of monitoring progress of risk reductionmeasures committed to by industry.

INTRODUCTION


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Next Steps: Completing the risk management processThe prole of the HEMS industry is dynamic. In order to provide condence that the risks identiedin this IRP are being effectively addressed and managed a plan for assurance monitoring has beenoutlined. The key focus is the identication, allocation and implementation of a detailed risk reduction

plan and the associated accountabilities to ensure action or to provide assurance that action is already inprogress. Timelines and activities are subject to industry participation.

ACTIVITY DETAILS TIMELINE

Launch of HEMS IRP toindustry

Release and distributionof HEMS IRP by FARE

Development of industryresponse includingsubmission of current orproposed industry riskreduction measures

Risk reductionplanning conference

Finalization of the HEMSIndustry Risk Reduction

Action Plan Release of HEMSIndustry RiskReduction Plan

Check pointreporting

Update riskreduction plan

Report to indus-try on progress

Update HEMS IRPContinuous follow upuntil prole is reduced toan acceptable level

Launch coordinated by Flight Safety Foundation as industry custo-dian of the IRP. Technical brieng provided to the media. Registereddownloadable electronic les available at www.ightsafety.org FARE has approved a grant to fund the printing and distribution ofcopies of the HEMS IRP to the industry distribution list outlined in Annex A. Additional copies available through FARE. www.fareonline.org

An inclusive invitation is made for the full spectrum of industrystakeholders to work through the HEMS IRP and develop an individ-ual submission of those industry level risk treatment strategies thatare either already being undertaken or are willing to be undertaken,resourced and implemented by the submitting organization. A step by step guide to aide the preparation of submissions can bedownloaded from the Flight Safety Foundation website.

One authorized representative from each stakeholder group will beinvited to the inaugural risk reduction planning conference whererisk reduction strategies will be agreed to and prepared as the HEMSIndustry Risk Reduction Action Plan for presentation to industry.

A small group of representatives from the industry to review theproposed HEMS Industry Risk Reduction Action Plan. An assurance

regime for monitoring and reporting progress will be established.

Industry Risk Reduction Plan formally released to industry.

Those industry stakeholders who have taken responsibility for anindividual risk treatment strategy will provide a status report on theirprogress against the HEMS Risk Reduction Action Plan. This informa-tion will be compiled and a report card prepared for public release.

Upon receiving the progress report from the above activity, theHEMS Industry Risk Reduction Action Plan will be updated and pre-pared for presentation to the risk monitoring and assurance group.

A formal progress report will be released to industry.

As the context of the industry changes, appropriate triggers for afull update or overhaul of the HEMS IRP will be determined. Thesetriggers may include signicant progress in completion of the riskreduction measures, emergence of signicant new risks, context ofthe industry shifts signicantly or the accident prole of the industryis not visibility decreased.The Industry to continue on the six monthly cycles for the formalmanagement of risk until an acceptable risk prole is achieved.

April 20, 2009

April 30, 2009

May 1, 2009 – July 15, 2009.

August 13-14, 2009

August 25, 2009

August 31, 2009

February 10, 2010

February 15, 2009

Feb 22, 2009

As determinedOngoing

S I X

M O N T H L Y C Y C L E


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Context of the Industry Risk Profile

PART 1


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PART 1 Context of the Industry Risk Profile

1 Ira Blumen, An Analysis of HEMS Accidents and Accident Rates, 2009 NTSB Hearings into the EMS Industry, 2009

Background Air medical transportation has become a key component of healthcare in many countries throughoutthe world. Air medical transport services are particularly important in large countries where travelingtimes to hospital care may be excessive by surface vehicles or where remote communities might other-

wise be deprived of the required level of healthcare service. In addition to acting as an air ambulanceservice, aircraft are particularly important in times of national emergency or to provide support torescue and other emergency services.

While air medical services may at rst glance appear expensive compared to traditional ground ambu-lances, an examination of the cost structures and benets on an annual system wide basis demonstratesits cost effectiveness. In many cases, air medical services may be the only option and the difference be-tween life and death for the patient. In other circumstances timely, appropriate initial care may provideongoing reduced cost over the lifetime of the patient. Integrated air medical resources are therefore anessential component of contemporary Emergency Medical Services (EMS) systems.

Helicopter Emergency Medical Services (HEMS) and EMS services are provided in the United Statesthrough a multitude of relationships involving Part 135 air carriers, public entities, hospitals and EMSproviders, by both prot and not-for-prot organizations. It is estimated by the Association of Air Medi-

cal Services (AAMS) that helicopters transport 400,000 patients annually in the United States. As the medical benets of rapid transport by air medical providers have become more recognized, therehas been ongoing growth and expansion since the 1970’s with HEMS operations beginning in 1972.Recent data shows that since 1995 the number of helicopters used in the EMS industry increased byapproximately 130% to 2008. Prior to 1995, there was a similar doubling of the number of helicoptersbeing utilized within the HEMS Industry over a ten year period.

Current Safety Concerns

The National Transportation Safety Board (NTSB) notes that there were 55 EMS related accidents (fataland non-fatal) that occurred between January 2002 and January 2005 and that many of them could havebeen prevented with simple corrective actions including: oversight, ight risk evaluations, improveddispatch procedures and the incorporation of available technologies. In the last twelve months the

NTSB investigated an additional nine fatal EMS accidents which killed 35 people. The Board has alsoadded helicopter EMS safety to its “Most Wanted List” of transport safety improvements.

The recent increase in the fatal accidents has created general concern by the Air Operators, the AirMedical Programs and the broader public community. The HEMS industry is actively working on manyfronts in an attempt to identify those issues that have led to these avoidable and, hence, unacceptableaccidents. Parallel to these industry driven initiatives, the government also committed to proactivelyexamining the causes of the high accident prole. This culminated in the February 2009 NTSB PublicForum regarding Operational Safety in the Helicopter EMS Industry and an agreement by the industrythat a “call to action is required”.

Over recent years, many industries have recognized that effective management of risk allows regulators,organizations and operators to target resources strategically to meet both governance obligations, com-mercial objectives and improve levels of safety.

Risk management takes place at multiple levels. This Industry Risk Prole (IRP) provides at a strategiclevel, a description of risk for the HEMS industry as a whole. The risk management process allows


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operators within the industry to develop individual risk frameworks and risk management plans. It canalso assist Regulators to develop regulatory solutions which achieve the statutory safety outcomes whileallowing individual operators the exibility to effectively meet their corporate goals.

An Industry Risk Prole can also be a “call to action” for all parties involved in the industry. It setsout in a clear and concise document both the problems and, more importantly, the solutions that areavailable to reduce the inherent risk prole.

Commission to Develop the HEMS Industry Risk Profile

As part of the industry’s commitment to the efforts of the International Helicopter Safety Team (IHST)and the achievement of the published goal of an 80% reduction in global helicopter accidents in thenext 10 years, the industry commissioned and funded the development of the HEMS IRP.

The IRP methodology utilized is usually applied by industry regulators or those industry sectors thathave been delegated self administration by the regulator. This innovative step for the HEMS industry toadopt and utilize this methodology demonstrated a level of maturity that is not common in industriesunder the public and regulatory spotlight.

The industry recognized the need for a holistic and broader view of the systemic strategic risks that areinherent in the current national HEMS model. It was realized that a ‘different’ approach was needed andthere was great value in an industry wide risk assessment that would provide a platform for the coordi-nation of nation wide initiatives to aggressively reduce the risk prole and the associated negative trendin safety.

PurposeThe purpose of the HEMS IRP is to identify the latent and systemic issues inherent in the currentnational HEMS structure and model that have the potential to induce operational or safety risk in orderto proactively address issues that have not yet been subject to attention.

Based on the use of the Reason accident causation model, and the accepted hierarchy of layers, barriersand defenses that exist in any organizational or industry level system, the HEMS IRP focuses on thesystemic issues that exist at the strategic level of the HEMS Industry.


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Objectives 1. Identify the systemic risks inherent in the current HEMS structure that may induce operational, safety

or organizational risks taking the industry wide assessment beyond traditional analysis of historicaldata into a proactive, risk based approach.

2. Utilize a data driven, evidence based approach that leverages off the array of current and pastinvestigations, reviews, studies, papers, analysis and knowledge publicly available on the topic ofHEMS safety. These efforts have been harnessed and utilized as risk identication inputs into theHEMS IRP.

3. Provide the strategic view of industry risks in one document that can be commonly understood byall stakeholders (aviation, medical, EMS, industry, regulatory, customer and government) and usedas a focal point for dening the accountability for change.

4. Utilize an accepted methodology (risk management) that is used broadly in both corporate Americaand the international aviation community allowing a common language to be adopted that is famil-iar to the industry and regulator alike.

5. Allow industry a tool to effectively rank and prioritize efforts for risk reduction, and where the risks

are unable to be controlled by the industry itself, the IRP provides a platform for the transfer orreferral of risk to the appropriate accountable body

6. Allow the alignment of accountability, responsibility and resourcing for the management andreduction of risk at multiple levels of the industry.

7. Provide industry with opportunity to develop alternate solutions that will achieve the reduction inrisk that is expected or even demanded by the government and the community

8. To propose risk treatment strategies that are performance or outcome based solutionsrather than the traditional prescriptive recommendations that often come out of studies, reviewsor investigations

9. A platform for the coordinated management of risks across the Industry - Prioritize the identiedrisks in order of seriousness and to provide a general sense of urgency for the treatment of risks to

meet the industry’s duty of care obligations 10. Assist the HEMS Industry in meeting recommendations from the National Transportation Safety

Board (NTSB)

11. Provide an up-to-date formal document that can be used by the HEMS industry to track andmonitor implementation of risk treatment and ultimately provide effective oversight andgovernance of the Industry

12. Provide Industry Associations with a vehicle to manage governance, compliance and liability issuesby demonstrating a proactive and risk based approach to change

13. Provide a framework within which individual operators can develop their own organizational riskproles and risk management plans to effectively position or respond to industry level risks


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AssumptionsThis Industry Risk Prole was developed within the context of the following assumptions:

1. Citizens of the United States of America have the right to expect a reasonable standard ofemergency medical transportation regardless of their location within the country.

2. The current accident and fatality rate in HEMS transport is unacceptable to Industry as a whole,individual operators, regulators and the public.

3. The information provided to Aerosafe Risk Management by the HEMS Industry for the purposes ofdeveloping this industry risk prole is complete, true and correct

4. Matters of concern raised in the consultation process, which could not be substantiated or veried by other risk identication sources, were considered as perceived risk for the purposesof the prole.

5. The Industry Risk Prole will be provided to stakeholders and interested parties for use instrategic planning, business planning, reporting and other processes to ensure appropriatemonitoring and oversight.

6. Statements made during the NTSB hearing (February 2009) were regarded as stakeholderinterviews and those interviewed included in the stakeholder list.

7. Formal position papers, documents and resources lodged on the public docket for the NTSBhearing were used in the HEMS IRP literature review and included in the documentation list.

8. Formal position papers by AMOA, AAMS and HAI were taken as a representative view of themembers it represents and this data input source was used in the HEMS IRP development process –follow on discussions and surveys with individuals from these organizations augmented this initialdata input source.

9. The denition of the HEMS Industry is taken to mean the full spectrum of stakeholders involved inHEMS activities at all levels and is not simply the part 135 operators.

10. That all invited industry stakeholders will actively participate in the development of the HEMS RiskReduction Work Plan and that this plan will acknowledge the many current initiatives alreadyunderway and in progress.

11. The Aerosafe Risk Management risk proling model and methodologies revealed to the HEMSIndustry will not be used, modied or reproduced without formal consent.

12. Addresses HEMS operations in the United States of America.


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LimitationsThis Industry Risk Prole is subject to the following limitations:

1. The Industry Risk Prole is conned to rotary wing operations. However, many of the risksidentied will be common to, and useful in, the development of a broader risk prole for EMS

operations. This prole excludes xed wing air medial operations.

2. The IRP specically addresses both commercial for-prot and not-for-prot operations whichoperate under Part 135 of the Federal Aviation Regulations.

3. This IRP does not cover the full spectrum of risk and other issues associated with public use HEMSoperators (County and Police) which conduct business as private category operations under Part 91of the Federal Aviation Regulations.

4. Not every stakeholder in the industry was subject to an individual interview in preparing theHEMS IRP.

5. During the consultation phase (review and interaction with the industry on the draft risk prolemade available from February 12, 2009 to April 10, 2009) a large degree of fragmentation and differ-ing understanding of the risk management process was noted.

6. The current environment and the sensitive debate around proposed legislative change affected theability of some stakeholder groups to effectively participate in this process.

7. The risk treatment strategies listed in the HEMS IRP have not been agreed or allocated to theindustry at the time of release.

8. The HEMS Risk Reduction work plan is under development and was not sufciently developed byindustry to release concurrently with the release of the HEMS IRP.

9. The current context and structure of the HEMS industry does not lend itself to a collaboration,ready agreement or a collective responses to risk.

10. The existing regulatory regimes across aviation, healthcare and EMS are not visibly integrated.

11. The HEMS IRP does not claim to have utilized every data source available to the industry. However a

rigorous and comprehensive process has been used and as a result, an 85% condence rating in theintegrity of the data and associated prole is acknowledged.

12. The industry have actively and visibly communicated the desire for voluntary change, yet theability for the industry to implement such change has not been evaluated or assessed.

Risk CriteriaThe following criteria were developed to allow the evaluation and quantication of risks. Since risk has twocomponents, likelihood and consequence, consideration was given to issues including:

- The positions of Association of Air Medical Services, Helicopter Association International and the Air Medical Operators Association, as stated in their paper to the NTSB Hearing, February 2009,that they “maintain a position of zero tolerance for accidents in the air medical industry.” It is

implied by this criteria that all reasonable measures will be taken to ensure that accidents do nothappen and that risks are appropriately managed.

- A positive perception of the Industry by the public, families of the deceased, the media, politicians,legislatures, the Regulators and investigators is vital to the continued viability of the industry.

- A person/patient transported by a HEMS operator has the right to the same protections as anyother member of the public traveling by air transport.

- Where the person/patient transported by a HEMS operator does not have a choice of carrier, a


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higher protection or duty of care than that of the travelling public exists.

- While the safety of the patient is the most important factor to be considered, the safety of themedical personnel and other crew on board is also critically important.

- Where emerging technologies will mitigate risk at reasonable costs, they should be considered as

optional adjuncts for operational safety.

Depth of AnalysisThe following is a synopsis of the depth of analysis used to develop the HEMS Industry Risk Prole:

- Context of the profile: This Industry Risk Prole has been developed in the context of providing adetailed, data-driven analysis of the issues that affect the key objectives of the HEMS Industry. Bydening and focusing on the HEMS Industry as a single entity, this prole can provide insight intothe various elements of the Industry and how the elements interact to achieve Industry objectives.The risk prole will be developed to cover the next ten year period commencing in January 2009.

- Literature review of publicly available documentation: A comprehensive review of a large and variedrange of publicly available documents published over the past two decades was conducted.

This review contributed to the development of an understanding of the HEMS Industry from ahistorical perspective. The documentation review also provided the basis on which key industryrisk issues were identied. A total of 267 Documents were reviewed during the documentreview process.

- Stakeholder Analysis: A comprehensive stakeholder analysis was conducted in order to identifythe stakeholders within the Industry that could provide the insight into the operations, status andissues impacting the HEMS Industry. The analysis identied stakeholders from public, private andgovernment organizations, enabling the project team to conduct interviews with key industrydecision makers. A total of 161 stakeholders were identied during the initial stakeholder analysisprocess and an additional 21 stakeholders were identied in the review of the draft HEMS IRP.

- Stakeholder Interviews: Once the industry stakeholders had been identied, several decisionmakers and opinion leaders within the industry were personally interviewed in order to collect a wide variety of information, both from the medical arena and the aviation industry. During theseinterviews a signicant number of industry risk issues were identied.

- Note: In line with the risk management process, the identied stakeholders were examined andit was determined whether formal communication, consultation or interaction was needed at theidentication, review or solution development phase of work. As a matter of clarication, thestakeholder analysis determined the best match of risk identication method to each stakeholdergroup. As a result, formal interviews or surveys were not conducted on every stakeholder. Alternate risk identication methods were exercised on those remaining stakeholders.

- Collection of Risk Issues: A total of 1280 risk issues were identied from the initial risk identicationsources. During the review of the draft HEMS IRP, and additional 200+ issues were identied andcross mapped to the risks listed in the HEMS IRP. The tabulated data was updated with theseadditional inputs. The main additions or amendments were in the risk impacts, a minoradjustment in the risk calculation and some additional proposed risk treatment strategies.Culminating in the presentation of 26 industry level risks worthy of attention, the HEMS IRP was nalized within the specic context outlined above.

- Risk Identification: This risk proling methodology allows for a greater level of depth in theidentication, selection and analysis of the risk information used in the risk identication step. Ingeneral available risk data consists primarily of qualitative information. As an attempt to minimizesubjectivity, fourteen separate risk identication methods were used and the data collected fromthese sources layered and cross mapped for themes and grouping against the IRP model.


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Rationale for Analysis Methodology

The HEMS Industry is committed to providing timely, quality patient transportation throughout theUnited States. This objective carries signicant challenges considering the large landmass involved,the diverse terrain, weather conditions encountered and the complexity of the business and regulatory

models. Solutions which are appropriate and effective in highly urbanized areas may not work in ruraland isolated environments. Given such variability in mission proles, options which ensure overallsystem safety, while allowing local exibility, require evaluation.

In recent years, developments such as the Reason Model have been used in the analysis of accidentsand incidents in the aviation industry. Reason identied that accidents occur when there are multiplefailures in the various levels of defenses - “when the holes line up”. This model can also be used todesign safety systems by identifying “defenses in depth”. Analysis of “defenses in depth” allows safetyexperts to identify potential points of failure and minimize the possibility of total system failure. Riskanalysis (identication and assessment) is the tool that identies potential points of failure in theReason Model.

Defenses in Depth and the Relationship with Risk Reduction

A systems approach also allows a structured consideration of possible defenses which can be layered toprovide safe outcomes. A systems approach also has the further advantage of identifying the defenses which are necessary for overall system integrity. In locations where specic tools for risk mitigationprove ineffective or inappropriate, alternatives can be derived to manage the risk. A hierarchy ofdefenses (legislative, regulatory, mandated customer driven change and voluntary change by industry), which link directly to the risk treatment or risk reduction strategies, will be developed and presented inorder of outcome effectiveness.

Methodology: Risk Management Process

Risk Management Process

The International Standards Organization (ISO) draft standard on risk management (FDIS ISO31000)outlines the methodology and risk management process used to develop the Industry Risk Prole.The following pictorial model is consistent with FDIS ISO31000 and provides the structure to classify,present and prioritize risk information. The risk prole was developed using the following process:

INDUSTRY

STRUCTURE

& OVERSIGHT

ORGANIZATIONAL

OPERATIONAL

ADAPTED FROM REASON ACCIDENT CAUSATIONAL MODEL


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Throughout every step of the risk management process a decision is made as to whatlevel of communication or consultation is required. Over 161 stakeholders were identiedin the initial and review stages of the HEMS IRP development each possessing a differentperspective on the industry and the issues requiring attention. The opportunity for review

and comment on the draft HEMS IRP was provided to 33 different stakeholder groups. Additional resource, dedicated briengs or a workshop was held with AAMS, AHS, AMOA, AMPA, CAMTS, FAA, FARE, Flight Safety Foundation, GAO, HAI, House Aviation SubCommittee, International Helicopter Safety Team, NEMSPA, NTSB, The Joint Commission.

At this industry level, the scope, denition and context of the industry itself was requiredin order to place some boundaries around the assessment. For the purposes of the IRP,the HEMS industry includes the aviation, medical and EMS disciplines. The FAA conrmedthere were 74 Part 135 Operators approved to operate HEMS activities. The IRP excludedxed wing air medical operations and any air medical operations conducted by publicuse operators.

For Industry level risk proling 10-14 risk identication methods are normally used toextract risk issues that are then run through the risk management process. In the caseof the HEMS IRP, 14 different risk identication methods were used which included acomprehensive literature review, stakeholder analysis, interviews, environmental scan,risk dimension analysis, data analysis, causal factor analysis, cultural assessment and taskanalysis. This process produced over 1400 data input sources to the IRP process.

Using the principles of the Reason accident causation model, a layering and classicationprocess was then used to analyze the risk data. From this process, 26 industry level risks were identied. The consequence and likelihood of each of these 26 risk issues wereassessed. A semi-quantative risk analysis tool was then used to calculate the level of riskassociated with each of the 26 risks.

Building upon the risk analysis step above, the risks were then ordered and ranked fromhighest to lowest. Where more than one risk attracted the same risk rating, sub criteria wasthen applied to determine the ranking.

Multiple treatments were identied to address each risk. They vary in their scope but aredesigned to complement each other and provide a comprehensive risk response. It is recog-nized that some treatments can be undertaken by regulators while others can be addressed by various industry bodies, the customer that requests the HEMS service or individual operatorsthemselves. A residual risk calculation was then made in light of the effectiveness of the risktreatment strategy listed. The risk treatment strategies listed in the HEMS IRP are performanceor outcome based. These solutions require actual tasks to be derived, allocated and resourcedin order to produce the HEMS Industry Risk Reduction Work Plan. It is recognized that manyactivities are already underway, this nal step of the risk process calls for these and futureinitiatives to be captured and presented in this joint industry assurance and accountability tool.

It is to be noted that the context, the risks and their signicance will change over time. TheHEMS IRP is a dynamic document and reects the assessment of the risk prole at a pointin time. The most critical aspect of the monitor and review stage of the risk process is thefollow through and implementation of the risk treatment strategies. Ultimately it is theseactions that will reduce the risk.

Analysethe Risks

Evaluatethe Risks

Treatthe Risks

Monitorand Review

Communication& Consultation

Establishthe Context

Identifythe Risks

International Risk Management Standard (ISO31000)*


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Methodology: Industry Risk Profile ModelThe industry risk prole model is used to classify and catalogue the risks identied in the HEMS IRP.This structure is used across the aviation industry and groups the issues into categories that generallyguide the level of action required. The rst three elements of the IRP model (oversight, compliance and

assurance) combine to form the governance of the industry.From here, other important elements are then depicted. It is to be noted, that each of these areas can befurther examined and assessed to a greater level of depth. For example the efforts of the InternationalHelicopter Safety Team’s JSAT, JSIT and subsequent HEMS Safety Committee or the effor ts of the NTSBindividual accident investigation process would be the next layer of depth provided in the safety proleelement of the HEMS IRP model.

HEMSINDUSTRY

RISK PROFILE

OVERSIGHT

MODEL

COMPLIANCE

REGIME

ASSURANCE

MODEL

OPERATOR

PROFILE

ACTIVITY

PROFILE

AIRCRAFT

CAPABILITY

PROFILE

INDUSTRY

OPERATING

ENVIRONMENT

PASSENGER

& PARTICIPANT

PROFILE

SYSTEMS

PROFILE

SAFETY

PROFILE

© Aerosafe 2008


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OVERSIGHT MODEL:

The governance regime that exists within theindustry in all facets at the highest level. In thecase of the HEMS industry this includes gover-

nance for the aviation, medical and emergencymanagement services aspects. This element ofthe IRP model is closely aligned with the compli-ance and assurance elements.

COMPLIANCE REGIME:

Considers the statutory and regulatory andframework in which the industry operates. Thecompliance element, along with the assuranceelement is a sub component of the overall over-sight model. At the industry risk proling level,these two pieces are addressed individually.

ASSURANCE MODEL:

What level of assurance is provided and to what level of depth? These aspects are exploredin the assurance element of the Industry RiskProle. The objective of assurance is toprovide ‘condence’.

OPERATOR PROFILE:

The operator prole looks at the composition,structure and models of the operator group within the industry. A greater level of depthcan be provided to this element if required byconducting an individual risk prole of eachoperator within the industry sector. Individualoperator risk proles are normally undertakenby the regulator as part of the regulators routinesurveillance and intervention regime.

ACTIVITY PROFILE:

This element of the Industry Risk Prole

examines the range of operational activities un-dertaken by the industry. In relation to the HEMSindustry risk prole the activity prole includesinter facility transfers, scene ights, specialityteam transports, training, maintenance, commu-nication functions to name a few.

AIRCRAFT CAPABILITY PROFILE:

This element looks at the aircraft capability,technology and equipment.

INDUSTRY OPERATINGENVIRONMENT:

The industry operating environment includes theoverall setting and landscape of the environmentin which the industry operates in its entirety.

PASSENGER & PARTICIPANT PROFILE:

Considers the demographics of the passengers orparticipants who are involved in the activity. Thiselement excludes aircrew or employees of theaviation operator which is covered in theoperator prole.

SYSTEMS PROFILE:

The denition and maturity of the various man-agement systems available and utilized within theindustry are covered in the scope of this elementof the Industry Risk Prole. This includes butis not limited to management systems, businesssystems, information systems and safetymanagement systems.

SAFETY PROFILE:

This element of the Industry Risk Prole takes

into account the incident and accident statisticsand the overall safety prole of the industry sec-tor. Much of the information and data covered inthis element is historical in nature.


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Summation of Results

PART 2


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PART 2 Summation of Results

VERYHIGH

(1)

VERYHIGH

(1)

VERYHIGH

(1)

The results of the HEMS IRP can be examined in

the following ways:

Risks presented by Risk Ranking (Pages 24-28)

The tabulated data indicated below in table 1 presents the risks from highest to lowest. For those risksthat have the same number (see numbering system in the far right hand column) this indicates the riskhas been quantied at the same level. Where this is the case, sub criteria have been used to rank therisks within this classication. The summation of results in this presentation format only depicts the riskassessment, being the identication and quantication of risk and does not list any solutions to reducethe risk. This information is provided as a snapshot of the issues from highest to lowest and is to beread in association with Part 3.

Risks presented against risk matrix (Page 29)

Risk is a measure of consequence and likelihood, the presentation of results against the risk matrixprovide a visual representation of the risks scatter plot. The two matrix provide a visual representationof the ‘before’ and ‘after’ risk treatment. The second being referred to as residual risk, or the risk that is

remaining after full implementation of risk reduction measures are achieved.

Risks presented against the IRP Model Categories (Pages 32-58)

Part 3 of the HEMS IRP provides the risk information catalogued against the elements of the IndustryRisk Proling model. This functional grouping allows the reader to examine risks in the related cat-egory. The information is presented in this fashion, as it is often the case that high level stakeholdersare looking for information against these classication elements (such as governance, aircraft capability,safety etc).

TABLE 1 Risks Presented by Risk Ranking

NUMBER RISKS RISK LEVEL

1 Risks associated with the lack of or limited denition of the national EMSstructure or governance framework for HEMS. The current regime wasnot purposefully designed and has evolved over the past twenty yearsto the current regime in the absence of a framework.(Risk Reference 1 HEMS IRP)

2 The risk that the current medical reimbursement model (primary payermodel) is no longer adequate to provide the appropriate level of

nancial coverage for either the current operating costs of the serviceor the impending upgrade of capability required through the additionof technology.(Risk Reference 15 HEMS IRP)

3 The risks associated with the complexity, non alignment and lackof clarity around the roles and scope of federal, state and countyagencies involved in oversight of the HEMS industry.(Risk Reference 3 HEMS IRP)


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VERYHIGH

(2)

VERYHIGH

(2)

VERYHIGH

(2)

VERYHIGH

(2)

VERYHIGH

(3)

HIGH

(4)

4 Cumulative risk associated with the variability among States over licensingrequirements and standards for HEMS programs, as well as inconsis-tent interpretation of the States’ authority to determine a need for, andlocation of, new or existing HEMS programs and bases, has produced widespread variability in quality and safety in HEMS transport.(Risk Reference 8 HEMS IRP)

5 There are signicant risk entrenched within the current tasking continuumused for allocating HEMS air medical assets. This inconsistency andlack of standardization in the tasking continuum spans the followingprocess ow that includes:

- The evaluation of the patient need for care- The necessity of utilization of an aircraft for the passenger transport- The requesting agency- The tasking process including the

allocation of the task to a specic resource- The acceptance of a task by a HEMS operator- Through to operational control once the task has been

accepted and undertaken(Risk Reference 16 HEMS IRP)

6 The industry has many different business models that often havecompeting objectives and interests. The diversity in this industrystructure has the potential to induce industry and organizational levelcompetition and growth in turn increasing the operational and safetyrisk exposure of the industry.(Risk Reference 10 HEMS IRP)

7 Safety management systems are only starting to be introduced in theHEMS industry are not yet sufciently mature to manage the level anddepth of change required in the safety philosophies, processes andpractices required.(Risk Reference 21 HEMS IRP)

8 The industry does not have one accredited agency that provides collectivedenition, oversight or monitoring for the combined aviation, health-

care and emergency management functions that shape the HEMS (orbroader air medical) industry.(Risk Reference 2 HEMS IRP)

9 The broad spectrum of stakeholders to the HEMS industry are notaware of the entire industry risk prole leading to an inability forthe industry to effectively identify, analyze and reduce the risks in aorchestrated and cohesive way.(Risk Reference 4 HEMS IRP)




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HIGH

(4)

HIGH

(4)

HIGH

(4)

HIGH

(5)

HIGH

(6)

10 The lack of National Airspace System and other infrastructure constraints in theairspace where HEMS operate dictate the conditions for the operationalprole for ight removing the option to HEMS Operators to y IFR.(Risk Reference 17 HEMS IRP)

11 The complexity of the oversight, compliance and regulatory regimesdoes not provide the structure required for the industry to have aninclusive assurance regime or program of audits, accreditation andchecking leading to an inability to provide condence that theindustry is being appropriately managed.(Risk Reference 7 HEMS IRP)

12 Owing to the nature of the task proles conducted in HEMS and theclose working relationship the aircrew have with medical personnelinvolved in the tasks, there is increased blurring of lines of role andresponsibility in respect to the medical personnel contribution to safeoperation of the aircraft. This risk of ambiguity is increased with medi-cal personnel involvement in NVG operations, passenger brieng, taskbrieng, loading and unloading of aircraft, operational risk manage-ment assessments and crew brieng and debrieng processes.(Risk Reference 20 HEMS IRP)

13 The risks associated with the lack of development of a tangible safetyculture that truly understands risk and the management of risk.

(Risk Reference 26 HEMS IRP)

14 There is inherent complexity in the compliance regime used to govern theHEMS industry which is confusing and dictated by a myriad of non-related stakeholders leading to an increased chance that HEMS opera-tors are non-compliant. This risk is induced by a number offactors that includes:- There are three distinct disciplines that all set the compliance

regime that affects the HEMS industry (aviation, healthcare andemergency services)

- The overlap or interface between these compliance regimes has notbeen clearly mapped out or is not easily accessible

-

There is no agreed inter-discipline hierarchy for regulation, policyor standards of either the national ascending hierarchy(Risk Reference 6 HEMS IRP)




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HIGH

(6)

HIGH

(6)

HIGH

(7)

HIGH

(7)

HIGH

(7)

HIGH

(8)

15 Risk that the current denition and scope of the industry is not well denedleading to limitations in the ability or appropriate agencies and stake-holders to effectively govern their aspect of the industry. The key riskinduced by this issue is the limitations on the ability for a complete andindustry wide data driven national solution to manage the landscape tobe identied, coordinated and effectively implemented.(Risk Reference 9 HEMS IRP)

16 The current safety analysis and monitoring of the HEMS industry isnot data driven leading to an inability for the Regulator or the Industryitself to have an accurate picture of real safety picture.(Risk Reference 24 HEMS IRP)

17 The operating environment and the associated infrastructure and standardindustry practices for the two routine task proles (inter-facility & sceneights) is not sufciently designed at the HEMS System level, leading to theincreased variance and application of ight proles, safety standards andsafety risk exposure to patient, aircraft, aircraft and the public.(Risk Reference 12 HEMS IRP)

18 Lack of integration and alignment of accountability, responsibility andresourcing for the standardization of helipad operations in the inter facil-ity environment by hospitals, impacting upon operation, maintenance

and continuous hazard management of helipads in the inter-facility envi-ronment by hospitals, primary HEMS operator and other helipad users.(Risk Reference 18 HEMS IRP)

19 The current training regime for a high percentage of the HEMS industry doesnot employ the use of simulators and advanced training methods broadlyused in other parts of the aviation industry predominately due to cost.(Risk Reference 25 HEMS IRP)

20 The current regulatory philosophy combined with the nancial risksinduced by the funding model of the industry engender a mind setor culture in the HEMS industry to only meet minimum prescribed

standards rather than managing risks in the operation through theimplementation of better practices.(Risk Reference 5 HEMS IRP)




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HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(9)

21 There is no activity or task prole denition set for the HEMS industrysector making it difcult to oversee the risks associated with the vari-ous task proles at an industry, national or State level. In addition tothis, changes to the trends in industry activities are not easily identiedor monitored and the platform for data driven monitoring does notexist to the level of maturity required to capitalize.(Risk Reference 11 HEMS IRP)

22 The risk that the HEMS industry does not consistently identify, adopt,utilize and maximize aircraft technology available in the aviationindustry to enhance safety parameters leading to a decrease in the riskof an accident or incident.(Risk Reference 13 HEMS IRP)

23 The risk associated with the inability to effectively resource andmanage the operational, technical and cultural change related to theintroduction of new technology into service.(Risk Reference 14 HEMS IRP)

24 The prole of the passenger or participant (patient and medical crew)prole in the HEMS industry differs signicantly from that of othersectors of the aviation community by virtue of the fact that the patientdoes not have a choice in the operator allocated to undertake

their transport.(Risk Reference 19 HEMS IRP)

25 Aviation and medical safety management systems are not integrated ata compliance or policy level leading to incoherent, conicting or com-peting priorities or practices which may stie the effective introductionof the SMS within the HEMS Industry.(Risk Reference 22 HEMS IRP)

26 Lack of effective and sound implementation of operational controlarrangements within the HEMS industry leading to the increasedincreases the risk of poor operational decisions and misalignment of

accountability and responsibility for ight operations.(Risk Reference 23 HEMS IRP)




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LIKELIHOOD

LIKELIHOOD

CERTAIN LIKELY POSSIBLE UNLIKELY

CERTAIN LIKELY POSSIBLE UNLIKELY

TABLE 2 Risks Presented against Risk Matrix

TABLE 2.A: BEFORE RISK TREATMENT

TABLE 2.B: AFTER RISK TREATMENT. RESIDUAL RISK

EXTREME

CRITICAL

MAJOR

MINOR

EXTREME

CRITICAL

MAJOR

MINOR

C O N S E Q U E N C E

C O N S E Q U E N

C E

VERYHIGH

(1)

VERYHIGH

(1)

VERYHIGH

(3)

VERYHIGH

(3)

VERYHIGH

(2)

VERYHIGH

(2)

HIGH(6)

HIGH(6)

MEDIUM(11)

MEDIUM(11)

LOW (15)

LOW (15)

HIGH(5)

HIGH(5)

HIGH(10)

HIGH(10)

HIGH(8)

HIGH

(8)

HIGH(4)

HIGH

(4)

HIGH(7)

HIGH(7)

MEDIUM(13)

MEDIUM(13)

MEDIUM(14)

MEDIUM(14)

LOW(16)

LOW(16)

HIGH(9)

HIGH(9)

MEDIUM(12)

MEDIUM

(12)


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Industry Risk Profile Tabulated Data

PART 3

How to Read Tabulated DataPart 3 of the HEMS IRP is a technical document which has been written to provide the in-depth iden-tication, analysis and proposed management strategies to treat the risk. When reading the tabulated

data, the contents are to be read from left to right. These risks are not ordered in priority from highestto lowest, but rather are grouped and classied against the IRP Model elements outlined on page 20.The table sub heading at the top of each page in the blue bar reects the relevant IRP model elementfor each risk.

Each page of the tabulated data contains explicit, in depth information. The far left column labelled“Description of the Risk” provides an overview of the risk statement. It is to be noted that these risksstatements are worded as risks (the chance something could happen - not the certainty that it is hap-pening) to this end the risk statement is to be read in concert with the likelihood column for that itemfor a complete picture of the risk.

The column to the right of the Risk Description is the impact that that risk may have on the HEMSIndustry. These dot points are potential consequences written long hand and are to be read in concert with the ‘Consequence” column in the risk assessment component of the table. This consequence rating

is the semi-quantative assessment of the word picture outlined in the “Impact” column. In essence thesetwo columns indicate one and the same thing using different language and methods.

Risk level is calculated by multiplying consequence and the likelihood on a two dimensional matrix.The risk level is indicated by both a word e.g. “High” and a number e.g.”(5)”. This number correlates tothe placement on the matrix as indicated on page 29 given each risk level spans a number of boxes.

The most critical aspect to the whole tabulated data and the IRP itself is the identication, resourcingand implementation of risk reduction measures known as “Risk Treatment Strategies”. For the purposesof this IRP, the risk treatment strategies listed in this tabulated data are “Performance or Outcomebased” and are not specic tasks allocated to any one group in industry. These reduction measuresneed to be further developed into actual tasks that can be implemented, tracked and measured. Thisinformation will be held in the HEMS Industry Risk Reduction Action Plan.

The residual risk rating uses this same process as the risk assessment step while taking into accountthe forecast of the risk level calculation (of both consequence and likelihood) once the proposed set oftreatments has been implemented. The residual risk can only be claimed by the industry once the treat-ments have been allocated, resourced and completed. A progress report against the implementationshould be undertaken regularly to track a downward motion of the risk prole.

The far right hand column labelled “Priority” provided an indication of where that itemized risk falls inthe risk ranking from 1-26.


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34/6434

T h e r i s k s a s s o c i a t e d

w i t h t h e c o m p l e x i t y ,

n o n a l i g n m e n t a n d

l a c k o f c l a r i t y a r o u n d

t h e r o l e s a n d s c o p e

o f f e d e r a l , s t a t e a n d

c o u n t y a g e n c i e s

i n v o l v e d i n o v e r s i g h t

o f t h e H E M S i n d u s t r y

- I n c o n s i s t e n c y w i t h t h e c r i t e r i a a n d p r o t o c o l s

t h a t d i c t a t e t h e u s e o f H E M S a s s e t s

- C h a l l e n g e s f o r t h e i n d u s t r y i n m a p p i n g o u t

t h e r e q u i r e m e n t s t h a t t h e y s h o u l d e i t h e r b e

c o m p l y i n g w i t h o r s t r i v i n g t o a c h i e v e

- L a c k

o f c l a r i t y a r o u n d t h a t b o d y o r

a g e n

c y i s t r u l y a c c o u n t a b l e

- N o s i n g l e r e g u l a t o r y b o d y h a s r e s p o n s i b i l i t y

f o r o

v e r s i g h t i n g t h e E M S s y s t e m a s a w h o l e

- C o n i c t i n g r e g u l a t o r y p r i o r i t i e s m a y p l a c e o p e r a t o r s i n a

p o s i t i o n w h e r e t h e y m a k e d e c i s i o n s t h a t a r e n

o t o p t i m a l

f o r e

i t h e r t h e a v i a t i o n o r m e d i c a l a r e a s o f t h e

s e c t o r

- R e g u

l a t o r s c a n m a k e i n d e p e n d e n t d e c i s i o n s w h i c h

m a y

c o m p r o m i s e s a f e t y i n t h e o t h e r a r e a

- T h e s c o p e a n d d e n i t i o n o f t h e i n d u s t r y r e m a i n s

u n c l e a r l e a d i n g t o i n a b i l i t y t o i m p l e m e n t a n

e f f e c

t i v e n a t i o n a l g o v e r n a n c e r e g i m e

- E c o n

o m i c c h a l l e n g e s a n d p o t e n t i a l c h a n g e s t o F e d e r a l ,

S t a t e

a n d p r i v a t e i n s u r a n c e r e i m b u r s e m e n t r e g i m e s

- U n d e r t a k e a d e t a i l e d a n a l y s i s o f a l l b

o d i e s

w i t h i n t h e U S A t h a t h a v e s o m e l e v e l

o f

a c c o u n t a b i l i t y o r r e s p o n s i b i l i t y f o r t h

e

r e g u l a t o r y a s p e c t s o f t h e H E M S s y s t e m i n

o r d e r t o d e v e l o p a c e n t r a l i z e d s t a k e h

o l d e r

d a t a b a s e a n d r e f e r e n c e p o i n t f o r c h a

n g e

- C l a r i f y a n d p u b l i s h t h e d e n i t i o n o f

r o l e s o f t h e v a r i o u s s t a k e h o l d e r s

- D e s i g n n a t i o n a l l e v e l p e r f o r m a n c e

b a s e d r e q u i r e m e n t s f o r n a t i o n a l

u s e n o t i n g t h e n e e d f o r c o n s i s t e n t

i m p l e m e n t a t i o n a t t h e S t a t e l e v e l

- A s p a r t o f t h e k e y i n d u s t r y a n d r e g u l a t o r y

b o d y t a s k f o r c e i n 1 a b o v e , e s t a b l i s h

w o r k i n g g r o u p t o d e v e l o p a n i n t e g r a t e d

o v e r s i g h t m o d e l f o r H E M S t h a t t a k e s

i n t o a c c o u n t t h e l e g a l j u r i s d i c t i o n a n d

a c c o u n t a b i l i t i e s o f t h e v a r i o u s s t a k e h o l d e r s .

- D e v e l o p o p t i o n s t o r e s o l v e t h e l a c k o f c l a r i t y

a r o u n d t h o s e a r e a s t h a t c r o s s t h e b o u n d s o f

b o t h f e d e r a l a n d s t a t e o v e r s i g h t r e g i m e s .

- D e n e t h e l e g i s l a t o r , r e g u l a t o r , c u s t o

m e r

a n d i n d u s t r y f o r t h e a v i a t i o n , m e d i c a

l a n d

e m e r g e n c y s e r v i c e s a s p e c t s o f H E M S

- O n c e t h e m e d i c a l r e g u l a t o r i s l o c a t e d ,

d e v e l o p a n d s e t m i n i m u m s t a n d a r d s

f o r a i r a m b u l a n c e m e d i c a l c a r e

- I m p l e m e n t t r e a t m e n t s f r o m n u m b e r

1 a n d 2

S e r i a l N o . 3

D E S C R I P T I O N

I M P A

C T O F T H E R I S K O N

R I S K

R I S K

T R E A T M E N T

R E S I D U A L

O F R I S K

T H E H E M S I N D U S T R Y

A S S E S S M E N T

S T R A T E G Y

R A N K I N G

RISK LEVEL VERY HIGH (1)

LIKELIHOOD: CERTAIN

CONSEQUENCE: EXTREME

PRIORITY: 3

RESIDUAL RISK: MEDIUM (11)


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T h e c u r r e n t r e g u l a t o r y

p h i l o s o p h y c o m b i n e d

w i t h t h e n a n c i a l

r i s k s i n d u c e d b y t h e

f u n d i n g m o d e l o f t h e

i n d u s t r y e n g e n d e r

a m i n d s e t o r

c u l t u r e i n t h e H E M S

i n d u s t r y t o o n l y m e e t

m i n i m u m p r e s c r i b e d

s t a n d a r d s r a t h e r t h a n

m a n a g i n g r i s k s i n t h e

o p e r a t i o n t h r o u g h

t h e i m p l e m e n t a t i o n

o f b e t t e r p r a c t i c e s .

- P r e s c r i p t i v e r e g u l a t o r y r e g i m e s p r o v i d e d e t a i l e d

d e s c r i p t i o n s o f h o w c o m p l i a n c e m u s t b e a c h i e v e d

r a t h e

r t h a n p r o v i d i n g o p p o r t u n i t i e s f o r m e e t i n g

t h e r e g u l a t i o n t h r o u g h a p p r o p r i a t e a c t i o n s t h a t a r e

s p e c i c a n d a c h i e v a b l e t o i n d i v i d u a l o p e r a t o r

s

- T h e y

l i m i t t h e a b i l i t y o f o p e r a t o r s t o i m p l e m e

n t e f c i e n t

s y s t e

m s t o m e e t t h e s a f e t y i n t e n t o f t h e r e g u l a

t i o n s

- O p e r a t o r s m a y c o n d u c t V F R i g h t s d u e

t o l i m

i t a t i o n s i n t h e r e g u l a t i o n s

- O p e r a t o r s m a y n o t i m p l e m e n t r e q u i r e d c h a n g

e s

d u e t o d e l a y s i n u p d a t i n g r e g u l a t i o n s

- O p e r a t o r s m a y i n c u r c o m p l i a n c e c o s t s f o r

a c t i o

n s w h i c h h a v e l i m i t e d s a f e t y v a l u e

- I n c r e

a s e s t h e p r a c t i c e w i t h i n i n d u s t r y o f w a i t i n g

f o r p

r e s c r i p t i v e r e g u l a t i o n s t o b e r e l e a s e d r a t h

e r

t h a n

t h a t t a k i n g a p r o a c t i v e b e t t e r p r a c t i c e s t a n c e

- I n d u s t r y t o d e v e l o p a n d a d o p t a n a c t i o n

a g e n d a t o i m p l e m e n t v o l u n t a r y c h a n

g e

t o a d d r e s s t h e k e y r i s k a r e a s t h e i n d u

s t r y

i s i n a p o s i t i o n t o c o n t r o l a n d i n u e n

c e

- I n d u s t r y t o d e v e l o p o r r e c o g n i z e b e t t e r

p r a c t i c e s t a n d a r d s ( c o m m u n i t y p r a c t i c e s ) t h a t

e x c e e d t h e m i n i m u m r e g u l a t o r y c o m

p l i a n c e

- E n c o u r a g e a p e r f o r m a n c e b a s e d

p h i l o s o p h y t o b e a d o p t e d f o r t h e

s p e c t r u m o f n e w d e v e l o p e d r e g u l a t i o n s

p e r t a i n i n g t o t h e H E M S I n d u s t r y

- I m p l e m e n t a n e d u c a t i o n c a m p a i g n a

c r o s s

t h e i n d u s t r y o n t h e p u r p o s e ,

b e n e t

a n d

u s a g e o f p e r f o r m a n c e b a s e d r e g u l a t i o n

- I m p l e m e n t a n e x e c u t i v e l e a d e r s h i p p

r o g r a m

f o r t h e c u s t o m e r s ( h o s p i t a l e x e c u t i v e

s , E M S

p e r s o n n e l a n d P a r t 1 3 5 e x e c u t i v e ) o n t h e

n a t u r e , r o l e a n d r e s p o n s i b i l i t i e s a s s o c i a t e d

w i t h p e r f o r m a n c e b a s e d r e g u l a t i o n

- F o r m a l l y s h o w c a s e b e t t e r p r a c t i c e

m o d e l s w i t h a f o c u s o f s h i f t i n g t h e

b a s e m i n d s e t a n d c u l t u r e

S e r i a l N o . 5

C O M

P L I A N C E R E G I M E

D E S C R I P T I O N

I M P A

C T O F T H E R I S K O N

R I S K

R I S K

T R E A T M E N T

R E S I D U A L

O F R I S K

T H E H E M S I N D U S T R Y

A S S E S S M E N T

S T R A T E G Y

R A N K I N G

RISK LEVEL HIGH (8)

LIKELIHOOD: POSSIBLE

CONSEQUENCE: CRITICAL

PRIORITY: 20

RESIDUAL RISK: MEDIUM (12)


37/64


38/6438

T h e c o m p l e x i t y o f t h e

o v e r s i g h t , c o m p l i a n c e

a n d r e g u l a t o r y r e g i m e s

d o e s n o t p r o v i d e t h e

s t r u c t u r e r e q u i r e d f o r

t h e i n d u s t r y t o h a v e

a n i n c l u s i v e a s s u r a n c e

r e g i m e o r p r o g r a m o f

a u d i t s , a c c r e d i t a t i o n

a n d c h e c k i n g l e a d i n g

t o a n i n a b i l i t y t o p r o -

v i d e c o n d e n c e t h a t

t h e i n d u s t r y i s b e i n g

a p p r o p r i a t e l y m a n a g e d

- T h e a u d i t i n g a n �