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Helicopter Emergency Medical Services (HEMS)
Industry Risk Profile
APRIL 2009
About the HEMS Industry Risk Profile An industry risk profile (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 definition of the context of the industry and the context of the risk profile, identification of risk issues, their associated impacts, the risk rating and presents proposed high level treatment strategies the associated residual risk and the risk 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.flightsafety.org
Flight Safety Foundation is an independent, nonprofit, international organization engaged in research, auditing, education, advocacy and publishing to improve aviation safety.
The Foundation’s mission is to pursue the continuous improvement of global aviation safety and the prevention of accidents.
The Foundation’s objectives are to:- Pursue the active involvement and participation of the
diverse 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, which provides risk management services, support and tailored solutions to aviation compa-nies around the world. With offices in North America, Australia, India, China and New Zealand, Aerosafe is recognized as an international leader in this important field. The Aerosafe Group has been invited to set standards with aviation regulators, industry groups and companies alike and operates at the operational, enterprise, sector and industry 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 2001 to support charitable, scientific 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-Medical Research & Education (FARE) is a non profit 501 (c) (3) charity serving the international air-medical community through: - supporting essential air-medical and critical-care transport research and
education 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 financial 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
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 Profile
© Copyright Aerosafe Risk Management Inc, April 2009
This document has been developed by Aerosafe Risk Management Inc (Aerosafe) in response to a specific body of work that was commissioned and funded by industry. The background intellectual property expressed through the methodologies, models, copyright, patent and trade secrets used to produce the Industry Risk Profile 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 Foundation to 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 Helicopter Textron and the subsequent licensing agreement with the Flight Safety Foundation.
While the author and publisher have taken reasonable precaution and have made reasonable efforts to ensure accuracy of material contained in this report, Aerosafe does not guarantee that this publication is without flaw of any kind. The authors and publisher makes no warranties, express or implied, with respect to 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.
IntRoductIon: Managing Risk in the HEMS IndustryForeword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
How to use the HEMS Industry Risk Profile (IRP) . . . . . . . . . . . . . 8
Next steps: Completing the risk management process. . . . . . . . . . 9
PARt 1: context of the Industry Risk Profile . . . . . . . . . . . . . . . . 11Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . 23Summation 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
7
The Helicopter Emergency Medical Services (HEMS) industry is to be congratulated for taking a leadership role in developing an industry approach to the management of risk in the vital area of air medical transportation.
Aviation has a long and proud history of addressing and managing risk, but the very nature of HEMS calls for new and innovative ways of ensuring that risk, in all its forms, is subjected to a rigorous process 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 HEMS industry, the industry’s objectives. This Industry Risk Profile is the starting point on the journey of addressing 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 Profile has many years of practical application throughout the world by all manner of industries including the full gamut of military and civilian aviation organizations. The adoption of the process set out in ISO FDIS 31000, which is derived from the long standing and well tested process of AS/NZS 4360:2004 is to be applauded.
Having received this Industry Risk Profile the challenge for the HEMS industry is to take the next step of developing their own unique risk framework to integrate the process into the management systems at 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 efficiently managed if all the objectives of the industry are to 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 the Flight Safety Foundation for their unwavering commitment to safety and the willingness to take on the role of custodian of the HEMS Industry Risk Profile.
Kevin W Knight AM CPRM, Hon FRMIA, FIRM (UK), LMRMIA
Chairman International Standards Organization (ISO) Working Group on Risk Management
Foreword
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How to use the HEMS Industry Risk Profile The HEMS IRP was developed for use at the national level by industry leaders, standard setters, industry associations, industry bodies and groups that have the ability to develop, resource and implement voluntary industry wide change initiatives to reduce the risk profile of the HEMS industry. The risk information presented in the HEMS IRP presents and assesses the identified risks and highlights appropriate performance based risk treatments or risk reduction measures.
Many of the treatments transcend the sphere of influence of any one individual organization such as an individual 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 may only 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 companies rather it presents the systematic risks inherent in the entire industry landscape that ultimately have the potential to induce risk at many levels of the industry.
developing Risk Reduction PlanThis profile 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 change in these areas as well.
The true value of an industry level risk profile 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 activities designed 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 profile. The responsibility for the management 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 Risk Reduction Action Plan.
the HEMS IRP will change over time Risk management is an iterative process. It is acknowledged that the HEMS IRP is dynamic and will change over time to reflect risk changes in the industry. This IRP provides a snapshot of the risk profile of the HEMS industry at the time of development (January – April 2009) based upon an analysis of the information available and accessed. As further data or information becomes available the risk profile can be updated. In addition to this, as risk reduction measures are completed the risk profile will reduce and the residual risk rating will be realized. It is anticipated that the HEMS IRP will be revisited every six months specifically with the intent of monitoring progress of risk reduction measures committed to by industry.
IntRoductIon
9
next Steps: completing the risk management process The profile of the HEMS industry is dynamic. In order to provide confidence that the risks identified in this IRP are being effectively addressed and managed a plan for assurance monitoring has been outlined. The key focus is the identification, allocation and implementation of a detailed risk reduction plan and the associated accountabilities to ensure action or to provide assurance that action is already in progress. Timelines and activities are subject to industry participation.
ACtIvIty DEtAIlS tIMElInE
Launch of HEMS IRP to industry Release and distribution of HEMS IRP by FARE
Development of industry response including submission of current or proposed industry risk reduction measures Risk reduction planning conference Finalization of the HEMS Industry Risk Reduction Action Plan Release of HEMS Industry Risk Reduction Plan
Check point reporting
Update risk reduction plan
Report to indus-try on progress
Update HEMS IRP Continuous follow up until profile is reduced to an acceptable level
Launch coordinated by Flight Safety Foundation as industry custo-dian of the IRP. Technical briefing provided to the media. Registered downloadable electronic files available at www.flightsafety.org FARE has approved a grant to fund the printing and distribution of copies 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 industry stakeholders to work through the HEMS IRP and develop an individ-ual submission of those industry level risk treatment strategies that are 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 be downloaded from the Flight Safety Foundation website. One authorized representative from each stakeholder group will be invited to the inaugural risk reduction planning conference where risk reduction strategies will be agreed to and prepared as the HEMS Industry Risk Reduction Action Plan for presentation to industry. A small group of representatives from the industry to review the proposed 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 an individual risk treatment strategy will provide a status report on their progress 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, the HEMS 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 a full update or overhaul of the HEMS IRP will be determined. These triggers may include significant progress in completion of the risk reduction measures, emergence of significant new risks, context of the industry shifts significantly or the accident profile of the industry is not visibility decreased. The Industry to continue on the six monthly cycles for the formal management of risk until an acceptable risk profile 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 determined Ongoing
SIx
MO
nt
HLy
Cy
CLe
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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 throughout the world. Air medical transport services are particularly important in large countries where traveling times 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 ambulance service, aircraft are particularly important in times of national emergency or to provide support to rescue and other emergency services.
While air medical services may at first glance appear expensive compared to traditional ground ambu-lances, an examination of the cost structures and benefits on an annual system wide basis demonstrates its 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 provide ongoing reduced cost over the lifetime of the patient. Integrated air medical resources are therefore an essential component of contemporary Emergency Medical Services (EMS) systems.
Helicopter Emergency Medical Services (HEMS) and EMS services are provided in the United States through a multitude of relationships involving Part 135 air carriers, public entities, hospitals and EMS providers, by both profit and not-for-profit 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 benefits of rapid transport by air medical providers have become more recognized, there has 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 by approximately 130% to 2008. Prior to 1995, there was a similar doubling of the number of helicopters being utilized within the HEMS Industry over a ten year period.
Current Safety ConcernsThe National Transportation Safety Board (NTSB) notes that there were 55 EMS related accidents (fatal and non-fatal) that occurred between January 2002 and January 2005 and that many of them could have been prevented with simple corrective actions including: oversight, flight risk evaluations, improved dispatch 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 also added 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 Air Medical Programs and the broader public community. The HEMS industry is actively working on many fronts in an attempt to identify those issues that have led to these avoidable and, hence, unacceptable accidents. Parallel to these industry driven initiatives, the government also committed to proactively examining the causes of the high accident profile. This culminated in the February 2009 NTSB Public Forum regarding Operational Safety in the Helicopter EMS Industry and an agreement by the industry that 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 Profile (IRP) provides at a strategic level, 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 can also assist Regulators to develop regulatory solutions which achieve the statutory safety outcomes while allowing individual operators the flexibility to effectively meet their corporate goals.
An Industry Risk Profile can also be a “call to action” for all parties involved in the industry. It sets out in a clear and concise document both the problems and, more importantly, the solutions that are available to reduce the inherent risk profile.
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 the next 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 that have been delegated self administration by the regulator. This innovative step for the HEMS industry to adopt and utilize this methodology demonstrated a level of maturity that is not common in industries under the public and regulatory spotlight.
The industry recognized the need for a holistic and broader view of the systemic strategic risks that are inherent in the current national HEMS model. It was realized that a ‘different’ approach was needed and there 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 profile and the associated negative trend in safety.
PurposeThe purpose of the HEMS IRP is to identify the latent and systemic issues inherent in the current national HEMS structure and model that have the potential to induce operational or safety risk in order to 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, barriers and defenses that exist in any organizational or industry level system, the HEMS IRP focuses on the systemic issues that exist at the strategic level of the HEMS Industry.
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PARt 1 context of the Industry Risk Profile
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 historical data into a proactive, risk based approach.
2. Utilize a data driven, evidence based approach that leverages off the array of current and past investigations, reviews, studies, papers, analysis and knowledge publicly available on the topic of HEMS safety. These efforts have been harnessed and utilized as risk identification inputs into the HEMS IRP.
3. Provide the strategic view of industry risks in one document that can be commonly understood by all stakeholders (aviation, medical, EMS, industry, regulatory, customer and government) and used as a focal point for defining the accountability for change.
4. Utilize an accepted methodology (risk management) that is used broadly in both corporate America and 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 or referral of risk to the appropriate accountable body
6. Allow the alignment of accountability, responsibility and resourcing for the management and reduction of risk at multiple levels of the industry.
7. Provide industry with opportunity to develop alternate solutions that will achieve the reduction in risk that is expected or even demanded by the government and the community
8. To propose risk treatment strategies that are performance or outcome based solutions rather than the traditional prescriptive recommendations that often come out of studies, reviews or investigations
9. A platform for the coordinated management of risks across the Industry - Prioritize the identified risks 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 and monitor implementation of risk treatment and ultimately provide effective oversight and governance of the Industry
12. Provide Industry Associations with a vehicle to manage governance, compliance and liability issues by demonstrating a proactive and risk based approach to change
13. Provide a framework within which individual operators can develop their own organizational risk profiles and risk management plans to effectively position or respond to industry level risks
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AssumptionsThis Industry Risk Profile 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 of emergency 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 of developing this industry risk profile is complete, true and correct
4. Matters of concern raised in the consultation process, which could not be substantiated or verified by other risk identification sources, were considered as perceived risk for the purposes of the profile.
5. The Industry Risk Profile will be provided to stakeholders and interested parties for use in strategic planning, business planning, reporting and other processes to ensure appropriate monitoring and oversight.
6. Statements made during the NTSB hearing (February 2009) were regarded as stakeholder interviews and those interviewed included in the stakeholder list.
7. Formal position papers, documents and resources lodged on the public docket for the NTSB hearing 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 the members 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 initial data input source.
9. The definition of the HEMS Industry is taken to mean the full spectrum of stakeholders involved in HEMS 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 Risk Reduction Work Plan and that this plan will acknowledge the many current initiatives already underway and in progress.
11. The Aerosafe Risk Management risk profiling model and methodologies revealed to the HEMS Industry will not be used, modified or reproduced without formal consent.
12. Addresses HEMS operations in the United States of America.
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PARt 1 context of the Industry Risk Profile
LimitationsThis Industry Risk Profile is subject to the following limitations:
1. The Industry Risk Profile is confined to rotary wing operations. However, many of the risks identified will be common to, and useful in, the development of a broader risk profile for EMS operations. This profile excludes fixed wing air medial operations.
2. The IRP specifically addresses both commercial for-profit and not-for-profit operations which operate 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 HEMS operators (County and Police) which conduct business as private category operations under Part 91 of the Federal Aviation Regulations.
4. Not every stakeholder in the industry was subject to an individual interview in preparing the HEMS IRP.
5. During the consultation phase (review and interaction with the industry on the draft risk profile made 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 the ability 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 the industry at the time of release.
8. The HEMS Risk Reduction work plan is under development and was not sufficiently developed by industry 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% confidence rating in the integrity of the data and associated profile is acknowledged.
12. The industry have actively and visibly communicated the desire for voluntary change, yet the ability for the industry to implement such change has not been evaluated or assessed.
Risk criteriaThe following criteria were developed to allow the evaluation and quantification of risks. Since risk has two components, 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 not happen 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 any other 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
17
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 the medical 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 Profile:
- Context of the profile: This Industry Risk Profile has been developed in the context of providing a detailed, data-driven analysis of the issues that affect the key objectives of the HEMS Industry. By defining and focusing on the HEMS Industry as a single entity, this profile can provide insight into the various elements of the Industry and how the elements interact to achieve Industry objectives. The risk profile 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 varied range 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 a historical perspective. The documentation review also provided the basis on which key industry risk issues were identified. A total of 267 Documents were reviewed during the document review process.
- Stakeholder Analysis: A comprehensive stakeholder analysis was conducted in order to identify the stakeholders within the Industry that could provide the insight into the operations, status and issues impacting the HEMS Industry. The analysis identified stakeholders from public, private and government organizations, enabling the project team to conduct interviews with key industry decision makers. A total of 161 stakeholders were identified during the initial stakeholder analysis process and an additional 21 stakeholders were identified in the review of the draft HEMS IRP.
- Stakeholder Interviews: Once the industry stakeholders had been identified, several decision makers 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 these interviews a significant number of industry risk issues were identified.
- note: In line with the risk management process, the identified stakeholders were examined and it was determined whether formal communication, consultation or interaction was needed at the identification, review or solution development phase of work. As a matter of clarification, the stakeholder analysis determined the best match of risk identification method to each stakeholder group. As a result, formal interviews or surveys were not conducted on every stakeholder. Alternate risk identification methods were exercised on those remaining stakeholders.
- Collection of Risk Issues: A total of 1280 risk issues were identified from the initial risk identification sources. During the review of the draft HEMS IRP, and additional 200+ issues were identified and cross mapped to the risks listed in the HEMS IRP. The tabulated data was updated with these additional inputs. The main additions or amendments were in the risk impacts, a minor adjustment 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 finalized within the specific context outlined above.
- Risk Identification: This risk profiling methodology allows for a greater level of depth in the identification, selection and analysis of the risk information used in the risk identification step. In general available risk data consists primarily of qualitative information. As an attempt to minimize subjectivity, fourteen separate risk identification methods were used and the data collected from these sources layered and cross mapped for themes and grouping against the IRP model.
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PARt 1 context of the Industry Risk Profile
Rationale for Analysis Methodology The HEMS Industry is committed to providing timely, quality patient transportation throughout the United States. This objective carries significant 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 rural and isolated environments. Given such variability in mission profiles, options which ensure overall system safety, while allowing local flexibility, require evaluation.
In recent years, developments such as the Reason Model have been used in the analysis of accidents and incidents in the aviation industry. Reason identified that accidents occur when there are multiple failures in the various levels of defenses - “when the holes line up”. This model can also be used to design safety systems by identifying “defenses in depth”. Analysis of “defenses in depth” allows safety experts to identify potential points of failure and minimize the possibility of total system failure. Risk analysis (identification and assessment) is the tool that identifies potential points of failure in the Reason 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 to provide safe outcomes. A systems approach also has the further advantage of identifying the defenses which are necessary for overall system integrity. In locations where specific tools for risk mitigation prove ineffective or inappropriate, alternatives can be derived to manage the risk. A hierarchy of defenses (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 in order of outcome effectiveness.
Methodology: Risk Management Process
Risk Management ProcessThe International Standards Organization (ISO) draft standard on risk management (FDIS ISO31000) outlines the methodology and risk management process used to develop the Industry Risk Profile. The following pictorial model is consistent with FDIS ISO31000 and provides the structure to classify, present and prioritize risk information. The risk profile 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 what level of communication or consultation is required. Over 161 stakeholders were identified in the initial and review stages of the HEMS IRP development each possessing a different perspective 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 briefings or a workshop was held with AAMS, AHS, AMOA, AMPA, CAMTS, FAA, FARE, Flight Safety Foundation, GAO, HAI, House Aviation Sub Committee, International Helicopter Safety Team, NEMSPA, NTSB, The Joint Commission.
At this industry level, the scope, definition and context of the industry itself was required in 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 confirmed there were 74 Part 135 Operators approved to operate HEMS activities. The IRP excluded fixed wing air medical operations and any air medical operations conducted by public use operators.
For Industry level risk profiling 10-14 risk identification methods are normally used to extract risk issues that are then run through the risk management process. In the case of the HEMS IRP, 14 different risk identification methods were used which included a comprehensive literature review, stakeholder analysis, interviews, environmental scan, risk dimension analysis, data analysis, causal factor analysis, cultural assessment and task analysis. This process produced over 1400 data input sources to the IRP process.
Using the principles of the Reason accident causation model, a layering and classification process was then used to analyze the risk data. From this process, 26 industry level risks were identified. The consequence and likelihood of each of these 26 risk issues were assessed. A semi-quantative risk analysis tool was then used to calculate the level of risk associated with each of the 26 risks.
Building upon the risk analysis step above, the risks were then ordered and ranked from highest to lowest. Where more than one risk attracted the same risk rating, sub criteria was then applied to determine the ranking.
Multiple treatments were identified to address each risk. They vary in their scope but are designed 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 operators themselves. A residual risk calculation was then made in light of the effectiveness of the risk treatment strategy listed. The risk treatment strategies listed in the HEMS IRP are performance or outcome based. These solutions require actual tasks to be derived, allocated and resourced in order to produce the HEMS Industry Risk Reduction Work Plan. It is recognized that many activities are already underway, this final step of the risk process calls for these and future initiatives 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 significance will change over time. The HEMS IRP is a dynamic document and reflects the assessment of the risk profile at a point in time. The most critical aspect of the monitor and review stage of the risk process is the follow through and implementation of the risk treatment strategies. Ultimately it is these actions that will reduce the risk.
Analyse the Risks
Evaluatethe Risks
Treatthe Risks
Monitorand Review
Communication & Consultation
Establish the Context
Identify the Risks
International Risk Management Standard (ISO31000)*
20
PARt 1 context of the Industry Risk Profile
Methodology: Industry Risk Profile Model The industry risk profile model is used to classify and catalogue the risks identified in the HEMS IRP. This structure is used across the aviation industry and groups the issues into categories that generally guide the level of action required. The first 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 be further examined and assessed to a greater level of depth. For example the efforts of the International Helicopter Safety Team’s JSAT, JSIT and subsequent HEMS Safety Committee or the efforts of the NTSB individual accident investigation process would be the next layer of depth provided in the safety profile element 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
21
ovERSIgHt ModEL: The governance regime that exists within the industry in all facets at the highest level. In the case of the HEMS industry this includes gover-nance for the aviation, medical and emergency management services aspects. This element of the IRP model is closely aligned with the compli-ance and assurance elements.
coMPLIAncE REgIME:Considers the statutory and regulatory and framework in which the industry operates. The compliance element, along with the assurance element is a sub component of the overall over-sight model. At the industry risk profiling level, these two pieces are addressed individually.
ASSuRAncE ModEL:What level of assurance is provided and to what level of depth? These aspects are explored in the assurance element of the Industry Risk Profile. The objective of assurance is to provide ‘confidence’.
oPERAtoR PRofILE:The operator profile looks at the composition, structure and models of the operator group within the industry. A greater level of depth can be provided to this element if required by conducting an individual risk profile of each operator within the industry sector. Individual operator risk profiles are normally undertaken by the regulator as part of the regulators routine surveillance and intervention regime.
ActIvIty PRofILE:This element of the Industry Risk Profile examines the range of operational activities un-dertaken by the industry. In relation to the HEMS industry risk profile the activity profile includes inter facility transfers, scene flights, speciality team transports, training, maintenance, commu-nication functions to name a few.
AIRcRAft cAPABILIty PRofILE:This element looks at the aircraft capability, technology and equipment.
InduStRy oPERAtIng EnvIRonMEnt:The industry operating environment includes the overall setting and landscape of the environment in which the industry operates in its entirety.
PASSEngER & PARtIcIPAnt PRofILE:Considers the demographics of the passengers or participants who are involved in the activity. This element excludes aircrew or employees of the aviation operator which is covered in the operator profile.
SyStEMS PRofILE:The definition and maturity of the various man-agement systems available and utilized within the industry are covered in the scope of this element of the Industry Risk Profile. This includes but is not limited to management systems, business systems, information systems and safety management systems.
SAfEty PRofILE:This element of the Industry Risk Profile takes into account the incident and accident statistics and the overall safety profile of the industry sec-tor. Much of the information and data covered in this element is historical in nature.
22
23
Summation of Results
PARt 2
24
PARt 2 Summation of Results
VeRy HIGH
(1)
VeRy HIGH
(1)
VeRy HIGH
(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 risks that have the same number (see numbering system in the far right hand column) this indicates the risk has been quantified at the same level. Where this is the case, sub criteria have been used to rank the risks within this classification. The summation of results in this presentation format only depicts the risk assessment, being the identification and quantification of risk and does not list any solutions to reduce the risk. This information is provided as a snapshot of the issues from highest to lowest and is to be read 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 matrix provide a visual representation of the risks scatter plot. The two matrix provide a visual representation of 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 Industry Risk Profiling 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 stakeholders are looking for information against these classification 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 definition of the national EMS structure or governance framework for HEMS. The current regime was not purposefully designed and has evolved over the past twenty years to the current regime in the absence of a framework. (Risk Reference 1 HEMS IRP)
2 The risk that the current medical reimbursement model (primary payer model) is no longer adequate to provide the appropriate level of financial coverage for either the current operating costs of the service or the impending upgrade of capability required through the addition of technology. (Risk Reference 15 HEMS IRP)
3 The risks associated with the complexity, non alignment and lack of clarity around the roles and scope of federal, state and county agencies involved in oversight of the HEMS industry. (Risk Reference 3 HEMS IRP)
25
VeRy HIGH
(2)
VeRy HIGH
(2)
VeRy HIGH
(2)
VeRy HIGH
(2)
VeRy HIGH
(3)
HIGH(4)
4 Cumulative risk associated with the variability among States over licensing requirements and standards for HEMS programs, as well as inconsis-tent interpretation of the States’ authority to determine a need for, and location 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 significant risk entrenched within the current tasking continuum used for allocating HEMS air medical assets. This inconsistency and lack of standardization in the tasking continuum spans the following process flow 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 specific 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 have competing objectives and interests. The diversity in this industry structure has the potential to induce industry and organizational level competition and growth in turn increasing the operational and safety risk exposure of the industry. (Risk Reference 10 HEMS IRP)
7 Safety management systems are only starting to be introduced in the HEMS industry are not yet sufficiently mature to manage the level and depth of change required in the safety philosophies, processes and practices required. (Risk Reference 21 HEMS IRP)
8 The industry does not have one accredited agency that provides collective definition, oversight or monitoring for the combined aviation, health-care and emergency management functions that shape the HEMS (or broader air medical) industry. (Risk Reference 2 HEMS IRP)
9 The broad spectrum of stakeholders to the HEMS industry are not aware of the entire industry risk profile leading to an inability for the industry to effectively identify, analyze and reduce the risks in a orchestrated and cohesive way. (Risk Reference 4 HEMS IRP)
tAblE 1 Risks Presented by Risk Ranking
nUMbER RISKS RISK lEvEl
26
PARt 2 Summation of Results
HIGH
(4)
HIGH
(4)
HIGH
(4)
HIGH
(5)
HIGH
(6)
10 The lack of National Airspace System and other infrastructure constraints in the airspace where HEMS operate dictate the conditions for the operational profile for flight removing the option to HEMS Operators to fly IFR. (Risk Reference 17 HEMS IRP)
11 The complexity of the oversight, compliance and regulatory regimes does not provide the structure required for the industry to have an inclusive assurance regime or program of audits, accreditation and checking leading to an inability to provide confidence that the industry is being appropriately managed. (Risk Reference 7 HEMS IRP)
12 Owing to the nature of the task profiles conducted in HEMS and the close working relationship the aircrew have with medical personnel involved in the tasks, there is increased blurring of lines of role and responsibility in respect to the medical personnel contribution to safe operation of the aircraft. This risk of ambiguity is increased with medi-cal personnel involvement in NVG operations, passenger briefing, task briefing, loading and unloading of aircraft, operational risk manage-ment assessments and crew briefing and debriefing processes. (Risk Reference 20 HEMS IRP)
13 The risks associated with the lack of development of a tangible safety culture 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 the HEMS 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 of factors that includes: - There are three distinct disciplines that all set the compliance
regime that affects the HEMS industry (aviation, healthcare and emergency services)
- The overlap or interface between these compliance regimes has not been clearly mapped out or is not easily accessible
- There is no agreed inter-discipline hierarchy for regulation, policy or standards of either the national ascending hierarchy
(Risk Reference 6 HEMS IRP)
tAblE 1 Risks Presented by Risk Ranking
nUMbER RISKS RISK lEvEl
27
HIGH
(6)
HIGH
(6)
HIGH
(7)
HIGH
(7)
HIGH
(7)
HIGH
(8)
15 Risk that the current definition and scope of the industry is not well defined leading to limitations in the ability or appropriate agencies and stake-holders to effectively govern their aspect of the industry. The key risk induced by this issue is the limitations on the ability for a complete and industry wide data driven national solution to manage the landscape to be identified, coordinated and effectively implemented. (Risk Reference 9 HEMS IRP)
16 The current safety analysis and monitoring of the HEMS industry is not data driven leading to an inability for the Regulator or the Industry itself to have an accurate picture of real safety picture. (Risk Reference 24 HEMS IRP)
17 The operating environment and the associated infrastructure and standard industry practices for the two routine task profiles (inter-facility & scene flights) is not sufficiently designed at the HEMS System level, leading to the increased variance and application of flight profiles, safety standards and safety risk exposure to patient, aircraft, aircraft and the public. (Risk Reference 12 HEMS IRP)
18 Lack of integration and alignment of accountability, responsibility and resourcing 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 does not employ the use of simulators and advanced training methods broadly used in other parts of the aviation industry predominately due to cost. (Risk Reference 25 HEMS IRP)
20 The current regulatory philosophy combined with the financial risks induced by the funding model of the industry engender a mind set or culture in the HEMS industry to only meet minimum prescribed standards rather than managing risks in the operation through the implementation of better practices. (Risk Reference 5 HEMS IRP)
tAblE 1 Risks Presented by Risk Ranking
nUMbER RISKS RISK lEvEl
28
PARt 2 Summation of Results
HIGH
(8)
HIGH
(8)
HIGH
(8)
HIGH
(8)
HIGH
(8)
HIGH
(9)
21 There is no activity or task profile definition set for the HEMS industry sector making it difficult to oversee the risks associated with the vari-ous task profiles at an industry, national or State level. In addition to this, changes to the trends in industry activities are not easily identified or monitored and the platform for data driven monitoring does not exist 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 aviation industry to enhance safety parameters leading to a decrease in the risk of an accident or incident. (Risk Reference 13 HEMS IRP)
23 The risk associated with the inability to effectively resource and manage the operational, technical and cultural change related to the introduction of new technology into service. (Risk Reference 14 HEMS IRP)
24 The profile of the passenger or participant (patient and medical crew) profile in the HEMS industry differs significantly from that of other sectors of the aviation community by virtue of the fact that the patient does 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 at a compliance or policy level leading to incoherent, conflicting or com-peting priorities or practices which may stifle the effective introduction of the SMS within the HEMS Industry. (Risk Reference 22 HEMS IRP)
26 Lack of effective and sound implementation of operational control arrangements within the HEMS industry leading to the increased increases the risk of poor operational decisions and misalignment of accountability and responsibility for flight operations. (Risk Reference 23 HEMS IRP)
tAblE 1 Risks Presented by Risk Ranking
nUMbER RISKS RISK lEvEl
29
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
co
nSE
Qu
Enc
Ec
on
SEQ
uEn
cE
VeRy HIGH
(1)
VeRy HIGH
(1)
VeRy HIGH
(3)
VeRy HIGH
(3)
VeRy HIGH
(2)
VeRy HIGH
(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)
30
31
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-tification, 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 highest to lowest, but rather are grouped and classified against the IRP Model elements outlined on page 20. The table sub heading at the top of each page in the blue bar reflects the relevant IRP model element for 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 risks statements 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 item for 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 HEMS Industry. 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 these two 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 to the 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 identification, resourcing and implementation of risk reduction measures known as “Risk Treatment Strategies”. For the purposes of this IRP, the risk treatment strategies listed in this tabulated data are “Performance or Outcome based” and are not specific tasks allocated to any one group in industry. These reduction measures need to be further developed into actual tasks that can be implemented, tracked and measured. This information 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 account the forecast of the risk level calculation (of both consequence and likelihood) once the proposed set of treatments 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 implementation should be undertaken regularly to track a downward motion of the risk profile.
The far right hand column labelled “Priority” provided an indication of where that itemized risk falls in the risk ranking from 1-26.
32
Ris
ks a
sso
ciat
ed w
ith
the
lack
of
or
limite
d
defi
niti
on
of
the
na-
tion
al E
MS
stru
ctu
re
or
gove
rnan
ce f
ram
e-w
ork
fo
r H
EM
S. T
he
curr
ent r
egim
e w
as n
ot
pu
rpo
sefu
lly d
esig
ned
an
d h
as e
volv
ed
over
the
pas
t tw
enty
ye
ars
to th
e cu
rren
t re
gim
e in
the
abse
nce
o
f a
fram
ewo
rk.
- T
he d
evel
opm
ent o
f st
ate
base
d EM
S sy
stem
s w
hich
are
not
con
nect
ed o
r co
nsis
tent
- D
iver
genc
e in
sta
ndar
ds a
t a S
tate
leve
l w
hich
can
hav
e na
tiona
l im
plic
atio
ns-
Incr
ease
d ch
ance
of
confl
ictin
g le
gisl
ativ
e an
d re
gula
tory
pra
ctic
es n
atio
n w
ide
- C
onfu
sion
in th
e in
dust
ry a
roun
d ac
cep
ted
pra
ctic
es-
The
con
tinuu
m o
f in
divi
dual
pat
ient
car
e an
d th
e le
vel o
f he
alth
care
is in
terr
upte
d or
not
str
eam
lined
-
Incr
easi
ng v
aria
nce
in b
usin
ess
mod
els
crea
ting
pot
entia
l con
flict
loca
lly a
nd n
atio
nally
-
No
pub
licly
vis
ible
acc
ount
abili
ty
stru
ctur
e fo
r th
e in
dust
ry
- In
crea
sed
occu
rren
ce o
f co
mp
etin
g in
tere
sts
- C
halle
nges
in g
aini
ng a
gree
men
t on
st
anda
rds,
acc
redi
tatio
n, p
ract
ices
and
p
roce
dure
s in
use
acr
oss
the
indu
stry
- V
aria
nce
in c
rite
ria
for
pro
fess
iona
ls w
orki
ng in
this
fiel
d-
Diffi
culti
es fo
r H
EMS
pro
gram
s to
nav
igat
e th
roug
h th
e co
mp
lianc
e re
gim
e -
Lack
of
desi
gn o
f th
e EM
S sy
stem
cou
ld
stifl
e gr
owth
or
exp
ansi
on-
Dup
licat
ion
of r
esou
rces
- D
isp
arity
in m
atch
ing
app
rop
riat
e re
sour
ces
to th
e he
alth
care
nee
ds-
Lack
of
confi
denc
e by
the
stak
ehol
ders
that
ef
fect
ive
heal
thca
re c
an b
e ef
fect
ivel
y de
liver
ed
- G
reat
er r
elia
nce
on th
e H
EMS
oper
ator
s to
mak
e de
cisi
ons
rega
rdin
g p
olic
y an
d p
ositi
on o
n
pat
ient
tran
spor
t – r
athe
r th
an b
eing
abl
e to
rel
y on
end
orse
d an
d ac
cep
ted
natio
nal p
roto
cols
-
Incr
ease
pro
babi
lity
of in
duce
d un
der
or o
ver
utili
zatio
n of
res
ourc
es
- La
ck o
f le
ader
ship
and
dir
ectio
n on
the
futu
re o
f EM
S an
d in
par
ticul
ar H
EMS
- Po
tent
ial f
or in
crea
sed
cont
rol b
y St
ates
- C
onve
ne a
task
forc
e of
key
indu
stry
an
d re
gula
tory
bod
ies
to c
olla
bora
tivel
y re
view
the
natio
nal E
MS
defin
ition
, fr
amew
ork
and
arra
ngem
ents
for
thei
r su
itabi
lity
and
effe
ctiv
enes
s -
Follo
win
g re
view
and
acc
epta
nce,
ado
pt t
he
enha
ncem
ents
or
rede
sign
of
the
natio
nal
EMS
fram
ewor
k to
cat
er fo
r th
e na
tiona
l, st
ate
and
loca
l nee
ds o
f th
e he
alth
care
com
mun
ity.
Thi
s bo
dy o
f w
ork
shou
ld in
clud
e an
as
sess
men
t/co
mp
aris
on o
f m
ultip
le o
ptio
ns-
Con
firm
the
pol
itica
l pos
ition
up
on
whe
ther
acc
ess
to a
ir m
edic
al
tran
spor
tatio
n is
con
side
red
an e
ssen
tial
serv
ice
(em
erge
ncy
med
icin
e)
- A
pp
oint
an
app
rop
riat
e jo
int a
genc
y to
p
rovi
de th
e hi
ghes
t lev
el o
f ac
coun
tabi
lity
for
the
effe
ctiv
e im
ple
men
tatio
n of
th
is e
nhan
cem
ent e
ffor
t to
imp
rove
th
e na
tiona
l EM
S fr
amew
ork
- T
he N
atio
nal E
MS
fram
ewor
k to
incl
ude
per
form
ance
bas
ed r
equi
rem
ents
for
the
Stat
es to
des
ign
and
imp
lem
ent
the
EMS
syst
em c
onsi
sten
t with
the
fram
ewor
k w
ithin
thei
r St
ate
- D
evel
op o
ptio
ns to
res
olve
the
ques
tion
of
fede
ral v
s st
ate
over
sigh
t of
the
med
ical
co
mp
onen
t of
HEM
S op
erat
ions
.-
Imp
lem
ent t
he e
nhan
ced
Nat
iona
l EM
S de
finiti
on a
nd s
truc
ture
(fr
amew
ork)
Seri
al n
o. 1
o
vER
SIG
Ht
Mo
DEl
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (1)
LIKELIHood: cERtAIn
conSEQuEncE: EXtREME
PRIoRIty: 1
RESIduAL RISK: MEdIuM (12)
33
Th
e in
du
stry
do
es n
ot
hav
e o
ne
accr
edite
d
agen
cy th
at p
rovi
des
co
llect
ive
defi
niti
on
, ov
ersi
ght o
r m
on
itor-
ing
for
the
com
bin
ed
avia
tion
, hea
lthca
re
and
em
erge
ncy
m
anag
emen
t fu
nc-
tion
s th
at s
hap
e th
e H
EM
S (o
r b
road
er A
ir
Med
ical
) in
du
stry
- La
ck o
f vi
sibl
e di
rect
ion
and
auth
ority
for
this
in
dust
ry s
ecto
r –
no o
ne b
ody
in c
harg
e -
Cha
lleng
es in
pro
vidi
ng a
n ad
equa
te le
vel o
f as
sura
nce
that
is c
omp
lete
and
enc
omp
assi
ng in
nat
ure
- C
omp
lex
and
mul
tiple
rep
ortin
g an
d co
mp
lianc
e re
quir
emen
ts o
ver
-bur
deni
ng in
divi
dual
op
erat
ors
- Po
tent
ial f
or fr
agm
enta
tion
in th
e in
dust
ry
by H
EMS
oper
ator
s si
ding
or
pre
ferr
ing
one
accr
edita
tion
pro
gram
ove
r an
othe
r
- La
ck o
f co
mbi
ned
over
sigh
t for
med
ical
, EM
S an
d av
iatio
n fu
nctio
ns is
not
pro
vide
d to
the
cust
omer
or
the
com
mun
ity a
t lar
ge
- C
ontin
ued
and
enha
nced
deb
ate
abou
t w
heth
er th
e av
iatio
n or
med
ical
indu
stry
is th
e p
rim
ary
auth
ority
or
cont
rolle
r re
spon
sibl
e fo
r ul
timat
e st
anda
rd s
ettin
g an
d as
sura
nce
- C
onfli
cts
of
or c
omp
etin
g in
tere
sts
- G
row
th o
f m
ultip
le a
genc
ies
and
accr
edita
tion
bodi
es
that
hav
e a
som
e st
ake
in s
ettin
g in
dust
ry s
tand
ards
- Po
tent
ial f
or th
e du
plic
atio
n of
eff
orts
by
sep
arat
e or
gani
zatio
ns o
r en
titie
s to
add
ress
th
e sa
me,
or
sim
ilar
indu
stry
ris
k is
sues
- B
est p
ract
ice
oper
atio
ns a
nd p
roce
dure
s ar
e no
t pro
pag
ated
thou
gh th
e in
dust
ry.
- C
onfu
sion
ove
r w
hat e
ntity
has
juri
sdic
tion
ov
er is
sues
ove
rsig
ht a
nd r
esol
utio
n
- N
on a
lignm
ent o
f ac
coun
tabi
lity,
res
pon
sibi
lity
and
re
sour
cing
for
the
man
agem
ent o
f in
dust
ry le
vel r
isks
-
Incr
ease
d co
st to
HEM
S O
per
ator
s an
d th
eref
ore
the
incr
ease
d ov
erhe
ad to
the
indu
stry
’s op
erat
ing
cost
- Se
ek a
ckno
wle
dgem
ent o
f H
EMS
as it
s ow
n in
dust
ry o
win
g to
the
uniq
ue fe
atur
es a
nd r
elia
nce
on th
e in
tero
per
abili
ty a
nd in
ters
ectio
n of
avi
atio
n,
heal
thca
re a
nd e
mer
genc
y se
rvic
es
- Es
tabl
ish
an in
tera
genc
y ta
sk fo
rce
char
ged
w
ith id
entif
ying
, defi
ning
and
ass
essi
ng th
e is
sues
ass
ocia
ted
with
the
inte
rsec
ting
poi
nts
of th
e th
ree
disc
iplin
es in
the
HEM
S in
dust
ry
from
a g
over
nanc
e an
d ov
ersi
ght p
ersp
ectiv
e
- In
dust
ry to
est
ablis
h a
volu
ntar
y cu
stod
ian
grou
p to
ove
rsee
and
mon
itor
the
risk
pro
file
of th
e in
dust
ry
- Id
entif
y th
e le
gisl
ator
, reg
ulat
or, c
usto
mer
an
d in
dust
ry fo
r th
e av
iatio
n, m
edic
al
and
emer
genc
y se
rvic
es a
spec
ts o
f H
EMS
(eg
loca
te th
e re
gula
tor
for
heal
thca
re a
spec
ts o
f H
EMS)
- D
evel
op o
ptio
ns to
res
olve
lack
of
clar
ity
rega
rdin
g fe
dera
l vs
stat
e ov
ersi
ght o
f th
e m
edic
al c
omp
onen
t of
HEM
S op
erat
ions
.-
Esta
blis
h a
join
t tas
k fo
rce
or e
ntity
(a
lbei
t it t
emp
orar
y) to
ove
rsee
al
ignm
ent o
f re
gula
tion
as r
equi
red
Seri
al n
o. 2
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (2)
LIKELIHood: cERtAIn
conSEQuEncE: cRItIcAL
PRIoRIty: 4
RESIduAL RISK: LoW (15)
34
Th
e ri
sks
asso
ciat
ed
with
the
com
ple
xity
, n
on
alig
nm
ent a
nd
la
ck o
f cl
arity
aro
un
d
the
role
s an
d s
cop
e o
f fe
der
al, s
tate
an
d
cou
nty
age
nci
es
invo
lved
in o
vers
igh
t o
f th
e H
EM
S in
du
stry
- In
cons
iste
ncy
with
the
crite
ria
and
pro
toco
ls
that
dic
tate
the
use
of H
EMS
asse
ts
- C
halle
nges
for
the
indu
stry
in m
app
ing
out
the
requ
irem
ents
that
they
sho
uld
eith
er b
e co
mp
lyin
g w
ith o
r st
rivi
ng to
ach
ieve
-
Lack
of
clar
ity a
roun
d th
at b
ody
or
agen
cy is
trul
y ac
coun
tabl
e -
No
sing
le r
egul
ator
y bo
dy h
as r
esp
onsi
bilit
y fo
r ov
ersi
ghtin
g th
e EM
S sy
stem
as
a w
hole
- C
onfli
ctin
g re
gula
tory
pri
oriti
es m
ay p
lace
op
erat
ors
in a
p
ositi
on w
here
they
mak
e de
cisi
ons
that
are
not
op
timal
fo
r ei
ther
the
avia
tion
or m
edic
al a
reas
of
the
sect
or-
Regu
lato
rs c
an m
ake
inde
pen
dent
dec
isio
ns w
hich
m
ay c
omp
rom
ise
safe
ty in
the
othe
r ar
ea-
The
sco
pe
and
defin
ition
of
the
indu
stry
rem
ains
un
clea
r le
adin
g to
inab
ility
to im
ple
men
t an
ef
fect
ive
natio
nal g
over
nanc
e re
gim
e -
Econ
omic
cha
lleng
es a
nd p
oten
tial c
hang
es to
Fed
eral
, St
ate
and
pri
vate
insu
ranc
e re
imbu
rsem
ent r
egim
es
- U
nder
take
a d
etai
led
anal
ysis
of
all b
odie
s w
ithin
the
USA
that
hav
e so
me
leve
l of
acco
unta
bilit
y or
res
pon
sibi
lity
for
the
regu
lato
ry a
spec
ts o
f th
e H
EMS
syst
em in
or
der
to d
evel
op a
cen
tral
ized
sta
keho
lder
da
taba
se a
nd r
efer
ence
poi
nt fo
r ch
ange
- C
lari
fy a
nd p
ublis
h th
e de
finiti
on o
f ro
les
of th
e va
riou
s st
akeh
olde
rs
- D
esig
n na
tiona
l lev
el p
erfo
rman
ce
base
d re
quir
emen
ts fo
r na
tiona
l us
e no
ting
the
need
for
cons
iste
nt
imp
lem
enta
tion
at th
e St
ate
leve
l -
As
par
t of
the
key
indu
stry
and
reg
ulat
ory
body
task
forc
e in
1 a
bove
, est
ablis
h
wor
king
gro
up to
dev
elop
an
inte
grat
ed
over
sigh
t mod
el fo
r H
EMS
that
take
s in
to a
ccou
nt th
e le
gal j
uris
dict
ion
and
ac
coun
tabi
litie
s of
the
vari
ous
stak
ehol
ders
. -
Dev
elop
op
tions
to r
esol
ve th
e la
ck o
f cl
arity
ar
ound
thos
e ar
eas
that
cro
ss th
e bo
unds
of
both
fede
ral a
nd s
tate
ove
rsig
ht r
egim
es.
- D
efine
the
legi
slat
or, r
egul
ator
, cus
tom
er
and
indu
stry
for
the
avia
tion,
med
ical
and
em
erge
ncy
serv
ices
asp
ects
of
HEM
S -
Onc
e th
e m
edic
al r
egul
ator
is lo
cate
d,
deve
lop
and
set
min
imum
sta
ndar
ds
for
air
ambu
lanc
e m
edic
al c
are
- Im
ple
men
t tre
atm
ents
from
num
ber
1 an
d 2
Seri
al n
o. 3
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (1)
LIKELIHood: cERtAIn
conSEQuEncE: EXtREME
PRIoRIty: 3
RESIduAL RISK: MEdIuM (11)
35
Th
e b
road
sp
ectr
um
o
f st
akeh
old
ers
to th
e H
EM
S in
du
stry
are
no
t aw
are
of
the
entir
e in
du
stry
ris
k p
rofi
le
lead
ing
to a
n in
-ab
ility
fo
r th
e in
du
stry
to
eff
ectiv
ely
iden
tify,
an
alys
e an
d r
edu
ce th
e ri
sks
in a
orc
hes
trat
ed
and
co
hes
ive
way
- T
he fu
ll ex
tent
of
the
risk
pro
file
of th
e H
EMS
indu
stry
has
not
bee
n id
entifi
ed, a
naly
sis
or
mea
sure
d an
d is
ther
efor
e no
t com
ple
tely
kno
wn
an
d ca
n th
eref
ore
not b
e en
tirel
y m
anag
ed.
- In
abili
ty fo
r th
e H
EMS
indu
stry
to r
egai
n
confi
denc
e by
the
com
mun
ity th
at th
e ri
sks
are
bein
g ef
fect
ivel
y m
anag
ed-
Ris
ks a
re n
ot a
pp
rop
riat
ely
iden
tified
, as
sess
ed o
r m
anag
ed
- Pr
olon
ged
ques
tion
arou
nd th
e in
tegr
ity o
f th
e H
EMS
indu
stry
and
ass
ocia
ted
oper
ator
s fr
om th
e p
atie
nt a
nd h
osp
ital c
omm
uniti
es
- T
he in
dust
ry m
ay n
ot e
ffec
tivel
y m
anag
e th
e st
rate
gic,
saf
ety,
op
erat
ion,
tech
nica
l, tr
ansi
tiona
l and
co
mp
etiti
on r
isks
cur
rent
ly p
rese
nt in
the
indu
stry
-
The
rig
ht b
odie
s, o
rgan
izat
ions
or
agen
cies
may
no
t be
awar
e of
the
role
they
pla
y in
pro
vidi
ng a
ke
y so
lutio
n th
at w
ould
red
uce
the
risk
pro
file
-
Inci
dent
or
acci
dent
rat
e co
uld
cont
inue
at
an
unac
cep
tabl
e le
vel
- Lo
ss o
f co
nfide
nce
by th
e in
sura
nce
indu
stry
le
adin
g to
the
pri
ce o
f in
sura
nce
bein
g dr
iven
up
or
in s
ome
case
s no
t und
erw
ritte
n
- T
he e
ffor
ts to
pro
vide
a s
olut
ion
to th
e ar
ray
of in
dust
ry is
sues
may
not
be
coor
dina
ted
-
Incr
ease
d ch
ange
in d
uplic
atio
n of
eff
ort i
n
som
e ar
eas
and
lack
of
cove
rage
in o
ther
s -
Incr
ease
d le
vel o
f ‘s
ilo’ b
ehav
ior
acro
ss
the
indu
stry
due
to la
ck o
f cr
oss
func
tiona
l kn
owle
dge,
aw
aren
ess
of o
wne
rshi
p
- N
egat
ive
imp
act o
n th
e in
dust
ry’s
nat
iona
l rep
utat
ion
-
Loss
of
pub
lic c
onfid
ence
in th
e in
dust
ry’s
abili
ty to
ad
equa
tely
pro
vide
ove
rsig
ht a
nd m
anag
e th
e re
sour
ces
and
pub
lic m
oney
pro
vide
d to
fund
med
ical
tran
spor
t -
Incr
ease
d sp
ot li
ght b
y re
gula
tors
and
legi
slat
ors
- In
crea
se c
hanc
e th
at le
gisl
ativ
e so
lutio
ns w
ill b
e p
ursu
ed-
Div
isio
n in
the
indu
stry
– le
adin
g to
ulti
mat
e im
pac
t up
on th
e de
liver
y of
pat
ient
car
e
- D
evel
op th
e H
EMS
Indu
stry
Ris
k Pr
ofile
and
as
soci
ated
HEM
S In
dust
ry R
isk
Redu
ctio
n
Plan
whi
ch is
der
ived
from
the
pro
pos
ed
risk
trea
tmen
ts p
rese
nted
in th
e p
rofil
e -
Form
ally
pro
vide
op
por
tuni
ty fo
r in
dust
ry
to s
eek
com
mitm
ent f
or th
e de
velo
pm
ent,
spon
sors
hip
and
imp
lem
enta
tion
of
risk
trea
tmen
t str
ateg
ies
to r
educ
e th
e ri
sk p
rofil
e of
the
indu
stry
-
Esta
blis
h an
indu
stry
leve
l cus
todi
an
grou
p to
mon
itor
the
imp
lem
enta
tion
of
the
HEM
S In
dust
ry R
isk
Redu
ctio
n Pl
an
- Li
nk th
is c
usto
dian
gro
up w
ith th
e in
tern
atio
nal e
ffor
ts o
f re
duci
ng
acci
dent
rat
es th
roug
h th
e In
tern
atio
nal
Hel
icop
ter
Safe
ty T
eam
(IH
ST)
- Es
tabl
ish
a se
lf a
ccou
ntab
ility
reg
ime
that
hol
ds th
e in
dust
ry to
acc
ount
for
the
imp
lem
enta
tion
of r
isk
redu
ctio
n
stra
tegi
es p
ublic
ly c
omm
itted
-
Rele
ase
the
HEM
S In
dust
ry R
isk
Profi
le
to in
dust
ry fo
r th
eir
use.
As
par
t of
this
co
mm
unic
atio
n ca
mp
aign
, est
ablis
h fo
rmal
br
iefin
gs to
indu
stry
ass
ocia
tion
grou
p B
oard
of
Dir
ecto
rs, N
atio
nal L
evel
Reg
ulat
ors,
Sta
te
Gov
erno
rs/E
MS
Age
ncie
s/Li
cens
ing
Bod
ies,
th
e cu
stom
ers,
med
ia a
nd th
e in
dust
ry
itsel
f. C
ondu
ct a
tech
nica
l bri
efing
with
the
med
ia in
ord
er to
pro
vide
the
full
spec
trum
of
info
rmat
ion
rega
rdin
g th
e ri
sk p
rofil
e.
- A
lign
the
curr
ent e
ffor
ts o
f th
e in
dust
ry a
nd m
easu
re
Seri
al n
o. 4
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (4)
LIKELIHood: LIKELy
conSEQuEncE: cRItIcAL
PRIoRIty: 9
RESIduAL RISK: LoW (15)
36
Th
e cu
rren
t reg
ula
tory
p
hilo
sop
hy c
om
bin
ed
with
the
fin
anci
al
risk
s in
du
ced
by
the
fun
din
g m
od
el o
f th
e in
du
stry
en
gen
der
a
min
d s
et o
r cu
lture
in th
e H
EM
S in
du
stry
to o
nly
mee
t m
inim
um
pre
scri
bed
st
and
ard
s ra
ther
than
m
anag
ing
risk
s in
the
op
erat
ion
thro
ugh
th
e im
ple
men
tatio
n
of
bet
ter
pra
ctic
es.
- Pr
escr
iptiv
e re
gula
tory
reg
imes
pro
vide
det
aile
d
desc
rip
tions
of
how
com
plia
nce
mus
t be
achi
eved
ra
ther
than
pro
vidi
ng o
pp
ortu
nitie
s fo
r m
eetin
g th
e re
gula
tion
thro
ugh
app
rop
riat
e ac
tions
that
are
sp
ecifi
c an
d ac
hiev
able
to in
divi
dual
op
erat
ors
- T
hey
limit
the
abili
ty o
f op
erat
ors
to im
ple
men
t effi
cien
t sy
stem
s to
mee
t the
saf
ety
inte
nt o
f th
e re
gula
tions
- O
per
ator
s m
ay c
ondu
ct V
FR fl
ight
s du
e to
lim
itatio
ns in
the
regu
latio
ns-
Op
erat
ors
may
not
imp
lem
ent r
equi
red
chan
ges
due
to d
elay
s in
up
datin
g re
gula
tions
- O
per
ator
s m
ay in
cur
com
plia
nce
cost
s fo
r ac
tions
whi
ch h
ave
limite
d sa
fety
val
ue-
Incr
ease
s th
e p
ract
ice
with
in in
dust
ry o
f w
aitin
g fo
r p
resc
rip
tive
regu
latio
ns to
be
rele
ased
rat
her
than
that
taki
ng a
pro
activ
e be
tter
pra
ctic
e st
ance
- In
dust
ry to
dev
elop
and
ado
pt a
n ac
tion
ag
enda
to im
ple
men
t vol
unta
ry c
hang
e to
add
ress
the
key
risk
are
as th
e in
dust
ry
is in
a p
ositi
on to
con
trol
and
influ
ence
-
Indu
stry
to d
evel
op o
r re
cogn
ize
bette
r p
ract
ice
stan
dard
s (c
omm
unity
pra
ctic
es)
that
ex
ceed
the
min
imum
reg
ulat
ory
com
plia
nce
- En
cour
age
a p
erfo
rman
ce b
ased
p
hilo
sop
hy to
be
adop
ted
for
the
spec
trum
of
new
dev
elop
ed r
egul
atio
ns
per
tain
ing
to th
e H
EMS
Indu
stry
-
Imp
lem
ent a
n ed
ucat
ion
cam
pai
gn a
cros
s th
e in
dust
ry o
n th
e p
urp
ose,
ben
efit a
nd
usag
e of
per
form
ance
bas
ed r
egul
atio
n
- Im
ple
men
t an
exec
utiv
e le
ader
ship
pro
gram
fo
r th
e cu
stom
ers
(hos
pita
l exe
cutiv
es, E
MS
per
sonn
el a
nd P
art 1
35 e
xecu
tive)
on
the
natu
re, r
ole
and
resp
onsi
bilit
ies
asso
ciat
ed
with
per
form
ance
bas
ed r
egul
atio
n
- Fo
rmal
ly s
how
case
bet
ter
pra
ctic
e m
odel
s w
ith a
focu
s of
shi
ftin
g th
e ba
se m
ind
set a
nd c
ultu
re
Seri
al n
o. 5
C
oM
PlIA
nC
E R
EGIM
E
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 20
RESIduAL RISK: MEdIuM (12)
37
Th
ere
is in
her
ent
com
ple
xity
in th
e co
m-
plia
nce
reg
ime
use
d
to g
over
n th
e H
EM
S in
du
stry
wh
ich
is
con
fusi
ng
and
dic
tate
d
by a
myr
iad
of
no
n-
rela
ted
sta
keh
old
ers
lead
ing
to a
n in
crea
sed
ch
ance
that
HE
MS
op
erat
ors
are
no
n-
com
plia
nt.
Th
is r
isk
is
ind
uce
d b
y a
num
ber
o
f fa
cto
rs th
at in
clu
des
: -
The
re a
re th
ree
dist
inct
dis
cip
lines
th
at a
ll se
t the
co
mp
lianc
e re
gim
e th
at a
ffec
ts th
e H
EMS
indu
stry
(av
iatio
n,
heal
thca
re a
nd
emer
genc
y se
rvic
es)
- T
he o
verl
ap o
r in
ter-
face
bet
wee
n th
ese
com
plia
nce
regi
mes
ha
s no
t bee
n cl
earl
y m
app
ed o
ut o
r is
not
ea
sily
acc
essi
ble
- T
here
is n
o ag
reed
in
ter-
disc
iplin
e hi
er-
arch
y fo
r re
gula
tion,
p
olic
y or
sta
ndar
ds
of e
ither
the
natio
nal
asce
ndin
g hi
erar
chy
or c
ross
func
tiona
l di
scip
lines
- St
anda
rds
or r
equi
rem
ents
cou
ld
beco
me
confl
ictin
g in
nat
ure
- In
crea
sed
risk
exp
osur
e fr
om a
le
gal a
nd s
afet
y p
ersp
ectiv
e -
Incr
ease
d ch
ance
sta
ndar
ds a
nd
crite
ria
are
not b
eing
met
- In
dust
ry fa
lls b
ack
onto
vol
unta
ry s
tand
ards
an
d ac
cred
itatio
n bo
dies
as
they
do
not h
ave
the
cap
acity
or
are
not a
war
e of
the
dep
th
and
com
ple
xity
of
the
issu
es a
t han
d
- T
he in
dust
ry d
oes
not a
dop
t or
imp
lem
ent a
ccep
ted
stan
dard
s-
Incr
ease
s th
e p
ossi
bilit
y of
diff
erin
g in
terp
reta
tions
or
opin
ions
-
The
link
bet
wee
n th
e re
gula
tory
reg
ime
and
th
e op
erat
iona
l sta
ndar
ds c
ould
incr
ease
co
nfus
ion
amon
g in
dust
ry p
artic
ipan
ts-
The
his
tori
cal b
asis
for
deci
sion
s is
no
t ade
quat
ely
docu
men
ted
-
Requ
irem
ents
or
stan
dard
s ca
n be
eas
ily c
hang
ed
with
a r
e-w
rite
of
a m
anua
l or
docu
men
t -
Com
plia
nce
requ
irem
ents
may
not
be
met
- In
duce
con
flict
or
disa
gree
men
t be
twee
n in
dust
ry s
take
hold
ers
- In
cons
iste
ncy
acro
ss th
e in
dust
ry
- O
per
atin
g st
anda
rds
and
pro
toco
ls m
ay b
e di
sjoi
nted
in
nat
ure
and
dup
licat
ion
may
be
exce
ssiv
e -
Incr
ease
bur
den
on th
e op
erat
or to
est
ablis
h
- Es
tabl
ish
a cr
oss
disc
iplin
e ov
ersi
ght
task
forc
e to
iden
tify
the
inte
rsec
tions
of
the
HEM
S in
dust
ry a
t the
hig
hest
leve
l -
Dev
elop
a s
tand
ard
com
plia
nce
road
m
ap w
hich
info
rms
the
HEM
S in
dust
ry
of th
e co
mp
lexi
ties
of th
e m
ultid
isci
plin
e co
mp
lianc
e re
gim
e to
pro
vide
a
mea
ns o
f lo
cal l
evel
nav
igat
ion
arou
nd
fede
ral a
nd s
tate
req
uire
men
ts
- Re
gula
tors
in th
e th
ree
func
tiona
l ar
eas
mee
t to
agre
e on
col
labo
rativ
e ar
rang
emen
ts to
str
eam
line
com
plia
nce
defin
ition
, mon
itori
ng a
nd in
terv
entio
n
- D
evel
op o
ptio
ns to
res
olve
the
ques
tion
of
lack
of
clar
ity a
nd in
ters
ect p
oint
s of
fede
ral v
s st
ate
over
sigh
t of
cert
ain
co
mp
onen
t of
HEM
S op
erat
ions
.-
Key
indu
stry
sta
keho
lder
and
org
aniz
atio
ns
coop
erat
e to
iden
tify
and
addr
ess
stru
ctur
al a
nd o
per
atio
nal s
afet
y is
sues
Seri
al n
o. 6
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (6)
LIKELIHood: cERtAIn
conSEQuEncE: MAJoR
PRIoRIty: 14
RESIduAL RISK: HIgH (7)
38
Th
e co
mp
lexi
ty o
f th
e ov
ersi
ght,
com
plia
nce
an
d r
egu
lato
ry r
egim
es
do
es n
ot p
rovi
de
the
stru
ctu
re r
equ
ired
fo
r th
e in
du
stry
to h
ave
an in
clu
sive
ass
ura
nce
re
gim
e o
r p
rogr
am o
f au
dits
, acc
red
itatio
n
and
ch
ecki
ng
lead
ing
to a
n in
abili
ty to
pro
-vi
de
con
fid
ence
that
th
e in
du
stry
is b
ein
g ap
pro
pri
atel
y m
anag
ed
- T
he a
uditi
ng a
nd c
heck
ing
that
doe
s ta
ke p
lace
doe
s no
t cov
er th
e fu
ll co
ntex
t of
the
HEM
S op
erat
ion
- T
he n
eed
for
mul
tiple
aud
its, a
ccre
dita
tion
an
d ch
ecki
ng p
rogr
ams
- In
abili
ty fo
r in
tegr
atio
n an
d ec
onom
ies
of s
cale
to
redu
ce th
e co
mp
lianc
e bu
rden
for
oper
ator
s -
No
one
body
hol
ds th
e co
mp
lete
pic
ture
of
com
plia
nce
and
assu
ranc
e to
giv
e th
e le
vel o
f co
nfide
nce
requ
ired
-
Tho
se a
genc
ies
or a
ccre
dita
tion
bodi
es th
at o
ffer
ac
cred
itatio
n m
ay n
ot h
ave
pro
tect
ion
unde
r a
stat
utor
y au
thor
ity to
form
ally
aut
hori
se o
r sa
nctio
n
par
ticip
ant o
ther
that
the
with
hold
ing
of a
ccre
dita
tion.
- O
per
ator
s ha
ve to
com
ply
or
achi
eve
mul
tiple
ac
cred
itatio
n or
aud
its a
s th
ere
is n
o on
e al
l em
brac
ing
assu
ranc
e re
gim
e th
at m
eets
all
need
s -
The
re is
a la
ck o
f cl
arity
aro
und
ex
actly
who
exp
ects
wha
t -
Lack
of
cons
iste
ncy
arou
nd w
heth
er th
e le
vel o
f se
rvic
e re
quir
ed is
bei
ng d
eliv
ery
and
achi
eved
- Po
tent
ial f
or a
udits
form
diff
eren
t bod
ies
to
issu
e co
nflic
ting
findi
ngs
and
requ
irem
ents
- Po
tent
ial f
or d
iffer
ent s
tand
ards
be
ing
requ
ired
in e
ach
Stat
e.
- Re
gula
tors
in th
e th
ree
func
tiona
l are
as
(avi
atio
n, h
ealth
care
and
EM
S) to
mee
t an
defi
ne th
e re
latio
nshi
ps
betw
een
the
gove
rnan
ce a
nd o
vers
ight
arr
ange
men
ts
in o
rder
to r
emov
e la
ck o
f cl
arity
aro
und
w
ho p
rovi
des
wha
t ass
uran
ce
- A
t a v
olun
tary
leve
l dev
elop
an
indu
stry
le
vel a
ssur
ance
reg
ime
as p
art o
f th
e in
dust
ry s
elf
gove
rnan
ce a
rran
gem
ents
m
app
ing
wha
t nee
ds to
be
chec
ked,
to
wha
t lev
el o
f as
sura
nce
and
by w
hat e
ntity
-
As
par
t for
the
indu
stry
leve
l ass
uran
ce
regi
me,
dev
elop
an
inte
grat
ion
map
of
all a
vaila
ble
indu
stry
acc
redi
tatio
n an
d
cert
ifica
tion
pro
gram
s to
aid
e in
edu
catin
g th
e in
dust
ry o
n th
e si
mila
ritie
s an
d di
ffer
ence
s -
Whe
re p
ossi
ble
iden
tify
any
pot
entia
l ga
ps
or o
verl
aps
whi
ch c
ould
be
mut
ually
ac
cred
ited
via
an a
pp
rove
d p
aral
lel p
ath.
-
Con
side
ratio
n of
a s
elf
adm
inis
trat
ion
mod
el
for
cert
ain
asp
ects
of
the
HEM
S in
dust
ry w
ith
the
app
rop
riat
e m
anda
te fo
r ut
iliza
tion.
Seri
al n
o. 7
A
SSU
RA
nC
E M
oD
El
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (4)
LIKELIHood: LIKELy
conSEQuEncE: cRItIcAL
PRIoRIty: 11
RESIduAL RISK: MEdIuM (11)
39
Cu
mu
lativ
e ri
sk
asso
ciat
ed w
ith th
e va
riab
ility
am
on
g St
ates
ove
r lic
ensi
ng
req
uir
emen
ts a
nd
st
and
ard
s fo
r H
EM
S p
rogr
ams,
as
wel
l as
inco
nsi
sten
t in
terp
reta
-tio
n o
f th
e St
ates
’ au
tho
rity
to d
eter
min
e a
nee
d f
or,
an
d lo
ca-
tion
of,
new
or
exis
ting
HE
MS
pro
gram
s an
d
bas
es, h
as p
rod
uce
d
wid
esp
read
var
iab
ility
in
qu
ality
an
d s
afet
y in
HE
MS
tran
spo
rt
- N
atio
nal l
evel
con
sist
ency
is n
ot a
chie
ved
-
Stat
es d
evel
op th
eir
own
requ
irem
ents
in li
eu o
f no
t ha
ving
gui
danc
e in
duci
ng a
div
erge
nce
of o
per
atio
ns
- H
EMS
pro
gram
s op
erat
ing
in m
ore
than
one
sta
te
have
to tr
ack
and
met
diff
eren
t req
uire
men
ts
for
licen
sure
in e
ach
of th
e st
ates
-
Incr
ease
d cr
eatio
n of
var
iabi
lity
and
dist
ract
ion
fr
om fo
cus
on p
atie
nt s
afet
y an
d qu
ality
tran
spor
t-
Incr
ease
d co
mp
lexi
ty in
the
com
plia
nce
regi
me
that
nee
ds to
be
man
aged
at t
he o
per
ator
leve
l -
Num
erou
s an
d di
ffer
ent i
nter
pre
tatio
ns
by S
tate
lega
l cou
nsel
lors
and
cre
ated
w
ides
pre
ad a
mbi
guity
and
con
fusi
on-
Une
qual
dis
trib
utio
n of
HEM
S se
rvic
es
in s
ome
area
s w
hile
oth
er a
reas
may
be
unde
serv
ed o
r no
t ser
ved
at a
ll -
Exp
ecta
tions
for
an e
qual
leve
l of
heal
th c
are
acro
ss
the
coun
try
is n
ot a
chie
ved
or d
eliv
ered
by
the
curr
ent e
mer
genc
y m
edic
al tr
ansp
ort s
yste
m
- A
CS
leve
l 1 tr
aum
a ca
re w
ithin
two
hour
s of
inju
ry is
not
ach
ieve
d, th
us fa
iling
to
mee
t a fu
ndam
enta
l exp
ecta
tion
of m
any
Am
eric
ans
and
trau
ma
care
pro
vide
rs
- So
me
area
s ha
ve p
oten
tial t
o be
sat
urat
ed w
ith a
ircr
aft
or H
EMS
asse
ts a
nd o
ther
are
as n
ot s
ervi
ced
at a
ll
- In
fight
ing
over
com
ple
tion
for
fligh
ts-
An
incr
easi
ng n
umbe
r of
sm
all o
per
ator
s ru
nnin
g on
pag
ers
and
not a
dher
ing
to
FAR
s, d
amag
ing
indu
stry
rep
utat
ion
- A
ssem
ble
the
app
rop
riat
e in
dust
ry
stan
dard
set
ters
and
ove
rsee
rs to
id
entif
y th
e in
ters
ect p
oint
s fo
r th
e va
riou
s di
scip
lines
that
fall
with
in th
e H
EMS
indu
stry
and
con
duct
inte
grat
ion
m
app
ing
to id
entif
y an
y ga
ps
or p
oten
tial
over
lap
s in
gov
erna
nce
arra
ngem
ents
-
Imp
lem
ent a
n en
hanc
ed n
atio
nal H
EMS
Fram
ewor
k an
d as
soci
ated
sys
tem
s,
requ
irem
ents
, sta
ndar
ds a
nd p
erfo
rman
ce
(out
com
e) b
ased
req
uire
men
ts th
at d
o
not r
estr
ict y
et r
athe
r p
rovi
de fl
exib
ility
fo
r ad
apta
ble
loca
l lev
el im
ple
men
tatio
n
with
in a
con
sist
ent i
nter
oper
able
reg
ime
- N
atio
nal p
erfo
rman
ce b
ased
req
uire
men
ts
to b
e de
velo
ped
and
pro
vide
d to
th
e St
ates
for
imp
lem
enta
tion
-
Imp
lem
ent a
form
al c
omm
unic
atio
n st
rate
gy
to th
e St
ate
Bas
ed a
utho
rize
s w
ith th
is
resp
onsi
bilit
ies
and
imp
lem
ent a
n in
dust
ry
netw
ork
pro
gram
mod
el fo
r ed
ucat
ion,
st
anda
rdiz
atio
n an
d sh
arin
g of
info
rmat
ion
-
conn
ect t
hese
sta
keho
lder
s as
a fo
rmal
gro
up
Seri
al n
o. 8
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (2)
LIKELIHood: LIKELy
conSEQuEncE: EXtREME
PRIoRIty: 5
RESIduAL RISK: LoW (15)
40
Ris
k th
at th
e cu
rren
t d
efin
itio
n a
nd
sco
pe
of
the
ind
ust
ry is
no
t w
ell d
efin
ed le
adin
g to
lim
itatio
ns
in th
e ab
ility
or
app
rop
riat
e ag
enci
es a
nd
sta
ke-
ho
lder
s to
eff
ectiv
ely
gove
rn th
eir
asp
ect o
f th
e in
du
stry
. Th
e ke
y ri
sk in
du
ced
by
this
is
sue
is th
e lim
itatio
ns
on
the
abili
ty f
or
a co
mp
lete
an
d in
du
stry
w
ide
dat
a d
rive
n
nat
ion
al s
olu
tion
to
man
age
the
lan
dsc
ape
to b
e id
entifi
ed,
coo
rdin
ated
an
d e
f-fe
ctiv
ely
imp
lem
ente
d
- T
he tr
ue s
cop
e of
the
indu
stry
and
its
act
iviti
es is
not
kno
wn
-
The
info
rmat
ion
pre
sent
ed m
ay n
ot b
e re
flect
ive
of th
e en
tire
indu
stry
, but
rat
her
thos
e w
ho a
re m
ost a
ctiv
e or
vis
ible
- T
he p
rofil
e of
the
airc
raft
flee
t of
the
indu
stry
sec
tor
can
not b
e m
onito
red
-
The
pro
file
of th
e ai
rcre
w (
pilo
ts)
of th
e in
dust
ry s
ecto
r ca
n no
t be
mon
itore
d-
The
true
pro
file
of th
e ac
tiviti
es u
nder
take
n
by th
e in
dust
ry u
s no
t kno
wn
-
An
accu
rate
cal
cula
tion
of th
e p
reci
se r
isk
exp
osur
e is
una
ble
to b
e de
term
ined
- T
he o
vers
ight
mod
el is
dri
ven
from
an
exp
erie
ntia
l ba
se r
athe
r th
an a
dat
a ba
sed
mod
el
- T
he c
omm
unity
will
not
get
a c
lear
pic
ture
of
the
HEM
S in
dust
ry a
s th
e as
sura
nce
mod
el
is n
ot fu
lly d
efine
d an
d th
e sy
stem
s an
d
pro
cess
es fo
r co
llect
ing
data
are
inad
equa
te
- A
com
par
ison
, ide
ntifi
catio
n of
cha
nge,
or
the
mon
itori
ng o
f tr
ends
can
not
eas
ily b
e ac
hiev
ed
- T
he s
cop
e of
ris
k of
the
indu
stry
sec
tor
and
in
par
ticul
ar th
e sa
fety
exp
osur
e is
unk
now
n
- O
verr
elia
nce
on p
ast i
ncid
ent d
ata
as
a p
seud
o co
mp
lete
ris
k p
rofil
e
- T
he v
olun
tary
eff
orts
of
indu
stry
to r
educ
e th
e ri
sk p
rofil
e m
ay b
e m
isgu
ided
and
not
fo
cuse
d in
the
high
est a
rea
of n
eed
- C
omm
issi
on a
bod
y of
wor
k to
acc
urat
ely
defin
e th
e in
dust
ry, d
evel
opin
g a
stak
ehol
der
mat
rix
for
use
by a
ny n
atio
nal o
r in
dust
ry
wid
e en
hanc
emen
t to
the
HEM
S in
dust
ry (
eg
Air
Med
ical
Tra
nsp
ort A
gend
a fo
r th
e fu
ture
)-
Dev
elop
the
crite
ria
for
data
and
in
form
atio
n th
at n
eeds
to b
e co
llect
ed fo
r th
e p
urp
ose
of e
nhan
ced
self
ove
rsig
ht
- Se
t up
cen
tral
dat
a co
llect
ion
poi
nts,
for
key
indu
stry
pro
filin
g in
form
atio
n, a
t ap
pro
pri
ate
pla
ces
with
in th
e in
dust
ry
to d
evel
op a
n ac
cura
te a
nd u
p to
dat
e p
rofil
e of
the
indu
stry
as
a w
hole
- Es
tabl
ish
an in
dust
ry d
ocum
enta
tion
regi
stry
to
ena
ble
a si
ngle
sou
rce
poi
nt fo
r in
dust
ry
liter
atur
e, s
tudi
es, r
esea
rch
and
reso
urce
- T
hrou
gh th
e H
EMS
Indu
stry
Ris
k Pr
ofile
up
date
s, tr
ack
and
mon
itor
the
shift
in
indu
stry
pro
file
(nat
iona
l sys
tem
leve
l ap
plic
atio
n of
FO
QA
like
pro
gram
) an
d us
e th
is d
ata
to a
dequ
atel
y dr
ive
the
calc
ulat
ed fu
ture
evo
lutio
ns to
th
e EM
S Fr
amew
ork
and
mod
el
Seri
al n
o. 9
o
PER
Ato
R P
Ro
FIlE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (6)
LIKELIHood: cERtAIn
conSEQuEncE: MAJoR
PRIoRIty: 15
RESIduAL RISK: MEdIuM (11)
41
Th
e in
du
stry
has
man
y d
iffe
ren
t bu
sin
ess
mo
del
s th
at o
ften
hav
e co
mp
etin
g o
bje
ctiv
es
and
inte
rest
s. T
he
di-
vers
ity in
this
ind
ust
ry
stru
ctu
re h
as th
e p
o-
ten
tial t
o in
du
ce in
du
s-tr
y an
d o
rgan
izat
ion
al
leve
l co
mp
etiti
on
an
d
grow
th in
turn
incr
eas-
ing
the
op
erat
ion
al
and
saf
ety
risk
exp
o-
sure
of
the
ind
ust
ry
- T
he in
dust
ry h
as n
o se
t sta
ndar
ds o
r gu
idel
ines
fo
r th
e go
vern
ance
of
indi
vidu
al o
rgan
izat
ions
- In
crea
sed
sens
itivi
ty to
taki
ng lo
w c
ost s
olut
ions
-
Span
of
cont
rol i
s w
ide
reac
hing
and
ha
rd to
sur
vey,
mon
itor
or c
ontr
ol
- In
crea
sed
chan
ce th
at th
e in
dust
ry w
ill
be r
atio
naliz
ed a
nd c
onso
lidat
ed-
Con
flict
ing
com
mer
cial
obj
ectiv
es in
duce
d
com
pan
ies
to ta
rget
com
mer
cial
lucr
ativ
e lo
catio
ns
or r
egio
ns in
crea
sing
the
com
pet
ition
- T
he h
osp
ital o
r p
atie
nt d
eman
d fo
r ai
r m
edic
al s
ervi
ce d
oes
not d
rive
gro
wth
- T
he c
hanc
e fo
r in
app
rop
riat
e ut
iliza
tion
of a
sset
s is
incr
ease
d
-
Furt
her
frag
men
tatio
n in
the
indu
stry
may
occ
ur
- Fi
nanc
ially
via
ble
loca
tions
will
be
over
ser
vice
d w
hile
th
ose
with
low
er v
olum
es m
ay b
e un
der
serv
iced
-
Incr
ease
d p
ress
ures
for
pro
gram
s an
d cu
stom
ers
to
com
pen
sate
and
run
non
-via
ble
pro
gram
s at
a lo
ss-
Incr
ease
d oc
curr
ence
of
com
pet
ing
pro
gram
s en
croa
chin
g on
est
ablis
hed
EMS
pro
gram
op
erat
ions
-
Inad
vert
ent fl
ow d
own
pre
ssur
e fo
r cr
ews
to a
ccep
t any
or
all t
asks
to a
ssis
t with
th
e su
rviv
abili
ty o
f th
eir
pro
gram
and
the
subs
eque
nt s
ecur
ity o
f th
eir
emp
loym
ent
- A
n in
crea
se th
at fu
rthe
r hy
brid
bus
ines
s m
odel
s w
ill
aris
e co
uple
d w
ith th
e co
mm
erci
al d
rive
rs a
nd p
ress
ures
fo
r vi
abili
ty w
ill s
hap
e th
e in
dust
ry e
nvir
onm
ent
- Po
tent
ial f
or e
xace
rbat
ing
othe
r m
isun
ders
tand
ings
w
ithin
the
indu
stry
aro
und
agen
das
and
pol
itica
l dri
vers
-
Incr
ease
the
diffi
culty
of
stan
dard
izin
g p
roce
ss,
pro
cedu
res
and
cultu
res
thro
ugho
ut th
e in
dust
ry-
The
cur
rent
op
erat
iona
l and
saf
ety
risk
exp
osur
e as
soci
ated
with
com
pet
ition
bet
wee
n H
EMS
pro
gram
s in
clo
se o
r ov
erla
pp
ing
geog
rap
hic
pro
xim
ity to
eac
h
othe
r th
at e
ncou
rage
s tr
ansp
ort t
eam
s to
acc
ept t
aski
ng
in o
rder
to m
axim
ize
fligh
t vol
umes
that
are
nec
essa
ry
to p
rese
rve
the
finan
cial
via
bilit
y of
pro
gram
s.
- A
s p
art o
f th
e N
atio
nal E
MS
Fram
ewor
k,
deve
lop
a s
et o
f co
rpor
ate
gove
rnan
ce
requ
irem
ents
that
nee
d to
be
met
by
the
all b
usin
ess
mod
els
in o
rder
to p
rovi
de a
n
app
rop
riat
e le
vel o
f se
lf g
over
nanc
e an
d
corp
orat
e ov
ersi
ght t
hat w
ill e
ffec
tivel
y id
entif
y, a
sses
s an
d m
anag
e th
e co
mp
any
or e
nter
pri
se r
isks
that
indu
ce u
nsaf
e co
mm
erci
al, o
per
atio
nal o
r sa
fety
pra
ctic
es.
(defi
ne e
xpec
tatio
ns a
roun
d co
rpor
ate
leve
l ac
coun
tabi
lity
and
man
agem
ent o
f av
iatio
n
oper
atio
ns o
r co
ntra
ctor
s). I
nteg
rate
this
re
sour
ce w
ithin
hea
lthca
re e
thic
s re
gim
e.
- D
evel
op a
viat
ion
cont
ract
or m
anag
emen
t gu
idel
ine
and
thos
e bu
sine
ss m
odel
s th
at d
o no
t op
erat
e th
eir
own
Part
135
(m
odel
off
oth
er p
arts
of
the
avia
tion
in
dust
ry s
uch
as p
ower
/ene
rgy
com
pan
ies,
m
inin
g in
dust
ry, o
il an
d ga
s in
dust
ry)
- C
ondu
ct a
nat
iona
l sem
inar
ser
ies
for
HEM
S In
dust
ry B
oard
Cha
irm
an, C
EOs
(acc
ount
able
exe
cutiv
e) a
nd P
rogr
am
Dir
ecto
rs in
the
area
s of
cor
por
ate
over
sigh
t, co
rpor
ate
gove
rnan
ce, r
isk
man
agem
ent
and
safe
ty m
anag
emen
t sys
tem
s
Seri
al n
o. 1
0
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (2)
LIKELIHood: LIKELy
conSEQuEncE: EXtREME
PRIoRIty: 7
RESIduAL RISK: MEdIuM (12)
42
Th
ere
is n
o a
ctiv
ity o
r ta
sk p
rofi
le d
efin
itio
n
set f
or
the
HE
MS
ind
ust
ry s
ecto
r m
akin
g it
dif
ficu
lt to
ove
rsee
th
e ri
sks
asso
ciat
ed
with
the
vari
ou
s ta
sk
pro
file
s at
an
ind
ust
ry,
nat
ion
al o
r St
ate
leve
l. In
ad
diti
on
to th
is,
chan
ges
to th
e tr
end
s in
ind
ust
ry a
ctiv
ities
ar
e n
ot e
asily
iden
ti-fi
ed o
r m
on
itore
d a
nd
th
e p
latf
orm
fo
r d
ata
dri
ven
mo
nito
rin
g d
oes
no
t exi
st to
th
e le
vel o
f m
atu
rity
re
qu
ired
to c
apita
lize
- T
he r
isk
pro
file
or c
hang
es to
the
risk
pro
file
may
not
be
iden
tified
ow
ing
to th
e la
ck o
f st
ruct
ural
defi
nitio
n of
the
indu
stry
-
The
bas
elin
e in
the
indu
stry
of
curr
ent u
sage
is n
ot a
vaila
ble
- T
here
is n
o co
mm
on p
latf
orm
for
lang
uage
or
mea
sure
men
t for
the
indu
stry
to c
omp
are
or c
ontr
ast a
t the
Fed
eral
or
Stat
e le
vel
- T
he s
cop
e, r
ole
and
task
pro
files
for
EMS
oper
ator
s ar
e no
t defi
ned
- Re
sour
ces
and
effo
rts
may
be
dire
cted
into
the
low
er r
isk
or lo
wer
exp
osur
e ac
tiviti
es o
r ta
sks
and
not m
axim
izin
g th
e im
pac
t or
opp
ortu
nity
-
Cha
nges
or
deve
lop
men
ts in
indu
stry
act
iviti
es m
ay
occu
r be
fore
the
regu
lato
ry r
egim
e ca
n ad
equa
tely
ac
com
mod
ate
the
com
plia
nce
imp
licat
ions
- D
evel
op a
nd m
aint
ain
a se
t of
stan
dard
ta
sk p
rofil
es fo
r th
e st
anda
rd n
atio
nally
ap
pro
ved
HEM
S ac
tiviti
es a
ssoc
iate
d
with
var
ious
sta
ndar
d ta
sks
- U
tiliz
e th
ese
task
pro
files
to d
evel
op a
set
of
oper
atio
nal r
isk
pro
files
and
link
to in
dust
ry
driv
en F
OQ
A s
yste
ms
to id
entif
y, c
aptu
re,
anal
yze
and
rep
ort d
evia
tions
from
the
norm
- A
dop
t op
erat
iona
l ris
k m
anag
emen
t m
odul
e as
par
t of
the
SMS
- K
ey s
take
hold
ers
to d
evel
op n
atio
nally
ac
cep
ted
EMS
tran
spor
t ter
ms
and
defin
ition
s.-
Cha
nge
curr
ent H
EMS
defin
ition
to r
emov
e th
e p
ossi
bilit
y of
a ‘e
mer
genc
y’ d
rive
n
cultu
re (
chan
ge n
ame
of in
dust
ry to
Air
M
edic
al T
rans
por
t rat
her
than
HEM
S)-
Embe
d th
e ac
tivity
pro
file
defin
ition
set
in
to a
ny in
dust
ry w
ide
data
col
lect
ion
in
orde
r to
acc
urat
ely
mon
itor
the
chan
ge
in th
e in
dust
ry o
vera
ll ac
tivity
pro
file
- Pr
ovid
e in
divi
dual
op
erat
ors
or a
ir
med
ical
pro
gram
with
the
crite
ria
for
activ
ity p
rofil
es in
ord
er to
allo
w
indi
vidu
al c
omp
anie
s to
mon
itor
the
chan
ge in
thei
r ow
n p
rofil
e ov
er ti
me
Seri
al n
o. 1
1 A
CtI
vIt
y P
Ro
FIlE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 21
RESIduAL RISK: LoW (15)
43
Th
e o
per
atin
g en
viro
nm
ent a
nd
the
asso
ciat
ed in
fras
tru
c-tu
re a
nd
sta
nd
ard
in
du
stry
pra
ctic
es f
or
the
two
ro
utin
e ta
sk
pro
file
s (i
nte
r-fa
cilit
y &
sce
ne
flig
hts
) is
no
t su
ffici
ently
des
ign
ed
at th
e H
EM
S Sy
stem
le
vel,
lead
ing
to th
e in
crea
sed
var
ian
ce
and
ap
plic
atio
n
of
flig
ht p
rofi
les,
sa
fety
sta
nd
ard
s an
d
safe
ty r
isk
exp
osu
re
to p
atie
nt,
airc
raft
, ai
rcra
ft a
nd
the
pu
blic
.
Inte
r-fa
cilit
y tas
k Pr
ofile
Fo
rmal
task
s p
rofil
es a
re n
ot e
vide
nt fo
r ri
sk m
anag
emen
t of
inte
r-fa
cilit
y tr
ansf
er
fligh
ts.
Issu
es in
min
imiz
ing
risk
for
are
:-
Inte
r-fa
cilit
y fli
ghts
are
oft
en u
nder
take
n
VFR
/NV
FR a
t low
leve
l whe
n IF
R m
ight
be
pos
sibl
e gi
ven
nece
ssar
y in
fras
truc
ture
- T
here
is a
gre
ater
pot
entia
l for
CFI
T o
r lo
ss o
f co
ntro
l due
to in
adve
rten
t IM
C e
ncou
nter
ed-
Pote
ntia
l for
traf
fic c
onfli
ctio
ns n
ear
busy
hos
pita
l he
lipad
s, e
spec
ially
if it
iner
ant u
sers
ap
pea
r-
No
stru
ctur
ed a
pp
roac
h to
inte
r-fa
cilit
y fli
ghts
Scen
e Flig
hts t
ask
Profi
le-
Scen
e fli
ghts
var
iabl
e p
rofil
es, c
an b
e hi
gh
risk
, man
y re
quir
e V
FR o
per
atio
ns.
- Fl
ight
s ar
e ge
nera
lly V
FR, e
ven
in
mar
gina
l wea
ther
con
ditio
ns-
The
cri
tical
ski
ll of
tran
sitin
g fr
om V
FR to
inst
rum
ent
fligh
t req
uire
d by
rec
over
y fr
om lo
ss o
f vi
sual
ref
eren
ce
is n
ot c
omm
only
ach
ieve
d ac
ross
the
indu
stry
-
Flig
hts
are
at lo
w le
vel w
ith le
ss m
argi
n fo
r er
ror
- Fl
ight
s at
nig
ht c
an e
ncou
nter
ver
y da
rk c
ondi
tions
w
hich
incr
ease
the
risk
for
VFR
op
erat
ions
- Fl
ight
s m
ay e
ncou
nter
inad
vert
ent I
MC
- Pi
lots
may
not
be
able
to fl
y by
vis
ual r
efer
ence
- Pi
lots
may
not
be
able
to n
avig
ate
by v
isua
l ref
eren
ce-
Pilo
ts m
ay n
ot h
ave
curr
ent t
rain
ing
to r
egai
n V
MC
- Pi
lots
may
not
hav
e re
curr
ent t
rain
ing
in r
ecov
ery
from
em
erge
ncy/
failu
re c
ondi
tions
at l
ow a
ltitu
de-
All
legs
of
an E
MS
fligh
t are
not
req
uire
d to
be
con
duct
ed to
the
sam
e st
anda
rd le
adin
g to
lead
ing
to le
sser
mar
gin
of s
afet
y
- Im
ple
men
t tas
k br
iefin
g an
d de
brie
fing
pro
cess
es a
cros
s th
e H
EMS
indu
stry
-
Imp
lem
ent a
n IF
R r
oute
str
uctu
re a
s p
art o
f th
e N
atio
nal A
irsp
ace
Syst
em-
Dev
elop
and
ado
pt n
eces
sary
infr
astr
uctu
re
to a
llow
the
IFR
inte
r-fa
cilit
y fli
ghts
to b
e co
nduc
ted
in a
mor
e co
ntro
lled
‘sta
ndar
d
fligh
t pro
file’
sim
ilar
to th
at o
f a
rout
ine
avia
tion
oper
atio
n th
at fl
ys fr
om k
now
n
poi
nt to
kno
wn
poi
nt. I
nfra
stru
ctur
e fo
r th
is to
incl
ude
Wea
ther
Ser
vice
, Pub
lishe
d
IFR
dep
artu
res
and
arri
vals
, IFR
rou
te
stru
ctur
e, A
DS
(B),
ded
icat
ed c
omm
on
use
freq
uenc
y fo
r ho
spita
l hel
ipad
s-
Equi
p a
ircr
aft s
o th
ey c
an s
afel
y re
gain
vis
ual fl
ight
con
ditio
ns if
they
en
coun
ter
inad
vert
ent I
MC
- Eq
uip
air
craf
t with
tech
nolo
gy to
ass
ist
in lo
w le
vel V
FR o
per
atio
ns e
spec
ially
at
nigh
t suc
h as
NV
G, H
TW
AS,
AD
S(B
) -
Dev
elop
a s
et o
f st
anda
rd
indu
stry
task
pro
files
- D
evel
op a
nd im
ple
men
t an
indu
stry
wid
e st
rate
gy to
sec
ure
fund
ing
subs
idy
or a
on
e of
f in
fras
truc
ture
/equ
ipm
ent c
apita
l fu
ndin
g in
ject
ion
give
n th
e na
tiona
l
Seri
al n
o. 1
2
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (7)
LIKELIHood: LIKELy
conSEQuEncE: MAJoR
PRIoRIty: 17
RESIduAL RISK: LoW (15)
44
Th
e ri
sk th
at th
e H
EM
S in
du
stry
do
es
no
t co
nsi
sten
tly
iden
tify,
ad
op
t, u
tiliz
e an
d m
axim
ize
airc
raft
te
chn
olo
gy
avai
lab
le
in th
e av
iatio
n in
du
stry
to
en
han
ce s
afet
y p
a-ra
met
ers
lead
ing
to a
d
ecre
ase
in th
e ri
sk o
f an
acc
iden
t or
inci
den
t
- Te
chno
logi
es a
re e
mer
ging
that
can
ass
ist i
n th
e m
itiga
tion
of r
isk
from
low
leve
l VFR
op
erat
ions
- A
dop
tion
of n
ew te
chno
logi
es r
equi
res
a fo
rmal
cha
nge
man
agem
ent p
lan
incl
udin
g tr
aini
ng, p
roce
dure
s am
endm
ent e
tc.
- A
ircr
aft a
nd c
rew
cap
abili
ty m
ay n
ot m
atch
th
e ta
sk p
rofil
e of
the
oper
ator
, the
sta
te
or th
e H
EMS
indu
stry
as
a w
hole
- B
oth
pro
activ
e an
d re
activ
e te
chno
logi
cal
enha
ncem
ents
may
not
be
-
Ass
essm
ent p
roce
sses
mus
t ide
ntify
tech
nolo
gy o
ptio
ns
whi
ch p
rovi
de th
e m
ost i
mp
act f
or fu
nds
avai
labl
e-
Tech
nolo
gies
mus
t be
asse
ssed
for
thei
r im
pac
t on
pilo
t per
form
ance
for
exam
ple
, inc
reas
e/re
duct
ion
of p
ilot w
orkl
oad,
hum
an fa
ctor
s is
sues
su
ch a
s fix
atio
n w
ith ta
sk w
ithin
the
cock
pit
etc,
-
Incr
ease
d fa
tigue
and
wor
kloa
d is
sues
-
Incr
ease
d re
lianc
e an
d ne
ed to
und
erta
ke
and
imp
lem
ent f
orm
al tr
aini
ng a
nd
com
mit
the
requ
ired
res
ourc
es
- Es
tabl
ish
an in
dust
ry/r
egul
ator
wor
king
gr
oup
to s
pec
ify a
nd a
sses
s cu
rren
t, em
erge
nt a
nd fu
ture
tech
nolo
gy
- Fo
r ke
y p
iece
s of
indu
stry
ap
plic
able
w
ide
tech
nolo
gy, a
ris
k an
d op
por
tuni
ty
asse
ssm
ent t
o be
con
duct
ed b
y th
e te
chno
logy
wor
king
gro
up
and
mad
e av
aila
ble
to in
dust
ry
to a
ide
in d
ecis
ion
mak
ing
- A
sses
s th
e su
itabi
lity
and
need
for
the
pot
entia
l cre
atio
n of
a n
ew fe
dera
l av
iatio
n re
gula
tion
spec
ific
to H
EMS
and
fix
ed w
ing
aero
-med
ical
tran
spor
t.-
Man
date
the
use
of c
erta
in p
erfo
rman
ce
stan
dard
s (o
utco
me
base
d) th
at c
an
be a
chie
ved
thro
ugh
tech
nolo
gy
- D
evel
op r
esou
rce
pla
n fo
r in
dust
ry
for
fund
ing
inje
ctio
n to
aid
e si
gnifi
cant
tech
nolo
gy u
pgr
ade
- A
gree
men
t fro
m m
anuf
actu
rers
that
cer
tain
p
erfo
rman
ce s
tand
ards
will
man
date
a
stan
dard
fit o
f so
me
tech
nolo
gy b
ased
on
the
addi
tiona
l saf
ety
limits
ach
ieve
d-
Purc
hase
, im
ple
men
t and
man
age
tech
nolo
gy
intr
oduc
tion
such
as
NV
Gs,
HTA
WS,
FD
R e
tc
Seri
al n
o. 1
3 A
IRC
RA
Ft C
APA
bIl
Ity
PR
oFI
lE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 22
RESIduAL RISK: LoW (16)
45
Th
e ri
sk a
sso
ciat
ed
with
the
inab
ility
to
effe
ctiv
ely
reso
urc
e an
d m
anag
e th
e o
per
atio
nal
, tec
hn
i-ca
l an
d c
ultu
ral
chan
ge r
elat
ed to
the
intr
od
uct
ion
of
new
te
chn
olo
gy
into
ser
vice
- T
here
will
be
a si
gnifi
cant
shi
ft in
the
oper
atio
nal c
onte
xt fo
r H
EMS
pro
vide
rs
- T
he in
dust
ry c
an n
ot k
eep
pac
e th
e ra
pid
adv
ance
of
tech
nolo
gy
- T
he in
dust
ry c
an n
ot in
dep
ende
ntly
val
idat
e th
e ef
ficac
y of
em
ergi
ng te
chno
logi
es
- T
he c
urre
nt w
orkf
orce
cap
abili
ty m
ay n
ot
pos
sess
the
skill
s an
d co
mp
eten
cies
req
uire
d
to w
ork
in th
is n
ew e
nvir
onm
ent
- Su
bseq
uent
new
ris
ks m
ay b
e in
duce
d th
at w
ere
not i
dent
ified
, ass
esse
d or
pot
entia
lly m
anag
ed
- T
he r
apid
imp
lem
enta
tion
of n
ew te
chno
logy
can
in
duce
unf
ores
een
risk
s in
to th
e op
erat
ing
envi
ronm
ent
- O
per
ator
s m
ay u
nder
estim
ate
the
reso
urce
s, ti
me
and
com
mitm
ent t
o in
trod
uce
new
tech
nolo
gy
- T
here
may
be
a sk
ills
shor
tage
in th
e in
dust
ry o
f su
itabl
e qu
alifi
ed in
stru
ctor
s to
aid
e th
e tr
aini
ng
and
imp
lem
enta
tion
of n
ew te
chno
logy
-
The
imp
lem
enta
tion
of n
ew te
chno
logy
w
ithou
t ind
ustr
y le
vel c
oord
inat
ion
can
lead
to
non
sta
ndar
d in
dust
ry c
onfig
urat
ions
- T
he p
oten
tial t
hat f
unds
are
inef
ficie
ntly
allo
cate
d-
The
op
por
tuni
ties
and
bene
fits
that
tech
nolo
gy
offe
rs m
ay c
omp
rom
ised
or
not m
axim
ized
-
A b
elie
f m
ay d
evel
op th
at n
ew te
chno
logy
is
a “
silv
er b
ulle
t” a
nd o
ther
form
s of
saf
ety
defe
nces
may
be
negl
ecte
d le
adin
g to
a
fals
e p
erce
ptio
n of
saf
ety
boun
dari
es
- O
ther
req
uire
d ch
ange
s to
the
oper
atin
g en
viro
nmen
t, st
anda
rds
and
trai
ning
may
not
be
as r
apid
ly im
ple
men
ted
gene
ratin
g a
lag
effe
ct
- T
he fi
nanc
ial m
odel
of
the
HEM
S in
dust
ry
need
s to
be
accu
rate
ly a
sses
sed
to
confi
rm v
iabi
lity
of in
crea
sed
stan
dard
s
- D
evel
op a
nd r
elea
se to
indu
stry
a “
chan
ge
man
agem
ent”
pac
kage
and
tool
kit t
o
assi
st H
EMS
orga
niza
tion
to m
anag
e th
e ri
sk o
f in
trod
uctio
n of
new
tech
nolo
gy
- D
evel
op a
sui
te o
f H
EMS
indu
stry
sp
ecifi
c ri
sk b
ased
- c
hang
e m
anag
emen
t too
l ki
ts fo
r 1)
intr
oduc
tion
of n
ew a
ircr
aft 2
) op
enin
g of
a n
ew b
ase
3) in
trod
uctio
n
of n
ight
vis
ion
gogg
les
4) in
trod
uctio
n
of e
nhan
ced
airc
raft
saf
ety
equi
pm
ent
5) in
trod
uctio
n of
saf
ety
man
agem
ent
syst
ems
6) m
erge
rs a
nd a
cqui
sitio
ns-
FAA
to c
onsu
lt w
ith s
take
hold
er to
p
lan
the
stru
ctur
ed a
dop
tion
of e
xist
ing
and
emer
ging
tech
nolo
gy. C
onsi
der
sup
por
ting
guid
ance
to th
e in
dust
ry in
th
eir
mat
urity
of
upta
ke. E
xam
ine
cultu
ral
fact
ors
such
as
rew
ard
and
ince
ntiv
es.
Seri
al n
o. 1
4
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 23
RESIduAL RISK: MEdIuM (14)
46
Th
e ri
sk th
at th
e cu
rren
t med
ical
re
imb
urs
emen
t mo
del
(p
rim
ary
pay
or
mo
del
) is
no
lon
ger
adeq
uat
e to
pro
vid
e th
e ap
pro
-p
riat
e le
vel o
f fi
nan
cial
co
vera
ge f
or
eith
er
the
curr
ent o
per
atin
g co
sts
of
the
serv
ice
or
the
imp
end
ing
up
grad
e o
f ca
pab
ility
re
qu
ired
thro
ugh
the
ad
diti
on
of
tech
no
log
y
- Re
tent
ion
of th
e in
cons
iste
ncie
s in
the
pay
or m
odel
from
Sta
te to
Sta
te-
Tech
nolo
gy m
ay n
ot b
e ab
le to
be
affo
rded
by
the
indu
stry
- Pr
icin
g p
ress
ure
on o
per
ator
s -
Del
ays
in th
e ad
optio
n an
d up
take
of
tech
nolo
gy-
Med
icar
e re
imbu
rsem
ent a
lone
(w
ithou
t add
ition
al
com
mer
cial
insu
ranc
e so
urce
s of
rei
mbu
rsem
ent)
w
ill n
ot a
llow
HEM
S tr
ansp
ort p
rogr
ams
to m
eet
oper
atio
nal e
xpen
ses
and
mai
ntai
n fin
anci
al v
iabi
lity.
-
Adv
ance
d an
d sa
fer
helic
opte
r eq
uip
men
t, e.
g., t
win
-eng
ines
, IFR
equ
ipp
ed, H
TAW
S,
NV
G a
nd m
ore
adeq
uate
ly tr
aine
d tr
ansp
ort
team
s m
ay n
ot b
e af
ford
able
or
amor
tized
-
The
Med
icar
e p
aym
ent m
odel
rei
mbu
rsem
ent f
or o
nly
tran
spor
t “lo
aded
mile
s” c
reat
es a
n un
real
istic
mod
el
for
pro
gram
s in
that
the
cove
ring
the
over
head
exp
ense
fo
r im
ple
men
ting
app
rop
riat
e ai
rcra
ft e
quip
men
t an
d cr
ew tr
aini
ng to
max
imiz
e sa
fety
is in
adeq
uate
- M
edic
are
reim
burs
emen
t for
HEM
S tr
ansp
ort f
oste
rs
the
pro
lifer
atio
n of
new
pro
gram
s th
at o
per
ate
in r
ural
ar
eas
and
that
incu
r th
e lo
wes
t op
erat
iona
l ove
rhea
d.-
The
hig
her
reim
burs
emen
t fro
m M
edic
are
for
tran
spor
ts fr
om r
ural
are
as, w
hich
pay
s on
ly fo
r “l
oade
d m
iles,
” in
adve
rten
tly p
enal
izes
tran
spor
t p
rogr
ams
oper
atin
g in
urb
an a
nd s
ubur
ban
area
s -
Prog
ram
ove
rhea
d m
ay b
e hi
gher
than
for
thos
e p
rogr
ams
oper
atin
g in
rur
al a
reas
not
co
ntem
pla
ted
in t
he s
tand
ing
mod
el
- In
crea
sed
pre
ssur
es o
n p
rogr
ams
to u
se lo
wer
cos
t ov
erhe
ad m
odel
s to
max
imiz
e fin
anci
al m
odel
-
Acc
epte
d sa
fety
trai
ning
pra
ctic
es s
uch
as th
e us
e of
sim
ulat
or tr
aini
ng m
ay b
e se
en a
s a
luxu
ry r
athe
r th
an a
n es
sent
ial t
ool f
or s
afet
y ow
ing
to th
e co
st
- N
egot
iatin
g re
imbu
rsem
ent f
or H
EMS
tran
spor
t w
ith M
edic
are
regi
onal
offi
ces
is fr
eque
ntly
co
nfro
ntat
iona
l, co
nsum
es c
onsi
dera
ble
time,
is in
effic
ient
and
was
tes
reso
urce
s
- D
evel
op a
pla
n to
rea
sses
s, e
valu
ate
and
rede
velo
p if
req
uire
d th
e m
edic
al
reim
burs
emen
t mod
el th
at u
nder
pin
s th
e re
venu
e ba
se o
f th
e H
EMS
indu
stry
in
ord
er to
pro
vide
ass
uran
ce th
at th
e ri
sks
curr
ently
indu
ced
have
bee
n
min
imiz
ed, r
emov
ed o
r at
the
leas
t ac
cep
ted
by th
e ap
pro
pri
ate
auth
ority
-
Reso
lutio
n th
at c
omp
etiti
on n
eeds
to b
e el
evat
ed a
nd o
ccur
at a
reg
iona
l or
stat
e le
vel r
athe
r th
an o
n a
task
by
task
bas
is
- A
dop
tion
and
imp
lem
enta
tion
of a
m
edic
al r
eim
burs
emen
t (or
rev
enue
m
odel
) th
at a
dequ
atel
y co
vers
bot
h
the
oper
atin
g co
sts
and
the
inve
stm
ent
in fu
ture
cap
abili
ty im
pro
vem
ents
Not
e: I
nter
vent
ion
from
hig
her
auth
ority
may
im
pro
ve q
uant
ifica
tion
of r
esid
ual r
isk.
Seri
al n
o. 1
5 In
DU
StR
y o
PER
AtI
nG
En
vIR
on
MEn
t R
ISK
S
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (1)
LIKELIHood: cERtAIn
conSEQuEncE: EXtREME
PRIoRIty: 2
RESIduAL RISK: HIgH (4)
47
Th
ere
are
sign
ifica
nt
risk
s en
tren
ched
w
ithin
the
curr
ent t
ask-
ing
con
tinu
um
use
d
for
allo
catin
g H
EM
S ai
r m
edic
al a
sset
s. T
his
in
con
sist
enci
es a
nd
la
ck o
f st
and
ard
iza-
tion
in th
e ta
skin
g co
ntin
uu
m s
pan
s th
e fo
llow
ing
pro
cess
fl
ow th
at in
clu
des
: -
The
eva
luat
ion
of th
e p
atie
nt n
eed
for
care
- T
he n
eces
sity
of
utili
zatio
n of
an
ai
rcra
ft fo
r th
e p
as-
seng
er tr
ansp
ort
- T
he r
eque
st-
ing
agen
cy
- T
he ta
skin
g p
roce
ss
incl
udin
g th
e al
loca
-tio
n of
the
task
to a
sp
ecifi
c re
sour
ce-
The
acc
epta
nce
of a
task
by
a H
EMS
oper
ator
- T
hrou
gh to
op
era-
tiona
l con
trol
one
the
task
has
bee
n ac
cep
t-ed
and
und
erta
ken
- T
here
is q
uest
ion
rais
ed a
roun
d th
e ap
pro
pri
ate
utili
zatio
n of
air
craf
t-
Som
e ar
eas
satu
rate
d w
ith a
ircr
aft,
othe
r ar
eas
less
ser
vice
d-
Alte
rnat
e m
eans
of
tran
spor
t are
no
t con
side
red
or e
ngag
ed
- In
crea
se in
occ
urre
nces
of
over
util
izat
ion
or
und
er u
tiliz
atio
n of
air
craf
t -
Stan
dard
s or
pro
toco
ls a
re n
ot c
onsi
sten
t -
Safe
ty r
isk
is in
duce
d at
any
com
pon
ent o
f th
e co
ntin
uum
, and
in s
ome
case
s, a
cum
ulat
ive
tota
l -
Com
pet
ition
for
task
s ca
n p
lace
pre
ssur
e on
cr
ews
to ta
ke m
argi
nal a
ssig
nmen
ts-
The
ran
ge o
f ri
sks
asso
ciat
ed w
ith th
e cu
rren
t ta
skin
g p
roce
ss fr
om a
sses
smen
t of
pat
ient
ne
ed, t
o th
e al
loca
tion
and
disp
atch
of
the
asse
t, th
roug
h to
op
erat
iona
l con
trol
is n
ot
stan
dard
ized
or
cons
iste
nt in
the
indu
stry
-
Incr
ease
d p
ress
ure
lead
ing
to a
n
incr
ease
in c
rew
fatig
ue-
Syst
emic
issu
es a
nd r
isks
indu
ced
in th
e ta
skin
g p
roce
ss a
re n
ot a
ble
to b
e m
inim
ized
or
rem
oved
- A
s p
art o
f th
e re
desi
gn o
f th
e N
atio
nal
EMS
Fram
ewor
k, r
edes
ign
the
syst
em
cont
inuu
m fo
r ta
sk id
entifi
catio
n, a
lloca
tion
an
d m
anag
emen
t to
achi
eve
alig
nmen
t of
pra
ctic
e fo
r th
e fu
ll sp
ectr
um o
f ta
skin
g ag
enci
es (
incl
udin
g Po
lice,
Fir
e,
EMS,
Hos
pita
ls e
tc)
that
util
ize
HEM
S -
As
par
t of
the
abov
e ac
tivity
, ide
ntify
and
de
fine
the
num
ber,
typ
e an
d va
rian
ce o
f ag
enci
es th
at a
re c
urre
ntly
invo
lved
in th
e ta
skin
g co
ntin
uum
in o
rder
to e
nhan
ce
the
curr
ent s
yste
m a
nd in
dica
te th
e sc
ope
of im
ple
men
tatio
n ef
fort
s re
quir
ed
- D
evel
op n
atio
nal t
aski
ng p
roto
cols
to
be im
ple
men
ted
by th
e St
ates
usi
ng th
e ‘p
erfo
rman
ce b
ased
’ ap
pro
ach
to p
roto
cols
de
velo
pm
ent (
use
CD
C g
uide
lines
as
sam
ple
)-
Imp
lem
ent e
nhan
ced
stru
ctur
e fo
r ta
skin
g ag
enci
es, c
ontr
ol a
nd c
omm
unic
atio
n ce
ntre
s
Seri
al n
o. 1
6
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (2)
LIKELIHood: LIKELy
conSEQuEncE: EXtREME
PRIoRIty: 6
RESIduAL RISK: tBc
48
Th
e la
ck o
f N
atio
nal
A
irsp
ace
Syst
em a
nd
o
ther
infr
astr
uct
ure
co
nst
rain
ts in
the
airs
pac
e w
her
e H
EM
S o
per
ate
dic
tate
the
con
diti
on
s fo
r th
e o
per
atio
nal
pro
file
fo
r fl
igh
t rem
ovin
g th
e o
ptio
n to
HE
MS
Op
erat
ors
to fl
y IF
R
- Re
mov
e th
e ab
ility
for
the
indu
stry
to m
axim
ize
the
opp
ortu
nity
to h
arne
ss th
e sa
fety
ben
efits
of
tech
nolo
gy
- Re
stri
cted
low
leve
l inf
rast
ruct
ure
forc
es o
per
ator
s to
em
plo
y V
FR w
hen
IFR
mig
ht o
ther
wis
e be
pos
sibl
e-
Incr
ease
d ex
pos
ure
owin
g to
the
volu
me
and
gr
owth
of
HEM
S tr
affic
in th
e vi
cini
ty o
f he
lipad
s -
Lack
of
wea
ther
ser
vice
s p
reve
nt I
FR o
per
atio
ns-
Nat
iona
l Air
Sp
ace
Syst
em is
not
sui
tabl
e an
d
does
not
allo
w fo
r th
e ri
sk in
duce
d th
roug
h
the
airs
pac
e op
erat
ing
envi
ronm
ent t
o be
re-
duce
d to
as
low
as
reas
onab
ly p
ract
icab
le
- A
ssur
ance
for
an e
quiv
alen
t lev
el o
f sa
fety
can
not
be
assu
red
- A
ny d
esir
ed s
tand
ard
of I
FR o
per
atio
ns c
ould
no
t be
effe
ctiv
ely
imp
lem
ente
d w
ithin
the
cur-
rent
reg
ime
of a
irsp
ace
infr
astr
uctu
re
- N
o co
mm
unic
atio
n se
rvic
es fo
r ho
spita
l hel
ipad
s-
Flig
hts
are
unde
rtak
en a
t low
leve
l whe
n
they
cou
ld b
e us
e IF
R p
roce
dure
s-
In m
argi
nal w
eath
er c
ondi
tions
gro
und
co
llisi
on r
isks
are
incr
ease
d-
The
re a
re n
o p
ublis
hed
coor
dina
tion
pro
cedu
res
for
oper
atio
ns a
roun
d fa
cilit
y he
lipad
s w
hich
may
cau
se
colli
sion
ris
ks, e
spec
ially
if it
iner
ant o
per
ator
s ap
pea
r-
Lack
of
pub
lishe
d ap
pro
ach/
dep
artu
re p
roce
-du
res
forc
e lo
w le
vel a
rriv
als/
dep
artu
res
- In
abili
ty to
man
age
the
broa
der
indu
stry
ex
pos
ure
for
inte
ract
ion
of H
EMS
oper
ator
s w
ith
the
broa
der
gene
ral a
viat
ion
com
mun
ity
- In
crea
sed
risk
of
mid
air
col
lisio
n of
ai
rcra
ft in
and
aro
und
airp
orts
and
pre
-do
min
atel
y un
cont
rolle
d ai
rsp
ace
- A
viat
ion
regu
lato
r an
d In
dust
ry to
join
tly
deve
lop
a n
atio
nal p
lan
for
infr
astr
uctu
re
- In
tegr
ate
requ
irem
ents
of
the
HEM
S co
mm
u-ni
ty (
and
the
broa
der
helic
opte
r co
mm
unity
as
a w
hole
) w
ith th
e p
lan
for
infr
astr
uctu
re
imp
rove
men
t in
the
Nat
iona
l Air
spac
e Sy
stem
an
d fu
ndin
g p
rop
osal
s to
sup
por
t thi
s p
lan.
- If
a s
uita
ble
pla
n is
not
abl
e to
be
reso
urce
d
or im
ple
men
ted
tran
sfer
the
risk
to th
e ap
-p
rop
riat
e ag
ency
for
acce
pta
nce
and
sign
off
-
Dev
elop
a n
atio
nal l
evel
low
rou
te
infr
astr
uctu
re fo
r he
licop
ter
oper
atio
ns
- U
tiliz
e a
loca
tion
base
d ri
sk p
rofil
ing
met
hodo
logy
to r
ank
and
pri
oriti
ze th
e or
der
and
timel
ines
by
whi
ch th
is n
atio
nal
infr
astr
uctu
re is
fund
ed a
nd in
trod
uced
Seri
al n
o. 1
7
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (4)
LIKELIHood: LIKELy
conSEQuEncE: cRItIcAL
PRIoRIty: 10
RESIduAL RISK: LoW (16)
49
Lack
of
inte
grat
ion
an
d a
lign
men
t of
acco
un
tab
ility
, re
spo
nsi
bili
ty a
nd
re
sou
rcin
g fo
r th
e st
and
ard
izat
ion
of
hel
ipad
op
erat
ion
s in
the
inte
r fa
cilit
y en
viro
nm
ent b
y h
osp
itals
. im
pac
ting
up
on
op
erat
ion
, m
ain
ten
ance
an
d
con
tinu
ou
s h
azar
d
man
agem
ent o
f h
elip
ads
in th
e in
ter-
faci
lity
envi
ron
men
t by
ho
spita
ls, p
rim
ary
HE
MS
op
erat
or
and
o
ther
hel
ipad
use
rs
- La
ck o
f st
anda
rds
for
hosp
ital h
elip
ads
incr
ease
the
risk
of
sub
stan
dard
faci
litie
s-
Unc
oord
inat
ed d
epar
ture
s/ar
riva
ls in
crea
se c
ollis
ion
risk
- La
ck o
f p
roce
dure
s in
crea
ses
risk
of
CFI
T-
Lack
of
wea
ther
dat
a as
par
t of
the
app
rove
d
wea
ther
ser
vice
mak
e IF
R o
per
atio
ns d
ifficu
lt-
Lack
of
inte
grat
ions
bet
wee
n fa
cilit
ies
on
acco
unta
bilit
y a
nd r
esp
onsi
bilit
y-
Inab
ility
to s
tand
ardi
zed
SOP’
s fo
r in
ter
faci
lity
helip
ads
- C
onfu
sion
bet
wee
n op
erat
ors
on S
OPs
and
p
refe
rred
pra
ctic
e fo
r va
ryin
g he
lipad
s-
Inab
ility
to c
ondu
ct a
udits
and
ev
alua
tions
to a
n in
dust
ry s
tand
ard
- D
ata
on h
osp
ital h
elip
ads
is n
ot r
eadi
ly a
vaila
ble
thro
ugh
the
Aer
onau
tical
Inf
orm
atio
n Se
rvic
es (
AIS
)-
The
re is
lim
ited
(and
info
rmal
) sh
arin
g of
op
erat
iona
l dat
a on
hel
ipad
s in
adj
acen
t loc
atio
ns-
Lack
of
infr
astr
uctu
re a
nd lo
w le
vel A
TC
sys
tem
.
- Id
entif
y th
e di
ffer
ent l
evel
and
typ
es o
f he
lipad
s in
use
acr
oss
the
HEM
S in
dust
ry,
and
whe
re a
vaila
ble,
iden
tify
the
rele
vant
co
mp
lianc
e re
gim
e un
der
whi
ch is
op
erat
es-
Whe
re a
man
dato
ry b
ased
com
plia
nce
regi
me
is n
ot a
vaila
ble,
dev
elop
and
im
ple
men
t vol
unta
ry s
tand
ards
to
ensu
re e
quiv
alen
t lev
els
of s
afet
y an
d ha
zard
man
agem
ent
- A
dop
t the
op
erat
iona
l ris
k m
anag
emen
t he
lipad
pro
filin
g m
odel
to a
sses
s th
e ri
sks
asso
ciat
ed w
ith h
elip
ads
- Im
ple
men
t a n
atio
nal l
evel
web
bas
ed
data
base
for
helip
ad in
form
atio
n th
at is
op
enly
ava
ilabl
e to
the
HEM
S in
dust
ry-
Imp
lem
ent a
sui
tabl
e se
lf a
dmin
iste
red
ov
ersi
ght r
egim
e fo
r th
e m
anag
emen
t of
helip
ads
used
for
HEM
S op
erat
ions
-
Esta
blis
hmen
t of
a na
tiona
l lev
el a
genc
y w
here
hel
ipad
non
-com
plia
nces
or
brea
ches
of
ap
pro
ved
pra
ctic
e ca
n be
rep
orte
d an
d
a su
itabl
e in
dust
ry b
ased
sur
veill
ance
and
in
terv
entio
n re
gim
e be
imp
lem
ente
d
Seri
al n
o. 1
8
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (7)
LIKELIHood: LIKELy
conSEQuEncE: MAJoR
PRIoRIty: 18
RESIduAL RISK: LoW (15)
50
Th
e p
rofi
le o
f th
e p
as-
sen
ger
or
par
ticip
ant
(pat
ien
t an
d m
edic
al
crew
) p
rofi
le in
the
HE
MS
ind
ust
ry d
iffe
rs
sign
ifica
ntly
fro
m th
at
of
oth
er s
ecto
rs o
f th
e av
iatio
n c
om
mu
nity
by
vir
tue
of
the
fact
th
at th
e p
atie
nt d
oes
n
ot h
ave
a ch
oic
e in
the
op
erat
or
al-
loca
ted
to u
nd
erta
ke
thei
r tr
ansp
ort
.
- T
he im
plie
d du
ty o
f ca
re fo
r bo
th th
e p
atie
nt a
nd
med
ical
per
sonn
el o
n bo
ard
the
airc
raft
is n
ot m
et
- T
he r
isk
crite
ria
for
wha
t con
stitu
tes
that
leve
l of
saf
ety
is in
crea
sed
owin
g to
the
pat
ient
s’
inab
ility
to e
lect
ivel
y se
lect
HEM
S p
rovi
ders
- In
crea
sed
chan
ce o
f un
-nec
essa
ry e
xpos
ure
to
the
pos
sibi
lity
of a
n ac
cide
nt o
r in
cide
nt-
Publ
ic o
utra
ge a
nd in
crea
sed
in m
edia
atte
ntio
n
- Ex
pec
tatio
n th
at th
e ri
sk a
ssoc
iate
d w
ith
pro
vidi
ng th
e p
artic
ipan
ts o
f a
HEM
S tr
ansp
ort
fligh
t with
an
equi
vale
nt, a
ccep
tabl
e le
vel
of s
afet
y is
exp
ecte
d by
soc
iety
. -
Incr
ease
in a
ccep
tanc
e of
task
s in
cir
cum
stan
ces
that
are
usu
ally
urg
ent o
r em
erge
nt th
at
wou
ld o
ther
wis
e no
t be
take
n
- In
crea
se in
pol
itica
l atte
ntio
n or
in s
ome
case
s p
oliti
cal i
nter
vent
ion
in th
is in
dust
ry
- Eq
uiva
lent
leve
ls o
f sa
fety
whe
n co
mp
ared
to o
ther
se
ctor
s of
the
avia
tion
indu
stry
can
not
be
met
put
ting
the
par
ticip
ants
of
a H
EMS
fligh
t at g
reat
er r
isk
- A
n eq
uiva
lent
leve
l of
safe
ty fr
om o
ne p
rovi
der
to th
e ne
xt c
an n
ot b
e de
finite
ly p
rovi
ded
-
Com
mun
ity e
xpec
tatio
ns to
pro
vide
an
envi
ronm
ent
with
an
acce
pta
ble
leve
l of
safe
ty is
not
pro
vide
d
- Te
HEM
S op
erat
or a
nd S
tate
s’ r
esp
onsi
bilit
ies
to h
onou
r p
ublic
trus
t in
pro
vidi
ng s
afe
tran
spor
t is
jeop
ardi
zed
- T
he n
atio
nal H
EMS
Syst
em is
que
stio
ned
an
d co
mes
und
er in
crea
sed
scru
tiny
-
Pock
ets
of p
erce
ived
or
real
uns
afe
pra
ctic
es
that
hav
e p
oten
tial t
o gr
eatly
und
erm
ine
pub
lic
confi
denc
e an
d tr
ust o
f th
e en
tire
indu
stry
- Q
uest
ion
rais
ed o
ver
indu
stri
es a
bilit
y to
con
tinue
to
sel
f m
anag
e un
der
curr
ent r
egim
e.
- C
onsi
der
man
datin
g th
at a
ll H
EMS
oper
atio
ns
whe
ther
a p
atie
nt is
on
boar
d or
not
, co
mp
ly w
ith P
art 1
35 s
tand
ards
alte
rnat
ivel
y co
nsid
er a
sp
ecia
l pur
pos
e ru
le –
the
ultim
ate
obje
ctiv
e to
ass
ure
an e
quiv
alen
t and
co
nsis
tent
leve
l of
safe
ty fo
r th
e w
hole
flig
ht
Seri
al n
o. 1
9 PP
ASS
EnG
ER &
PA
RtI
CIP
An
t PR
oFI
lE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 24
RESIduAL RISK: MEdIuM (12)
51
Ow
ing
to th
e n
atu
re
of
the
task
pro
file
s co
nd
uct
ed in
HE
MS
and
the
clo
se w
ork
-in
g re
latio
nsh
ip th
e ai
rcre
w h
ave
with
m
edic
al p
erso
nn
el
invo
lved
in th
e ta
sks,
th
ere
is in
crea
sed
b
lurr
ing
of
lines
of
role
an
d r
esp
on
sib
ility
in
resp
ect t
o th
e m
edic
al
per
son
nel
co
ntr
ibu
tion
to
saf
e o
per
atio
n o
f th
e ai
rcra
ft. T
his
ris
k o
f am
big
uity
is in
crea
sed
w
ith m
edic
al p
erso
n-
nel
invo
lvem
ent i
n
NV
G o
per
atio
ns,
pas
-se
nge
r b
riefi
ng,
task
b
riefi
ng,
load
ing
and
u
nlo
adin
g o
f ai
rcra
ft,
op
erat
ion
al r
isk
man
-ag
emen
t ass
essm
ents
an
d c
rew
bri
efin
g an
d
deb
riefi
ng
pro
cess
es.
- T
he d
ivis
ion
of th
is is
sue
in in
dust
ry
rem
ains
un-
reso
lved
-
Indi
vidu
al H
EMS
oper
ator
s m
ake
calc
ulat
ed
or in
form
al d
ecis
ions
by
virt
ue o
f th
e ac
tiviti
es
thei
r m
edic
al p
erso
nnel
are
invo
lved
in
- In
abili
ty fo
r m
edic
al p
erso
nnel
to m
et th
e cu
rren
t av
iatio
n st
anda
rds
and
crite
ria
(eg
drug
and
alc
ohol
sc
reen
ing,
cre
w fi
tnes
s st
anda
rds,
trai
ning
req
uire
men
ts)
- In
crea
sed
exp
osur
e fo
r in
dust
rial
rel
atio
n is
sues
-
The
pre
mis
e up
on w
hich
the
crew
com
pos
ition
is
op
erat
ing
on fr
om a
reg
ulat
ory
per
spec
tive
is o
utda
ted
and
inco
rrec
t and
doe
s no
t re
flect
com
mon
pra
ctic
e or
rea
lity
- C
onfu
sion
incr
ease
s fo
r bo
th p
ilots
and
med
ical
cre
w
abou
t sp
ecifi
c ro
les
in p
rom
otin
g av
iatio
n sa
fety
and
ho
w to
ap
ply
and
use
the
educ
atio
n th
ey h
ave
each
re
ceiv
ed in
Air
Med
ical
Res
ourc
e M
anag
emen
t (A
MR
M)
- In
tern
al c
onfli
ct a
nd c
ontr
over
sy a
roun
d in
fli
ght r
oles
cha
lleng
ed a
nd e
xace
rbat
ed-
The
true
ext
ent o
f th
e le
gal r
amifi
catio
ns
and
cost
imp
licat
ions
is u
nkno
wn
-
The
bas
is fo
r th
e w
hole
par
ticip
ant m
odel
is fl
oore
d
lead
ing
to a
n in
accu
rate
foun
datio
n of
defi
nitio
n-
The
par
ticip
ant m
edic
al c
rew
, pat
ient
s, p
ublic
who
en
gage
in m
edic
al tr
ansp
ort d
o no
t tru
ly u
nder
stan
d
the
risk
pro
file
asso
ciat
ed w
ith E
MS
syst
em in
w
hich
the
HEM
S op
erat
ors
unde
rtak
e th
ese
task
s -
The
line
bet
wee
n ai
rcre
w a
nd m
edic
al
per
sonn
el o
n bo
ard
mig
ht b
ecom
e bl
urre
d-
The
pro
cess
for
asse
ssin
g w
heth
er a
par
ticip
ant
is in
form
ed is
mig
ht n
ot b
e cl
earl
y de
fined
.-
The
ass
ocia
ted
indu
stri
al is
sues
ass
ocia
ted
with
any
ty
pe
of c
hang
e w
ill r
equi
re d
elib
erat
e m
anag
emen
t
- Re
gula
tory
cla
rific
atio
n of
the
stat
us
of o
n bo
ard
med
ical
per
sonn
el
need
s to
be
pro
vide
d-
Onc
e p
rovi
ded,
the
imp
lem
enta
tion
of th
is
pos
ition
and
enf
orce
men
t of
com
plia
nce
with
th
ese
requ
irem
ents
nee
ds to
be
unde
rtak
en
Seri
al n
o. 2
0
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (4)
LIKELIHood: LIKELy
conSEQuEncE: cRItIcAL
PRIoRIty: 12
RESIduAL RISK: MEdIuM (11)
52
Gen
eral
ly, s
afet
y m
anag
emen
t sys
tem
s ar
e o
nly
sta
rtin
g to
b
e in
tro
du
ced
in th
e H
EM
S in
du
stry
are
n
ot y
et s
uffi
cien
tly
mat
ure
to m
anag
e th
e le
vel a
nd
dep
th
of
chan
ge r
equ
ired
in
the
safe
ty p
hilo
so-
ph
ies,
pro
cess
es a
nd
p
ract
ices
req
uir
ed
- Pu
sh b
ack
from
with
in E
MS
orga
niza
tions
re
sulti
ng in
neg
ativ
e p
erce
ptio
ns to
war
ds w
hat
a SM
S is
and
why
it s
houl
d be
imp
lem
ente
d-
Lack
of
confi
denc
e fr
om o
per
ator
s to
war
ds
the
regu
lato
r as
a r
esul
t of
not p
rovi
ding
gu
idan
ce fo
r im
ple
men
tatio
n
- SM
S be
com
es a
non
pri
ority
and
th
e st
atus
quo
take
s af
fect
- Su
pp
ort f
or S
MS
from
indu
stry
is s
egm
ente
d
dela
ying
com
plia
nce
dead
lines
if s
et-
Inab
ility
to s
tand
ardi
ze r
egul
ator
y ev
alua
tion
and
p
ract
ice
of S
MS
crea
ting
conf
usio
n in
indu
stry
-
Fall
behi
nd H
EMS
inte
rnat
iona
l bes
t pra
ctic
e-
The
pot
entia
l tha
t key
SM
S el
emen
ts
are
not i
mp
lem
ente
d in
a c
onsi
sten
t m
anne
r ac
ross
the
HEM
S in
dust
ry.
- O
per
ator
s ar
e un
able
to o
btai
n a
clea
r p
ictu
re o
f th
e sa
fety
ris
ks th
at im
pac
t on
thei
r or
gani
zatio
n.-
Safe
ty in
form
atio
n is
not
col
lect
ed-
Stra
tegi
c an
d op
erat
iona
l dec
isio
ns m
ay
be m
ade
with
out a
full
know
ledg
e of
the
safe
ty p
ositi
on o
f th
e H
EMS
oper
ator
-
The
indu
stry
is n
ot y
et in
a p
ositi
on
whe
re s
afet
y ef
fort
s ar
e da
ta d
rive
-
The
saf
ety
risk
pro
file
for
the
avia
tion
asp
ects
of
the
SMS
are
cate
red
for
app
rop
riat
ely
- In
cide
nt r
epor
ting
may
not
get
ade
quat
ely
fed
back
to
the
lead
ers
driv
ing
chan
ge in
the
HEM
S in
dust
ry
- T
he r
eal s
afet
y cu
lture
with
in th
e H
EMS
indu
stry
may
rem
ain
unkn
own
- T
here
is n
o re
quir
emen
t for
op
erat
ors
to
have
a S
afet
y M
anag
emen
t Sys
tem
in li
ne
with
avi
atio
n in
dust
ry s
tand
ards
-
Safe
ty in
form
atio
n w
ithin
the
oper
ator
s or
gani
zatio
n an
d p
arac
hutin
g in
dust
ry
mig
ht n
ot b
e ad
equa
tely
dis
sem
inat
ed-
Con
tinue
d la
ck o
f SM
S p
rofe
ssio
nals
- C
all t
he in
dust
ry to
act
ion
to c
omm
it to
the
imp
lem
enta
tion
of S
afet
y M
anag
emen
t Sys
tem
s p
rior
to it
s m
anda
ted
com
plia
nce
base
d tim
elin
es-
Seek
the
indu
stry
’s c
omm
itmen
t to
ad
opt a
n in
tegr
ated
SM
S th
at c
over
s th
e m
edic
al, a
viat
ion
and
com
mun
icat
ion
as
pec
ts o
f H
EMS
indu
stry
- D
evel
op p
ract
ical
res
ourc
es fo
r th
ose
com
men
cing
imp
lem
enta
tion
- D
evel
op a
nd m
ake
avai
labl
e to
indu
stry
ed
ucat
ion
and
trai
ning
for
thos
e th
at a
re le
adin
g th
e im
ple
men
tatio
n
and
intr
oduc
tion
of th
eir
SMS
- Pr
ovid
e a
mec
hani
sm to
mea
sure
th
e up
take
and
eff
ectiv
enes
s of
SM
S im
ple
men
tatio
n –
pro
vidi
ng a
ben
chm
ark
for
indu
stry
that
mat
ures
ove
r tim
e
Seri
al n
o. 2
1 SS
ySt
EMS
PR
oFI
lE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL vERy HIgH (2)
LIKELIHood: LIKELy
conSEQuEncE: EXtREME
PRIoRIty: 8
RESIduAL RISK: LoW (15)
53
Avi
atio
n a
nd
med
ical
sa
fety
man
agem
ent
syst
ems
are
no
t in
te-
grat
ed a
t a c
om
plia
nce
o
r p
olic
y le
vel l
ead
ing
to in
coh
eren
t, co
nfl
ict-
ing
or
com
pet
ing
pri
ori
ties
or
pra
ctic
es
wh
ich
may
stifl
e th
e ef
fect
ive
intr
od
uct
ion
o
f th
e SM
S w
ithin
th
e H
EM
S In
du
stry
- T
he H
EMS
Op
erat
or S
MS
from
a p
ure
regu
lato
ry
per
spec
tive
only
add
ress
es h
alf
the
oper
atio
n
(avi
atio
n as
pec
t), h
alf
the
airc
raft
and
hal
f th
e cr
ew
(per
sonn
el e
mp
loye
d by
cer
tifica
te h
olde
r)-
Lack
of
agre
emen
t bet
wee
n av
iatio
n an
d
med
ical
lead
ers
of a
HEM
S O
per
ator
on
the
imp
orta
nce,
sco
pe
and
reso
urci
ng o
f th
e SM
S -
A k
ey fu
nctio
nal p
art o
f th
e H
EMS
indu
stry
m
ay n
ot b
e ca
tere
d fo
r w
ithin
the
HEM
S-
The
saf
ety
man
agem
ent s
yste
m a
dop
ted
do
es n
ot c
over
the
full
spec
trum
of
activ
ities
co
vere
d by
the
HEM
S O
per
ator
-
Dup
licat
ion
of e
ffor
ts, p
olic
ies
and
pra
ctic
es in
re
spec
t to
the
avia
tion
and
med
ical
SM
S an
d
othe
r ex
istin
g sy
stem
s su
ch a
s th
e m
edic
al q
ualit
y m
anag
emen
t / q
ualit
y im
pro
vem
ent s
yste
ms
- D
iffer
ent u
nder
pin
ning
phi
loso
phi
es a
re a
dop
ted
fo
r th
e tw
o ke
y as
pec
ts o
f th
e H
EMS
team
- D
iffer
ence
s of
op
inio
n of
lead
ers
of th
e H
EMS
indu
stry
or
the
HEM
S O
per
ator
s
- La
ck o
f al
loca
tion
of r
esou
rce
or
com
mitm
ent t
o ef
fect
ivel
y im
ple
men
t-
Incr
ease
d oc
curr
ence
of
the
HEM
S in
dust
ry s
imp
ly
re-b
rand
ing
thei
r cu
rren
t saf
ety
pro
gram
as
an S
MS
-
Op
erat
iona
l ris
k p
rofil
es (
risk
ass
essm
ent)
onl
y ta
ke
into
acc
ount
par
t of
the
deci
sion
mak
ing
pro
cess
-
The
op
por
tuni
ty to
incr
ease
the
rate
of
imp
lem
enta
tion
of
SM
S ac
ross
the
EMS
Indu
stry
is lo
st-
Atti
tude
with
in th
e in
dust
ry th
at S
MS
is n
ot n
eede
d
or w
ill n
ot b
e im
ple
men
ted
unle
ss it
is d
rive
n
by th
e re
gula
tor
of th
e sp
ecifi
c di
scip
line
- T
he g
ener
al a
bsen
ce o
f an
y co
ntra
ctua
l re
quir
emen
t for
saf
ety
man
agem
ent s
yste
ms
betw
een
Med
ical
Pro
gram
s an
d EM
S Pr
ogra
ms.
- A
viat
ion
and
med
ical
reg
ulat
ors
or s
tand
ard
sette
rs to
con
vene
to
deve
lop
op
tions
for
com
pat
ible
of
inte
grat
ed S
MS
regu
lato
ry r
equi
rem
ents
sp
ecifi
cally
for
the
HEM
S in
dust
ry
- T
he H
EMS
indu
stry
to a
dop
t an
“i
nteg
rate
d sa
fety
man
agem
ent s
yste
m”
that
link
s th
e av
iatio
n SM
S w
ith th
e m
edic
al S
MS
or e
quiv
alen
t sys
tem
- D
evel
op a
n in
dust
ry p
ublic
atio
n th
at
pro
vide
s a
mea
ning
ful r
efer
ence
on
th
e as
pec
ts o
f sy
stem
s in
tegr
atio
n
- Fo
r ce
rtai
n bu
sine
ss m
odel
s, b
uild
in
the
requ
irem
ent f
or th
e in
tegr
atio
n
and
alig
nmen
t of
syst
ems
with
in th
e co
ntra
ct b
etw
een
the
vari
ous
par
ties
- In
dust
ry a
ssoc
iatio
ns to
faci
litat
e th
e sh
arin
g of
bes
t pra
ctic
es a
cros
s th
e in
dust
ry.
Seri
al n
o. 2
2
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (8)
LIKELIHood: PoSSIBLE
conSEQuEncE: cRItIcAL
PRIoRIty: 25
RESIduAL RISK: MEdIuM (14)
54
Th
e p
ote
ntia
l ris
k as
so-
ciat
ed w
ith in
effe
ctiv
e im
ple
men
tatio
n o
f o
per
atio
nal
co
ntr
ol a
r-ra
nge
men
ts w
ithin
the
HE
MS
ind
ust
ry le
adin
g to
the
incr
ease
d
chan
ce o
f p
oo
r o
per
atio
nal
dec
isio
ns
no
t bei
ng
iden
tified
an
d in
terc
epte
d.
- M
isal
ignm
ent o
f ac
coun
tabi
lity
and
re
spon
sibi
lity
for
fligh
t op
erat
ions
. -
Task
ing
deci
sion
s ca
n be
mad
e w
ithou
t the
pilo
t ha
ving
acc
ess
to a
ll th
e ne
cess
ary
info
rmat
ion
- D
ecis
ion
mak
ing
en r
oute
can
be
mad
e w
ithou
t th
e p
ilot h
avin
g al
l the
nec
essa
ry in
form
atio
n-
Pilo
t may
be
unaw
are
of k
ey c
hang
es to
op
erat
iona
lly s
igni
fican
t inf
orm
atio
n-
Poor
info
rmat
ion
flow
and
sub
optim
al d
ecis
ion
m
akin
g bo
th p
re a
nd d
urin
g fli
ght.
- M
anag
emen
t of
reso
urce
s m
ay b
e le
ss e
ffec
tive
- T
he p
roba
bilit
y of
flyi
ng in
to I
MC
and
in p
artic
ular
ha
zard
ous
cond
ition
s su
ch a
s fo
g at
nig
ht a
re in
crea
sed
- In
crea
sed
pot
entia
l for
abo
rted
mis
sion
s-
Poor
com
mun
icat
ion
and/
or a
dmin
istr
ativ
e p
roce
dure
s
- A
dop
tion
of a
dvan
ced
oper
atio
nal
cont
rol a
rran
gem
ents
- C
omm
issi
on a
form
al c
omp
arat
ive
stud
y be
twee
n th
e op
erat
iona
l con
trol
mod
el o
f Pa
rt 1
21 a
nd P
art 1
35 o
per
ator
s to
ass
ess
the
bene
fits
and
suita
bilit
y of
the
app
roac
h
to th
e co
ntex
t of
HEM
S op
erat
ions
- D
evel
op fo
rmal
str
ateg
ies
to r
evie
w a
nd
imp
rove
com
mun
icat
ion
both
bet
wee
n
oper
ator
s op
erat
ing
in th
e sa
me
area
an
d in
tern
ally
with
in c
omp
anie
s.
- In
res
pec
t to
send
ing
and
rece
ivin
g as
pec
ts o
f th
e H
EMS
oper
atio
nal e
quat
ion,
co
nsid
er th
e vi
abili
ty o
f th
e ap
plic
atio
n
and
adap
tatio
n of
‘op
erat
iona
l con
trol
’ to
th
e he
alth
care
and
EM
S ar
rang
emen
ts –
an
d if
imp
lem
ente
d ad
opt a
per
form
ance
or
out
com
e ba
sed
regi
me
to p
rovi
de
flexi
bilit
y ye
t con
sist
ency
in a
pp
licat
ion
Seri
al n
o. 2
3 S
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (9)
LIKELIHood: unLIKELy
conSEQuEncE: EXtREME
PRIoRIty: 26
RESIduAL RISK: MEdIuM (12)
55
Th
e cu
rren
t saf
ety
anal
ysis
an
d m
on
itor-
ing
of
the
HE
MS
ind
us-
try
is n
ot d
ata
dri
ven
le
adin
g to
an
inab
ility
fo
r th
e R
egu
lato
r o
r th
e In
du
stry
itse
lf to
hav
e an
acc
ura
te p
ictu
re
of
real
saf
ety
pic
ture
- Sa
fety
pri
oriti
es a
re d
rive
n fr
om a
n ex
per
ient
ial
base
rat
her
than
a d
ata
base
d m
odel
-
The
re is
no
cent
raliz
ed d
ata
sour
ce th
at th
e In
dust
ry
can
draw
up
on to
dri
ve in
dust
ry s
afet
y ch
ange
-
The
indu
stry
is d
rive
n by
rea
ctiv
e da
ta (
acci
dent
st
atis
tical
ana
lysi
s) r
athe
r th
an p
roac
tive
risk
bas
ed s
urve
illan
ce a
nd a
naly
sis
- D
ata
colle
ctio
n ac
tiviti
es a
re fr
agm
ente
d
and
may
pos
ses
gap
s -
The
sco
pe
of r
isk
of th
e in
dust
ry s
ecto
r an
d in
p
artic
ular
the
safe
ty e
xpos
ure
is u
nkno
wn
-
With
out a
n on
goin
g an
alys
is o
f st
anda
rdiz
ed in
dust
ry
data
the
pot
entia
l exi
sts
that
ear
ly w
arni
ng o
f in
dust
ry
safe
ty r
isks
will
not
be
iden
tified
in ti
me
for
the
imp
lem
enta
tion
of c
orre
ctiv
e ac
tion
acro
ss th
e in
dust
ry-
Dat
a co
llect
ed c
anno
t be
accu
rate
ly c
olle
cted
–
do y
ou m
ean
cann
ot b
e va
lidat
ed?
- A
com
par
ison
, ide
ntifi
catio
n of
cha
nge,
or
the
mon
itori
ng o
f tr
ends
can
not
eas
ily b
e ac
hiev
ed
- H
EMS
oper
ator
s ar
e al
way
s “fi
ghtin
g fir
es”
in r
egar
ds to
saf
ety
issu
es-
Safe
ty m
onito
ring
is n
ot d
ata
driv
en le
adin
g to
em
otiv
e ra
ther
than
fact
bas
ed c
hang
e -
Safe
ty a
nd r
isk
docu
men
tatio
n st
agna
tes
and
loss
es r
elev
ance
to o
per
atio
ns.
- D
egen
erat
ive
cultu
re th
at d
oesn
’t fu
lly
com
pre
hend
con
sequ
ence
of
actio
ns-
Inab
ility
to tr
end
accu
rate
ly r
esul
ting
in p
oor
data
ana
lysi
s an
d in
corr
ect fi
ndin
gs w
ith
subs
eque
ntly
inap
pro
pri
ate
trea
tmen
t str
ateg
ies
- N
o ev
olut
ion
of d
ata
anal
ysis
- T
he d
own
side
of
risk
s ar
e on
ly e
ver
eval
uate
d
mis
sing
op
por
tuni
ties
that
may
pre
sent
them
selv
es.
- “G
ood
catc
hes”
are
not
rec
ogni
zed,
an
alyz
ed o
r re
war
ded
resu
lting
in p
oor
mor
ale
amon
gst E
MS
per
sonn
el-
Neg
ativ
e m
edia
cov
erag
e, in
dust
ry s
afet
y st
atis
tics
and
mis
man
agem
ent o
f SM
S-
Inac
cura
te s
tatis
tics
and
rep
ortin
g.
- In
dust
ry le
vel d
ata
colle
ctio
n
requ
irem
ents
and
sp
ecifi
catio
ns
deve
lop
ed,
agre
ed a
nd im
ple
men
ted
-
Nat
iona
l lev
el d
ata
colle
ctio
n,
anal
ysis
and
man
agem
ent s
trat
egy
be
deve
lop
ed w
ith th
e p
urp
ose
of a
dvis
ing
of th
e da
ta b
ase
requ
irem
ents
-
Ado
ptio
n of
FO
QA
and
ORV
R p
rogr
ams
-
Esta
blis
h a
vehi
cle
for
shar
ing
stat
istic
al
data
for
tren
d an
alys
is p
urp
ose
- Em
bed
the
crite
ria
for
rep
ortin
g on
cr
itica
l asp
ects
of
the
data
equ
atio
n
into
com
plia
nce
base
d re
gim
es to
ac
hiev
e m
anda
ted
rep
ortin
g st
atus
. -
Revi
ew, a
lignm
ent a
nd c
onfir
mat
ion
that
the
app
rop
riat
e le
gal p
rote
ctio
ns a
re in
pla
ce to
p
rote
ct d
ata
(pri
vacy
, con
fiden
tialit
y an
d an
ti-tr
ust)
alo
ng w
ith a
n as
sess
men
t of
how
op
en
safe
ty r
epor
ting
cultu
res
can
be c
ultiv
ated
Seri
al n
o. 2
4 SA
FEty
PR
oFI
lE &
PA
RtIC
IPA
nt
PRo
FIlE
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (6)
LIKELIHood: cERtAIn
conSEQuEncE: MAJoR
PRIoRIty: 16
RESIduAL RISK: MEdIuM (14)
56
Th
e cu
rren
t tra
inin
g re
gim
e fo
r a
hig
h
per
cen
tage
of
the
HE
MS
ind
ust
ry d
oes
n
ot e
mp
loy
the
use
o
f si
mu
lato
rs a
nd
ad
van
ced
trai
nin
g m
eth
od
s b
road
ly u
sed
in
oth
er p
arts
of
the
avia
tion
ind
ust
ry p
re-
do
min
atel
y d
ue
to c
ost
- C
rew
are
unp
rep
ared
for
unus
ual o
r ra
re s
ituat
ions
- C
rew
are
unp
rep
ared
for
emer
genc
y si
tuat
ion
such
as
engi
ne fa
ilure
- C
rew
coh
esiv
enes
s no
t as
stro
ng
and
stru
ctur
e as
it m
ight
be
- Tr
aditi
onal
trai
ning
met
hods
do
not p
rovi
de a
pp
rop
riat
e tr
aini
ng fo
r un
usua
l or
emer
genc
y si
tuat
ions
- Li
mite
d kn
owle
dge
of s
tren
gths
and
w
eakn
esse
s of
new
tech
nolo
gy-
Dec
isio
n m
akin
g an
d ri
sk m
anag
emen
t le
ss s
truc
ture
d th
at it
cou
ld b
e-
An
esta
blis
hed
cultu
re th
at h
as b
uilt
a re
sist
ance
to c
hang
e as
a r
esul
t of
inad
equa
te
safe
ty a
nd r
isk
man
agem
ent e
duca
tion
th
roug
h th
e EM
S ed
ucat
iona
l pro
cess
- La
ck o
f co
nfide
nce
with
in th
e H
EMS
com
mun
ity
beca
use
of th
e va
ryin
g ed
ucat
iona
l req
uire
men
ts
and
limite
d st
anda
rdiz
ed a
cros
s th
e co
untr
y -
Inab
ility
to a
udit
and
eval
uate
ag
ains
t an
indu
stry
cri
teri
a.-
Inab
ility
to b
ench
mar
k ag
ains
t in
tern
atio
nal t
rain
ing
stan
dard
s-
The
des
ired
leve
l of
pilo
t ski
ll ba
sed
and
trai
ning
st
anda
rds
are
not a
dequ
atel
y ac
hiev
ed
- D
evel
op a
nat
iona
l tra
inin
g st
rate
gy fo
r th
e H
EMS
indu
stry
, thi
s st
rate
gy w
ould
cov
er
the
full
spec
trum
of
trai
ning
nee
ds a
naly
sis
(eg
HEM
S Ed
ucat
ion
& T
rain
ing
Age
nda)
- T
he F
AA
and
Op
erat
ors
to c
onve
ne to
re
view
and
est
ablis
h m
inim
um s
cena
rio
ba
sed
sim
ulat
or tr
aini
ng r
equi
rem
ents
.-
Esta
blis
h a
helic
opte
r sa
fety
edu
catio
n
cons
ortiu
m to
pro
vide
the
full
spec
trum
of
acc
redi
ted
safe
ty tr
aini
ng
- C
oop
erat
ion
amon
g op
erat
ors
in th
e us
e of
sim
ulat
ors
for
new
air
craf
t.-
Iden
tify
reso
urce
and
exp
ertis
e in
res
pec
t of
sim
ulat
or w
orki
ng g
roup
s at
eith
er th
e na
tiona
l or
inte
rnat
iona
l lev
el (
eg R
Aes
)
Seri
al n
o. 2
5 S
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (7)
LIKELIHood: LIKELy
conSEQuEncE: MAJoR
PRIoRIty: 19
RESIduAL RISK: MEdIuM (11)
57
Th
e ri
sks
asso
ci-
ated
with
the
lack
o
f d
evel
op
men
t of
a ta
ngi
ble
saf
ety
cultu
re
that
tru
ly u
nd
er-
stan
ds
risk
an
d th
e m
anag
emen
t of
risk
- T
he d
esir
ed le
vel o
f p
ilot s
kill
base
d an
d tr
aini
ng
stan
dard
s ar
e no
t ade
quat
ely
achi
eved
-
The
indu
stry
cul
ture
can
rew
ard
risk
taki
ng b
ehav
ior
- T
he in
dust
ry is
just
beg
inni
ng to
imp
lem
ent
safe
ty m
anag
emen
t sys
tem
s-
Seni
or m
anag
emen
t may
not
be
awar
e of
th
e im
por
tanc
e of
a r
epor
ting
cultu
re-
The
sta
tus
quo
is m
aint
aine
d as
a r
esul
t of
inad
equa
te r
egul
atio
n an
d gu
idan
ce fr
om in
dust
ry-
The
HEM
S in
dust
ry b
ecom
es n
on s
usta
inab
le-
The
indu
stry
dev
elop
s a
poo
r re
put
atio
n
in th
e av
iatio
n se
ctor
res
ultin
g in
inab
ility
to
attr
act a
sus
tain
able
wor
kfor
ce-
“old
sch
ool o
f th
inki
ng”
is m
aint
aine
d le
adin
g to
in
crea
sed
chal
leng
es to
trul
y ac
hiev
e th
e de
sire
d cu
lture
-
Imp
lem
enta
tion
of c
hang
e ta
kes
long
er th
an r
equi
red
- Re
silie
nt s
taff
ove
r-m
otiv
ated
to tr
ansp
ort
and
care
for
criti
cally
inju
red/
ill p
atie
nts
- La
ck o
f hu
man
fact
or to
ols/
initi
ativ
es
- D
evel
op a
n 10
poi
nt in
dust
ry p
lan
for
cultu
ral c
hang
e in
clud
ing
the
indu
stry
’s lis
t of
mos
t una
ccep
tabl
e be
havi
ours
, p
ract
ices
and
atti
tude
s an
d se
ek
com
mitm
ent f
rom
Air
Op
erat
ors,
cus
tom
er
and
indu
stry
gro
ups
alik
e to
join
the
cam
pai
gn to
enh
ance
the
cultu
re
- Im
ple
men
t an
agre
ed in
dust
ry w
ide
educ
atio
n ca
mp
aign
for
the
indu
stry
in
res
pec
t to
the
com
ple
xitie
s of
the
safe
ty e
quat
ion
in th
e H
EMS
indu
stry
-
Imp
lem
ent a
ded
icat
ed e
xecu
tive
sem
inar
ser
ies
for
seni
or le
ader
s w
ithin
the
indu
stry
at t
he g
over
nanc
e an
d p
rogr
am m
anag
emen
t lev
els
- Im
ple
men
t a d
edic
ated
cus
tom
er a
nd
user
trai
ning
ser
ies
to e
ncou
rage
the
cust
omer
bas
e to
pla
y a
mor
e ac
tive
role
in o
vers
ight
and
gov
erna
nce
- D
evel
op a
ser
ious
soc
ialis
ed m
arke
ting
and
com
mun
icat
ions
cam
pai
gn to
p
rom
ote
and
inst
il th
e ke
y m
essa
ges
and
beha
viou
rs w
ithin
indu
stry
-
Des
ign
and
imp
lem
ent a
cul
ture
that
re
war
ds s
ound
ris
k de
cisi
on m
akin
g -
Ado
pt j
ust c
ultu
re a
nd n
on-p
uniti
ve
rep
ortin
g sy
stem
s ac
ross
indu
stry
-
Rede
sign
and
up
date
of
curr
ent c
rew
re
sour
ce m
anag
emen
t (C
RM
) an
d A
ir
Med
ical
Res
ourc
e M
anag
emen
t (A
MR
M)
trai
ning
to b
ette
r re
flect
5th
or
6th
ge
nera
tion
CR
M (
incl
udin
g er
ror
and
th
reat
man
agem
ent e
tc)
as p
art o
f an
wid
e hu
man
fact
ors
stan
dard
s an
d p
rogr
am.
Seri
al n
o. 2
6
dES
cRI
PtIo
n
IMPA
ct
of
tHE
RISK
on
RI
SK
RISK
tRE
AtM
Ent
RESI
du
AL
of
RISK
tH
E H
EMS
Ind
uSt
Ry
ASS
ESSM
Ent
StRA
tEg
y RA
nKI
ng
RISK LEvEL HIgH (5)
LIKELIHood: PoSSIBLE
conSEQuEncE: EXtREME
PRIoRIty: 13
RESIduAL RISK: MEdIuM (12)
58
Supporting Appendices
PARt 4
59
Appendix AHeMS IRP StAKeHOLDeR AnD DIStRIbUtIOn LIStAerospace Medical Association (AsMA) Aerosafe Risk Management Air Medical Operators Association: United in Safety (AMOA)Air Medical Operators holding a Part 135 Certificate (copy per organization) Air Medical Programs (copy per organization) Air Medical Physicians Association (AMPA)Air and Surface Transport Nurses Association (ASTNA)American Academy of Pediatrics (AAP)American Ambulance Association (AAA)American Association of Critical Care Nurses (AACN)American Association for Respiratory Care (AARC)American College of Emergency Physicians (ACEP)American College of Surgeons (ACS)American Hospital Association (AHA)American Helicopter Society (AHS) American Society for Healthcare Engineers (ASHE) American Society for Healthcare Risk Management (ASHRM)Association of Air Medical Services (AAMS)Aviation Safety Network Executive Group (ASN)Aviation Safety Network Alumni (ASN Alumni) Bell Helicopters TextronCommission Accreditation of Medical Transport Systems (CAMTS)Department of Health and Human ServicesEmergency Nurses Association (ENA)Federal Aviation Administration (FAA)Flight Safety FoundationFoundation for Air-Medical Research and Education (FARE)Government Accountability Office (GAO)Helicopter Association International (HAI)Helicopter Emergency Medical Services Committee House Aviation Sub Committee International Association of Flight Paramedics (IAFP)International Helicopter Safety Team (IHST)International Standards Organization Committee for Risk Management National Association of Air Medical Communications Specialists (NAACS)National Air Transport Association (NATA) National Association of EMS Physicians (NEMSP)National Association of Emergency Medical Technicians (NAEMT)National Association of Neonatal Nurses (NANN)National Association of State EMS Officials (NEMSO)National EMS Pilots’ Association (NEMSPA) National Transportation Safety Board (NTSB)Patients First Air Ambulance Alliance (PFAA)Risk & Insurance Management Society Inc (RIMS)
The Joint Commission
60
PARt 4 Supporting Appendices
Appendix BSUPPORtInG DOCUMentAtIOn Accompanying Documentation: - Executive Summary: An executive summary is provided to assist the industry in understanding the
background, scope and contents of the HEMS IRP. The next steps for risk reduction are also outlined.
- HEMS Industry Risk Reduction Plan: the main driver of assessing risk is to proactively reduce risk through the implementation of risk treatment strategies of solutions to the risk issues. Following the release of the HEMS IRP a facilitated process will take place calling for submission by stakeholders who wish to take carriage of industry wide risk reduction measures. This work will be compiled into the HEMS Industry Risk Reduction Plan.
Information Packages- Technical Media Briefing Package: Given the comprehensive nature of the information presented
in the HEMS IRP, a technical briefing was delivered to the media on Monday April 20, 2009 at the National Press Club in Washington DC.
- FAQs: Frequently asked questions are provided as a supporting resource.
Guide & template- Industry Submission – Risk Treatment Strategies: Guidance material has been made available to indus-
try to assist in the preparation of their submission of risk treatment strategies that will be compiled in the HEMS Industry Risk Reduction Plan.
- Guide for Associations – How to use the HEMS IRP: Provided for use by industry associations and groups to inform their members and boards.
- Guide for Air Medical Operators – How to use the HEMS IRP: Provided for use by Part 135 Operators to assist in understanding how the HEMS IRP can be utilized at an organizational level by Board Members, CEOs and Company Executives.
- Guide for Air Medical Programs – How to use the HEMS IRP: Provided for use by Air Medical Pro-grams to assist in understanding how the HEMS IRP can be utilized at an organizational level by Board Members, Hospital Executives CEOs, Program Directors, Program Executives.
- Guide for State EMS Agencies – How to use the HEMS IRP: Provided to State EMS Agencies in order to provide information on how the HEMS IRP could be utilized at the State level.
61
Appendix cAbbReVIAtIOnS
AAMS Association of Air Medical Services
ADS(B) Automatic Dependent Surveillance - Broadcast
AHS American Helicopter Society
AMOA Air Medical Operators Association: United in Safety
AMRM Air Medical Resource Management
ATC Air Traffic Control
CRM Crew Resource Management
EMS Emergency Medical Services
FAA Federal Aviation Administration
FARE Foundation for Air-Medical Research and Education
FOQA Flight Operation Quality Assurance
FSF Flight Safety Foundation
GAO Government Accountability Office
HAI Helicopter Association International
HEMS Helicopter Emergency Medical Services
HTWAS Helicopter Terrain Warning Avoidance System
IFR Instrument Flight Rules
IHST International Helicopter Safety Team
IMC Instrument Meteorological Conditions
IRP Industry Risk Profile
IRSMS Integrated Risk & Safety Management Systems
ISO International Standards Organization
JSAT Joint Safety Analysis Team (part of IHST)
JSIT Joint Safety Implementation Team (part of IHST)
NTSB National Transportation Safety Board
NVG Night Vision Goggles
SMS Safety Management Systems
VFR Visual Flight Rules
62
PARt 4 Supporting Appendices
Appendix dPROjeCt COntACt DetAILS AnD PROjeCt ACKnOWLeDGeMentS
Project Contact Kimberley Turner Chief Executive Officer Aerosafe Risk Management 1325 G Street NW Washington DC Ph: 202 449 7693 Fax: 202 449 7701 kturner@aerosafe.com.au
Staff Acknowledgments In addition to the contact named above, Bradley Glassington, HEMS IRP Project Manager; Robin Graham, Senior Risk Advisor (Aviation); John W.Overton, Jr., M.D., Senior Risk Advisor (Medical) and Katherine Robinson, Senior Planner & Communications Manager have all made key contributions to this report. Graphic Design provided by GraphikExposure.
Technical Review Special thanks to Kevin W Knight, Chairman ISO Standards Committee Risk Management for undertaking a technical review of the HEMS IRP.
Custodian of the Flight Safety Foundation is to be commended for their enthusiasm in taking HEMS IRP on the role as custodian of this body of work. It is with great appreciation
and deepest thanks to Joan Sullivan Garrett, Vice Chairman Flight Safety Foundation; William R. Voss President and CEO Flight Safety Foundation; Emily McGee, Director of Communications for the support and interest in this initiative.
Review & comment The opportunity for review and comment on the draft HEMS IRP was providedon the Draft HEMS IRP to 33 different stakeholder groups. Additional resource, dedicated briefings
or a workshop was held with AAMS, AHS, AMOA, AMPA, CAMTS, FAA, FARE, Flight Safety Foundation, GAO, HAI, House Aviation Sub Committee, International Helicopter Safety Team, NEMSPA, NTSB and The Joint Com-mission. The project team would like to thank these organizations for the time taken to review, discuss and provide feedback on either the concept of utilizing risk management at the industry level or the provision of comment on the draft HEMS IRP over the period February 12, 2009 – April 15, 2009.
Obtaining Copies Flight Safety Foundations web site www.flightsafety.org Copies are availableof the HEMS IRP at no cost.
Order by mail The Foundation of Air Medical Research and Education has taken on respon-or phone sibility for printing and distribution of the HEMS IRP to industry. Contact
details for ordering copies are on the back cover of this document. Special acknowledgment and thanks to FARE Board, their Chair Dr Kevin Hutton and staff for their ongoing commitment to safety research & education.
63
foR MEdIA InQuIRIES, contAct:
EMILy McgEE, director, communicationsflight Safety foundation, 601 Madison Ave, Alexandria vA 22314 Phone: 703 739 6700 Email: mcgee@flightsafety .org
foR InQuIRIES on tHE HEMS IRP, contAct:
BRAdLEy gLASSIngton, HEMS IRP Project ManagerAerosafe Risk Management, 1325 g Street nW, Washington dcPhone: 202 449 7693 Email: bglassington@aerosafe .com .au
to REQuESt youR coPy of tHE HEMS IRP contAct:
AMBER BuLLIngton, Program Managerfoundation Air Medical Research and Education526 King Street, Suite 415, Alexandria, vA 22314Phone: 703 836-8732 Email: abullington@aams .org
FOUNDATION FOR AIR-MEDICAL RESEARCH & EDUCATION
The HEMS Industry Risk Profile helps fulfill FARE’s mission of raising awareness, and advancing research in the emergency-medical-transport field. FARE is distributing this document, in its hardcopy form, to air-medical service professionals and others interested in the field to be used as a tool in advancing safety for the entire HEMS community.
To order your copy of the HEMS IRP go to
www.fareonline.org
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