The Norwegian Sea Health Conference 2014, Bergen, 27-28th August 2014

1. Quality assurance of medical examiners: an approach tailored to maritime medicine
Dr Sally Bell
Chief Medical Advisor
UK Maritime and Coastguard Agency

2. What is QA?
•Agree and set standards
•Put systems in place to comply with standards
•Evaluate to ensure that standards are being met
•Identify areas for improvement
•Review standards

3. Plan
Implement
Evaluate
Review

4. How do non-maritime organisations achieve QA?
•Industry and others – ISO (process orientated)
•Some tailored programmes specific to their organisation
•Healthcare specific standards +/- ISO
•Verify with either internal or external audit

6. What does the maritime sector want from QA?
The maritime agenda varies greatly -
•National maritime administrations
•Shipping companies/Manning agencies
•Insurance companies (P & I Clubs)
•Seafarers and unions
•Providers of maritime medical services
•Providers of accreditation services

7. Maritime Administrations
•Statutory requirement
–MLC
–STCW
–ILO/IMO guidelines
•Fulfils aim to ensure safety and efficiency in ships carrying their flag, and their own seafarers
MCA “Safer lives, Safer ships, Cleaner seas”

9. Maritime Administrations
•Philippines (ISO, PCAHO)
•Some other maritime authorities to varying degrees (eg UK, Germany and Netherlands audit at home and visit their overseas doctors)
•Failure of all to provide consistent QA led to the need for shipowners and P & I clubs to fill the gap.

10. Shipping companies Manning agencies
•Compliance with of STCW, MLC 2006 and ILO/IMO guidelines
•Confidence in health care providers responsible for certificates
•REDUCE COSTS
•Some have their own QA schemes…

11. P & I Club schemes
•Offer a service to members
•Reduce costs subsequent to illness and injury
•View of costs may be skewed as only those reaching claim status are seen

12. But….
•Loss of experienced crew if medical standards over stringent or unnecessary tests conducted
•Cost element
•Company/P & I examinations have no statutory status
……..

13. …….
•Usually no appeal mechanism
•Ethics and accountability need to be considered
•Employer/agent can be liable under employment law if someone is fit in statutory terms, but they are turned down because they don't meet company criteria

14. Seafarers, Unions
•Fair, ethical and confidential treatment
•No discrimination – not excluded from a job that they are fit to perform
•Confidence in their employer and medical provider
•Job security for those who are fit to work…. But not for the unfit

16. Providers of maritime medical services
•Demonstrate the quality of their service to clients
•Increase business whilst improving efficiency
•Provide better care for seafarers
•Single accreditation scheme reduces burden of multiple approval visits
•All QA involves paperwork and admin!

19. Providers of QA
•International providers such as companies providing ISO – trained auditors, independent, but standards non-specific to healthcare/maritime
•Individuals employed direct by stakeholders
–Aims tally with those of the stakeholder
•IMHA QUALITY
–Registered charity, whose objects are to improve the quality and effectiveness of the interventions used to prevent and treat illness in seafarers or to improve their safety

20. Some aims clash, but all want:
•Compliance with regulation - Requirements of STCW, MLC 2006 and ILO/IMO guidelines,
•Improved crew welfare
•Clinical outcomes
–Valid, consistent and ethical decisions
–improved fitness and safety

21. What is the current situation?
•Lists of approved doctors, driven by stakeholders
•Audit visits, by stakeholders
•Outcomes data
•Balance cost and benefit
•Patchy, national or company driven

22. What is the current situation?
•Public awareness of quality assurance in all areas has never been so high
•Changed from being an optional extra to a foundation of practice
•Quality assurance in healthcare is expected by patients and other stakeholders
•Much evidence shows that accreditation is a powerful tool for quality assurance and quality improvement

23. Literature reviews
Accreditation Canada. The value and impact of healthcare accreditation: A literature review. July 2012
Annals of Saudi Medicine. 2011 Jul- Aug; 31(4): 407–416 Impact of Accreditation on the Quality of Healthcare Services: a Systematic Review of the Literature

24. Staten Island Ferry 2003 11 killed, 165 injured

25. What is needed for maritime health QA?
A system that is
•Is tailored to maritime health
•Includes valid external review that is unbiased and internationally recognised
•Is acceptable to all stakeholders
•Includes Peer Review (not seen in many current systems)

26. Peer Review
•Peer defined as “Someone you would consider an equal in terms of role, expertise and understanding”
•In this context, this means a maritime health physician
•Essential in health care settings to QA clinical decisions and processes

27. Peer Review
•Reviewers should be trained and competent to make judgements regarding the compliance against the agreed set of standards.
•The process should reflect the current range of views and opinions of the field
•Reviewers must be impartial with no conflict of interest
•The process should help to improve quality of services by providing clarity around areas for improvement and acknowledging good practice

29. This is why we have developed IMHA QUALITY
•Fulfils needs outlined above
•Can provide peer review to internationally agreed standards from trained assessors
•Gives an unbiased view of clinic practice
•Will enable providers to avoid multiple audit visits

30. Participation in peer reviewed QA confirms commitment to:
•Compliance with regulation
•Improved clinical outcomes
•Risk mitigation
•Safety, efficiency, accountability
•Continuing quality improvement
Sends a powerful message to key decision- makers and the public

31. What are the challenges?
•Understanding of language of quality
•Engaging and motivating different stakeholders – who goes first?
•Who bears the cost of implementing change?

33. Thank you!
Sally.bell@mcga.gov.uk