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

1. The development of quality assurance for clinical decisions by the UK maritime authority.
Tim Carter
Norwegian Centre for Maritime Medicine, Bergen

2. What makes a quality system?
Good standards and guidance?
Supporting casework advice?
Assessor’s professional status and experience?
Training in seafarer fitness assessment?
Accountability for decisions taken?
Audit?
Based on 10 years of system management in UK.

3. Visible output
Decision on:
•‘Fitness’ for proposed duties
•Any restrictions on duties or voyage patterns
•Any time limitations Expressed on statutory fitness certificate. OR Decision on:
•Temporary unfitness
•Permanent unfitness Expressed on form giving details of appeal procedures.

4. UK experience
Year
Total
% time limit
% restrict
% t unfit
% p unfit
2005
35363
7
5
1.5
0.5
2009
39920
7
5
1.2
0.3
2012
52200
8
6
1.2
0.2
UK approved doctors c 75% of medicals
c. 200
Non-UK A.D.s c 25% of medicals
c. 50
Referees - UK based (40-80 reviews/year)
7-9
MCA
CMA ½ time. 3 admin staff.

5. Good standards and guidance?
Pre 2001 –simple list of conditions and decisions
2001-10 table – evidence, on diagnosis and when stabilised, when to go to guidance or obtain specialist opinion. Mix of specification and discretion in decisions. Supported by guidance on 14 common and difficult conditions. Reduction in failures, increase in restrictions.
2010-present – detailed revisions, take account of new diagnosis and treatment methods. Reduction in appeals.

6. Purpose of statutory criteria
To ensure that all certified seafarers reach an agreed standard for the benefit of maritime safety and efficiency and for the safe employment of UK seafarers? YES, YES, YES
- clarity, consistency, validity, equity, engage and empowering seafarers to look after their health

7. Purpose of employer add-ons to criteria
To help employers/insurers each have the opportunity to engage the lowest risk members of the pool of UK seafarers? NO, NO, NO
-stratification, basis for blame – lots of ‘tests’ no clarity on actions to follow finding of abnormal result, mistrust of seafarers, evidence-base for criteria displaced by anecdotes of costly cases.
Should medical exam findings form a part of competitive recruitment or should they be excluded from it on legal or ethical grounds?
Consequence – best ship operators get lowest risk seafarers. Bad operators get high-risk ones.

8. Quality criteria
- clarity, consistency, validity, equity, engage and empowering seafarers to look after their health
Tried in UK 2001 – 2010
Formed basis for ILO/IMO Guidelines – now a common good.
Standards above the minimum should still conform to these criteria if they are to be fit for purpose.

9. Supporting casework advice?
•Phone and email help-line to ADs
•Files of common questions – standard replies
•Six monthly newsletter, with advice on recent case questions – disseminate to all ADs
•Annual seminar (>100 attend). Case and scenario discussions.
•Revision of standards and guidance based on questions from ADs Improved consistency, learning organisation.

10. Professional status and experience?
In UK most ADs are primary care doctors, a few OH clinics.
Outside UK more maritime and OH clinics.
AD temperament – rule following or ‘seat of pants’. Not clearly related to specialist status in OH or maritime health. Competence = know limits of knowledge!!
Detailed criteria mean more open recruitment. Discretion on complex cases probably better with specialists, but can be biased by commercial links to employer.

11. Training in seafarer fitness assessment?
Essential unless all ADs come with specialist knowledge. Bonding to MCA and methods. Two elements: - Assessments by medical examiner using pre- set criteria.
-Meet MCA administrative and quality requirements. Training CD complete in first year– 20 hours. Visit by CMA in first year (UK goal).

12. Accountability for decisions taken?
Contacts with MCA – well formed questions, right information given Complaints by seafarers/employers – v rare. ‘seat of pants’ ADs Appeals to referees – was initial decision a sound one? 100% QA by peer review on all referee decisions. Annual return of medicals done, conditions found and decisions taken. Outliers investigated

13. Audit?
Clinical and administrative audit visits. >95% up to date in UK, c 30% outside. Standard recording of findings and feedback on shortcomings and on innovations.
Priority for re-visit decided after each audit.
About 25 per year now.
Common findings: vision testing poor, records unclear, use of criteria and decision taking inconsistent. More frequent in ADs recruited prior to induction training.
35% comply, 45% minor problems, 18% larger problems, 2% terminated.
Approval is renewed each year and some poor performers are not re- appointed.

14. What makes a good system for seafarer fitness decisions?
‘Experience-based ranking’
1 Good standards and guidance?
2 Audit?
3 Accountability for decisions taken?
4 Training in seafarer fitness assessment?
5 Supporting casework advice?
6 Assessor’s professional status and experience?
Based on 10 years of system management in UK.

15. Contrast with PEMEs
1.System to safeguard all not just those whose employers’ want it?
2.Safety risks, health risks and economic risks are balanced equitably?
3.There is public accountability for criteria and for decisions taken?
4.System is hard to corrupt – by employers, seafarers, or by state?
5.Ethical aspects applied globally –aim.

16. Is this a “quality” system? - Shortcomings:
1.Quality of performance data – still manual.
2.Variable AD behaviour – obesity
3.Statutory/PEME conflicts
4.Fee restrictions
5.MCA resource limits
6.I WAS NOT QUALITY ASSURED But: it has been in a state of continuous improvement for 14 years. The ILO/IMO Guidelines are modeled on it. Others freeload on it as they trust it.

18. Lessons for other QA and accreditation systems
1.Audit and accountability are key
2.This does improve system performance
3.It needs to be an open process
4.It should operate in the common interest
5.It must be done by competent assessors
6.It should be a learning experience
7.It improves the acceptability of certificates IMHA Quality ticks all these boxes None of the P&I or employer arrangements do.