Quality assurance of

medical examiners:

an approach tailored to

maritime medicine

Dr Sally Bell

Chief Medical Advisor

UK Maritime and Coastguard Agency

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

Plan

Implement

Evaluate

Review

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

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

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”

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.

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…

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

But…

But….

• Loss of experienced crew if medical

standards over stringent or

unnecessary tests conducted

• Cost element

• Company/P & I examinations have no

statutory status

……..

…….

• 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

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

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!

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

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

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

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

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

Staten Island Ferry 2003

11 killed, 165 injured

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)

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

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

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

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

What are the challenges?

• Understanding of language of quality

• Engaging and motivating different

stakeholders – who goes first?

• Who bears the cost of implementing

change?

Thank you!

Sally.bell@mcga.gov.uk