The development of quality assurance for

clinical decisions by the UK maritime

authority.

Tim Carter

Norwegian Centre for Maritime Medicine,

Bergen

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.

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.

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.

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.

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

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.

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.

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.

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.

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).

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

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.

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.

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.

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.

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.