The systems used for risk management in maritime health depend heavily on professional decisions taken in valid and ethical ways. These decisions are liable to be compromised to meet the operational requirements of an industry that is driven by tight global constraints on its economics and which is also free to escape from restrictive national jurisdictions on employment rights and on the recognition that seafarers’ organisations have a role in shared decision- taking.
For this reason effective quality systems are needed to confirm that those with expertise are exercising it correctly and also to ensure that those whose expertise is limited are not going beyond the boundaries of their competence. Quality assurance may be seen as an integral part of ship management within a ship operating company, it may be part of the requirements for those who insure or charter a ship, while legally it is an obligation on the states that register a ship to operate under their flag. Quality services may be provided external bodies, such as ISO the international body that exists to develop technical and managerial criteria for worldwide use , who uses criteria that are accepted by others.
There are problems in applying the sort of criteria used by ISO and similar organisations to healthcare activities. This is because of the large amount of professional discretion, based on training and experience, that underpins decision taking. Many countries are now requiring health professionals to have the quality of their knowledge and practice appraised periodically as a pre-requisite remaining on the register of active practitioners. This can be an important safeguard for overall standards, but in general such systems, which are designed to confirm the quality of clinical practice are not tailored to meet the particular conditions and ethical conflicts that arise in maritime health. In countries where such systems do not operate and where registration and a licence to practice are issued for life it can be difficult for international organisations to determine which practitioners to select as advisers.
Professional re-accreditation systems, which were originally developed for a limited range of professions, such as medical doctors, have now become more widely used not only for other health professions but also for non-clinical advisers in areas such as safety and ergonomics. The arrangements for approval of doctors by maritime authorities to issue seafarer medical fitness certificates are an example of personal accreditation to perform a task in maritime health. However only a minority of maritime authorities, mainly in the traditional maritime nations, have put measures in place to assess the quality of decision taking among their own approved doctors. Where this has been done it can both improve consistency and compliance with statutory fitness criteria as well as providing useful feedback to the authority on ways in which criteria can be improved.
Individual re-accreditation may not be sufficient to determine the quality of performance in complex healthcare facilities such as hospitals and large clinics. A number of dedicated healthcare accreditation systems are in use., but to date only one set of quality criteria that are specific to maritime health have been developed, primarily for use as part of the approach to accreditation for seafarer medical examinations by IMHA Quality. However some ship operators and their insurers, the P&I Clubs, have informal methods for assessing clinic performance. This is often done in ways that are themselves less than fully quality assured and goals may focus simply on reducing the costs of treatment and repatriation rather than being aligned to wider objectives of securing seafarer health and maritime safety in an equitable way that avoids unfair discrimination.
Making judgements about the quality of healthcare services in such an international sector as shipping can be complex as expectations are embedded in national attitudes to health, to business and to equity. This is an area that is in its infancy, but where there are real needs in a sector where crewing, ship ownership, insurance and location are worldwide.