1. Proposals for strengthening the management of Approved Doctors to improve the quality and consistency of the standards which they apply Kirsty Wicks Lead Auditor Corporate Governance and Risk

2. Current method for monitoring the application of medical standards Audits – administrative and clinic aspects of ENG1 medical examinations AD Annual returns – identifies trends and consistencies in medical conditions, and AD decision making CMA advice system – highlights common queries suggesting where further guidance / training is required Medical Referee Casework Audit meetings

3. The drivers for this project Non conformities identified during audits Inconsistencies identified during the analysis of statistical annual returns Misinterpretations of MCA guidance Resource restraints and the desire to improve efficiency and ensure continual improvement Desire to improve communications with ADs to overcome barriers caused by technology

4. Common Shortcomings identified through audits

5. Security / standards issues = 12% Non conformities Storage of medical certificates Separation of records of doctors working at the same premises Pre-signed certificates Forwarding ENG2 medical reports on to agents / employers

6. Issue of certificates & completion of medical forms 10% Non conformities ENG2 reports not completed in full Incorrect issue of ENG3 forms Medical info included on ENG1 certificate Alteration of certificates following an error Use of restrictions

7. Colour vision / visual acuity testing 28% Non conformities Insufficient lighting for Snellen Chart 3m distance not marked Snellen Chart not fixed to wall Snellen Chart discoloured/unfit for use Lack of awareness of testing procedures and supplementary tests available

8. Administrative issues / Record keeping 24% Non conformities Manuals not kept up to date Green copies of ENG1s not kept on pad Lack of organised records

9. Examination procedures 11% Non conformities Failure to draw seafarers attention to the back of the ENG1 Withdrawal of previous medical certificate AD personally taking medical history, examining, and issuing documentation to seafarer BMI not always calculated Chaperone not offered Seafarer ID not checked Urine sample not carried out at Health Centre

10. AD QUESTIONNAIRE Issued to all 238 ADs – 123 returned Focused on training and support, audit, and communication & technology Identify AD views on how they are managed by MCA, and any changes / improvements they feel need to be made

11. Satisfaction with existing guidance / info Highest satisfaction levels relate to Standards and Manual Raise awareness on those areas with no comment?

12. Audit 66% of ADs are subject to an internal audit, but in only 33% of these cases does this audit include their role as an MCA AD.

13. Alternative methods to face to face audits

14. Details on other suggestions IT based work / training – immediate access to info for MCA Document assessment – sending in ENG3s Feedback from seafarers Concerns / Issues for consideration Geographical local of casework mts and seminars Stopping face to face audits altogether

15. Preferred methods to follow up from audits

16. Sustainable audit programme Conclusions Local casework audit mtgs most popular choice for alternative to face to face audits 66% ADs subject to internal audit 1/3 AD favour a higher level of audit follow up – written correspondence Audit & Training Online system will provide immediate access to information – efficient for MCA & ADs Method of audit, follow up & training needs to be considered in terms of acceptability of professional group of doctors. Used as incentives to improve performance Recommendations Introduce local casework audit mtgs. Combine as training. Use MOs / MRCCs to reduce cost. Webcam/ teleconferencing for overseas ADs. MAT make better use of existing available info. Liaise with other MAs. Introduce formal audit action report; requirements, risks/ implications, evidence Continually review to ensure consistent application of stds &MCA to learn where to improve. New interactive T-CD, facility to check answers…interpretation Pursue case for online system, taking account of list of AD desirables Situational leadership model – adapt suitable communication and learning style for to ADs. Use AD working group to discuss & trial agreed recommendations.

17. Mutually beneficial supplier relationship Conclusions ADs satisfied with advice & support Lower level of satisfaction with training & guidance Improvements to existing guidance required Improvements to communication with ADs rqd – esp overseas Recommendations Improve access to advice, raise awareness of existing services available. Monitor CMA FAQs. PDCA to ensure continual improvement Introduce further training & guidance. Review AD Manual, Standards & website. Buddy system? Promote awareness. Review to make more user friendly. Update to take account of clinical updates Introduce Casework audit mtg for overseas ADs? Video / teleconferencing to allow participation in training events Collaboration with other MAs. Invite AD articles for newsletters Seek regular feedback from ADs

18. Thank you for listening, and a special thank you to all of you who took the time to complete and return the AD questionnaire to assist with my research. Any questions?