Management of Ill Health in the Workplace: A system should be established which provides access to primary, secondary and emergency medical facilities, as well as to occupational health expertise where appropriate, and which is underpinned by a systematic approach to maintaining and improving the quality of care within the health system. (A) Governance: This approach to improving the quality of healthcare is described in some countries as clinical governance. The important elements of this governance system that are applicable to oil and gas field medical activities are described below, and include: (a) managing clinical effectiveness; (b) managing risk; (c) patient safety and incident reporting; and (d) using evidence. (A.1) Managing Clinical Effectiveness: Clinical effectiveness can be described as the right person doing: (a) the right thing (evidence-based practice); (b) in the right way (skills and competence); (c) at the right time (providing treatment/services when the patient needs them); (d) in the right place (location of treatment/services); and (e) with the right result (clinical effectiveness/ maximizing health gain). Evidence that clinical effectiveness is being utilized in a health-care system includes the following important activities: (a) Clinical or medical audit to critically review current practice. (b) The identification of treatment outcome measures. (c) The presence of protocols/processes in support of clinical governance. (A.2) Managing Risk: There are various day-to-day risks involved in the running of field medical operations. Things that could, and can, go wrong include: slips, trips and falls involving medical staff, patients and the public; administrative errors that impact on patient care; and clinical incidents that have a direct effect on the outcome of patient care. Risk management is a standardized process used in industry to reduce occupational injuries, errors, faults and accidents, and at the same time improve quality. Companies need to manage risk at two overlapping levels: (a) the strategic/management level; and (b) the day-to-day staff/patient operational level. Risk management is seen as an essential component in the delivery of safe and effective care. The development of a risk management matrix will be influenced by a mix of local legislative and regulatory requirements as well as by specific standard-based company guidance. Evidence that risk management is being utilized in a health-care system includes the following important activities: (a) Availability of risk management documents, e.g. risk assessment protocols, logs, register, action plans, etc. (b) Identifying and learning from risks across the company; this could involve coordinating and communicating information from different sources. (c) Incident reporting of errors and near misses. (d) Clinical effectiveness and audit projects that may impact or influence risk. (e) Complaints and claims management that identify risks. (f) Clinical outcome indicators that tell you whether you have achieved what you want from an intervention. Company health-care professionals need to know that they will be supported in the identification, reporting and management of risks in their work area. Creating a culture that values complaints and the reporting of incidents is an essential part of risk management. (A.3) Patient Safety and Incident Reporting: Research indicates that, in developed health management systems, around 10% of patient contacts result in harm to patients or staff. It is estimated that half of these harmful or adverse incidents are preventable. Clinical incidents and near misses, where there is no harm to the patient, highlight the need for appropriate action to be taken to reduce or manage risks. Reporting and learning from such events is part of the risk management process to protect the safety of patients and health-care staff. Evidence that patient safety and incident reporting are being utilized in a health-care system includes: Procedures for reporting and analysis of clinical errors and incidents. For further information on patient safety see Scally and Donaldson 1998, IoM 1999 and DH 2000. (A.4) Using Evidence: Clinical decisions about treatments and services should be made on the basis of the best available evidence to make sure care is safe and effective. Health professionals need to have the correct skills to identify and assess information from a variety of evidence sources to help them make decisions about care. Health-care professional development involves keeping up to date and reviewing practice on a regular basis. Activity in the following important areas demonstrates that evidence is being used in a health-care system: (a) Use of evidence-based practice. (b) Development of clinical guidelines. (c) Procedure for continuing professional development (CPD) of health-care staff. (B) Medical Facilities at Location: Strategic health management (SHM) principles should be applied wherever needed and practicable SHM involves systematic, cooperative planning in each phase of the lifecycle of a project to protect the health of the workforce and promote lasting improvements in the health of the host community. (B.1) Primary Care Facility: In some locations it may be sufficient to appoint a local doctor as a general practitioner to provide for the workforce. In other locations it may be necessary to develop a company clinic, which could include bringing in expatriate medical staff to provide care or work alongside local medical staff. (B.2) Secondary Care Facility: In most locations the company will identify approved local clinics or hospitals for further care. (B.3) Emergency Medical Care: The requirements for provision of emergency medical care are described on pages 5 to 8. Annex 3 provides further information about the knowledge and skill requirements for health professionals, and the medical equipment requirements for primary, secondary and emergency medical facilities. An example of a template to assist with auditing a local medical facility can be found in Annex 4. (B.4) Occupational Health-Care Facility: An occupational health-care facility may be set up to provide the following: (a) clinical health surveillance of employees hired locally or from outside the region; (b) immunizations; (c) evaluation of health aspects of catering, living accommodation, waste disposal and water testing; (d) support for evaluation and management of occupational health risks; (e) arrangements for first-aid and training; (f) conforming to local occupational health legislation; (g) briefing new arrivals on local health risks; (h) fitness for task, rehabilitation and return to work assessments9; and (i) support for human resources employment policies and procedures. In some locations it may be sufficient to appoint a local doctor as an occupational health practitioner for the workforce, whilst in other locations it may be necessary to bring in expatriate medical staff to provide occupational health support. Clinical health surveillance should be the responsibility of a doctor who has knowledge of preventative health care, ideally in the relevant occupational health setting. A nurse working directly under the supervision of such a doctor can carry out some of the procedures. Legislation regarding immunizations and their administration varies from country to country. Usually, a nurse may give immunizations provided that she is acting under the written direction of a doctor who has assessed the nurse's competence to immunize and deal competently with any adverse reactions. Evaluation of the health and hygiene aspects of catering, living accommodation, waste disposal and water testing should only be done by a doctor, nurse or other health professional who has sufficient knowledge and experience to perform the task in a competent manner. Support for the evaluation and management of occupational health risks should only be performed by a health professional that has sufficient knowledge and experience to perform the task in a competent manner. First-aid training should only be given by a health professional competent and certified to give such training. (B.5) Pharmaceutical and Inventory Management: Pharmaceutical and inventory management is, in principle, no different at field locations than at medical facilities in more accessible locations, though logistics and cold chain management may be more challenging. A cold chain10 is a temperature-controlled supply chain, which aims at maintaining the product at a given temperature range, thus extending and assuring the shelf life of pharmaceutical drugs. One common temperature range for a cold chain in the pharmaceutical industry is from 2° to 8°C, but the specific temperature (and time at temperature) tolerances depend on the actual drug or vaccine being transported. Remoteness, hot climate and customs delays pose well-known risks in relation to keeping the cold chain unbroken. Some common ways to achieve an unbroken cold chain include the use of refrigerator trucks, specialized packaging and temperature data loggers, as well as carrying out a thorough analysis, including taking measurements and maintaining documentation. At some geographical locations, the type and availability of controlled drugs, as well as the definition of what constitutes a controlled drug, may vary. However, whilst this is business as usual for most companies, local legislation relating to controlled drugs must be respected to ensure that the correct procedures are in place for the receipt, storage, record keeping and disposal of such drugs. Companies operating in remote locations have typically learnt to inspect not expect, and such an approach applies also to the need for pharmaceuticals and related inventory. It is important to ensure that labelling, instruction leaflets and procedures relating to pharmaceuticals match the language competence of the staff handling the medication. All pharmaceuticals on site should be stored securely with regular periodic checks of stock. It may be better to have a good standard inventory which is well known to staff than to add on a number of more advanced drugs with which staff are unfamiliar. Medical field services are often supplied by medical service providers or seismic contractor companies. Where this is the case, the operator company must include pharmaceutical-related issues in their risk assessment and follow-up. (B.6) Medical Equipment Management and Maintenance: Medical equipment management includes the business processes (e.g. procurement, installation and commissioning, training, maintenance and repair, record keeping, inventory management, decontamination and disposal) used in the interaction and oversight of the medical equipment involved in the diagnosis, treatment and monitoring of patients. It is a recognized profession within the medical logistics domain. A systematic approach to the management of medical equipment should be taken to minimize the risks associated with its use. This should include the purchasing, deployment, maintenance, repair and disposal of medical equipment. It is essential that whenever an item of medical equipment is used, it is: (a) suitable for (and only used for) its intended purpose; (b) used in accordance with manufacturers instructions; (c) properly understood by the professional user, i.e. staff should be appropriately trained and competent; (d) maintained in a safe and reliable condition; (e) recorded on a database; (f) selected and acquired in accordance with the company's recommendations; and (g) disposed of appropriately at the end of its useful life. A complete description of the requirements of a comprehensive medical equipment management system is beyond the scope of this guideline document. See MHRA 2006 for more information on this subject. (C.1) The Health and Welfare of the Local Workforce: Globalization has had an impact on the health, safety, well-being and culture of populations worldwide, as have new technologies, workplace organization, work practices, mobility and demographic trends. All of this has been associated with new types of diseases and health concerns among the working population and their families, together with an increased awareness of health issues. A workforce may consist of a combination of local, national and international staff, and short- and long-term contractors and rotators. Their terms of contract will be equally diverse but, as a guideline, the health-care provisions should follow the principles set out in this document. Management has a duty of care and must be sensitive to the diversity and individual requirements of its workforce and their dependants. Elements that should be considered by management and, in particular, by health-care personnel include: (a) occupation; (b) literacy, education and training; (c) culture; (d) language; (e) religion; (f) tradition; (g) superstition; (h) gender; (i) family; (j) dietary habits; (k) sanitation; (l) hygiene standards; (m) public health; (n) endemic conditions; (o) medical and health briefs; (p) alternative and traditional medicine; (q) local law and political climate; and (r) safety culture (fatalism and education). The importance of familiarity with cultural norms of the workforce cannot be overemphasized. (C.2) Medical Aspects of Health Care in a Local Environment: There should be close cooperation between: (a) national health-care workers; (b) company health representatives; (c) local health-care authorities; and (d) relevant stakeholders. Health-care personnel should take into account the diversity of the population they serve. In some countries, distance and access to certain specialities should be taken into account, as should racial, cultural and religious aspects, for example: (a) all individuals being treated with equal respect; (b) women's needs to be treated by female healthcare personnel; (c) fasting periods required by religious practices; (d) requirement for the provision of interpreters; (e) the impact of religion and culture on health education programmes; and (f) the complementary benefits of traditional and western medical practices. (C.3) Communication: Effective communication is essential for any operation and, in particular, for the management of health-related problems. Communication can be performed by: (a) telephone (fixed phone, mobile, satellite); (b) radio; (c) fax; (d) computers (e-mail, Internet); (e) video transmission; and (f) telemedicine (See below). Communication is necessary to enable the health professional in the field to contact company health professionals, approved specialists, relevant authorities, medical evacuation companies and managers. It enables health professionals to obtain advice, provide appropriate medical care, obtain necessary medication and material, and access medical websites and online medical journals to update their knowledge, organize medical evacuations and keep management informed of relevant medical decisions. (C.4) Telemedicine: Telemedicine can be defined as the use of telecommunication technologies to deliver medical information and services to locations at a distance from the care giver or educator. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and videoconferencing equipment to conduct a realtime consultation between medical specialists in two different countries. It can be used to provide medical consultations (routine or emergency), advice and assistance in diagnosis and treatment by providing a second opinion with a specialist. It can be used to coordinate and interpret diagnostic procedures and to transmit laboratory and radiological results (electrocardiogram, medical imaging, etc Telemedicine can also help the isolated health professional by providing on-site education. Telemedicine can be broken into three main categories: (a) store-and-forward; (b) remote monitoring; and (c) interactive services: (c-a) Store-and-Forward Telemedicine: involves acquiring medical data (like medical images, biosignals etc.) and then transmitting these data to another health-care professional at a convenient time for assessment offline. It does not require the presence of both parties at the same time. The store-and-forward process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination. (c-b) Remote Monitoring: also known as self-monitoring or self-testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is used primarily for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus or asthma. This service can provide health outcomes comparable to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective. (c-c) Interactive Telemedicine Services: provide real-time interactions between patient and provider, and include telephone conversations, online communication and home visits. Many activities, such as history review, physical examination, psychiatric evaluations and ophthalmology assessments, can be conducted comparably to those done in traditional face-to-face visits. In addition, clinician-interactive telemedicine services may be less costly than in-person clinical visits. Ideally, telemedicine requires a computer, a digital camera, diverse adapted diagnostic equipment, acceptable communication systems (sufficient bandwidth) and an agreement with specialized health-care providers. However, a basic telephone call or e-mail with a scanned or digital picture or X-ray attached can suffice in many cases. A number of problems remain to be solved concerning telemedicine, including privacy, confidentiality and security, as well as medico-legal responsibility and payment.