Proctoring Policy

Purpose

The purpose of a proctoring program is to assure that surgeons applying for medical staff privileges practice in a safe manner, within the standard of care for their subspecialties.

Who should proctor

Members of the medical staff within the same subspecialty, preferably with senior status and extensive experience, should act as proctors. Avoidance of bias or conflict of interest is of paramount importance when selecting a proctor. Proctoring by more than one individual is recommended whenever possible.

Ground rules for proctoring

a) The credentials committee of the medical staff must validate the capabilities of the surgeon for the performance of his/her duties, so it must be responsible for ensuring the fairness and validity of the proctoring process.

b) The credentials committee should generate a specialty-specific proctoring report form that delineates the areas of performance that are to be evaluated by the proctor(s). This form should be provided to both the proctor(s) and the proctoree.

c) The number of cases to be proctored should be reasonable (e.g., 5-10), with the understanding that additional observation may be necessary in some cases. Similarly, the time allotted to complete the proctoring process should be reasonable, allowing the proctor(s) and proctoree enough time to complete the required observations.

d) It is not acceptable for a proctor to be a casual or transient observer of a surgical procedure, because he/she must observe enough to ensure a complete evaluation that includes all of the important features of the procedure. A proctor may act as an assistant during a case, but this is not necessary to fulfill his/her responsibilities.

e) Communication between the proctoree and the proctor must be sufficient to ensure that the proctor is aware of when the operations are to take place, their indications, and the manner in which they are to be carried out.

f) The proctoree is responsible for reasonable prior notification of the proctor for the cases to be observed. A record should be kept of the cases for which a proctor has been requested, and problems with unavailability of a proctor after reasonable notification should be reported promptly to the credentials committee.

g) The proctor must complete case evaluation forms in a timely manner, paralleling the hospital policy for completing operative notes.

h) The proctor must hold information related to the proctored events strictly confidential. Unauthorized release or sharing of opinions or information related to proctored events is a violation of ethical standards.

i) The completed proctoring evaluation forms must be available to the proctoree upon request.

j) To ensure procedural fairness, an appeal mechanism must be in place to accommodate the proctoree who wishes to file a complaint about the proctoring process. Similarly, an appeal mechanism must be in place for members of the medical staff who wish to contest the granting of privileges based on what they believe to be inadequate or flawed proctoring.

k) The role of proctor is important for appropriate privileging in hospitals, so accepting that responsibility should be a criterion for medical staff membership.

Special Situations and Exceptions

a) If there is no specialist on the medical staff who qualifies as an expert for the procedures to be proctored, the credentials committee should use an alternate system for ensuring safety and competence of an applicant surgeon. This could include documentation of prior experience and letters of reference from qualified individuals at other institutions or recruitment of an appropriately qualified proctor from outside the institution.

b) If a surgeon is requesting privileges to use new technologies for which there is no experience within the institution, the medical staff should establish an alternative to proctoring, such as documentation of an appropriate training course.

Approved by the STS Board of Directors on January 29, 2006.

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