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Ask the expert: Correction to last week's proctoring question

Medical Staff Leader Connection, February 27, 2008

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Editor's note: Last week's "Ask the expert: Who is likely to sue as a result of improper or inadequate proctoring?" stated "There is no legal or regulatory requirement to proctor every physician new to the medical staff, so it is important for hospitals to make clear that not all newly privileged clinicians will be proctored if this is not the uniform practice at the institution."

However, this tip did not take into account Joint Commission standard MS.4.30, which states that the organized medical staff is responsible for defining the circumstances that merit the evaluation of a physician's performance.

According to The Joint Commission, MS.4.30 became effective on January 1, 2007, with the exception of Element of Performance (EP) 1, which requires physicians to undergo a period of focused professional practice evaluation for all initially granted privileges. EP 1 went into effect on January 1, 2008.

The book Proctoring and Focused Professional Practice Evaluation: Practical Approaches to Verifying Physician Competence, by Robert J. Marder, MD; Mark A. Smith, MD, MBA, FACS; and Todd Sagin, MD, JD, from which last week's "Ask the Expert" was extracted, was published before EP 1 was published.

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