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Small Hospital Challenges Monthly: Proctoring in small hospitals

Medical Staff Leader Connection, October 10, 2008

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Dear medical staff leaders and professionals,

Proctoring poses unique challenges for small hospitals. For starters, members of medical staffs at small hospitals go to the same banks and grocery stores, and their kids go to the same schools. With this kind of work-life crossover, many physicians find it difficult to participate in the performance evaluation of a colleague. In addition, small hospitals are also challenged by the fact that there are not as many practitioners with similar privileges.  Keeping these challenges in mind, how can small hospitals develop effective proctoring programs?

For this, we need to think outside the box. Although many think of proctoring as the real-time observation of another practitioner performing a procedure, it may also be prospective or retrospective. For example, when proctoring a surgeon, it is important to assess the pre-procedural evaluation, the procedure itself, and post-procedural care.

Thus, we need to expand our current definition of proctoring to include:

• Prospective: Ensuring the evaluation rendered before definitive care is given is appropriate.
• Concurrent: Ensuring the procedure/treatment is done well.
• Retrospective: Evaluating the case from admission to discharge. This type of review is routinely done post-discharge.

Widening our definition of proctoring not only helps us better assess a practitioner’s competence, it is also less burdensome on the physician proctor. The reason many physicians hesitate to proctor their colleagues is because they feel it takes them away from their own practices. In addition, many feel that they do not need to proctor a lot of cases to determine a physician’s technical skills, yet they are often asked to do so.

Prospective and retrospective reviews are not as burdensome on the proctor, and valuable information can be gained. Often, physicians are more willing to engage in proctoring when a minority of their time is spent on concurrent review and more cases are evaluated prospectively or retrospectively. This can be helpful in small hospitals to ensure that the limited number of physicians on staff are not overburdened with this responsibility.

A discussion of proctoring is incomplete without mentioning retrospective external case review and the use of teleproctoring. Sometimes, small hospitals have a difficult time finding a physician on staff with similar privileges to the physician under review and who does not have a significant conflict of interest. In these cases, it is useful to do external peer review on a limited number of cases. (If you can do this collaboratively with another hospital, it can be done at minimal cost).

With the use of remote imaging, it is now increasingly common to see a procedure proctored remotely by another physician. This can also ease any burdens you may have with credentialing outside proctors to observe cases in your institution.

When it comes to proctoring, keep it simple:

• Keep the number of cases proctored reasonable; enough that you feel you can say the practitioner is competent, but not so many that physician proctors feel overwhelmed
• Use prospective and retrospective proctoring and limit concurrent proctoring to a minimum 
• Use external case review if needed for proctoring
• Remember that teleproctoring is a viable alternative if you have access to communication technology 

Best regards,
Mary Hoppa, MD, MBA, CMSL
Senior Consultant The Greeley Company

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