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Renewed Interest in Proctoring

Patient Safety Quality Monthly, September 15, 2006

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Dear Colleague,

While proctoring has historically been part of our medical culture to create and verify physician competency, its use has diminished over the past few decades. That is about to change. Two factors are driving this change and will increase the need to perform proctoring well: the 2007 JCAHO Standards and public concerns regarding patient safety.

First, let's talk about the 2007 Standards. There are two forms of practitioner evaluation described in the new standards: Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). OPPE is based on evaluating routine measurement processes that are used for peer review. FPPE is the evaluation of current competency when data from your organization (i.e., a new applicant or a new privilege) is unavailable or when a concern is raised by your ongoing measurement process.

In a perfect world, we would have all the data we need available to us to verify physician competency. However, in the real world today, we don't. The JCAHO recognizes this, so they now call for FPPE--what we have traditionally labeled as proctoring in its multiple forms--as the means to get that data.

The second factor driving interest in proctoring is increased focus on patient safety. As safety lessons are translated to healthcare from other high risk industries, serious questions are raised about how well we do in understanding and verifying physician current competency.

If you would just step out of our healthcare view of the world for a moment, let's look at how airline pilots are evaluated. When an airline hires a new pilot and entrusts that individual with equipment worth millions of dollars and people's lives worth much more, they just don't take the pilot's word that he/she can fly a 747. The pilot is required to demonstrate his/her skills through both simulation and observation to verify current competency. And each year, even if a pilot has a good record of performance, he/she is required to be recertified.

Clearly the rigor of our evaluation of physician current competency today is nowhere near this standard, and the public and regulators are beginning to recognize the large gap between these two systems.

So what is proctoring? Like any term, proctoring can have multiple meanings and implications. Proctoring can be performed prospectively, concurrently, and retrospectively. It can be limited to evaluation or it can involve mentoring or even intervention. In can involve direct observation, simulation, interviews, chart review, outcomes data analysis, or combinations of all of these methods.

There are a number of historical, logistical, measurement, and ethical issues that have made proctoring difficult in the past. However, there are also solutions to these issues that have been developed and implemented successfully.  The question now is not whether you will do proctoring. Rather, the question is how can you design and implement a systematic proctoring program that provides real information about physicians' current competency and is fair, cost effective, and practical?

Regards,

Bob Marder, MD
Practice Director, Quality and Patient Safety
The Greeley Company

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