New Staff Member Initial Appointment Responsibilities

PROCTORING - Prospective, retrospective and concurrent proctoring and/or chart review will be used to confirm clinical competence according to each department’s guidelines.

New Staff Member – Initial Appointment Responsibilities

All practitioners are subject to proctoring. Proctoring begins at the time privileges are initially granted at the time of initial appointment, granting of temporary clinical privileges, or granting of any new privileges between appointments.

1. The new staff member will review the summary of clinical privileges granted and proctoring requirements as delineated on their delineation of privilege form (DOP).
2. The new staff member will accept the responsibility to arrange for a proctor and to schedule his/her cases at a time when an eligible proctor has agreed to be available. The involvement of two or more proctors in the proctoring process is encouraged.
3. Within the first 90 days on staff, the new staff member will submit to their Department Chair or Division Chief a complete packet of proctoring reports according to their department’s proctoring guidelines and request an extension for additional time for any proctoring that is not complete.

Medical Staff AdministrationResponsibilities

1. Medical Staff Administration will provide each new staff member at initial appointment with blank proctoring forms,a summary of clinical privileges granted, and proctoring requirements as delineated on their delineation of privilege form (DOP). A copy of the DOP and proctoring requirements will be sent to the new staff member’s department.
2. Medical Staff Administration will include a summary of clinical privileges granted and proctoring requirements with the new staff member’s Governing Board appointment letter.
3. Medical Staff Administration will send a reminder to new staff members60 days after their initial appointment to submit their proctoring reports to their Department Chair or Division Chief within the first 90 days on staff. A copy of the reminder will be sent to the new staff member’s department.

Proctor Responsibilities

1. A proctor will complete and sign a confidential proctoring form for each case proctored and return this form to the new staff member to compile for submission to their Department Chair or Division Chief.
2. The proctor’s role is to observe and record the performance of the practitioner being proctored. The proctor is not mandated to intervene when he/she observes what could be construed as deficient performance on the part of the practitioner being proctored.
3. In an emergency situation, the proctor may intervene; even though he/she has no legal obligation to do so, and in such a circumstance, the proctor is acting in good faith should be qualified as a Good Samaritan within the “Good Samaritan” laws of the State of California.
4. The activities of the proctor constitute an integral part of the peer review system of the Medical Staff, and as such, any and all information and records regarding the proctorship shall be subject to all confidentiality requirements within the Bylaws and proctors are subject to all immunities accorded Medical Staff peer review activities and any applicable regulations, statutes or legal decisions.

Other Institutions

UCSD Medical Center shall accept evidences of proctoring completed at a nearby institution to supplement actual observation on the premises if the following conditions are present:

1. The proctor must be a member in good standing of the medical staff at both institutions.
2. The proctor is eligible to serve as a proctor at UCSD Medical Center according to Department/Division guidelines.
3. The range and level of privileges requested is similar at both institutions.
4. A proctor will complete and sign a confidential proctoring form for each case proctored and return this form to the new staff member to compile for submission to the Department Chair or Division Chief.
5. The Credentials Committee Chair may grant exceptions to the above conditions upon requestfrom the Department Chair or Division Chief.
6. Review of medical records or other examples of Focused Professional Practice Evaluation (FPPE) may be used to supplement proctoring when appropriate.

Department Responsibilities

1. Each new staff member will be assigned a proctor by the department or given a listing of names of individuals who are eligible proctors with the same range and level of privileges as the new staff member. The Department Chair will make an appropriate proctoring assignment if problems identifying a proctor are encountered.
2. The Department Chair will submit a summary to the Credentials Committee Chair 90 days after the initial appointment evaluating the performance of the new staff member’s proctoring activities. The summary will identify the successful completion of the proctoring requirements and any outstanding privileges that require an extension of time for completion of proctoring.

Completion of Proctoring

Successful Completion - Proctoring shall be deemed successfully completed when the practitioner satisfactorily completes the required number of proctored cases within the time frame established and the practitioner’s performance in the cases meet the standard of care of the Medical Center.

Failure to Complete Necessary Volume – Any practitioner who fails to submit to his/her Department Chair or Division Chief the required number of proctored cases within 90 days shall be deemed to have withdrawn voluntarily his/her request for the relevant privileges. The department has the discretion to extend the time for completion of proctoring up to one-year subject to ratification by the MSEC.

Failure to Complete Proctoring Satisfactorily – Refer to Medical Staff Bylaws Section 5.8.C.2 “Proctoring” if a practitioner completes the necessary volume of proctored cases but fails to perform satisfactorily during proctoring.