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The purpose of this policy is to provide the Facility Credentials Committee with a tool to evaluate the clinical competence of an Allied Health Professional seeking clinical privileges to perform a procedure for which such Allied Health Professional’s current training and experience do not immediately indicate current competence. Proctoring provides an opportunity for objective evaluation of an Allied Health Professional’s clinical competence to perform a procedure, including the technical and cognitive skills utilized in the performance of the procedure, by the sponsoring and/or the supervising physician(s) who holds current privileges to perform the procedure(s) for which proctoring is being requested. Successful completion of a proctoring program helps to ensure that Allied Health Professionals seeking clinical privileges at a Atrium Health facility practice in a safe manner, within the standard of care for their specialty and/or subspecialty.

 The Facility Credentials Committee may recommend proctoring for any Allied Health Professional seeking clinical privileges, including the following:
  • Practitioners seeking initial non-core clinical privileges in their specialty and/or subspecialty.
  • Existing practitioners seeking clinical privileges to perform new or rarely performed procedures.
  • Practitioners seeking clinical privileges to perform procedures who have not provided sufficient evidence of clinical competence or experience in performing such procedures.
  • Practitioners for reappointment seeking a renewal of currently-held clinical privileges to perform procedures without sufficient volumes to determine clinical competence or experience in performing such procedures.

Types of Proctoring:

  • Allied Health Professionals may only be proctored by Concurrent Proctoring, i.e. the physician proctor actually observes the Allied Health Professional’s work. This method is used so that the medical staff will have first‐hand knowledge necessary to assure that the Allied Health Professional is competent.
  • Proctoring by Simulation is based on actual patient scenarios and images; the new training tool provides valuable experience performing procedures, without compromising patient safety. Benefits of proctoring by simulation for the physician include:
    • standardized and consistent training;
    • exposure to difficult cases;
    • less risk to the patient;
    • shortened learning curve;
    • standardized and guided training of procedural risks and potential reduction in complications related to the procedure; and
    • the ability to provide detailed computerized information regarding performance and skill level.

It is noted that proctoring by simulation may only be obtained through Carolina College of Health Sciences.



The development of an appropriate proctoring program should take into account the following factors:

  • The number of cases to be proctored should be reasonable with the understanding, that, additional observation may be necessary in some cases.
  • The time allotted to complete the proctoring process should be reasonable, allowing the proctor(s) and proctoree enough time to complete the required observations. The proctoring program should not exceed two (2) years in length.
  • It is not acceptable for a proctor to be a casual or transient observer of the procedure(s). The proctor(s) must observe enough to ensure a complete evaluation that includes all of the important aspects of the procedure.
  • The proctor must complete case evaluation forms in a timely manner. The completed proctoring evaluation forms must be available to the proctoree upon request.
  • The sponsoring and/or supervising physician, acting as a proctor, should have extensive experience in performing the proctored procedure.
  • Proctoring by more than one physician is recommended whenever possible.


In the event that requests for clinical privileges by an Allied Health Professional applicant or existing Allied Health Practitioner, suggest that proctoring would be appropriate, the applicable Department Chief shall recommend the terms of the proctoring, including the type of proctoring, the number of cases required, the length of the proposed program, the names of the proctor(s), and any other details or requirements specific to the procedures to be proctored. The Permission to be Proctored Request Form for the Allied Health Professional attached to this Policy should be used. The Chief of the Department shall recommend a suitable proctoring program prior to the commencement of the proctoring. The recommendation of the Chief will be forwarded to the Facility Credentials Committee and the Facility Medical Executive Committee for action; however, proctoring shall commence after Chief recommendation.


Upon completion of the proctoring program, the proctoree will submit completed proctoring report forms for all required procedures, as well as, an updated Delineation of Privileges Form requesting the procedure to the Department Chief. After evaluation of the completed proctoring program and related reports, the Department Chief shall submit a report to the Facility Credentials Committee indicating whether the proctoree should:
  • be granted the privileges to perform the subject procedures, as requested on the updated Delineation of Privileges Form;
  • be required to submit to an extended proctoring period or separate proctoring program; or
  • have clinical privileges restricted or terminated in accordance with the medical staff bylaws.

This information will be submitted to the Facility Credentials Committee for its review and recommendation.