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Based on interview and record review, the hospital failed to implement its written criteria in proctoring its Emergency Department (ED) physicians. Three of 10 ED physicians' credentialing files reviewed did not have proctoring (the process of supervised tests to evaluate a medical staff's competency) records (A, D, and E), and six ED physicians (D, F, G, H, I, and J) were proctored by one physician only. This had the potential to cause the hospital unable to ensure the competency and judgment of its ED physicians.

Findings:

On April 16, 2010 at 3:50 PM, three credential files were reviewed with Medical Staff Manager (MSM). The following issues were identified:

1. Physician A was a board certified ED physician who started working at the hospital in June 1994. There were no proctor reports found in his file.

2. Physician D was a board certified ED physician who started working at the hospital in March 2000. There were no proctor reports found in his file.

3. Physician E was a board certified ED physician who started working at the hospital in July 1997. There were no proctor reports found in his file.

4. During a concurrent review of six physicians' files (D, F, G, H, I, and J) and the hospital policy and procedure on proctoring with the MSM on May 19, 2010 at 3:15 PM. All files showed that these six ED physicians were proctored by only one proctor instead of two. The "Rules And Regulations Department of Medicine" subtitled "VIII. PROCTORING," and under "A. All new appointees to the Provisional Staff shall have at least two (2) proctors who shall act as a advisors to...and are responsible for the overall evaluation of the applicant." These ED physicians' proctoring did not follow the rules and regulations of the Medicine Department as written and approved by the hospital Governing Board.

On May 19, 2010 at 2 PM, during an interview, the MSM verified the above findings and was unaware of the missing proctoring records. She stated, "I have an internal problem."