OBJECTIVE Procedural skills assessment is critical in residency training. The Council of Academic Family Medicine recommends the Procedural Competency Assessment Tool (PCAT) for assessing procedure competence of family medicine residents. We sought to evaluate the reliability of the PCAT and to better identify its strengths and limitations. METHODS In this mixed-methods study conducted in 2017, 18 faculty members of an academic family medicine residency program watched a video of one of the authors performing a simulated shave biopsy with intentional errors. Faculty scored the procedure using the shave biopsy PCAT, then participated in a focus group discussion of the rationale for the scores given. Qualitative analysis assessed perceived benefits and challenges of the PCAT. Following the discussion, faculty scored the same procedure again, using a PCAT modified with additional objective criteria. RESULTS On the original PCAT, 40% of respondents rated the physician as competent. This dropped to 21.4% on the modified PCAT (P=.035). Respondents scored competent even though procedure components were scored as novice. Score variability decreased with the checklist-based PCAT. Qualitative analysis revealed that the PCAT is subjective and interpretation of the tool varies widely. CONCLUSIONS Further studies regarding PCAT validity and reliability are needed. The PCAT may require further norming with additional objective criteria to improve reliability. Residencies may train faculty on using the PCAT to improve interobserver agreement, or decide to use a more intuitive checklist evaluation tool.