About Specialty Certifications
Specialty certifications are the formal recognition of specialized knowledge, skills and experience, demonstrated by the achievement of standards to promote optimal health outcomes.1 The American Board of Medical Specialties differentiates board certification from medical licensure. Medical licensure describes the minimum competency required to diagnose and treat patients, as opposed to board certifications, which demonstrate expertise in a particular specialty. Furthermore, licensure is a credential that is issued by a governmental entity, sometimes by using the established certification. If a state has a statutorily or regulatorily defined scope of practice for the profession, regardless of what the state chooses to call it, then authorized individuals are licensed.2
Specialty certifications exist in nursing, radiology, respiratory therapy, medical laboratory sciences and many other healthcare professions. The American Board of Nursing Specialties identifies more than 60 certifications from more than 20 certifying agencies. These specialties range from emergency nursing to wound care nursing. Depending on the type of nursing and department the nurse is employed in, certification may be required. For example, if a helicopter air ambulance program is accredited by the Commission of Accreditation for Medical Transport Services (CAMTS) and employs a nurse or a paramedic, the providers must obtain their specialty certification as a certified emergency nurse, certified fight nurse, certified transport nurse, certified critical care nurse, certified fight paramedic or certified critical care paramedic within two years of hire.3
One may argue that many of the skills and knowledge can be obtained through on-the-job training. This is true, and often a crucial component of specialty certifications. In fact, many of the specialty certifications encourage healthcare providers to work for a certain amount of time prior to being eligible for the specialty certification exam. Experience has a huge benefit to clinical performance and knowledge. However, even with on-the-job training, a minimum bar must be set to ensure everyone has achieved a set level of competence as determined by the industrial standards of the certifying agency.
In EMS, we are overwhelmed with dozens of certifications that are made available to the industry from a variety of continuing education sources. It’s important to realize that there is a significant difference between assessment-based certifications and professional certifications. Assessment-based certifications are awarded after successful completion of a proprietary curriculum followed by a content assessment exam.4 A professional certification is used to validate an individual’s competence and knowledge through an established confirmatory system. A prime example of this can be found in critical care transport. Programs such as the Critical Care Emergency Medical Transport Provider at University of Maryland, Baltimore County (UMBC) or the Cleveland Clinic’s now defunct Certified Intensive Care Provider certification were achieved after successful completion of those respective educational programs. These certification exams, however, were written specifically for those proprietary educational programs and are more accurately classified as final course exams. In EMS, these programs are often treated as specialty certifications, but they lack some of the core components of specialty certification, which include psychometric validity and the legally defensible foundations of specialty certification exams. Existing specialty certification exams are offered by the Board for Critical Care Transport Paramedic Certification (BCCTPC), such as Certified Flight Paramedic (FPC) or Certified Critical Care Paramedic (CCP-C). The FP-C and CCP-C are true EMS specialty certifications in critical care transport that meet the criteria for professional certifications.
Throughout the healthcare field, agencies exist for the sole purpose of validation of competency. There are some fundamental components that allow these entities to function in a thorough and unbiased manner. The agencies and certifications must have a defined scope of practice that separates it from initial certification, along with a researchbased body of knowledge that supports the scope. The certifying agency must be an autonomous, non-governmental entity. While government entities may be consulted for the development of standards and content, accreditation is considered a non-governmental process.5 Eligibility criteria must exist for the certifications. The examinations must be valid, psychometrically sound and secure. Lastly, a recertification process must be established by the certifying agency to ensure continued competency.
Each certifying agency has set standards for its certification process. Content of the exams is based upon the standards developed from a job analysis that is distributed and evaluated by the certifying agency. The job analysis evaluates the knowledge that the providers within the profession feel are the most important. Exam validation is a multifaceted process. First, the certifying agency makes a request of subject matter experts (SME), who are actively involved within the specialty, to submit items (test questions) to the certifying organization through a predetermined process. Afterward, a group of SMEs meet as a committee to review all of the submitted items and make alterations to ensure there is no regional bias, terminology complications or other issues with each item. Then all of the items are sent to a psychometrician to ensure that there is no inherent discrimination. After the items are deemed psychometrically sound, the questions must be pilot tested by certification applicants. Lastly, the items are reviewed by the certifying agency and analyzed for weighted scoring depending on the test method construction. Tests methods can include Angoff, modified Angoff, Beuk, Hofstee or a variety of other methods.
Current Status of Specialty Certifications in EMS
In February 2015, the National Association of State EMS Officials (NASEMSO) released a report titled A National Strategy for EMS Specialty Certifications.6 This document discusses the need for specialty certifications in EMS and makes recommendations on how to achieve this goal. NASEMSO declares that the certifying entity cannot be a governmental entity because government entities are responsible for licensure. However, it describes how government entities can implement specialty certifications into their EMS system without developing a new level of licensure for each specialty.
The NASEMSO document identifies several key points about EMS specialty certifications. First, it recognizes the need for a board to manage specialty certifications within EMS. A board must exist that is comprised of industry representatives. Each specialty must be backed up by evidence that the specialty necessitates knowledge that exceeds initial certification. The content must be developed by a job analysis identifying core knowledge expected by certified clinicians working in the specialized industry. Furthermore, each specialty certification must have an accredited examination.
Currently, there are two major certifying entities in EMS. The most well-known entity, the National Registry of Emergency Medical Technicians (NREMT), is responsible for initial certification. The NREMT is comprised of a board of EMS professionals from across the country, and its examinations are developed by committees that include SMEs, state officials and physicians involved in EMS. The examinations are reviewed by a psychometrician and validated through an extensive process. Eligibility for the examination is defined by the state, but must include graduation from an accredited paramedic program or state-approved EMR, EMT or AEMT program. Once a provider is certified, there are defined criteria for recertification through continuing education or retaking the cognitive examination. A large portion of the U.S. utilizes the NREMT for initial certification, and this process is written into many revised statutes and/or administrative codes.7
The other certifying entity, the BCCTPC, has been in existence since 2000 and was created because a need for certifying fight paramedics that was identified.8 As the Critical Care Transport (CCT) and Helicopter Air Ambulance (HAA) industries grew, providers working in the profession received on-the-job training and experience, but lacked the validation of a professional certification. Requests for certification grew when accrediting agencies required certified personnel in order to obtain or maintain organizational accreditation. While CCT and HAA are generally regulated by states, some states require accreditation by the Commission on Accreditation of Medical Transport Systems (CAMTS). On top of some states requiring CAMTS, the three largest HAA providers also have many of their bases accredited. Since the current CAMTS standards state that paramedics who operate as a critical care paramedic or fight paramedic must obtain their CCP-C or FP-C within two years of hire, these certifications have been in high demand.
As a specialty certification board, the BCCTPC is comprised of SMEs who are involved within the specialty industries. The board is comprised of providers from across the country, physicians who are involved in the various EMS specialties, and representatives from other agencies who share the same vision. Together they vote on specialty certifications that should be added and collaborative efforts that the BCCTPC should become a part of, and they participate in item writing for the BCCTPC.
The BCCTPC currently offers the Certified Flight Paramedic exam, Certified Critical Care Paramedic exam and Certified Tactical Paramedic exam (TP-C). Later this year, they are also releasing the Certified Community Paramedic exam (CP-C) under contract with the North Central EMS institute, an EMT/AEMT version of the TP-C that will be known as the Certified Tactical Responder exam (TR-C), and the Certified Medical Transport Safety Professional exam (MTSP-C) that is in partnership with the Association of Air Medical Services. These specialty certification exams were developed after industrial representatives of the specialties presented to the board the need for specific knowledge that exceeds initial certification. Each examination is developed by SMEs, paramedics (several of whom hold licenses as a paramedic, RN or nurse practitioner) and physicians, in conjunction with board representatives. The SMEs contribute items and the Item Writing Committee meets to review each item to ensure the questions’ validity and remove any regional bias. Afterward, the questions are sent to a psychometrician, piloted and reviewed. The examinations are given an Angoff Cut Score based on the difficulty of the questions to determine a passing grade for each individual exam.
Once specialty certification is acquired, the BCCTPC has set standards for recertification. Each certification has a set amount of continuing education hours that must be obtained within that specialty during the certification period. Along with the designated hours, an approved renewal course must be completed. Usually, the hours acquired for specialty certification can be used for NREMT & state recertification as long as it meets all other distance requirements and other standards set by the state and/or the NREMT.
In EMS, the pathways for upward mobility are limited. Many providers end up leaving the industry early due to issues with pay, fatigue, injuries and a variety of other reasons. As EMS providers begin to work in specialty settings, doors open up. This can help providers who feel as though they have nowhere else to climb, but desire more knowledge and opportunity. Specialty certifications can also help administrators justify an increase in pay due to recognized, externally validated achievements. Some of the specialties can provide pathways for providers who were injured but still have a desire to work in the field. By incorporating specialty certifications into EMS, we provide options for our workforce to help retain, challenge and compensate great providers who want to grow within the industry.
Specialty certification is needed for healthcare providers who work in areas that exceed the knowledge of their initial education. In EMS, we have a group of providers who regularly work in a specialty area outside of their initial education. These providers often receive on-the-job training, however, external validation is imperative to ensure that clinicians have met and maintained a set bar as determined by the certifying entity.
The need for specialty certifications has been identified throughout allied healthcare. Within our own industry, a need has been identified by NASEMSO. EMS providers are currently operating in specialty settings where the knowledge base exceeds their initial education. The BCCTPC has several specialty examinations in place that help validate the EMS provider’s competency in that body of knowledge. They are also expanding beyond the realm of critical care transport, at the request of other industrial entities to help provide specialty certifications in a variety of other areas.
As EMS grows beyond our traditional roles, specialty certification will help validate the knowledge that providers have as well as their commitment to achieving competency. As it has in other professions, specialty certifications allow the specialized sections of EMS to improve its professional appearance, potentially increase pay and meet the requirements of national accrediting bodies. This step forward shows other healthcare professions that we identify specialties in our industry as well. Within these specialties, EMS providers with specialty certifications have the knowledge to work alongside other healthcare providers with specialty certifications at a comparable level for the greater good of patient care.