Personnel Credentialing

     The National EMS Scope of Practice speaks to four interdependent components that establish the framework in which EMS providers work. While education, certification, licensure and credentialing are all related and interdependent of each other, credentialing is often missing in EMS systems, possibly because there is no standard method published by which the process can be accomplished by EMS agencies.

     When I was hired as the first full-time medical director for the Wichita-Sedgwick County (KS) EMS System in late 2004, one of my directives was to implement a process of local credentialing. I am no stranger to this process. Having served as the medical director in Eagle Pass, TX, I had implemented credentialing in that department with a high degree of success. However, the challenge of implementing the process in a system with nearly 800 prehospital care providers has proved to be significant.

     Development of the credentialing process was tasked to my training manager, Jon Friesen, BS, MICT, who brought EMS system agencies together using an instructional system design process, which is the same process used to develop our clinical training. The process follows the basic ADDIE format of Assess, Design, Develop, Implement and Evaluate, and brings accountability to the development processes.

Assessment
     Literature searches turned up little in regard to the credentialing of EMS personnel. Interviews with agencies that were actively doing local credentialing yielded no "set" structure. It became apparent that we were going to have to begin from square one; thus, we began to bring our agency stakeholders together to help define the process. The following objectives were developed:

• The process should demonstrate for the medical director that providers are competent to a minimally acceptable level for the certification they possess.
• The process should be designed in a manner that is valid and reliable.
• The process should be "open" to allow for providers to prepare and meet the objectives.
• The process should be dynamic as to respond to the changes in standards and expectations.

Design
     With these objectives, the development team moved forward to establish the process' design. Four areas would be evaluated in order to show the minimal level of competency.

1. Cognitive knowledge would be assessed using a valid and reliable written examination.
2. Psychomotor skills would be assessed using scenarios with standardized check sheets.
3. All providers would undergo a medically oriented back-ground check to ensure they are not under investigation or censure by the regulatory board. A driver's license check will be conducted to determine if an individual has had a DUI or other issues that relate to the ability to safely operate a motor vehicle. Finally, a check will be conducted with the attorney general's violent and sexual predator list.
4. Advanced providers would submit documentation demonstrating a successful endotracheal intubation and IV competency in the past 12 months.

Development
     With the design outline done, Jon and the development team began work on the basic- and advanced-level written examinations. Key stakeholders were invited to participate in developing written examinations. To ensure that we were approaching the psychometrics of the exam correctly, we reached out to Johnson County, KS, Med-Act for technical assistance. With their help, training was given on item writing, and a test blueprint was developed and used to construct the examinations. Another part of the development team began to work with the practical examination component of the process. Skills were identified for each level of certification in our system. From this list, skill check sheets were developed that identified critical criteria for each skill. The team then moved on to develop scenarios that incorporated multiple skills and used the skill sheets to develop evaluation tools for each scenario. We worked to develop paper and tracking processes for the credentialing components. Forms were developed that allowed for the tracking of providers through the credentialing process. A process for remediation was developed that assists those providers needing help meeting the credentialing requirements.

Implementation
     We moved forward into implementation of the process this year. Our plan is to credential 100 providers. We consider this to be a year for correction and refining the process. Providers going through the process this year are credentialed if successful, and will be placed into next year's process if unsuccessful. Next year we will bump the number of providers moving through the process to 200 and will sustain that each year. Each provider will be expected to credential every four years.

Evaluation
     Our next step is to move into the evaluation phase of the process. We have put several processes in place to effectively evaluate what we are doing. Using software from NCS Pearson Assessments, we will work diligently at the validity and reliability of the written examinations. Our practical skill component processes are subjected to ongoing review by the development team, and individuals who are going through the credentialing process are surveyed post-process to elicit feedback as to how our mechanisms are working. One of the things we recognize is that failure to credential will likely result in loss of a job for the provider. Given this, it is important that our assessment tools be both valid and reliable. This process requires much patience. It began more than three years ago, and one of our biggest obstacles has been getting buy-in from departments outside the provider agencies. For example, because of the DL and AG list checks, the human resources departments have had multiple discussions with the medical director and various department heads about how to do this before agreeing to a mutually acceptable plan.

The Future
     The most important part of the process is creating space for dialogue, discussion and debate. As medical director, I have to carefully balance the need for input and collaboration with the liability and responsibility that I hold as the person responsible for all clinical care delivered in the system. Most important, I know that pursuing this process is a vital step in ensuring that our practice is sound, accountable and open. There should be no surprises for anyone in the credentialing process. The process should enable us to validate the knowledge and skill of the majority of our providers who serve the public day after day, and to identify those who need more training and education in order to achieve success.

     I would like to acknowledge and personally thank Major Jon Friesen for his hard work on the credentialing program in Sedgwick County. It is through his dedication and effort that this program is now being successfully implemented as envisioned a few years ago. For more information about the credentialing process at Wichita-Sedgwick County, e-mail cyoung@sedgwick.gov or jfriesen@sedgwick.gov.

Catherine Young, MD, is a board-certified pediatrician and the full-time medical director for the Wichita-Sedgwick County (KS) EMS System. The system includes nearly 800 EMS providers from five different agencies.