Infection Control Today - 10/2003: Knowledge is Power

Knowledge is Power, Certification is the Fuel

BY NANCY CHOBIN, RN, CSPDM

Many professions have developed certification programs to help establish standards and promote best practices. For the past 20 years, the sterile processing (SP) profession has had certification available to its constituents; however, there are still more sterile processing department (SPD) employees who are not certified than there are certified.

Why is that? It’s because of a number of reasons. First and foremost, formal educational preparation for the examination is not available to everyone. While not required to sit for the exam (this has not been proven to be a minimum standard), many candidates prefer this form of preparation. Therefore, candidates assume that since they cannot prepare for the exam, why spend the money? Second, in most professions (e.g., nursing), facilities recognize certification by title and offer additional money. If nursing and other professions can recognize certification, why doesn’t the healthcare community recognize sterile processing’s certification? While some facilities do recognize sterile processing certification by title and an increase in salary, two separate salary surveys performed in 1994 and 2001 by the Certification Board for Sterile Processing and Distribution (formerly NICHSPDP) found the recognition to be in the minority of instances.

To better understand this issue, one needs to look back at the history of sterile processing. SP is a relatively new profession, coming of age in the 1950s. Second, the department does not generate revenue like the operating room. Third, the department is labor-intensive due to the nature of the work performed. For many years, the SPD processed items such as bedpans, urinals, solutions and floor trays, and most commonly was responsible for supply distribution. During development of the profession, surgical instruments were cleaned and sterilized in the end-use departments (operating room, labor and delivery, and the emergency department), not SPD.

As time passed it was determined that centralized processing was a best practice to ensure standardized processing of instrumentation that could result in cost savings for the facility. Today, it is common practice for the SPD to process all instrumentation for the nursing units and ancillary departments. While initially the concept of relocating all surgical instruments from the OR to SPD was met with reluctance, the concept today is well accepted. During this time the medical community experienced the introduction of minimally invasive surgery (MIS). This radical approach to surgery has revolutionized the design of surgical instruments and created a new arena of medical devices to support such surgery. These instruments require special cleaning, assembly and sterilization techniques. Many of the devices require special sterilization techniques and as a result, SPD — which for years only used saturated steam under pressure and ethylene oxide gas for sterilization — now were faced with newer and faster methods of sterilization.

Concurrent to these changes, SPD leaders recognized the need for educational materials to train new employees and a certification program to verify their competency. Today, certification is a recognized method of determining an individual’s competency. Unlike licensure programs that are usually governed by the state and focus on entry-level competency, “certification attests to a more advanced or an expert level of performance.”1 The value of certification is to “enable the public in general and employers in particular, to identify those individuals who have met a standard that is usually set well above the minimum level required for licensure.”²

Standards and Guidelines for Certification

The National Organization for Competency Assurance (NOCA) is the professional membership organization for certification programs. Individuals as well as certification boards and psychometric providers are eligible to join. NOCA provides the education, research, publications and networking for individuals developing or working with voluntary certification programs. In 1989, the National Commission for Certifying Agencies (NCCA) was formed by NOCA and provides “quality benchmarking against which voluntary certification programs may measure themselves.”³

The NCCA has developed guidelines for certification bodies. These guidelines detail the best practices for certification programs. Why comply with the NCCA guidelines? NOCA states, “To provide psychometric characteristics that must be considered by an organization to produce valid and reliable examinations.” While voluntary, these guidelines ensure that credentials awarded truly protect the public. This is the value of certification — public (patient) safety. In addition to compliance with NCCA guidelines, certification programs can be accredited. NOCA also coordinates the accreditation process for certification programs. Any certification board can apply for NCCA accreditation through NOCA; however, the requirements for accreditation are very specific and require strict compliance with the NCCA guidelines. When the CBSPD received its accreditation from NCCA in 2001, it received a full five-year accreditation with commendation. “Accreditation by NCCA provides objective evidence that the organization meets the level of quality represented within the NCCA standards. Accreditation can assist in demonstrating the fairness and appropriateness of certification programs in legal challenges.”⁴

“Employers have a legal obligation to make an effort to determine the credibility and standards underlying a credential obtained through voluntary certification, especially when it influences decisions on employment or promotion.”⁵

If a certification program is accredited and complies with the NCCA standards, then the certification should be recognized. Conversely, certification boards have an ethical and legal obligation to provide a certificate that ensures a fair and equitable measurement of the candidate’s ability. In many instances, the results of the measurement can impact the professional growth of the candidate, therefore, “accuracy of the measurement cannot be understated.”⁶

The Examination Process

The knowledge and skills being measured must be appropriate to the credential. The relevance is determined by a majority of the practitioners via a Job Analysis Survey (JAS). It is customary to update the JAS every five years since major changes in technology can be expected during that time frame. The JAS is the foundation for a quality certification program. The knowledge and skills identified become the blueprint for the examination in terms of categories of knowledge (domains) and quantity of questions in each domain. How the examination is administered is being debated today. In the past, paper/pencil exams with four multiple-choice answers were the norm. About 10 years ago, testing agencies began to develop examinations that could be administered via computer. This process allowed for easier access to examination sites and was thought to enhance security (exams would not be shipped to and from a test site). However, this process is still being debated. Security breaches have occurred with computer-based testing. Item banks must be considerably larger since the examinations are usually offered anytime. Some certification groups have reported that the number of candidates taking the exam drastically dropped with computer-based testing (one group reported this was due to candidate concerns using a computer for the exam). In addition, computer-based testing can be the most expensive form of testing.

If the certifying body uses a professional testing agency, all the security mechanisms are built into the process. Any non-compliance by the proctors can result in disciplinary and or legal action against the proctor (breach of contract with the certification board to comply with all rules for administering the exam).

In compliance with NCCA guidelines, certification programs also need to establish and implement a process in which the credential is protected by enforcement of discipline, in the form of suspension or revocation of the credential, on ethical or criminal activities that are investigated and found to be true. It is important to remember that the candidate does not own the credential, the certification board does and therefore has the right to revoke or suspend the credential with due cause.

Re-Certification

Once a candidate’s competence has been determined, continued competence is required. Re-certification of an individual’s competence can be performed by re-examination or by a combination of continuing education, work experience and testing.

The re-certification process is critical. Many individuals think once they have become certified they do not have to do anything else until they get a reminder that it is time to re-certify. In actuality, the certificants should continue their competency by attending continuing education (CE) classes/ courses yearly. Furthermore, the CE should be relevant to the areas of exam content. CE activities should not be automatically recognized. It is important that the certification board has a CE committee that has been given specific guidelines regarding the topics that may be approved. Activities such as vendor exhibits (unless specific CE is provided at their booth) and breaks should not be awarded CE points. Again, when selecting CE programs/seminars, select those that have received CE approval from the certification board. If the program sponsor has not submitted the program, the candidate should submit the program to the CE committee for consideration.

Increasing Professionalism

Certification encourages professionalism. It is a process of training, continuing education and re-education. SP has made great strides over the years; however, we still have much work to do. The profession needs to determine its own destiny. These are some suggestions for SP professionals:

• Agree to one name for the profession. With so many titles/names, no wonder no one knows who we are or what we do. The World Federation for Central Services in Hospitals in 1999 recommended that everyone adopt “sterile processing” as the name for the profession since it states what we do.
• Develop standardized orientation guidelines that will ensure basic training for all new hires with competent return demonstrations. The orientation period should be based upon the ability of the employee, not some arbitrary time frame established by the department manager.
• Managers need to set an example for their subordinates by becoming certified.
• Managers need to support the certification process and encourage their employees to become certified.
• Managers should develop and provide CE to their employees. Time constraints should not conflict with this. There are many CE articles, videos, etc. already available for use. It is essential that time be designated at least monthly for CE. The CE should relate to topics that will foster continued competency in the core examination areas.
• Standardized minimal qualifications for SPD employees should be developed.
• Work with human resources and administration to recognize certification by title and salary. This will provide the incentive to become certified and remain certified.
• Work with state officials to make certification mandatory in your state �¡ Work with the human resources department to develop reasonable salaries for SPD employees. There is something inherently wrong when people working in the fast food industry earn more than SPD employees.
• Develop a career ladder for SPD employees based upon certification. A suggested formula is to lower the entry-level salary for trainees. After six to 12 months and upon satisfactory performance, the salary is increased to technician level with the title. After successful completion of the certification examination, promote them to specialist with a 50-cent to $1 per hour increase. The employee must provide documentation of their certification remaining current. If the employee desires to enter management, lead technicians can be created.

All of these suggestions will enhance retention of trained employees. While this is not an all-encompassing list, it is a good start. The SP professional and his/her facility should accept this challenge and lead us on the road to true professionalism for SP. The time is now to acknowledge that the SPD provides critical services to the facility. Educate your administration that the costly equipment they purchase for the OR all require processing by SPD. We need well-educated, certified personnel to support the state-of-the-art technology in surgery. It should make no difference where the sterile processing activities take place (hospital, surgery center, doctor’s office) because the patient has the right to a safe, sterile device every time.

Knowledge is power, and certification is the fuel. Just like an automobile that needs fuel to go places, certification is the key to professional growth and enhancement. However, to be successful, education is needed. The two are inter-dependent upon each other.

With all the focus on patient safety, certification is a positive action that will benefit the patient and provide improved performance and self esteem to SPD.