1. Miller, Lisa A. CNM, JD
  2. Founder

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Healthcare institutions and organizations are increasingly focused on quality and safety in patient care and are utilizing a variety of approaches to ensure that clinicians at the bedside are competent in practice, especially in the area of electronic fetal monitoring (EFM). There is good reason from a medicolegal standpoint for this focus, but there is also much confusion about the differences between 4 primary topics: education, competency assessment, EFM certification, and EFM credentialing. Given that allegations regarding EFM continue to dominate in birth injury cases, it is incumbent upon healthcare leadership to understand the differences in these 4 areas. This column provides an overview of the differences as well as discussion points for clinicians and clinical leadership, beginning with a brief review and definition of each topic.



The broadest of the 4, education in EFM, encompasses the widest variety of options and is available through a number of different resources. Education may be formal or informal, in a classroom, online, or at the bedside. There are numerous textbooks on the subject, and many courses are offered by a variety of professional organizations and medical and nursing education companies.* The Association of Woman's Health, Obstetric, and Neonatal Nurses provides both online and in-person education open to all clinicians.1 Other professional organizations in midwifery, obstetrics, and family practice also provide educational offerings and resources. In addition to education programs available from external sources, many hospital systems provide in-house education through formal or informal means. These may include individual or group classes, in-service education, multidisciplinary EFM tracing review, journal clubs, or teaching rounds.


The majority of hospitals and hospital systems have standards for minimal or required education in EFM for labor and delivery nurses; many are incorporating similar standards for physicians and midwives, both employed and independent. In addition to the initial education requirements for clinical practice, hospital systems may mandate ongoing education in EFM. This is commonly on an annual or biannual basis. In some cases, the education may be specifically delineated as to a particular course or offering; in many cases, the mandate may be for a number of continuing education credits in the subject matter, rather than a particular program. With the plethora of educational opportunities available in EFM, it would be difficult, if not impossible, to identify a single option as meeting the legal "standard of care" that is a reasonableness standard. However, having clinicians at the bedside using EFM without evidence of any training in the subject matter could certainly be seen as unreasonable, and hence a violation of the standard of care. For this reason, both hospital entities and individual clinicians should be able to discuss and confirm some type of educational process if EFM has been completed. In addition, it is important to note that completion of an education program, even those that provide some type of testing or a certificate demonstrating completion, is not the equivalent of formal credentialing or certification offered by the National Certification Corporation (NCC) or the Perinatal Quality Foundation (PQF), both of which are discussed later in this column. Finally, it is interesting to note that in many states, education requirements may be influenced by state laws governing public health and perinatal care and there may be set requirements for staff training and education in specialty areas such as obstetrics.



In addition to baseline requirements for core education in EFM, many hospitals and hospital systems have instituted some form of ongoing competency assessment. These programs vary widely, just as the aforementioned educational options. Frequency of competency assessments vary as well, and while the majority of hospitals may have instituted ongoing competency assessment for nurses, that is not currently the case regarding providers such as midwives and physicians. There is no nationally recognized legal standard for what constitutes valid competency assessment in EFM, which means that hospitals and other healthcare entities are left to their own interpretation of what they mandate as competency assessment. Many institutions confuse the concept of competency assessment with the concept of ongoing education and dictate completion of an online education module or attendance at an EFM program of some type to be "competency assessment." But this is simply ongoing education. Assessment implies evaluation, so for a competency assessment to be reasonable from a legal standpoint, there must be some type of evaluation process, whether through individualized skills assessment laboratories, simulation exercises, or some form of testing. While a variety of options exist, many institutions are turning toward the use of a formally recognized program of certification or credentialing for clinicians versus an internally developed form of competency assessment.



The NCC is a not-for-profit organization founded in 1975 that offers certification examinations, including a subspecialty certification in EFM (C-EFM).2 To be eligible for C-EFM, the clinician must be a registered nurse, nurse practitioner, nurse midwife, physician, physician's assistant, or paramedic with current licensure in the United States or Canada. To obtain C-EFM status, the candidate must successfully pass an online or written examination that is proctored and must be performed through a registered computer testing center or as part of a designated testing site approved by the NCC.3 Test questions for the EFM subspecialty examination are subjected to psychometric evaluation and the NCC conducts regular content validation studies that are published on its Web site.4 The EFM subspecialty certification program offered by the NCC is accredited by the National Commission for Certifying Agencies and is currently approved to meet the requirements for Maintenance of Certification (MOC) Part IV Improvement in Medical Practice through the American Board of Obstetrics and Gynecology.5 As of September 2017, nearly 24 000 clinicians have been awarded certificates of added qualification in EFM through the NCC. Once a clinician has C-EFM status, the subspecialty certification can be maintained by the clinician by earning continuing education credits during the 3-year certification period. The NCC also offers a variety of educational materials in support of each of its certification examinations; clinicians are able to create online accounts with the NCC allowing them to access materials as well as track certifications.



The PQF is a nonprofit foundation established in 2005 and is an independent affiliate of the Society of Maternal Fetal Medicine. In 2013, the PQF began development of an online credentialing tool in EFM called Fetal Monitoring Credentialing (FMC), which was made available in January 2014.6 The FMC is an online examination composed of 2 types of questions: knowledge-based questions where there is one correct answer, and judgment-based questions with answers provided in a 5-point Likert scale, each answer on the scale providing a weighted score based on the answers given by an expert panel. The test does have time constraints and the PQF Web site states it is not meant to be an open-book examination; however, it is not proctored and can be taken from any computer with appropriate Internet access.7 The credentialing is considered valid for 3 years, after which recredentialing is achieved by taking the full examination again; there is no option for maintaining credentialing through continuing education.8 Like C-EFM, FMC also meets the requirements for MOC Part IV Improvement in Medical Practice through the American Board of Obstetrics and Gynecology.8



Litigation in obstetrics is a very real and serious issue, and allegations related to EFM interpretation and management in birth trauma cases are simply a fact of life. When clinicians are faced with defending themselves, they will be questioned both at deposition and at trial regarding their background and qualifications. Clinicians and healthcare systems need to be able to describe and explain educational background in EFM, including independent study, coursework through professional organizations, clinical meeting, or online educational offerings as well as any certification or credentialing that they have successfully completed. Being able to differentiate between education, competency assessment, certification, and credentialing will help clinicians explain a foundation in EFM and go a long way in establishing credibility with the jury. There are many options open to clinicians for maintaining and improving core clinical knowledge, and this is perhaps nowhere more important in perinatal care than in the area of EFM, the most common procedure in obstetrics today and the most litigious. Ultimately, the jury is the arbiter of what is reasonable when it comes to education and background, and the purpose of this column is not to suggest the superiority of any single approach. Rather it is written with the hope that clinicians and hospitals will recognize that the more they can do in the area of enhancing the knowledge base of bedside clinicians, the better, and that both individuals and hospital organizations need to consider and understand the differences inherent in education, competency assessment, certification, and credentialing. The only proven way to avoid litigation is to avoid a poor outcome, and the best way to avoid a poor outcome is to have a well-prepared team. It is the opinion of this columnist that there is no such thing as too much when it comes to knowledge, and the more avenues there are for learning, the safer the care provided to women.


-Lisa A. Miller, CNM, JD




Perinatal Risk Management and Education Services


Portland, Oregon




1. Association of Women's Health, Obstetric & Neonatal Nurses. Fetal heart rate monitoring. https:// Accessed January 29, 2017. [Context Link]


2. National Certification Corporation. http:// Accessed January 29, 2017. [Context Link]


3. National Certification Corporation. Certification examination electronic fetal monitoring. https:// Accessed January 29, 2017. [Context Link]


4. National Certification Corporation. 2014 NCC task analysis content validation study: Electronic fetal monitoring subspecialty examination. http:// Accessed January 29, 2017. [Context Link]


5. National Certification Corporation. The NCC EFM Certification Exam now meets MOC requirements! http:// Accessed January 29, 2017. [Context Link]


6. Perinatal Quality Foundation. Fetal monitoring credentialing. Accessed January 29, 2017. [Context Link]


7. Perinatal Quality Foundation. Frequently asked questions. Accessed January 29, 2017. [Context Link]


8. Perinatal Quality Foundation. FMC accepted by ABOG for MOC category IV. Accessed January 29, 2017. [Context Link]


*The author wishes to disclose that she provides such education through a variety of companies. [Context Link]