Measuring the Value of Wound Care Certification in a Quality-Based Healthcare System

As the definition of clinical quality care evolves, should wound care providers give thought to how ongoing education prepares them to meet regulatory challenges while maintaining patient satisfaction?

Use of the term “quality” has become increasingly more common in today’s healthcare lexicon — particularly as it relates to patient care and how that care is measured. As the United States healthcare system migrates to a value-based reimbursement structure, the idea of what it means to provide quality healthcare (and the monetary worth of such care) is now judged not primarily by patient satisfaction scores but by the correlation between care rendered and an aging patient population’s ability to remain out of the hospital. Healthcare providers and their employers will continue to face more incentivized levels of accountability as determined by the government’s ever-scrupulous assessment of measurable clinical outcomes. That being said, what place does education hold in establishing a baseline for the provider delivering quality healthcare in the first place? Is the current state of education within academic institutions one that properly prepares clinicians to meet the standards of care for wound prevention, diagnosis, assessment, and treatment when most nursing and medical programs don’t offer a robust wound education curriculum? At the same time, how does a licensed clinician determine which continuing education programs will give a level of education that meets current best practices and positions them to meet financial and quality care bench marks? That all depends on whom you ask.

From a quality education perspective, the answer to these questions are school- and program-specific, according to Kevin Daugherty Hook, MSN, MA, CRNP, vice president, nursing practice and education, at Genesis HealthCare, Kennett Square, PA. “We, as healthcare providers, all have a basic level of training in what it means to provide quality care — that being ‘Am I being safe in my patient care as a practitioner?’ — but people spend a lifetime defining what quality means,” Hook said. “The difference today is that we’re now trying to measure it and record it. Quality has become less about the individual and more about how a system designs its workflow and processes to meet certain [federal] standards. And with quality measures now the reality, there’s no getting away from wound care being one of those benchmarks that care quality is going to be measured against.”

As patients live longer with more difficult-to-treat chronic wounds and comorbid conditions, it has become critical for clinicians to acquire and maintain an intimate knowledge of the medical advancements within this specialized field. Additionally, providers should be as meticulous with their resources (time and money) when determining what quality education really means as the federal government is when deciding what constitutes the quality care that it will pay for, according to Hook and other clinicians who recently spoke with OWM. In fact, the value of an educational program should be reflected by how well that education leads to improved patient outcomes. To that extent, the best value for one’s dollar in wound care education is most often going to lead to specialty certification, according to those recently interviewed by OWM.

“Specialty certification is certainly a way forward,” Hook said. “And the key to being specialty certified is that you’ve learned things at a depth that you didn’t experience during your initial education and preparation. You have to prove that you understand what you’ve been taught by taking an exam [approved by a nationally accredited board].”

As Hook and others attest, the earning of a specialty certification is not as loosely defined as the idea of quality has become. Those clinicians working within the wound care industry who are seeking specialty credentials specific to wound care must be cognizant of the difference between the value of what truly is deemed specialization and general continued education.

DEFINING ‘SPECIALTY’ EDUCATION IN WOUND CARE

Before moving forward with the notion of what does and does not qualify as specialty wound care certification, let’s address a prevailing irony: It’s confounding to consider what the scope of possessing a specialty certification in wound care means for those within a cohort that is well known to not be officially recognized as a medical “specialty” by such organizations as the American Medical Association and the American Board of Medical Specialties compared to, just to name a few, the fields of cardiology, oncology, and dermatology. There are, however, achievable nationally accredited credentials that designate individuals as specialists in wound care. These include, again to name a few, the CWS^® (Certified Wound Specialist^®), which is available to any licensed healthcare professional possessing a bachelor’s, master’s, or doctoral degree with three or more years of clinical wound care experience through the American Board of Wound Management (ABWM), and the CWON^® (Certified Wound Ostomy Nurse), which is offered exclusively to registered nurses (RNs) through the Wound, Ostomy, and Continence Nursing Certification Board. Additionally, and similarly exclusive to nurses, the American Nurses Association, the largest nursing organization in the U.S., formally recognizes wound, ostomy and continence (WOC) nursing as an actual specialty.

“While the practice of wound care as a specialty has been recognized by some in the nursing profession, it is not yet fully recognized and embraced by other major healthcare organizations or board-specialty groups, including the American Board of Physical Therapy Specialists, which offers eight board-certification specialties in the profession of physical therapy,” said Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA, director of public policy and education at American Medical Technologies, Irvine, CA. “Although there has been a concerted effort to get wound care approved as a specialty within the profession of physical therapy, the process for recognition of a new board specialty can be a daunting process for any profession to undertake. The American Physical Therapy Association (APTA) recognizes wound care within the organization as a ‘special interest group’, which is moving us in the right direction. On the other hand, as things stand today, anybody can hang up a piece of paper in their office and say they’re a ‘wound care specialist.’ But there’s no credibility with that.”

The credibility factor, then, according to Scarborough, who also serves on the faculty of the Wound Certification Prep Course (WCPC), an educational program that prepares clinicians to sit for certification board examinations, is rooted in the earning of an actual certification offered by a well-respected institution that’s independently accredited to award such certification (ie, board certification). This is in stark contrast to, say, maintaining one’s licensure through the accumulation of required continuing education units (CEUs) or attending a seminar, workshop, or similar program that distributes a certificate acknowledging participation.

“A ‘certificate of course completion’ does not make you ‘board certified,’” Scarborough continued. “To just use the term ‘wound specialist’ following your name and title — that’s not a credential. The difference is, do you have an accredited credential? If you’re using bona fide credentials, they usually have a copyright attached to them.”

VALIDATING QUALITY OF SPECIALTY CERTIFICATION

Understanding the difference between specialty certification and a certificate are not the only factors that clinicians should weigh when choosing routes to furthering one’s education. A clinician of more than 30 years who has practiced in a variety of settings, including acute, outpatient, home health, and long-term care, Scarborough claims the level of research required for finding appropriate certification should be as rigorous as researching for the purposes of writing a scientific paper. At the very least, the process should be taken as seriously, she said. 

“During our prep courses, we encourage people to do their ‘homework’ related to the board certification they want to take,” she continued. “You want to look at the outline of the content being offered as well as the knowledge that you must have to pass board certification — whether you’re going for several certifications or just one. Look at the faculty. What is their basic healthcare license? Are they certified? If so, what type of certification do they have? Also, are there practice tests and other study tools available? A viable board certification is going to have valuable support materials accessible to help clinicians prepare for the exam.

Essentially, it’s reached a point where clinicians really need to be educated about how to appropriately assess the type of continued education that is best for them given their clinical background.  

 “We also try to educate people for the credential that is going to give them the best credibility and recognition within their area of healthcare,” Scarborough added.

For instance, a hospice nurse or a licensed vocational nurse (LVN) could benefit from a WCC^® (Wound Care Certified; National Alliance of Wound Care and Ostomy) credential, depending on the course being offered, but that doesn’t mean a physical therapist (PT) or physician would be best served by this credential. Hollie Mangrum, PT, DPT, CWS, area vice president with Healogics, a management company that oversees outpatient wound centers across the country, said that in her role, in which she manages the operation of multiple wound centers in her region (the company’s South Central zone covering west Tennessee, north Mississippi, and north Alabama), she’ll often get questions from her personnel (individual wound clinic program directors, approximately half of whom hold healthcare credentials) about the different types of educational programs that exist.

“And I, along with our regional director of clinical operations, who also holds the CWS, am most likely to refer the clinicians to those credentials offered by an organization like the ABWM, because it has existed for quite some time and has the respect of the wound care community,” said Mangrum, a PT of more than 20 years who formerly served as the wound center program director at the Wound Management Center at Jackson-Madison County General Hospital, Jackson, TN. “I encourage staff to seek out courses and education that is evidence based and that’s going to discuss the basics of wound care as well as what is current evidence and treatment. I’ll also sit with them individually and review the website and the agenda for whatever program they’re considering. There doesn’t have to be an exam involved as far as someone seeking general education in wound care [especially as it pertains to nonclinical staff members], but I wouldn’t recommend a certification program that did not involve an exam.” Scarborough suggests an additional mode of validation when choosing a course: Clinicians should be sure to ask themselves, ‘Does the online information about the course give enough information about the content in order for me to make an informed decision about the suitability of the course for my professional needs?’” she said.

In addition, Mangrum said she makes sure to discuss what does and does not equate to becoming a true specialist. “You have to ensure that the staff member understands that attending an educational session on wound care does not necessarily make them ‘certified,’” she explained. “You have to delineate the differences between going to a continuing education course and being a certified wound care specialist.”

Yet another factor that should be given prominence when evaluating program validity is identifying conflicts of interest that may exist among faculty and the particular program, as well as the program and the accreditation body, Scarborough implores. “A conflict of interest is a situation in which the concerns or aims of two different parties are incompatible — a situation in which a person or organization is in a position to derive personal benefit from the actions or decisions made in their official capacity,” she explained. “So, in layman’s terms, is someone receiving personal financial benefit from not only the course they provide but also the certification process? Are they feeding information to the students to help them pass the board for which they provide the credentialing? Is there a risk that professional judgments or actions regarding a primary interest are unduly influenced by a secondary interest? That would be a conflict of interest.”

The ability to recognize a potential conflict of interest as well as the overall value of an educational program is especially important in today’s digital climate, where anyone with access to the Internet can offer educational programs at varying costs and levels of quality just as easily as clinicians can sign up for and financially commit to such programs. That said, the Internet can also be a boon to those individual providers and organizations looking to promote their specialty certification status because patients are already looking for such proof of care quality, according to Jeanine Maguire, MPT, CWS, senior director, clinical outcomes, skin integrity and wound management at Genesis.

“As consumers, we all have access to the Internet and we are all evaluating what our options are with all things in life — whether it be shopping around for cars or hotels, or for that matter seeking the best nursing home and wound care clinicians,” she said. “So, if I’m searching for something online, I’m going to ‘Google’ and compare. And when I find those who are certified in wound care, that’s going to hold more value if I’m a healthcare consumer, and I may not know anything about certifications for wound care. But I’ll know that it holds higher credibility when an individual holds additional credentialing.”

Scarborough can relate. “Recently, a patient told me he chose to come see me about his care because I was the one he saw with the ‘most letters after my name’ when he did an online search,” she said. “Today, patients are more savvy about healthcare than at any time in our history, and they’re looking for people who are well educated for whatever their health issue might be, including chronic wounds. And, when I’m the patient, I research the person I’m going to visit. Because I want to be able to trust them with my health and my life.” Those who may not take the Internet’s power seriously need to think again, Scarborough warned. “I’ve had doctors tell me, ‘I can’t stand the Internet because patients come in with questions and challenge me on what I’m doing,’” she said. “Well, that’s not necessarily a bad thing to have to justify what you’re doing with your patients.”  

IT PAYS TO EDUCATE

According to those interviewed by OWM, employers are beginning to become more cognizant of what determines value and quality when it comes to supporting employee education, not only for the sake of their organizations’ patient care outcomes but due to the government’s perspective on reimbursement. Employers are also interested in the measurement of the return on investment when offering incentive programs that fund employee education and certification. At Genesis, Hook is among those within administration who’ve implemented a program that allows wound care nurses to seek specialty wound care training and even goes as far to encourage it through the adoption of flexible employment schedules as well as the promise of education reimbursement for certifications earned — which literally might be the most direct route to paying it forward given today’s healthcare landscape.

“We [as an administrative body] agreed that encouraging people to pursue certification would more likely have long-term benefits to everyone due to the level of commitment involved,” he said. “The impetus was, we have a patient population that’s becoming more complicated to treat and we have to find ways to encourage nurses to become experts in a variety of areas. And the avenue for that is specialty certification. The bar has been raised. While you certainly are learning while working as a nurse, or whichever role you’re in, I think there’s something to be said for formal education that supplements your work experience because it gives you a great conceptual and theoretical foundation from which to operate. [That education] helps you to frame what you’re seeing happening with your patients and puts everything into a larger context.”

Hook said the standard requirements for what qualifies as reimbursable education are similar to those that he and others here have suggested that clinicians themselves consider when choosing a program. “It was a pretty simple process,” he continued. “We went out and looked at the type of education programs available and said, ‘Which of these makes sense in our environment?’ That included wounds. We wanted to make sure the education opportunities offered were broad enough to allow for the complexity of the people we’re seeing in addition to being germane to the practitioner’s discipline. Obviously, if you’re working here, we’re not going to pay for you to become specialty certified in pediatrics.”

Additionally, “all approved programs for reimbursement are accredited by an organization that’s recognized, approved, or owned by a major national nursing organization, such as the American Nurses Credentialing Center, to name one,” Hook said. “They’re the recognized experts, so we looked at them first. Either way, it would have to be education from an accredited body by a professional nursing organization that would vouch for that education. There’s also money available for whatever the specialty certification body suggests should be purchased in order to access, study, and acquire the knowledge base necessary; and we’ll reimburse for the cost of the exam and materials once the person has passed.” In order to gain acceptance into Genesis’ education reimbursement initiative, employees must engage their direct supervisors in a conversation, and the supervisors have the autonomy and authority to give the green light. “The formal approval process is in place because achieving a specialty certification is more difficult than sitting in for your CEUs or attending a course, signing an evaluation, and being given a certificate,” Hook said. “Our goal behind encouraging certification is that, because of the length of time you have to spend to earn it — studying for it, participating in the exam — is ensuring it will actually change your practice. So we’re providing a listing of the actual certifications available for reimbursement, as well as the links to the certifying association. But the staff members are taking charge of their own career development by actually going out and getting that education. We want to be supportive, but also want to see our employees take some initiative to take charge of their career.”

ACKNOWLEDGING PRACTICE “CHANGE”

Among those who’ve taken advantage of this opportunity at Genesis is Maguire, who in her role is overseeing more than 500 of the company’s facilities (including skilled-nursing, assisted living, and rehabilitation). One with more than 20 years of clinical experience as a PT (all in wound care) who began her career as a PTA and earned her CWS in 2003, Maguire said the most evident impacts the certification has had on her practice has been in the change in her relationships with other clinicians, particularly those who also hold wound certification.

“This credential means that I speak the same language as another CWS — that we all understand the current standards of care and have the same expectations for patients who are living with wounds,” she said. “Also, when different groups, whether it’s national organizations or state groups, are looking for speakers or participants for different clinical tasks — they’re seeking people with the CWS. So that gives me credibility to speak to the expertise of wound care with other clinicians.”

Mangrum, who earned the CWS in April 2000 after five years working with wound care patients at that point, said she most noticeably sees a difference between her relationships with physicians pre- and post-certification. “There’s certainly a confidence level that you gain, and physicians respect it as well, which gave me more confidence,” she said. “Our wound center got more promotion and attention in the region, and we saw an uptick in referrals. I saw more of a collaborative approach after becoming certified as a wound specialist, where the physicians were more inclined to ask me questions or ask for my opinions on wound care than they had been previously. It’s like the ‘barrier’ between disciplines was broken and we were able to feel like we were putting the patients’ first more easily because we were all working together toward the same goal. For physicians [in this region] we truly became an automatic referral for any wounds. They weren’t just sending their most difficult wounds or ‘wounds they did not want to see’ anymore.

And once you build that level of confidence with the physicians, over time they want their patients to be cared for in the wound center. They want to ensure their patients are seeing the specialists and being offered that collaborative of care where there’s one shared goal based on evidence-based knowledge.”

Speaking from the physician’s point of view, Lee C. Ruotsi, MD, FACCWS, UHM, shares the same sentiments as Mangrum concerning the physician’s relationship with the nurse (or any clinician) who holds specialty certification in wound care. “As a wound care specialist myself, if I’m speaking with another provider who holds the CWS, we have a similar understanding of the pathophysiology of wounds and what it is that we need to do to get a diabetic foot ulcer, or a venous leg ulcer, or a pressure ulcer healed,” said Ruotsi, who also serves as WCPC faculty with Scarborough. “And that’s important. But where it’s equally important is for those doctors who are expected to sign healthcare orders for wound care when they don’t have any experience in wound care. In that scenario, the CWS who’s seeing the patient in the home, is coming face to face with the wound, and has that skill set and knowledge, is going to be able to give accurate information and good recommendations based on that information to the physician. And that gives the physician the opportunity to give better recommendations.”

That’s not to say there aren’t those working in the industry who aren’t rightfully considered to be experts in wound care without possession of specialty certification, Scarborough clarified. “There are absolutely some top wound care clinicians out there in this country who are recognized as wound experts who are never going to get the specialty certification,” she said. “But they are the exception to the rule. And what the wound care credential does is, it recognizes that you have passed a standardized examination with the basic body of knowledge that you must have to be able to perform the skills that you need to be a wound specialist. It’s a leveling field. And it gives you a level of credibility among your peers that you likely will not have without the credentials.”

Additionally, Hook, a graduate of Columbia University who’s currently finishing a master’s degree in bioethics and health policy and was recently accepted to the doctor of nursing practice program at George Washington University, said it wouldn’t be surprising to think education, even at the undergraduate level, is already trending in the direction of training perspective clinicians to be closer to that specialist ideal — specifically as it relates to the concepts of quality processes, workflows, and the ideas behind the “Triple Aim” of achieving care quality sooner in their studies.

“Today, it’s really not until the graduate level that you get that,” he said. “But in the future I could see early curricula focusing more on what it means to teach people to be ‘lifelong learners.’ It could be that process improvement becomes so important that accrediting bodies require that undergraduates get some serious preparation on this. I think it’s safe to say that people are already looking at that.”

Joe Darrah is managing editor at HMP Communications.