FEES Training and Competency
Are you interested in becoming FEES competent?
Prior to beginning the journey of FEES competency, it is important to note that there are currently no agreed upon FEES competency requirements in the United States or internationally. To help make the process of FEES competency and training easier to understand, our team has created this page with resources and tools to provide you with current guidelines and information.
FEES Training and Competency Resources
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The American Speech-Language-Hearing Association (ASHA) provides an overview of FEES including its history, indications, contraindications, procedure, precautions, and more. Learn more here.
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In the United States, individual states may have specific requirements for instrumental evaluations. According to ASHA the following states have specific laws, regulations, or policies for the conduction of instrumental evaluations: Alabama, Arkansas, California, Colorado, Georgia, Illinois, Indiana, Maryland, Michigan, Missouri, New Jersey, New York, North Carolina, Pennsylvania, South Dakota, Tennessee, and Virginia. Learn more here.
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This article, written by representatives from the American Board of Swallowing and Swallowing Disorders (ABSSD) and ASHA Special Interest Group 13: Swallowing and Swallowing Disorders provides guidance for professionals who are training for or utilizing FEES with adults. The article discusses the history of FEES, equipment, training, conduction, analysis, report writing, and more. Learn more here.
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This article, written by members of the ABSSD and SIG13 details the history of pediatric FEES, knowledge and skills pertinent to performing and interpreting the examination, indications and contraindications, developmental anatomical and physiological changes across childhood, exam conduction, medical collaboration, and safety. The authors additionally, detail guidelines for training for the use of FEES in the pediatric population. Learn more here.
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This document was created by The Royal College of Speech and Language Therapists (RCSLT) in conjunction with a working group of experienced speech-language pathologists. The finalized competency guide underwent consultation with experts within the UK and internationally. Access the framework here.
Guidelines for Training and Competency for Adult FEES
Attend and complete an ASHA CE approved external FEES course or internal facility mentored training
Courses should be comprehensive, and historically are comprised of two full days including 12 hours of lecture and a minimum of 4 hours of hands-on practice. Individuals instructing courses should have extensive clinical experience in FEES and dysphagia. Course content should include information on examination background, preparation, handling the endoscope, FEES protocols, intervention trials, interpretation of findings, rating scales, interpretation, patient variability, and practical programmatic applications.
Examination Completion
Completion of an examination at the end of a formal course. Examinations should be devoted to cognitive skills as well as core knowledge and interpretation. It is recommended that the following competencies be assessed during the examination processes: description of the elements necessary in a comprehensive FEES examination, study indications and contraindications, risks, benefits, and precautions, identifications of anatomical landmarks, changes over the course of a lifespan, description of cranial nerve innervation for structures in view, identification of sensation and secretion management, adaptation of procotols as needed, recognition of abnormal findings during preswallowing tasks, recognition of abnormal findings during oral intake of foods and liquids, interpretation of underlying problems, implementation of rating scales, the identification of treatment interventions, and the ability to use examination results to make recommendations.
Passing and Handling the Scope: Healthy Volunteers
It is recommended that trainees pass/handle a flexible scope on a minimum of 10 healthy volunteers under the direct supervision of a mentor who is experienced at performing FEES.
Note: The use of a simulation such as a mannequin can be used as a first step to help trainees gain confidence.
Passing the Scope and Performing a FEES Exam: Patients
After the completion of 10 passes with healthy volunteers and a minimum of 15 FEES examinations with patients, the mentor(s) may deem a trainee competent. If the mentor does believe the trainee is ready for independent procedures, they may recommend further training.
Indirect Supervision: Final Step
Mentees should complete a final 5 - 10 FEES examinations under indirect supervision. This means that a mentor will view the recorded examination and the written report and will provide the mentee with feedback.
*Note: For a comprehensive review of these guidelines, please see the reference cited below.
References
Langmore, S. E., Scarborough, D. R., Kelchner, L. N., Swigert, N. B., Murray, J., Reece, S., Cavanagh, T., Harrigan, L. C., Scheel, R., Gosa, M. M., & Rule, D. K. (2022). Tutorial on clinical practice for use of the fiberoptic endoscopic evaluation of swallowing procedure with adult populations: Part 1. American Journal of Speech-Language Pathology, 31(1), 163–187. https://doi.org/10.1044/2021_AJSLP-20-00348
Guidelines for Training and Competency for Pediatric FEES
Attend and complete an ASHA CE approved pediatric FEES Course
Courses may be broad or patient population-specific. Courses should include background information, examination preparation, procedure protocol, intervention trials, scoring and rating, practice handling and passing the flexible endoscope, practical programmatic applications, as well as cognitive and technical competencies.
Knowledge Verification: Exam
Completion of an examination at the end of a formal course. Examinations should include interpretative and core knowledge components with inclusion of case examples. Examinations should be passed with at least 80% accuracy. After course completion, SLPs should be mentored at their home facility by experienced mentors until obtaining technical and cognitive competencies.
Identify an Expert Mentor or Mentor Team
Prior to attempting any FEES practice with patients, a mentor team including an SLP with expertise in pediatric dysphagia and FEES as well as a physician such as a pediatric ENT that is trained in performing pediatric flexible nasoendoscopy is preferred. If the SLP is unable to find an SLP mentor experienced in pediatric dysphagia and FEES, a physician mentor is recommended for passing the endoscope, however, clinical interpretation and assessment mentorship from an experienced Speech Pathologist remains vital. In this case, an external SLP mentor may be required. The SLP in training will work with their mentorship team to determine a plan for training and competency. An SLP’s competency is determined by a mentor based on performance.
Passing and Handling the Flexible Endoscope - Healthy Volunteers
Completion of 10 supervised passes with healthy adults prior to pediatric application.
Observation of a minimum of 10 FEES procedures performed on pediatric patients by a FEES-trained clinician.
Interpretation of a minimum of 10 previously recorded FEES examinations on pediatric patients under direct supervision.
Assist the mentor in protocol determination and performance of FEES.
Passing and Handling the Flexible Endoscope
Perform a minimum of 25 mentor-supervised pediatric FEES that includes passing the flexible scope and/or directing, interpreting, and summarizing findings.
Both an SLP and ENT should be involved in this aspect of training to provide the mentee with an understanding of anatomical variances in pediatrics.
Demonstration of Competency
At the point in competency training when mentors believe a mentee has completed the necessary training, the Dysphagia Competency Verification Tool (DCVT) may be used. Continued oversight and mentorship may be needed and is determined at the discretion of the mentors and the facility requirements.
Indirect Supervision
When an SLP is independently performing pediatric FEES, they should be demonstrating all cognitive and technical skills components necessary for FEES conduction. Complete independence is achieved when an SLP no longer needs direct or indirect supervision.
*Note: For a comprehensive review of these guidelines, please see the reference cited below.
References
AB-SSD Task Force-Pediatric Group:, Miller, C. K., Reynolds, J., Kelchner, L. N., Scarborough, D., Langmore, S., & Gosa, M. (2023). Tutorial on clinical practice for use of the fiberoptic endoscopic evaluation of swallowing procedure with pediatric populations: Part 2. American Journal of Speech-Language Pathology, 32(1), 55–82. https://doi.org/10.1044/2022_AJSLP-22-00057
Guidance from the ASHA team - FEES training, competency, equipment, and resources
Getting Started with FEES
Written by Stefanie LaManna, MS, CCC-SLP, CNT; ASHA Associate Director, Health Care Services in SLP
Interested in learning about FEES or starting a FEES program, but don’t know where to begin? Here’s a rundown of everything you need to know to add endoscopy to your clinical skillset.
Certification and Competency Considerations
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Some state licensing boards have specific regulations about endoscopy, including the number of passes needed, documentation and supervision requirements, and other considerations. ASHA’s state by state webpage is a good starting point, but it is always recommended to contact your state’s board, even if your state isn’t listed.
A good question to ask your licensing board would be “is there anything in our practice act that requires me to have a certain number of endoscope passes and physician oversight, and if so, what documentation is required?”
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When a state does not have specific regulations or laws surrounding the use of FEES in practice, it is then up to the facility to create procedure protocols, safety guidelines, policies surrounding equipment, and competencies. The equipment manufacturer may have recommendations for some of those needs, so if you are or will be working with a representative from one of those companies, you may want to consider asking them for their input.
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ASHA does not require additional certifications outside of the Certificate of Clinical Competence, so we don't set standards for other training or certification programs or for FEES competencies. The Code of Ethics does address competency as it relates to clinical activities (Principle I, Rule A), but it’s a self-identified level of competency, so it’s up to the individual clinician to make decisions about their skills and practice.
Different clinicians may require a different number of passes before they feel competent to perform the procedure independently. As with any new skill, there may be a lot of ground between meeting a minimum employer or state licensing standard and establishing competency at an independent level. As an example, completing an intensive course may help an SLP meet their state’s requirement for the minimal number of normal and disordered scope passes, but they may need many more months of collaborative learning to feel confident in the complexities of the assessment. It may be helpful to talk directly to some of the companies that offer FEES training about their or other health care facilities’ experiences for insight about clinicians’ average time to competency, lessons learned for clinicians new to FEES, and tips for translating newly learned skills into practice.
The Dysphagia Competency Verification Tool (DCVT) is another helpful tool developed by SIG 13: Swallowing and Swallowing Disorders and the American Board of Swallowing and Swallowing Disorders Joint Committee on Dysphagia Competencies, but it is not intended to replace formal instruction and instead can be used as a guide to develop your own competencies.
It’s usually a good idea to have written competencies to protect yourself from liability and because reviewers (like The Joint Commission) may want documentation of it; though ASHA doesn’t require written competencies for clinical skills, we’d be happy to support you and your facility in developing a competency plan that fits your needs.
Helpful Links:
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There are many options for training and equipment. ASHA does not endorse any particular program or product. Click on each bullet point below to access resources to help guide you in deciding which course and manufacturer may be right for you and your facility:
o Tips for Choosing and Evaluating Continuing Education Courses
o What to Ask When Evaluating Any Procedure, Product, or Program
o Certificates, Certifications, and Competency: Investing in Your Future
You’ll want to discuss starting a FEES program with your administrators and ask questions like:
• What budget do we have for training courses and purchasing equipment? Are there grants we can apply for or is there support from the facility’s charitable foundation?
• What is our facility’s current process for cleaning equipment and what is the turnover time?
• How will we fit time into our schedules to support training, practice, and mentorship? Will we have access to per diem help or can we advocate for a new position to support this program development?
• Are there video storage or integration limitations with our current EMR and if so, how can we bypass that to support collaboration between SLPs and the medical team?
The equipment manufacturer will likely provide you with information to share with your administrators about equipment cost and EMR integration and storage, as well as requirements for processing and caring for endoscopic equipment.
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Physician involvement may or may not be needed when developing a FEES program, depending on your state’s practice act and guidelines and if you have a competent SLP who is independent in passing a scope on a variety of patients and is capable of mentoring others. Though you may not need a physician in a mentorship role for passing a scope, you likely want to involve your hospital’s medical leadership in developing guidelines for the procedure and for emergency protocols.
You’ll also want to consider who may be reviewing the FEES recordings with input from your medical leadership. Instrumental swallowing evaluations are certainly within the SLP scope of practice, but SLPs do not differentially diagnose medical conditions. If you or one of your colleagues identifies an anatomical impairment on a FEES, you’ll want to have a clear pathway to referral within the interprofessional team so you can expedite care for your patient.
Helpful Link:
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If you have more questions or want to take a deeper dive into all things FEES, here are a few other resources you might find helpful:
o Use of Endoscopy by Speech-Language Pathologists: Position Statement
o Frequently Asked Questions: Swallowing and Feeding (Dysphagia)
Our team is here to help support you!
Undergoing FEES training and competency can seem daunting - our team is here to support you in the process! We are happy to provide you with more information on resources for FEES courses, competency and training, and FEES equipment. For more information, contact us below.