For Audiology
IV. Clinical Fellowship: Requirements and Procedures
The American Speech-Language-Hearing Association (ASHA) maintains that academic and practicum experiences alone are not sufficient preparation for an individual to function as an independent, competent professional providing high quality care in audiology. Therefore, all applicants for the Certificates of Clinical Competence (CCC) are required to successfully complete a clinical fellowship (CF) in addition to the required academic and practicum experiences and the national examination in audiology. The clinical fellowship is an important transitional phase between supervised graduate-level practicum and the independent delivery of services. Inherent in this transition are:
- development of a total commitment to quality speech, language, and hearing services;
- integration and application of theoretical knowledge gained in academic training;
- evaluation of individual strengths and limitations;
- refinement of clinical skills;
- and development of clinical skills consistent with the current scope of practice in the profession.
The clinical fellow is an individual who is obtaining the supervised professional clinical experience required to obtain the CCC. Professional experience includes direct patient contact, consultations, record keeping, or any other duties relevant to a bona fide program of clinical work. Time spent in supervision of students, academic teaching, and research, as well as administrative activity that does not deal directly with patient management, may not be counted as professional experience in this context. The clinical fellow may not supervise students in clinical practicum.
Academic and clinical practicum requirements must be completed before the clinical fellowship is initiated. The clinical fellow must request supervision from a person holding a current CCC in the area in which certification is sought. It is the responsibility of the clinical fellow to verify the certification status of the clinical fellowship supervisor before initiating the experience and to verify the supervisor's continuing certification throughout the duration of the clinical fellowship experience. Individuals may verify the certification status of their supervisor in the following ways: (a) Call ASHA's Action Center toll-free at 800-498-2071, (b) Call Certification Administration at the National Office (301-296-5700), or (c) Ask to see your supervisor's ASHA membership card with the expiration date.
Information to note:
- A family member or individual related in any way to the clinical fellow may not serve as a clinical fellowship supervisor.
- If dual certification is sought, full clinical fellowship requirements must be met in each area.
- ASHA's Ethical Practice Board has determined that clinical fellows may specify "CF/A" after their names. However, if you wish to provide clinical services in the United States, you must first contact the appropriate state regulatory agency for specific regulations regarding use of the designation of audiologist (A) or speech-language pathologist (SLP).
Before beginning a clinical fellowship, the individual should determine what the state licensing agency requires of persons fulfilling a clinical fellowship. Some states use a different designation for the fellowship (e.g., Required Professional Employment). Many states require clinical fellows to register with the licensing agency, obtain a provisional or temporary license, and/or file a clinical fellowship plan. The addresses and phone numbers of the state regulatory agencies are on ASHA's Web site. Completing the clinical fellowship without also meeting the state requirements may jeopardize one's ability to practice.
Clinical Fellowship Setting
It is recognized that services for persons with speech, language, and hearing disabilities can be provided in any one of a number of diverse employment settings. The determination of whether a given setting is appropriate for the clinical fellowship is made by first applying the criterion of whether the particular program or program component is designed to evaluate, habilitate, or rehabilitate individuals with speech, language, and hearing disabilities. Second, the program must afford the possibility that clinical fellowship supervisory requirements can be met. It is the clinical fellow's responsibility to obtain employment in a setting that meets these criteria. It is also the clinical fellow's responsibility to abide by ASHA's Code of Ethics during the clinical fellowship.
It is further recognized that many highly specialized programs are appropriate for the clinical fellowship, even though they deal intensively with only a small number of individuals. Evaluation and treatment programs in schools, clinics, hospitals, community agencies, nursing homes, and home health agencies are appropriate clinical fellowship settings. However, programs that primarily provide screening services are not suitable for the clinical fellowship experience.
Because the clinical fellowship is not intended to be an extension of the clinical practicum experience undertaken as part of academic study, the clinical service program of an educational program may not be an appropriate work setting for the clinical fellowship. If such a site is selected for the clinical fellowship, it is important that the clinical fellow perform clinical services as a bona fide staff member and that all of the requirements for the clinical fellowship are met.
If the clinical fellow changes the clinical fellowship site, the clinical fellowship supervisor, or the category of number of hours worked per week, the clinical fellow must document any changes in the final Clinical Fellowship Report as noted below. For example, if a clinical fellow began the clinical fellowship indicating the intent to work 18 hours/week and after 2 months of work he/she changes to 26 hours/week or after 3 months of work selects another supervisor and moves to another facility, then those changes must be documented in the final report, with a separate report submitted for each component of the experience.
Professional Services Board Accreditation. The Professional Services Board (PSB) of ASHA administers a voluntary accreditation program for speech-language pathology and audiology programs in a variety of clinical facilities in which the clinical fellowship experience may occur. The program documents and verifies use of standards established by the Council on Professional Standards. The PSB "Standards for Professional Service Programs in Audiology and Speech-Language Pathology" address the following areas: program mission, goals, and objectives; nature and quality of services; quality improvement and program evaluation; administration; financial resources and management; human resources; physical facilities and program environment; and equipment and materials.
PSB accreditation demonstrates to regulatory agencies, insurance carriers, HMOs, and other funding agencies that a clinical program meets ASHA's nationally recognized standards of quality service delivery. PSB accreditation is currently used by many state funding agencies as the criterion for selection of speech-language pathology and audiology service providers. Although it is not required that the facility in which an individual completes the clinical fellowship be accredited by ASHA's Professional Services Board (PSB), it is recognized that the current PSB standards do ensure the provision of both high quality services to the public and a commitment to adequate supervision of noncertified staff members. Individuals completing their clinical fellowship in a PSB-accredited facility will not be required to complete the entire Clinical Fellowship Report (Form D [PDF]), as described later.
The clinical fellowship is defined as no less than 36 weeks of full-time professional employment. A minimum of 30 hours of work per week constitutes full-time employment. At least 80% of the clinical fellowship work week must be in direct client contact (assessment, diagnosis, evaluation, screening, habilitation, or rehabilitation) related to the management process. Thus, in a 30-hour work week, at least 24 hours must be devoted to direct clinical activities. The clinical fellowship requirement can also be met by less than full-time employment. For example, if the clinical fellow works:
- 25 29 hours per week, the length of the clinical fellowship must be at least 48 weeks.
- 20 24 hours per week, the length of the clinical fellowship must be at least 60 weeks.
- 15 19 hours per week, the length of the clinical fellowship must be at least 72 weeks.
Professional employment of less than 15 hours per week may not be used to fulfill any part of the clinical fellowship requirement . If the clinical fellowship is not completed within 4 years of the date the academic and practicum education is completed, the clinical fellow must reapply and meet the academic and practicum requirements in effect at the time of reapplication.
The CCB recognizes that under certain circumstances alternative mechanisms may be necessary to meet the clinical fellowship supervision requirements. A request to use an alternative method to meet clinical fellowship supervision requirements must be submitted in writing to the CCB. The request must include a detailed outline explaining the type, length, and frequency of each alternative supervisory activity and the reason for the alternative. For example, if the request is for the use of videotapes instead of direct observations, the fellow must specify the length of each videotaped session, how often the videotapes will be made, and the total number of such videotapes. The request and the detailed outline of the proposed alternate supervisory program must be approved by the CCB before initiation of the clinical fellowship.
A clinical fellow can be supervised only by an individual holding a valid CCC in the professional area in which the clinical fellow is seeking certification. A family member or individual related in any way to the clinical fellow may not serve as the clinical fellowship supervisor.
It is the responsibility of the clinical fellowship supervisor to maintain his/her certification during the entire clinical fellowship period through timely payment of annual dues and fees.
If the clinical fellowship supervisor's certification lapses, the clinical fellow may be required to extend his/her clinical fellowship. Currently, individuals are not required to work a minimum amount of time after becoming certified before supervising other individuals. However, clinical fellows are encouraged to seek supervisors with some prior supervisory experience.
If a clinical fellow is supervised by multiple individuals, it is the responsibility of one clinical fellowship supervisor to collate the evaluations of all supervisors and to verify that the policies governing supervision and evaluation have been met. All clinical fellowship supervisors must hold a current CCC in the area in which certification is sought and must maintain this certification throughout the period of supervision.
Mandatory Supervision Requirements. Clinical fellowship supervision must include the personal and direct involvement of the supervisor. The clinical fellowship supervisor must directly observe diagnostic and therapeutic procedures in order to monitor and evaluate the clinical fellow's performance in professional employment. The clinical fellowship is divided into three equal segments, each segment representing one third of the total experience. For example, a 36-week clinical fellowship is divided into three 12-week segments; a 72-week clinical fellowship is divided into three 24-week segments.
The clinical fellowship supervisor must complete no less than 36 supervisory activities spaced uniformly throughout the clinical fellowship. The supervisor must complete at least 18 on-site observations (one hour = 1 on-site observation). At least 6 on-site observations must be accrued during each third of the experience (up to 6 hours may be accrued in one day). In addition to direct observation, the clinical fellowship supervisor must complete 18 other monitoring activities, at least 6 per segment. Such activities may include:
- conferring with the clinical fellow concerning clinical treatment strategies
- monitoring changes in clients' communication behaviors
- evaluating the clinical fellow's clinical records, including (a) diagnostic records, (b) treatment records, correspondence, (d) plans of treatment, and (e) summaries of clinical conferences
- monitoring the clinical fellow's participation in case conferences
- evaluating the clinical fellow on the basis of consultation with professional colleagues and employers
- evaluating the clinical fellow's work on the basis of consultation with clients and their families
- monitoring the clinical fellow's contributions to professional meetings and publications, as well as participation in other professional growth opportunities.
Clinical Fellowship Supervisor's Responsibilities. From time to time, the Ethical Practice Board or the Council on Professional Ethics determines that members and certificate holders can benefit from additional analysis and instruction concerning a specific issue of ethical conduct. Issues in Ethics statements are intended to heighten sensitivity and increase awareness. They are illustrative of the Code of Ethics and intended to promote thoughtful consideration of ethical issues. They may assist members and certificate holders in engaging in self-guided ethical decision-making. These statements do not absolutely prohibit or require specified activity. The facts and circumstances surrounding a matter of concern will determine whether the activity is ethical. The text of the Issues in Ethics statement regarding "Responsibilities of Individuals Who Mentor Clinical Fellows," published by the Board of Ethics in 2007, is given in Appendix 4.
Guidelines for Direct Expense Reimbursement for Clinical Fellowship Supervisors. It is the interpretation of the CCB that clinical fellowship supervisors should not accept compensation for supervision or sponsorship from the clinical fellow being supervised or sponsored, beyond reasonable reimbursement for direct expenses. The guidelines below apply specifically to those instances in which direct expenses are personally assumed by the clinical fellow.
1. The clinical fellow and the clinical fellowship supervisor should execute a written agreement, and each should retain a signed copy. The agreement should include:
- the duration of the supervision
- the number of on-site supervisory activities and the duration of each on-site supervisory activity
- the occasion, nature, and number of other monitoring activities
- the mechanism whereby the clinical fellow receives feedback
- the clinical fellowship supervisor's commitment to complete and sign the Clinical Fellowship Report within 30 days of completion of the CF experience
- a mechanism for terminating the clinical fellowship if it becomes necessary before the expected completion date
- an account of the direct expenses for which the clinical fellowship supervisor will be reimbursed (e.g., transportation, meals, lodging, telephone, etc.)
- the payment schedule for reimbursement of direct expenses incurred by the clinical fellowship supervisor (Payment must not be conditional upon the clinical fellowship supervisor's recommendation for approval of the clinical fellowship.)
- a statement that both the supervisor and the clinical fellow have verified that the clinical fellowship supervisor's certification is current throughout the clinical fellowship.
2. Expenses should be reimbursed at a reasonable level. Reasonable refers to the exact expenses incurred for transportation, meals, lodging, telephone, and postage.
3. If the clinical fellow and the clinical fellowship supervisor work for the same employer or institution, there shall be no remuneration.
The Standards for the Certificates of Clinical Competence require the clinical fellowship supervisor to conduct periodic formal evaluations of the clinical fellow. The section on Clinical Fellowship Skills Inventory (CFSI A)" contains instructions for use during the formal evaluations. It is the responsibility of the clinical fellow and the clinical fellowship supervisor to make certain that they follow the instructions in these sections and that the clinical fellowship supervisor uses the CFSI A (see Form E [PDF] and Appendix 5 [PDF]) to complete the mandatory evaluations. As stated in the CCB Implementation Procedures, the clinical fellowship supervisor must use the current evaluation instrument at least once during each of the three segments of the clinical fellowship. That is, the supervisor must conduct at least three formal evaluations using the Clinical Fellowship Skills Inventory, spaced uniformly throughout the clinical fellowship. No later than 4 weeks after the clinical fellowship is completed, the clinical fellow and the clinical fellowship supervisor must sign, date, and submit to the National Office for review by the CCB a Clinical Fellowship Report and the Clinical Fellowship Skills Inventory Rating Form reflecting the three formal evaluations.
If a clinical fellow is supervised by multiple individuals, it is the responsibility of one clinical fellowship supervisor to collate the evaluations of all supervisors and to verify that the policies governing supervision and evaluation have been met. All clinical fellowship supervisors must hold a current CCC in the area in which certification is sought, and they must maintain this certification throughout the period of supervision.
Ongoing Feedback. Because one purpose of the clinical fellowship is to improve the clinical effectiveness of the clinical fellow, supervisors must provide performance feedback to the clinical fellow throughout the clinical fellowship. Feedback and goal-setting require two-way communication whereby both the clinical fellowship supervisor and the clinical fellow share important information about the clinical fellow's performance of clinical activities. A specific time should be set aside for each performance feedback session at the end of each of the three segments of the clinical fellowship. This session should be used to identify performance strengths and weaknesses and, through discussion and goal-setting, to assist the clinical fellow in developing the required skills.
If the clinical fellowship supervisor anticipates at any time during the clinical fellowship that the clinical fellow under supervision will fail to meet requirements, the clinical fellowship supervisor must counsel the clinical fellow both orally and in writing and maintain written records of all contacts and conferences over the ensuing months. If the clinical fellowship experience is terminated at any time before completion of the clinical fellowship, or if the clinical fellowship supervisor does not recommend approval of the clinical fellowship experience at the end of the clinical fellowship, he/she must so indicate in Section 8 of the Clinical Fellowship Report. Within 30 days of making the negative recommendation, the clinical fellowship supervisor must submit to the CCB (a) a letter of explanation and supporting documentation, (b) a signed Clinical Fellowship Report completed for the portion of the clinical fellowship he/she supervised, and a signed Clinical Fellowship Skills Inventory Rating Form completed for the portion of the clinical fellowship he/she supervised. This information must be shared with the clinical fellow. Following a negative recommendation, the clinical fellow may complete an entirely new clinical fellowship, a portion of the clinical fellowship, and/or request a Special Review by the CCB.
Special Review. To request a Special Review, the clinical fellow must submit to the CCB within 30 days of the negative recommendation (a) the completed and signed Clinical Fellowship Report, (b) the completed and signed Clinical Fellowship Skills Inventory Rating Form (if the supervisor has not submitted either or both), and a letter of explanation and supporting documentation to indicate why the clinical fellowship should be accepted. The CCB may share this information with the clinical fellowship supervisor and may solicit any additional information the supervisor wishes to provide. The decision to approve the clinical fellowship rests solely with the CCB. The CCB will review all information submitted to determine if the clinical fellowship experience will be approved, in part or in full. (For more information see Section VII. Procedures for Appeal).
Clinical Fellowship Skills Inventory (CFSI A). The CFSI A provides the means for determining whether the clinical fellow can satisfactorily perform the skills necessary for independent practice and addresses the need to assess the clinical fellow in developing these skills. The CFSI A stresses the need for both the clinical fellowship supervisor and the clinical fellow to identify performance areas in which improvement is needed and then to develop and implement performance improvement plans. This approach to the performance appraisal process includes the following features: (a) a standardized system for reviewing the clinical work of all clinical fellows at regularly scheduled intervals, (b) a procedure to ensure that the clinical fellow has the skills for independent practice, a means by which the clinical fellowship supervisor can meaningfully supervise the clinical fellow's progress in attaining and improving skills, (d) a process by which the clinical fellow gains experience in the self-evaluation of his or her skills, and (e) a collaborative effort in which the clinical fellowship supervisor and the clinical fellow are encouraged to work together to make the clinical fellowship a valuable learning experience. Performance appraisal protects the public interest and serves as a clinical teaching and learning tool.
The CFSI A consists of 21 skill segments covering four areas. The skills selected for inclusion in the CFSI A are derived from a role delineation and validation study conducted for ASHA by the Professional Examination Service. Following is a general description of each of the four performance areas:
- Evaluation (8 skills): selection, adaptation, administration of an assessment battery and interpretation of results
- Treatment (5 skills): selection, development, adaptation, and implementation of treatment plans and intervention strategies
- Management (3 skills): service activities and compliance with administrative and policy requirements
- Interaction (5 skills): communication skills and collaboration with other professionals
The rating scale for each skill has been designed along a 5-point continuum, ranging from "5" (representing the most effective performance) to "1" (representing the least effective performance). The clinical fellowship supervisor will match the clinical fellow's performance to the descriptors for each skill. The ratings for one skill may not be the same as the ratings for other skills. For each skill included on the CFSI A the clinical fellowship supervisor will have to decide which point on the scale best reflects the performance of the clinical fellow during the segment being rated. The category "Not Applicable (NA)" appears on ten items of the rating scale and may be used only for these items. NA should be used only if the facility does not provide an opportunity for the clinical fellow to perform the skill during the segment . However, the clinical fellowship supervisor is encouraged to coordinate the observation schedule to ensure that all applicable skills are observed and evaluated.
The clinical fellowship supervisor must use the rating scale at least once during each of the three segments of the clinical fellowship. This evaluation must be shared and discussed with the clinical fellow, and the CFSI Rating Form (Form E [PDF]) must be signed and dated by both. Supervisors must follow the instructions below to complete the rating process at the end of each segment.
- The clinical fellowship supervisor completes the machine-scannable CFSI Rating Form (Form E [PDF]) to rate the performance of the clinical fellow on each of 21 skills.
- Both the clinical fellowship supervisor and the clinical fellow must sign the CFSI Rating Form and note the dates when the performance feedback sessions were held.
- At the end of the clinical fellowship, the clinical fellowship supervisor mails the completed CFSI Rating Form and the completed Clinical Fellowship Report to Certification Administration at ASHA.
- The clinical fellowship supervisor retains a photocopy of the completed CFSI Rating Form.
At the beginning of the first segment of the clinical fellowship, the clinical fellowship supervisor and the clinical fellow should meet to discuss assigned work responsibilities, performance expectations, and the requirement that regularly scheduled performance appraisals be conducted during the clinical fellowship. They should review the CFSI A to ensure that both the skills to be evaluated and the rating scale are understood and to determine if there is a particular skill or skill area requiring a special focus. Setting goals at this time to prepare for the second and third segments will give the clinical fellowship supervisor and the clinical fellow an opportunity to discuss concerns that have arisen and to plan new performance goals before the beginning of another segment. Goal setting also encourages the supervisor and fellow to consider realistically how much improvement can be achieved from one performance assessment to another. It is an important component in the performance appraisal process one that requires collaboration between the clinical fellowship supervisor and the clinical fellow.
The clinical fellow should prepare for each performance feedback session by reviewing the CFSI A (i.e., the performance skills and rating scale). It is also recommended that the clinical fellow conduct a self-evaluation using the CFSI A. Self-evaluation can provide the clinical fellow with important insights to use in improving performance. The clinical fellow can then compare his or her own ratings with those given by the clinical fellowship supervisor.
Minimum Rating for Core Skills. Core skills must be assessed during at least one segment of the clinical fellowship, and each skill must receive a rating of at least a "3" on a 5-point scale during the last segment in which the core skill is rated. The core skills are 2 5, 8 11, 14, 15, and 17-20 and are so noted on the list of skills found in Appendix 5.
For clinical fellowships initiated as of September 1, 1997, a minimum rating of "3" on core skills during the last segment in which the core skill was rated will be required for approval of the fellowship.
Supervisors may rate the clinical fellow only on the clinical skills identified in the CFSI. If a rating of "3" is achieved for each of the core skills during the last segment in which the core skill was rated, the supervisor must include in the final Clinical Fellowship Report a positive recommendation for certification or provide a specific rationale and documentation for why the fellow is not being recommended for certification.
Upon completion of the clinical fellowship, a conference must be held to provide the clinical fellow the opportunity to discuss the evaluation with the supervisor. The supervisor and the clinical fellow must complete, sign, and submit the Clinical Fellowship Report (CF Report) and the Clinical Fellowship Skills Inventory Rating Form to the CCB as soon as possible after completion of the clinical fellowship. If the application for certification has not been submitted to the National Office, it must be filed at this time.
If a change is made in the clinical fellowship site, clinical fellowship supervisor, or category of hours worked per week, the clinical fellowship supervisor must submit to the CCB, within 4 weeks of the change, the completed and signed Clinical Fellowship Skills Inventory Rating Form and the Clinical Fellowship Report for the portion of the clinical fellowship that was completed.
Remember: A separate CF Report must be submitted for each component of the clinical fellowship that involved a change of site, supervisor, or work schedule.