Competency Verification - The Foundation of the Professional Certification

Posted : 06/08/21 in In the News

Competency Verification - The Foundation of the Professional Certification
Ellie MacGregor

Posted 1 year ago

Competency Verification - The Foundation of the Professional Certification

By: Ellie MacGregor, MPH, CLC, Karin Cadwell, PhD, RN, IBCLC, ANLC


Health professionals and members of the healthcare team are mandated to acquire and maintain a set of skills and an ever evolving base of knowledge in order to assure the public that they can do their job safely and effectively. Historically, hours of training were the measurement of whether or not the required skills and knowledge had been acquired and maintained. For example, educational seminars would be provided to professional staff members by hospitals in order to check a box on a form attesting that the staff had been trained and were therefore “up to date” in their knowledge and skills. Unfortunately, according to substantive research, training hours alone are not sufficient to inculcate or change behaviors of healthcare personnel.


Competency verification is an alternative approach to training hour requirements and rote learning that has been growing in popularity within the healthcare field and among other professions.[i] Competency verification is an assessment of an individual’s knowledge and skills using tools that observe and measure abilities and attitudes. At its core, the competency verification method seeks to measure the ability of a professional to apply their knowledge and skills in practical situations.[ii]


According to Howanitz, Valenstein & Fine there are four levels of competence:[iii]


Level 1 = what an individual “knows” measured by his or her general knowledge

Level 2 = what an individual “knows how” to act measured by his her competence

Level 3 = what an individual “shows how” to act as measured by his or her performance

Level 4 = what an individual “does” as measured by his or her action


Lactation Support Professionals


Lactation support professionals (LSPs) are individuals who have had education and training designed to support families and individuals along their breastfeeding journeys. The types of training and required training hours vary greatly among different LSPs. For example, Lactation Educators trained through the Childbirth and Postpartum Professional Association (CAPPA) typically have 20 hours of training. Breastfeeding Peer Counselors require approximately 20 hours of training through various community models, such as Women, Infants, and Children (WIC). Certified Lactation Counselors® (CLC®) complete 52 hours of didactic training, require competency verification at Howanitz, Valenstein & Fine Level 3, and complete a certification exam which includes an additional competency at Howanitz, Valenstein & Fine Level 3. Lactation consultants, such as the Advanced Nurse Lactation Consultant (ANLC) the Advanced Lactation Consultant and the International Board Certified Lactation Consultant® (IBCLC®) complete 90 hours of didactic training, plus additional requirements, and a certification exam.[iv] The Advanced Nurse Lactation Consultant (ANLC) and the the Advanced Lactation Consultant (ALC) require competency verification at Howanitz, Valenstein & Fine Level 3, and a certification exam which includes an additional competency at Howanitz, Valenstein & Fine Level 3.


Despite all of the variations in training models, the World Health Organization (WHO) has recommended that 20 hours of breastfeeding education is the minimum amount of required didactic hours to establish the foundation for a LSP to be able to effectively and efficiently assist a breastfeeding individual.[v]


The variability among LSP hourly training requirements supports the notion that rote learning in a classroom or virtual setting is not the best method for having skilled, knowledgeable, and competent providers. There is no guarantee, and little rationale behind the notion, that a first-time trainee who sits through 90 hours of didactic training is going to be a better LSP than a person who sits through 20 hours of didactic training and has 30 years of experience working as a LSP in an uncredentialed capacity.


Why Competency Verification is the New Standard


If the lactation support profession can uniformly transition to the training method of competency verification, rather than solely focusing on the number of accrued training hours, then one might expect patient care and patient health outcomes to improve.


The WHO/UNICEF Baby Friendly Hospital Initiative® (BFHI) is embracing the shift towards the competency standard. Through their Ten Steps to Successful Breastfeeding, the BFHI aims to ensure that mothers and newborns receive “timely and appropriate care before and during their stay in a facility providing maternity and newborn services.”[vi] In 2018, following a WHO revision of the Ten Steps, Step 2: “Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding,” was revised to reflect a transition in the foundation from a focus on training hours (formerly 20 hours) to competency verification. “The new Step 2 focuses on verification to ensure that direct care providers have the knowledge, competence and skills to support breastfeeding, especially during the first few days in maternity facilities.”[vii]


The training and certification philosophy behind the CLC ANLC® and ALC ® certifications has been competency verification since their inception with the underlying belief that although general knowledge can be gained through classroom learning about health sciences and tested at Level 1 though written examinations, the application of that knowledge and when to apply those skills in directly observed scenarios or case study situations, as expected at Howanitz, Valenstein & Fine Level 3 is a more valuable indicator of an individual’s ability to work as a LSP.


Competency verification is not just about checking off boxes on an organization’s competency checklist, either. Assessment of technical skills only is not the purpose of competency verification. Instead, the assessment of critical thinking and interpersonal skills are key to a robust competency verification program. Measuring competency focuses on the verification or demonstration of knowledge, skill, behavior or attitude. [viii] While education alone can contribute to some individuals reaching the goal of being able to be verified, it is not the best pathway solution to demonstrate and verify that an individual is truly capable of performing the behaviors required by their profession.




[i] Burke, A. E., Benson, B., Englander, R., Carraccio, C., Hicks, P. J. (2014). Domain of competence: Practice-based learning and improvement. Academic Pediatrics, 14(2 Suppl), S38–S54.doi:10.1016/j.acap.2013.11.018 24602636.

[ii] Chapin EM, Chen C-H, Dumas L, et al. The Paradigm Shift in BFHI Step 2: From Training to Competency Verification. Journal of Human Lactation. March 2021. doi:10.1177/0890334421995098.

[iii] Howanitz PJ, Valenstein PN, Fine G. Employee competence and performance-based assessment: A college of American pathologists Q-probes study of larboratory personnel in 522 institutions. Arch Pathol Lab Med. 2000 Feb;124(2):195-202. doi: 10.1043/0003-9985(2000)124<0195:ECAPBA>2.0.CO;2. PMID: 10656726.)

[iv] United States Breastfeeding Committee (USBC). Lactation Support Providers Descriptors Table. Available from:

[v] World Health Organization & UNICEF. Breastfeeding Promotion and Support in a Baby-friendly Hospital, a 20-hour course for maternity staff. 2009. Available from:

[vi] World Health Organization, UNICEF.  Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-Friendly Hospital Initiative. Geneva: World Health Organization; 2018 (

[vii] Competency verification toolkit: ensuring competency of direct care providers to implement the Baby-friendly Hospital Initiative. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020. License: CC BY-NC-SA 3.0 IGO.

[viii] Wright D. (2005). The Ultimate Guide to Competency Assessment in Health Care. Third Edition. Minneapolis: Creative Health Care Management.