FEES Competency Information
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FEES Competency Training beyond basic training is strongly recommended if planning to provide endoscopic instrumental swallowing assessment services in any medical setting. SA Swallowing Services delivers a rigorous, one-week competency field training experience for qualified SLPs. Trainees accompany supervising SASS Associates to medical facilities and perform FEES assessments with actual patients. The training practices begin with patient chart reviews, then equipment and test materials setup to FEES administration to endoscope disinfecting to analysis and final report.
To be competent, the SLP must be able to:
(1) perform the setup of the specific FEES videoendoscopy equipment and show a thorough understanding of its operation and functions;
(2) explain the rationale for and demonstrate the proper and consistent use of a predetermined, standard FEES administration protocol with every patient (1, 2, 3);
(3) explain the rationale for discontinuing a study prematurely based upon a predetermined “bail-out” criteria;
(4) safely perform the hand-eye coordinated skills of endoscope insertion and manipulation to ensure the endoscope is placed properly for optimum video-recording observations of each swallowing event, and that the quality of the images will allow high-quality analyses (3);
(5) identify, name, and describe the anatomical structures of the pharynx, larynx, and proximal trachea and their physiological functions for swallowing peristalsis and airway protection before, during, and after a swallow event (1);
(6) identify the presence of possible pathology in the pharynx, larynx, and proximal trachea and describe it based on factors such as structural asymmetry, location, mass effects, color, mobility, and size (1, 3);
(7) identify and explain the potential medical complications that could occur during the FEES procedure and demonstrate what steps, or protocol, to take if they should happen (1,2,3);
(8) describe and show a thorough understanding of infection control procedures, whether using high-level disinfectant or sterilization (2);
(9) identify and describe the observable consequences (normal or abnormal) of each swallowing event using predetermined and standard scoring systems for swallowing peristalsis and airway protection;
(10) quantify the scored results for swallowing peristalsis and airway protection and differentiate normal from abnormal swallowing consequences;
(11) to judge the significance and severity of any swallowing impairment from the results of the FEES study and relate the dysphagia to the underlying primary patient illness or illnesses.
(12) write a concise and usable clinical report.
(13) describe, demonstrate, and apply all of the above criteria in the presence of a qualified, experienced, and competent mentor using a minimum of 10 actual patients (2).
Note: Contrary to some opinions, FEES competency cannot be accomplished through a two-day training course and with a day or so of supervised scope practice. Supervised training must be from a qualified, experienced FEES provider, not a physician, occasional FEES user, or non-SLPs.
The “Magical 25” Endoscope Passes:
♦ Newly trained FEES clinicians are not prepared to assess the elderly, combative patients, or the young TBI patient after only twenty-five endoscope passes on normal volunteers.
♦ Langmore, Scarborough, Kelchner…Rule (2021) (1) recommends that during training, SLPs should “pass and handle” the endoscope under supervision with a minimum of 10 healthy volunteers (during or) after the basic training course. They further recommend 15 more supervised procedures with patients. The “25 passes,” as a requirement, is only required at the local facility policy level or at the state regulatory level, such as in Tennessee. It is not an ASHA policy or recommendation.
♦ SASS requires, during its basic FEES training course, a minimum of 15 supervised scoping “procedures” on normal volunteers. This “procedure” training follows a step-by-step, progressive training protocol designed to help the SLP develop technical and cognitive skills and confidence when inserting and manipulating the endoscope. Included in this training is establishing the best position for viewing the swallow event (Position 1 or Home), announcing the swallow trial with test volume and consistency, into a close view of the subglottic area (Position 2), and being able to carry out this procedure over multiple trials (3). The remaining practice procedures should be carried out on real patients with suspected dysphagia under appropriate supervision until competency is established.
SASS Qualifications & Requirements:
Because training course content, procedures, and supervision vary widely across instructors and FEES courses, some SLPs are not adequately prepared for competency training. To qualify for SASS FEES Competency training, the SLP must complete the SASS basic FEES Training Course. Requests for competency training will not be considered unless the SLP has attended the SASS basic training course.
References:
Miller, C. K., Schroeder, J. W., Jr, & Langmore, S. (2020). Fiberoptic Endoscopic Evaluation of Swallowing Across the Age Spectrum. American Journal of Speech-Language Pathology, 29(2S), 967–978. https://doi.org/10.1044/2019_AJSLP-19-00072
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
Langmore, S. (2001). Endoscopic evaluation and treatment of swallowing disorders. 1st ed. New York: Thieme.Endoscopic evaluation and treatment of swallowing disorders
For more information and planning, contact Michelle Skelley, M.Ed., CCC-SLP at 615-306-3693 or Michelle@sasspllc.com.
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Purpose:
To enable trainees to acquire advanced skills required to perform all aspects of flexible endoscopic evaluations of swallowing independently
Objectives:
After intensive one-week training the trainee will be able to:
1. Insert the endoscope into the naris with minimal discomfort and achieve a stable position 1 that allows for the initiation of study trials.
2. Manipulate the endoscope, after each trial, within the hypopharynx to achieve position 2, and return to position 1 for the presentation of the next trial.
3. Perform SASS’s standardized administration protocol for FEES.
4. Utilize SASS’s scoring protocol to quantify swallowing behaviors.
5. Interpret the quantified behaviors in terms of the underlying biomechanics and physiology.
6. Report findings in a clear and concise report that will be entered into the patient’s medical record.
Reference:
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
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Prerequisites to FEES Competency Training:
Prior to competency training, trainees are required to complete the SASS Basic FEES Training Course to:
1. Develop a better knowledge and understanding of the neurology and physiology of normal swallowing;
2. Cultivate a deeper understanding and useable knowledge of the underlying biomechanics of disordered swallowing;
3. Be familiar with and understand SASS’s FEES administration protocol and its application;
4. Be familiar with and learn to apply SASS’s FEES scoring and analysis protocols;
5. Undergo supervised instruction to learn proper and safe endoscope insertion and manipulation using the SASS 15-step training protocol; and
6. Build rapport with SASS’s trainers who will spend the week of competency supervising your training.
Methods:
Trainees will spend 5 consecutive days with two SASS trainers who carry the endorsement for endoscopy and endoscopy training in the state of Tennessee. Trainees will complete each FEES procedure beginning with equipment set up to final report writing and infection control cleaning of equipment.
Trainees will be assessed for FEES competency using a derivation of the Dysphagia Competency Verification Tool (DCVT): Fiberoptic Endoscopic Evaluation of Swallowing (FEES) (Link: ASHA).
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General Questions:
Are there any specific eligibility requirements for SASS competency training?
Yes, trainees are required to:
Take the SASS Basic FEES Training Course no more than two years prior to competency.
**COVID-19 requirements**
Masks are still required in all medical facilities.
If I have already taken a basic FEES course with another company, am I still required to take SASS’s basic FEES course?
Yes. Training course content, procedures, and supervision vary widely across FEES courses. We want your week to be successful. This policy was created to ensure that your training goes smoothly. Over the years, we found that some SLPs arrived for training but were not adequately prepared to scope patients, analyze swallowing behaviors, and write a concise report. This resulted in frustration, anxiety, and valuable time wasted.
How long does competency training last?
Students come to Nashville for one week (typically arriving Saturday or Sunday prior to training and leaving Saturday following completion of competency).
We ask that you get in early enough on Sunday to spend 1-2 hours with us for a quick equipment and policy orientation prior to starting on Monday morning.
We also ask that—if possible—you do not fly out until Saturday. If you leave on Friday, it presents problems with scheduling FEES for Friday. If you fly out on Friday, we cannot guarantee that you will be able to complete the week of training.
Will SASS continue to provide mentorship after the week of training?
Yes, we have no limit on how long we will continue to provide mentorship, and we do not charge you for continued “access” to us. We still have students, who came for competency many years ago, that call/text/email on a daily basis.
How many students do you supervise each year?
20. We have a limited number of spots, and we do not typically take students in January or February. Slots fill up quickly.
We are routinely scheduling 6 – 12 months out from the time of inquiry.
For example, if you inquire in January, the earliest available slot is likely to be July or later.
What is a typical day like?
You spend the entire day with one of our experienced endoscopy trainers, completing each swallow study from chart review to writing the full FEES report. We cover the entire state of Tennessee, and there is a good amount of time spent driving in the car. Days can be long (10 – 12 hours with drive time can be spent with your trainers).
During training, the entire FEES process for a single patient often takes 3 – 4 hours.
We tend to complete 2 – 3 FEES per day with students.
See Schedule for a Typical Day of Training.
Do you have any expectations for me as a student?
We expect that you have a solid understanding of normal and disordered swallowing prior to beginning your week with us.
If it has been several months since your basic FEES class, we suggest that you spend some time reviewing that material prior to coming to Nashville.
Understanding anatomy—as viewed endoscopically—and biomechanics/pathophysiology is paramount to having a successful week of training.
If you are not conversant in normal and disordered swallowing prior to beginning training, SASS cannot guarantee that you will be able to complete the week of training.
When clinicians are not properly prepared, valuable time (which could be spent scoping, analyzing, and report writing) is wasted going over remedial information.
What should I wear?
We wear scrubs every day.
If you don’t wish to wear scrubs, you should wear comfortable professional clothing that would be appropriate in hospitals, SNFs, long-term care facilities, etc.
What is the cost?
$3,000.00 – For the 5-days of competency training. This fee does not include the cost of your basic FEES course.
If it has been greater than two years since your basic FEES class, you will need to take the basic class again.
A deposit is required to secure your week of training. Payment of half of the total cost for competency, $1500.00, will reserve your week of training.
An invoice from SASS will be created and sent to you electronically.
The remaining $1,500.00 is to be paid the week prior to your arrival.
An invoice from SASS will be sent electronically the week before you arrive for training.
Payment options:
Check – checks should be made payable to SA Swallowing Services
Venmo – personal payments may be made to @MichelleSkelleyAsh1
I am interested in/starting a mobile FEES company, is there any training associated with the business side of mobile FEES?
Business training is not a formal part of competency. However, Michelle (the President and Co-Owner of SA Swallowing Services) has been operating as a mobile FEES provider for more than 10 years.
If this is of interest to you, please let us know prior to your arrival.
SASS cannot guarantee this aspect of training, but with advance notice, we will make every attempt to accommodate this request.
Questions once you have reserved a training week:
Where should I stay?
Do NOT stay in downtown Nashville. Nashville has a significant traffic problem. An average of 100 people per day have been moving to Nashville for the last few years and traffic congestion is a huge issue. While downtown Nashville is pretty great, we will NOT be able to get you to and from your lodging downtown.
When searching, you want to be within 2-3 miles of:
780 Old Hickory Boulevard, Brentwood, TN 37027
This area is just south of Nashville and very safe for those traveling alone.
Do I need a car?
The short answer is that renting a car is not required. We can get you to and from your lodging for training each day, and we are happy to do so.
However, if you choose to stay in downtown Nashville or more than 2-3 miles from our central location, you may need a car and will be responsible for getting to and from your lodging on your own. This option is suboptimal, and it can result in you spending a substantial amount of your personal time in your car early in the morning and later in the evening.
Do you stop for lunch during a typical day?
No, we typically bring snacks and water with us, and we eat on the go.
When should I plan to get to Nashville?
Plan to get in on Saturday evening or Sunday—early enough for a short (1-2 hour) orientation with us.
When should I plan to leave?
If possible, we ask you to stay until Saturday. It is nearly impossible to schedule a full day of FEES on Friday and get you to the airport on time. If you leave on Friday, we are unable to guarantee you will receive a full day of training.
What SASS wants you to know about competency of training:
We love our jobs. We enjoy scoping and helping individuals with swallowing disorders, and we are passionate about sharing our knowledge. The week-long training is intense, but we have a great time with the trainees.
Prior to mentoring in competency training, each trainer completes advanced FEES training in scoping, scoring, and analysis. In fact, each trainer completed the same week-long process that you are embarking upon.
Furthermore, trainers carry an endorsement for endoscopy and for endoscopy training from the state of Tennessee Board for Communication Disorders and Sciences.
If you are seeking an endoscopy endorsement for a license in the state of Tennessee, competency training must be completed by an otolaryngologist or by a speech-language pathologist who has completed a minimum of 50 FEES and has been signed off by an ENT as capable of training other SLPs. SLPs without this endorsement cannot provide competency training in the state of Tennessee.
The process of learning to scope, analyze videos, and write reports requires multiple layers of learning:
Scoping is a physical skill that relies upon proper posture, breathing, body mechanics, proprioception, muscle memory, and fine motor coordination.
Passing the scope on actual patients also means listening to instructions from your trainer and making real-time adjustments based on patient performance, which requires significant mental effort.
Analysis and report writing entails understanding normal and disordered swallowing, knowing the impact of age and disease on swallowing, evaluating patient performance, determining the severity of dysphagia, and assessing the impact of dysphagia or treatment options on whole-body homeostasis.
We have trained scores of clinicians over the years, and we have made many life-long friends through the process. We look forward to getting to know you and helping you in all of your FEESing endeavors.
If you have further questions, e-mail, text, or call Matt Ward (Director of Clinical Education) or Michelle Skelley-Ashford (President & Co-Owner).
Matt Ward
Director of Clinical Education for SA Swallowing Services
E-mail: tnvolunteer81@gmail.com
Phone: 615-878-0944
Michelle Skelley-Ashford
President & Co-Owner SA Swallowing Services
E-mail: michelleskelley711@gmail.com
Phone: 615-306-3693
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*Sample Training Schedule
07:00 Pick up at trainee’s lodging
07:00 – 08:30 Drive to the first facility location
08:30 – 08:45 Unpack equipment and meet facility clinician
08:45 – 09:00 Complete review of patient history
09:00 – 09:15 Setup equipment and complete final infection
09:15 – 09:45 Proceed to patient’s room, set up equipment, and complete the study
09:45 – 10:00 Perform infection control, break down equipment, and return to office/workspace
10:00 – 12:45 Scoring and frame-by-frame analysis of FEES video; writeup final report
12:45 – 13:00 Perform final infection control protocols return equipment to car
13:00 – 13:45 Drive to second facility; snack/eat lunch
14:00 – 14:15 Unpack equipment and meet facility clinician
14:15 – 14:30 Setup equipment and complete final infection control checks
14:30 – 15:00 Head to patient’s room, setup equipment, and complete the study
15:00 – 15:15 Perform infection control, break down equipment, and return to office/workspace
15:15 – 18:00 Scoring and frame-by-frame analysis of FEES video; writeup final report
18:15 – 18:30 Perform final infection control protocols return equipment to car
18:30 – 19:00 Return to student lodging
Total FEES: 2
Total Hours: 12
*This schedule serves as an example, and actual days/times of training may vary.