What a Real Competency Score Should Measure

I have recertified in Basic Life Support many times. It is always the same. Some outside office, somewhere across town. A manikin on a clunky desk in a room that was not built for this. Twenty minutes on the floor beside a filing cabinet. And then a card.

Sometimes a device on the manikin shows the numbers. Sometimes there isn’t. It doesn’t matter either way — because whatever it measured doesn’t go on the card. The card says pass.

In all those years, in all those rooms, nobody has ever told me how good my compressions were.

They told me I passed.

The gate and the space behind it

Let me be fair to certification, because the criticism of it is usually lazy. The course does its job. You show up, you practice, someone checks that you can do it, and you get a card. That is a reasonable gate.

But it is a gate. Not a measurement.

When it comes to BLS competency tracking, here is what nobody has: any way of knowing what happened after you walked out of that room. Not the day after. Not eight months later, at two in the morning, when it matters. Between the day you certify and the day you certify again, your competence is simply assumed. For two years. By everyone.

No instrument exists for the space in between. That space is where patients arrest.

So what would it take to measure it?

Not a better course. Not a longer one. A score — a real one, recorded, dated, and comparable. Here is what it would have to do.

It must separate the components. Depth. Rate. Recoil. Skills that fail independently of each other. A nurse who compresses deep enough but never lets the chest come back up is pumping an empty pump — and a provider who releases beautifully but goes two centimeters too shallow has an entirely different problem with an entirely different fix. Roll them into one verdict, and you have learned nothing about either. If a score cannot tell someone what to work on, it isn’t a score. It is a grade.

It must be continuous. There is a world of difference between the person who scraped over the line and the person who cleared it easily. Right now, they are indistinguishable — both certified, both on the schedule tonight. Give me a distribution instead, and I can see the tail. Before an arrest finds it first.

It must be time-stamped and account for skill decay. This is the part nobody wants to say aloud. Manual skills fade; that is not conjecture, but a fact demonstrated repeatedly over decades and familiar to anyone who teaches resuscitation. Yet the card remains valid for two years, as if the hands-on day seven hundred is the same as the hands-on day one. They are not. An honest score must reflect time. Without a date, a score is only a rumor.

It must be comparable. Across people. Across units. Across hospitals and across countries. If a score means one thing in my institution and something else in yours, it is not a measurement — it is an opinion with a number attached to it. That means published thresholds, a fixed protocol, and the same conditions every time. Not an instructor’s impression in a borrowed room on a Tuesday afternoon.

It must belong to the clinician. This is where competency measurement usually dies, and I want to be blunt about why. A score that exists only to be reported upward is a threat. People route around threats — quietly, reliably, and forever. But a score you own, that you carry to your next job, that you can improve on a Sunday evening without asking anyone’s permission, is something you want. Identical data. Opposite outcome. Whoever builds this and hands the data to management first will fail and will deserve to.

It must predict something real. And here I must be careful, because the alternative is doing exactly what I am accusing everyone else of doing. The endpoint that matters is survival — not depth in centimeters. Connecting competency scores to actual arrest outcomes is a multi-year problem, and nobody has solved it. I have not solved it. But it is the right target, and any score not built to be validated against it eventually is just a more sophisticated card.

The question I cannot answer

Build that score. Run it across one hospital — not on certification day, but on an ordinary Tuesday, eight months into the cycle, on people who are certified and working and, on the schedule, tonight. What does the distribution look like?

Nobody knows.

Read that again. We have certified millions of clinicians, for decades, in every country on earth, and no one has ever measured what those certificates correspond to in the months when it counts. The most consequential number in resuscitation has never been collected.

Do I have a suspicion? Of course I do. So does every physician who has run a code and watched the first two minutes.

But a suspicion is not evidence, and if I published mine as though it were, I would be doing the very thing I have just spent a thousand words objecting to — asserting competence without measuring it, with my name on the certificate instead of somebody else’s.

So, the work is not to argue about this. The work is to measure it.

A card tells you someone was in a room once.

A score should tell you what their hands can do, when they last did it, and what is fading right now.

Until we have that, we are not verifying competence. We are recording attendance.

BLSXR – BLS Competency Tracking Gives You the Real Score

BLSXR is VRKure’s BLS VR training app for hospital staff and healthcare professionals that teaches critical skills using real-time hand-tracking to measure compression quality and workflow accuracy. Using VR BLS training modules and VR competency tracking, it enables caregivers to enhance competency, train safely, and reduce costs with high-fidelity virtual practice sessions, ensuring improved outcomes for patients worldwide. Reach out today to know more.