Entrustment Decision Making in the Core Entrustable Professional Activities: Results of a Multi-Institutional Study

Graduating Residents' Readiness for Unsupervised Practice

OBJECTIVE

This study sought to determine whether graduating residents were deemed ready for unsupervised practice for each of the 17 general pediatrics entrustable professional activities (EPAs).

METHODS

At the end of the 2021-22, 2022-23, and 2023-24 academic years, the authors collected entrustment-supervision levels assigned by clinical competency committees for graduating residents from pediatric and medicine/pediatrics residency training programs to determine readiness for unsupervised practice at the time of graduation. They did this for each of the general pediatrics EPAs and examined the levels reported to determine the proportion of residents ready for unsupervised practice on each EPA and on all EPAs. They compared rates of readiness by academic year using a mixed-effects logistic regression model.

RESULTS

Across all EPAs, 33 190 total entrustment-supervision levels were reported for 2276 graduating pediatrics residents, and 2607 entrustment-supervision levels were reported for 168 graduating medicine/pediatrics residents. There were no EPAs in which programs reported more than 89% of residents as ready for unsupervised practice at the time of graduation. Only 31.3% of graduating residents with observations on all EPAs (414/1322) were deemed ready for unsupervised practice for all EPAs. Graduating medicine/pediatrics residents were more likely than pediatrics residents to be deemed ready for all EPAs (P = .002). Across study years, the rates of readiness at graduation for all EPAs rose from 18.0% to 38.5% (linear contrast P < .001).

CONCLUSION

While there are reasons beyond actual resident readiness that may contribute, this study highlights a gap in readiness for unsupervised practice at the time of graduation.

Integration of Entrustable Professional Activities in a Competency-Based Clinical Assessment Tool in a Nurse Practitioner Program

BACKGROUND

Entrustable professional activities (EPAs) are used in competency-based clinical assessment.

PROBLEM

Faculty in a Family Nurse Practitioner program aimed to improve their clinical assessment tool to more effectively measure students' clinical performance, outline expectations, track progress, and document evidence related to clinical competence.

APPROACH

EPAs that aligned with the American Association of Colleges of Nursing Essentials and National Organization of Nurse Practitioner (NP) Faculties Core NP Competencies were integrated into a clinical assessment tool. Student performance expectations at different points in the program were outlined. Students documented each time they performed an EPA during clinical experiences.

OUTCOME

The EPA-based clinical assessment tool captured valuable information about student performance during clinical experiences and contributed to evidence related to competencies.

CONCLUSIONS

EPAs can be used to assess clinical performance and document evidence of competence and readiness for practice. Tracking the frequency of EPA performance was essential to ensure students had sufficient practice.

Next steps for workplace-based assessments of entrustable professional activities

BACKGROUND

Florida International University Herbert Wertheim College of Medicine (FIU-HWCOM) participated in the AAMC Core Entrustable Professional Activities (EPA) implementation pilot. Entrustment decision processes based on data from workplace-based assessments (WBAs) were piloted. Outcomes illustrated challenges including variability across EPAs with regards to learner level alignment and feasibility of data collection in the form of WBAs. In addition, students reported discomfort requesting WBA completion by preceptors and dissatisfaction with associated feedback.

APPROACH

To guide future directions, we conducted a survey of third-year students to better understand their experience with and perceptions of WBAs used to evaluate EPAs at FIU-HWCOM.

EVALUATION

Survey response was 96% (n = 107/112). Most (84%) reported that WBAs were not valuable to their development and that preceptors often did not complete WBAs in a timely fashion. Many (47%) reported not receiving verbal feedback. Most students (78%) used language in written responses demonstrating confusion between the EPAs and the WBAs used to assess them.

IMPLICATIONS

The use of WBAs to assess EPAs did not have its intended impact at FIU-HWCOM. For future classes, WBA forms will consist of paper cards with questions directly assessing performance of skills aligned with EPAs 1, 5 and 6 only. To continue to promote feedback, students will be required to collect WBAs on all clerkships, but the number of required WBAs will be less than prior and no entrustment decisions will be made.

How well do workplace-based assessments support summative entrustment decisions? A multi-institutional generalisability study

BACKGROUND

Assessment of the Core Entrustable Professional Activities for Entering Residency requires direct observation through workplace-based assessments (WBAs). Single-institution studies have demonstrated mixed findings regarding the reliability of WBAs developed to measure student progression towards entrustment. Factors such as faculty development, rater engagement and scale selection have been suggested to improve reliability. The purpose of this investigation was to conduct a multi-institutional generalisability study to determine the influence of specific factors on reliability of WBAs.

METHODS

The authors analysed WBA data obtained for clerkship-level students across seven institutions from 2018 to 2020. Institutions implemented a variety of strategies including selection of designated assessors, altered scales and different EPAs. Data were aggregated by these factors. Generalisability theory was then used to examine the internal structure validity evidence of the data. An unbalanced cross-classified random-effects model was used to decompose variance components. A phi coefficient of >0.7 was used as threshold for acceptable reliability.

RESULTS

Data from 53 565 WBAs were analysed, and a total of 77 generalisability studies were performed. Most data came from EPAs 1 (n = 17 118, 32%) 2 (n = 10 237, 19.1%), and 6 (n = 6000, 18.5%). Low variance attributed to the learner (<10%) was found for most (59/77, 76%) analyses, resulting in a relatively large number of observations required for reasonable reliability (range = 3 to >560, median = 60). Factors such as DA, scale or EPA were not consistently associated with improved reliability.

CONCLUSION

The results from this study describe relatively low reliability in the WBAs obtained across seven sites. Generalisability for these instruments may be less dependent on factors such as faculty development, rater engagement or scale selection. When used for formative feedback, data from these instruments may be useful. However, such instruments do not consistently provide reasonable reliability to justify their use in high-stakes summative entrustment decisions.

A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees

INTRODUCTION

The real-world mechanisms underlying prospective entrustment decision making (PEDM) by entrustment or clinical competency committees (E/CCCs) are poorly understood. To advance understanding in this area, the authors conducted a realist synthesis of the published literature to address the following research question: In E/CCC efforts to make defensible prospective entrustment decisions (PEDs), what works, for whom, under what circumstances and why?

METHODS

Realist work seeks to understand the contexts (C), mechanisms (M) and outcomes (O) that explain how and why things work (or do not). In the authors' study, contexts included individual E/CCC members, E/CCC structures and processes, and training programmes. The outcome (i.e. desired outcome) was a PED. Mechanisms were a substantial focus of the analysis and informed the core findings. To define a final corpus of 52 included papers, the authors searched four databases, screened all results from those searches and performed a full-text review of a subset of screened papers. Data extraction focused on developing context-mechanism-outcome configurations from the papers, which were used to create a theory for how PEDM leads to PEDs.

RESULTS

PEDM is often driven by default (non-deliberate) decision making rather than a deliberate process of deciding whether a trainee should be entrusted or not. When defaulting, some E/CCCs find red flags that sometimes lead to being more deliberate with decision making. E/CCCs that seek to be deliberate describe PEDM that can be effortful (when data are insufficient or incongruent) or effortless (when data are robust and tell a congruent story about a trainee). Both information about trainee trustworthiness and the sufficiency of data about trainee performance influence PEDM. Several moderators influence what is considered to be sufficient data, how trustworthiness data are viewed and how PEDM is carried out. These include perceived consequences and associated risks, E/CCC member trust propensity, E/CCC member personal knowledge of and experience with trainees and E/CCC structures and processes.

DISCUSSION

PEDM is rarely deliberate but should be. Data about trainee trustworthiness are foundational to making PEDs. Bias, equity and fairness are nearly absent from the papers in this synthesis, and future efforts must seek to advance understanding and practice regarding the roles of bias, equity and fairness in PEDM.

Powerful medical education improves health care quality and return on investment

INTRODUCTION

Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness.

METHODS

This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations.

RESULTS

PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment.

CONCLUSIONS

The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot

In 2014, the Association of American Medical Colleges (AAMC) published 13 Core Entrustable Professional Activities (EPAs) that graduating students should be able to perform with indirect supervision when entering residency. A ten-school multi-year pilot was commissioned to test feasibility of implementing training and assessment of the AAMC's 13 Core EPAs. In 2020-21, a case study was employed to describe pilot schools' implementation experiences. Teams from nine of ten schools were interviewed to identify means and contexts of implementing EPAs and lessons learned. Audiotapes were transcribed then coded by investigators using conventional content analysis and a constant comparative method. Coded passages were organized in a database and analyzed for themes. Consensus among school teams regarding facilitators of EPA implementation included team commitment to piloting EPAs; agreement that: proximal EPA adoption with curriculum reform facilitates EPA implementation; EPAs 'naturally fit' in clerkships and provided opportunity for schools to reflect on and adjust curricula and assessments; and inter-school collaboration bolstered individual school progress. Schools did not make high-stakes decisions about student progress (e.g., promotion, graduation), yet EPA assessment results complemented other forms of assessment in providing students with robust formative feedback about their progress. Teams had varied perceptions of school capability to implement an EPA framework, influenced by various levels of dean involvement, willingness, and capability of schools to invest in data systems and provide other resources, strategic deployment of EPAs and assessments, and faculty buy-in. These factors affected varied pace of implementation. Teams agreed on the worthiness of piloting the Core EPAs, but substantial work is still needed to fully employ an EPA framework at the scale of entire classes of students with enough assessments per EPA and with required data validity/reliability. Recommendations stemming from findings may help inform further implementation efforts across other schools adopting or considering an EPA framework.

How much is enough? Proposing achievement thresholds for core EPAs of graduating medical students in Canada

PURPOSE

The transition towards Competency-Based Medical Education at the Cumming School of Medicine was accelerated by the reduced clinical time caused by the COVID-19 pandemic. The purpose of this study was to define a standard protocol for setting Entrustable Professional Activity (EPA) achievement thresholds and examine their feasibility within the clinical clerkship.

METHODS

Achievement thresholds for each of the 12 AFMC EPAs for graduating Canadian medical students were set by using sequential rounds of revision by three consecutive groups of stakeholders and evaluation experts. Structured communication was guided by a modified Delphi technique. The feasibility/consequence models of these EPAs were then assessed by tracking their completion by the graduating class of 2021.

RESULTS

The threshold-setting process resulted in set EPA achievement levels ranging from 1 to 8 across the 12 AFMC EPAs. Estimates were stable after the first round for 9 of 12 EPAs. 96.27% of EPAs were successfully completed by clerkship students despite the shortened clinical period. Feasibility was predicted by the slowing rate of EPA accumulation overtime during the clerkship.

CONCLUSION

The process described led to consensus on EPA achievement thresholds. Successful completion of the assigned thresholds was feasible within the shortened clerkship.[Box: see text].

Core Entrustable Professional Activities for Entering Residency: A National Survey of Graduating Medical Students' Self-Assessed Skills by Specialty

BACKGROUND

The Association of American Medical Colleges described 13 Core Entrustable Professional Activities (EPAs) that graduating students should be prepared to perform under indirect supervision on day one of residency. Surgery program directors recently recommended entrustability in these Core EPAs for incoming surgery interns. We sought to determine if graduating students intending to enter surgery agreed they had the skills to perform these Core EPAs.

STUDY DESIGN

Using de-identified, individual-level data collected from and about 2019 Association of American Medical Colleges Graduation Questionnaire respondents, latent profile analysis was used to group respondents based on their self-assessed Core EPAs skills' response patterns. Associations between intended specialty, among other variables, and latent profile analysis group were assessed using independent sample t -tests and chi-square tests and multivariable logistic regression methods.

RESULTS

Among 12,308 Graduation Questionnaire respondents, latent profile analysis identified 2 respondent groups: 7,863 (63.9%) in a high skill acquisition agreement (SAA) group and 4,445 (36.1%) in a moderate SAA group. Specialty was associated with SAA group membership (p < 0.001), with general surgery, orthopaedic surgery, and emergency medicine respondents (among others) overrepresented in the high SAA group. In the multivariable logistic regression models, each of anesthesiology, ophthalmology, pediatrics, psychiatry, and radiology (vs general surgery) specialty intention was associated with a lower odds of high SAA group membership.

CONCLUSION

Graduating students' self-assessed Core EPAs skills were higher for those intending general surgery than for those intending some other specialties. Our findings can inform collaborative efforts to ensure graduates' acquisition of the skills expected of them at the start of residency.

Competency-Based Frameworks in Medical School Education Programs: A Thematic Analysis of the Academic Medicine Snapshots, 2020

PURPOSE

Educational program objectives (EPOs) provide the foundation for a medical school's curriculum. In recent years, the Liaison Committee on Medical Education (LCME) endorsed an outcomes-based approach to objectives, to embrace the movement toward competency-based medical education (CBME). The purpose of this study was to explore the CBME frameworks used by medical schools in formulating their EPOs. A secondary aim was to determine factors related to the selection of specific frameworks.

METHOD

The authors performed a quantitative content analysis of entries to the 2020 Academic Medicine Snapshot. Publicly available data gathered included demographic features of each program (e.g., year founded, accreditation status, affiliation, etc.), participation in national medical education consortia, and presence of specific CBME frameworks identified in EPOs. Descriptive statistics were used to examine trends in frameworks used by medical schools. Bivariate comparisons between factors and frameworks were conducted using chi-square tests. Logistic regression was used to examine factors predicting use of more recently developed CBME frameworks.

RESULTS

A total of 135 institutions submitted Snapshots (RR = 88%). All institutions endorsed 1 or more CBME frameworks, with 37% endorsing 2 and 20% endorsing 3 or more. The most common was the Accreditation Council for Graduate Medical Education core competencies (63%). In addition to published frameworks, 36% of institutions developed their own competencies. Schools with pending LCME visits were 2.61 times more likely to use a more recently developed curricular framework, P = .022.

CONCLUSIONS

Medical schools in the United States have embraced the CBME movement through incorporation of competency-based frameworks in their EPOs. While it is encouraging that CBME frameworks have been integrated in medical school EPOs, the variability and use of multiple frameworks identifies the pressing need for a unified CBME framework in undergraduate medical education.

Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020

IMPORTANCE

Gaps in readiness for indirect supervision have been identified for essential responsibilities encountered early in residency, presenting risks to patient safety. Core Entrustable Professional Activities (EPAs) for entering residency have been proposed as a framework to address these gaps and strengthen the transition from medical school to residency.

OBJECTIVE

To assess progress in developing an entrustment process in the Core EPAs framework.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study in the Core EPAs for Entering Residency Pilot, trained faculty made theoretical entrustment determinations and recorded the number of workplace-based assessments (WBAs) available for each determination in 2019 and 2020. Four participating schools attempted entrustment decision-making for all graduating students or a randomly selected subset of students. Deidentified, individual-level data were merged into a multischool database.

INTERVENTIONS

Schools implemented EPA-related curriculum, WBAs, and faculty development; developed systems to compile and display data; and convened groups to make theoretical summative entrustment determinations.

MAIN OUTCOMES AND MEASURES

On an EPA-specific basis, the percentage of students for whom an entrustment determination could be made, the percentage of students ready for indirect supervision, and the volume of WBAs available were recorded.

RESULTS

Four participating schools made 4525 EPA-specific readiness determinations (2296 determinations in 2019 and 2229 determinations in 2020) for 732 graduating students (349 students in 2019 and 383 students in 2020). Across all EPAs, the proportion of determinations of "ready for indirect supervision" increased from 2019 to 2020 (997 determinations [43.4%] vs 1340 determinations [60.1%]; 16.7 percentage point increase; 95% CI, 13.8-19.6 percentage points; P < .001), as did the proportion of determinations for which there were 4 or more WBAs (456 of 2295 determinations with WBA data [19.9%] vs 938 [42.1%]; 22.2 percentage point increase; 95% CI, 19.6-24.8 percentage points; P < .001). The proportion of EPA-specific data sets considered for which an entrustment determination could be made increased from 1731 determinations (75.4%) in 2019 to 2010 determinations (90.2%) in 2020 (14.8 percentage point increase; 95% CI, 12.6-16.9 percentage points; P < .001). On an EPA-specific basis, there were 5 EPAs (EPA 4 [orders], EPA 8 [handovers], EPA 10 [urgent care], EPA 11 [informed consent], and EPA 13 [patient safety]) for which few students were deemed ready for indirect supervision and for which there were few WBAs available per student in either year. For example, for EPA 13, 0 of 125 students were deemed ready in 2019 and 0 of 127 students were deemed ready in 2020, while 0 determinations in either year included 4 or more WBAs.

CONCLUSIONS AND RELEVANCE

These findings suggest that there was progress in WBA data collected, the extent to which entrustment determinations could be made, and proportions of entrustment determinations reported as ready for indirect supervision. However, important gaps remained, particularly for a subset of Core EPAs.

Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Despite explanations in the literature, a returning question in the use of entrustable professional activities (EPAs) is how to distinguish them from competencies and skills. In this article, we attempt to analyze the causes of the frequent confusion and conflation of EPAs with competencies and skills, and argue why the distinction is important for education, qualification and patient safety. 'Tracheotomy', 'lumbar puncture', 'interprofessional collaboration' for example are colloquially called 'skills', but its is a person's ability to perform these activities that is the actual skill; the EPA is simply the activity itself. We identify two possible causes for the confusion. One is a tendency to frame all educational objectives as EPAs. Many objectives of medical training can be conceptualized as EPAs, if 'the ability to do X' is the corresponding competency; but that does not work for all. We offer ways to deal with objectives of training that are not usefully conceptualized as EPAs. A more fundamental cause relates to entrustment decisions. The permission to contribute to health care reflects entrustment. Entrustment decisions are the links or pivots between a person's readiness for the task and the actual task execution. However, if entrustment decisions do not lead to increased autonomy in the practice of health care, but only serve to decide upon the advancement to a next stage of training, EPAs can become the tick boxes learners feel they need to collect to 'pass'. Gradually, then, EPAs can loose their original meaning of units of practice for which one becomes qualified.

Competency-based medical education across the continuum: How well aligned are medical school EPAs to residency milestones?

INTRODUCTION

Competency-based medical education (CBME) provides a framework for describing learner progression throughout training. However, specific approaches to CBME implementation vary widely across educational settings. Alignment between various methods used across the continuum is critical to support transitions and assess learner performance. The purpose of this study was to investigate alignment between CBME frameworks used in undergraduate medical education (UME) and graduate medical education (GME) settings using the US context as a model.

METHOD

The authors analyzed content from the core entrustable professional activities for entering residency (Core EPAs; UME model) and residency milestones (GME model). From that analysis, they performed a series of cross-walk activities to investigate alignment between frameworks. After independent review, authors discussed findings until consensus was reached.

RESULTS

Some alignment was found for activities associated with history taking, physical examination, differential diagnosis, patient safety, and interprofessional care; however, there were far more examples of misalignment.

CONCLUSIONS

These findings highlight challenges creating alignment of assessment frameworks across the continuum of training. The importance of these findings includes implications for assessment and persistence of the educational gap across UME and GME. The authors provide four next steps to improve upon the continuum of education.