Implementing Competence Committees on a National Scale: Design and Lessons Learned

Eight ways to support faculty with Entrustable Professional Activities

Competency Based Medical Education (CBME) is pushing the medical profession to be more accountable in our standards of assessment. This has led us to focus our efforts at the top of Miller's pyramid, where we aim to see what the trainee 'does' in the clinical environment. In Canadian Royal College specialty training, this has come in the form of workplace-based supervision of trainees performing Entrustable Professional Activities (EPAs). This is unfamiliar territory for many residents and faculty, and implementation of an additional assessment process into already busy clinical practice has been particularly challenging. Because EPA assessments serve as significant contributors in new programs of assessment, failure to collect high quality EPA assessments threaten the validity of this new system. Understanding the barriers to and enablers of EPA acquisition can inform faculty development initiatives to ensure success. Based on our previous work studying early experiences of EPA assessment acquisition in Emergency Medicine, we have identified eight key concepts to guide faculty development initiatives, namely: the rationale for CBME, the 'behind the scenes' of CBME, how to construct rich narrative comments, effective use of supervision scales, the tension of EPA assessments being both formative and summative, the importance of a shared responsibility between residents and faculty for EPA assessment completion, familiarity with the suite of EPAs, and tips and tricks for incorporating EPA assessment completion into busy clinical practice. These key concepts can be integrated into an overall faculty development strategy for building this now essential skill set.

Croix R, van Melle E. Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Coaching in Competence by Design: A New Model of Coaching in the Moment and Coaching Over Time to Support Large Scale Implementation

Coaching is an increasingly popular means to provide individualized, learner-centered, developmental guidance to trainees in competency based medical education (CBME) curricula. Aligned with CBME's core components, coaching can assist in leveraging the full potential of this educational approach. With its focus on growth and improvement, coaching helps trainees develop clinical acumen and self-regulated learning skills. Developing a shared mental model for coaching in the medical education context is crucial to facilitate integration and subsequent evaluation of success. This paper describes the Royal College of Physicians and Surgeons of Canada's coaching model, one that is theory based, evidence informed, principle driven and iteratively and developed by a multidisciplinary team. The coaching model was specifically designed, fit for purpose to the postgraduate medical education (PGME) context and implemented as part of Competence by Design (CBD), a new competency based PGME program. This coaching model differentiates two coaching roles, which reflect different contexts in which postgraduate trainees learn and develop skills. Both roles are supported by the RX-OCR process: developing Relationship/Rapport, setting eXpectations, Observing, a Coaching conversation, and Recording/Reflecting. The CBD Coaching Model and its associated RX-OCR faculty development tool support the implementation of coaching in CBME. Coaching in the moment and coaching over time offer important mechanisms by which CBD brings value to trainees. For sustained change to occur and for learners and coaches to experience the model's intended benefits, ongoing professional development efforts are needed. Early post implementation reflections and lessons learned are provided.

Design and Implementation of a National Program of Assessment Model - Integrating Entrustable Professional Activity Assessments in Canadian Specialist Postgraduate Medical Education

Traditional approaches to assessment in health professions education systems, which have generally focused on the summative function of assessment through the development and episodic use of individual high-stakes examinations, may no longer be appropriate in an era of competency based medical education. Contemporary assessment programs should not only ensure collection of high-quality performance data to support robust decision-making on learners' achievement and competence development but also facilitate the provision of meaningful feedback to learners to support reflective practice and performance improvement. Programmatic assessment is a specific approach to designing assessment systems through the intentional selection and combination of a variety of assessment methods and activities embedded within an educational framework to simultaneously optimize the decision-making and learning function of assessment. It is a core component of competency based medical education and is aligned with the goals of promoting assessment for learning and coaching learners to achieve predefined levels of competence. In Canada, postgraduate specialist medical education has undergone a transformative change to a competency based model centred around entrustable professional activities (EPAs). In this paper, we describe and reflect on the large scale, national implementation of a program of assessment model designed to guide learning and ensure that robust data is collected to support defensible decisions about EPA achievement and progress through training. Reflecting on the design and implications of this assessment system may help others who want to incorporate a competency based approach in their own country.