1. Patricia Kokotailo, Sarah Pitts, Sheryl Ryan, Karen Soren, Maria Trent
Entrustable Professional Activities: What You Need to Know to Improve Your Residency and Subspecialty Training
Patricia Kokotailo, Sarah Pitts, Sheryl Ryan, Karen Soren, Maria Trent
March 25, 2014
SAHM

2. Boston University School of Medicine asks all individuals involved in the development and presentation of Continuing Medical Education (CME) activities to disclose all relationships with commercial interests. This information is disclosed to CME activity participants. Boston University School of Medicine has procedures to resolve apparent conflicts of interest. In addition, presenters are asked to disclose when any discussion of unapproved use of pharmaceuticals and devices is being discussed.
We, (Patricia Kokotailo, Sarah Pitts, Karen Soren, Maria Trent and Sheryl Ryan), have no commercial relationships to disclose.
Jointly Sponsored by Boston University School of Medicine and the Society for Adolescent Health and Medicine

3. Objectives
After attending this workshop a participant will be able to:
Define the terms competencies, milestones and entrustable professional activities (EPA’s).
Describe the mapping or reframing of a medical competency in a clinical context of an EPA.
Describe elements of a curriculum to be used to support the knowledge, skills and attitudes to perform the functions needed to be entrusted with a professional activity.

4. Systems-Based Practice
DOMAINS OF COMPETENCE
EPAs
SUB-COMPETENCIES
MILESTONES
Patient Care
Medical Knowledge
Systems-Based Practice
PBL&I
Sub-competency example: Provide transfer of care that ensures seamless transitions
Milestone example: Struggles to organize patient care responsibilities, leading to focusing care on individual patients
rather than multiple patients to maximize safe and effective multitasking of responsibilities in
essentially all situations; a role model of efficiency
Professionalism
IP&C Skills
Modified from the original version created by Dr. Ann Burke

5. Defining EPAs
“the routine care delivery activities that define a specialty or subspecialty”
answers the question: “Do you trust this person to provide care for this patient with X problem without direct supervision?”
the integration of multiple competencies into a clinical context unique to a specialty
observable and measurable units of work
includes the knowledge, skills, and attitudes (KSA) necessary for care delivery
lead to a recognized outcome

6. Where we are thus far? EPAs:
The ABP approved the 4 EPAs
The EPAs were described and mapped to the key domains of competence
Now we must map the EPAs to the sub-competencies critical to ensure entrustment keeping in mind that these will be the activities that will need to be evaluated in a systematic way.
January 2014: ACGME finalized the 21 (out of 52) sub-competencies for required milestone reporting

7. Taking a Step Back: How EPAs will Build on Smaller Units for Trainee Assessment

8. Systems-Based Practice
DOMAINS OF COMPETENCE
EPAs
SUB-COMPETENCIES
MILESTONES
Patient Care
Medical Knowledge
Systems-Based Practice
PBL&I
Sub-competency example: Provide transfer of care that ensures seamless transitions
Milestone example: Struggles to organize patient care responsibilities, leading to focusing care on individual patients
rather than multiple patients to maximize safe and effective multitasking of responsibilities in
essentially all situations; a role model of efficiency
Professionalism
IP&C Skills
Modified from the original version created by Dr. Ann Burke

9. Milestones
Milestones are observable developmental steps moving from beginning of residency to expected level of proficiency at graduation and ultimately to the level of expert or master
Developed by expert panel of members of different disciplines of the RRCs, American Board certifying boards, program directors and trainees
Organized under the 6 competencies
Describe a trajectory of progress
Articulate shared understanding of expectations across the continuum

10. Milestones
Milestones are observable developmental steps moving from beginning of residency to expected level of proficiency at graduation and ultimately to the level of expert or master
Developed by expert panel of members of different disciplines of the RRCs, American Board certifying boards, program directors and trainees
Organized under the 6 competencies
Describe a trajectory of progress
Articulate shared understanding of expectations across the continuum

11. Developmental Milestones
He crawls, he cruises, he walks, he runs, he wins the Olympic marathon!
Can be used across the continuum from medical student to practicing physician

12. Competency Domains

13. What are Milestones?
“Milestones provide the narrative descriptions of behaviors that represent the developmental progression of performance along a continuum from student to expert practitioner and should be used to guide learner assessment and ultimately entrustment decisions.”
-Carol Carraccio, MD, MA, Chair, Pediatric Milestones Working Group
Goal is to more fully measure competency by better elaboration of anchors
To establish the construct, criterion and predictive validity of Milestones will require use and collation of national data over several years, collected on thousands of residents and fellows

15. Milestone Examples

16. Milestones in Action

17. E-value Assessment

18. Milestone Approach

19. EPA #1
Provide care for adolescent and young adult patients with acute physical and mental health issues.
Maps to competencies:
Patient Care
Medical Knowledge
Interpersonal and Communication Skills

20. EPA #2
Provide continuity of care for adolescent and young adult patients with chronic medical problems and complex health conditions.
Maps to competencies:
Patient Care
Medical Knowledge
Interpersonal and Communication Skills
Systems-based Practice

21. EPA #3
Provide preventive health care that includes the conditions specific to the adolescent and young adult population.
Maps to competencies:
Patient Care
Medical Knowledge
Practice –Based Learning and Improvement
Interpersonal and Communication Skills
Systems-based Practice

22. EPA #4
Transition care of the adolescent and young adult patient to adult health care settings.
Maps to competencies:
Patient Care
Interpersonal and Communication Skills
Professionalism
Systems-based Practice

23. The EPA Mapping Exercise

24. Identifying EPAs for Subspecialties
Describing functions & mapping of EPAs to competencies & milestones begins
Describing functions & mapping of EPAs to competencies & milestones complete
Peds Review Committee identifies subset of milestones for reporting to ACGME
Intro EPA Project at Spring Meetings
Vetting of draft list within communities
Revisions to EPA list based on feedback
3/ Spring 13
6/13
8/13
10/13
12/13
2/14
Spring 14
7/14
12/14
EPA meeting at ABP
Draft list of subspecialty specific EPAs
Working
list of subspecialty specific EPAs
Engage subspecialty communities in beginning to develop curricula to address functions of EPAs
Subspecialty Programs begin tracking milestones for reporting to ACGME
Subspecialty Programs begin reporting milestone achievement for fellows to ACGME

25. Timeline and Next Steps
Curriculum development
Development of assessment tools/strategies
Importance of direct observation; who does it and how often
Milestone reporting
Other….