Presentation on theme: "Competencies, Milestones & EPAs: What Does It All Mean?"— Presentation transcript:
1 Competencies, Milestones & EPAs: What Does It All Mean? Susan B. Promes, MD, FACEPProfessor and Program DirectorDepartment of Emergency MedicineDirector, Curricular AffairsOffice of GME
2 Historical Perspective ACGME Outcomes ProjectInitiative to increase emphasis on educational outcomesIn 1999, Advisory committee identified six competencies and programsThe previous model of accreditation captured the potential of a GME program to educate residents by focusing on structure and process components.Programs are expected to show evidence of how they use educational outcomes data to improve individual resident and overall program performance.With funding in part by a grant from the Robert Wood Johnson Foundation, the ACGME Outcome Project is changing the focus of GME accreditation.As of July 2002, programs are responsible for requirements related to the competencies.
3 Why Outcomes? Accountability Process vs. Product Department of Education RequirementsPolitical NeedThe impetus to emphasize educational outcomes assessment in GME accreditation is based on the following factors.Accountability: Our system of medical education relies heavily on considerable public funding. We therefore need to be accountable to the public in terms of both meeting public needs and preparing well-qualified new physicians in the most cost-effective way possible.Process vs. Product: Measuring program quality by examining structure and process is not a direct or complete measure of the quality of the educational outcomes of a program.Dept of Education: The U.S. Department of Education spearheaded a movement in the 1980s aimed at greater inclusion of outcomes assessment in the accreditation process.Political Need: Availability of educational outcomes-based data is necessary to inform discussions with policymakers and others who have become increasingly focused on issues related to funding for medical education, and, most recently, on patient safety.
4 Criticism of Modern Medical Education Our medical education systems of the 20th century are no longer “good enough”. We need to do better.How can we ensure the public that our graduates are competent?
5 Criticism of Modern Medical Education Is there a better way to ensure competence than just time spent in a training program?
6 We believe that in the future, expertise rather than experience will underlie competency-based practice and…certification.Aggarwal & Darzi, NEJM 2006Competency based medical education is being discussed worldwide…even in major journals like the New England Journal of Medicine.
7 Competency Based Medical Education Flexibility for individualsEfficiencyLess time-orientedPublic accountabilityRelevance assuredTransparent standardsLogical progression
8 Six ACGME Competencies Medical KnowledgePatient CarePractice Based Learning and ImprovementSystem Based PracticeProfessionalismInterpersonal and Communication Skills
9 Medical KnowledgeResidents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and how to apply this knowledge to patient care.AcquisitionAnalysisApplication
10 Patient CareResidents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.Gathering informationSynthesisPartnering with patients/families
11 ProfessionalismResidents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.Professional behaviorEthical principlesCultural competence
12 Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care.Health care delivery systemCost effective practicePatient safety and advocacy/Systems causes of error
13 Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective informationexchange and teaming with patients, their patients families, and professional associates.Communicating with patients and familiesCommunicating with team membersScholarly Communication
14 Practice-based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.Life-long learningEvidence based medicineQuality improvementTeaching skills
15 Measuring the unmeasurable “Domainindependent”skillsDoesShows howMiller’s pyramidKnows howKnows“Domain specific” skillsCees van der VleutenMaastricht University
16 Measuring the unmeasurable Importance of domain-independent skillsIf things go wrong in practice, these skills are often involved (Papadakis et 2005; 2008)Success in labor market is associated with these skills (Meng 2006)Cees van der VleutenMaastricht University
17 Measuring the unmeasurable Self assessmentPeer assessmentPatient assessmentMultisource feedbackJournals or logsSimulationPortfolio assessmentCees van der VleutenMaastricht University
18 Competency definedAn observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.KSA – knowledge skills and abilitiesMed Teach. 2010;32(8):Competency-based medical education: theory to practice.Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, Harris P, Glasgow NJ, Campbell C, Dath D, Harden RM, Iobst W, Long DM, Mungroo R, Richardson DL, Sherbino J, Silver I, Taber S, Talbot M, Harris KA.The International CBME Collaborators 2009Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
19 Competent definedPossesses the required abilities in all domains in a certain context at a defined stage of medical education or practice.The International CBME Collaborators 2009Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
20 Competence definedEntails more than the possession of knowledge, skills and attitudes; it requires you to apply them in the clinical environment to achieve optimal resultsMedical competence: The interplay between individual ability and the health care environmentTJO ten Cate, L Snell, C CarraccioMedical Teacher 32 (8),Example of driving a car:CompetencyCan accelerate and brake smoothlyCan approach an intersection and can turn leftCompetentPasses driver’s education classesPasses driver’s exam to get the licenseCompetenceDrives safely on interstate or during bad weather, avoids accidents, no traffic ticketsParents hand over the keys and walk awayTen Cate, Medical Teacher, 2010Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
21 Competency Competent Competence Competency Can identify the various key cooking utensilsDemonstrates appropriate hygeine and understanding of infection control in the kitchenCompetent (Required KSA in that particular context)Passes each of the cooking examsReceives qualifications in each of their areas of distinctionCompetenceDrives safely on interstate or during bad weather, avoids accidents, no traffic ticketsParents hand over the keys and walk awayCompetentCompetence
22 Recent Events MedPac, IOM and Macy Foundation call for GME Reform Concern for Gov’t regulation of GME2011 Macy Report: Ensuring an Effective PhysicianWorkforce• IOM new initiative: Governance and Financing ofGraduate Medical Education
23 New ACGME Program Requirement V.A. The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)ACGME Program Requirement V.A.
24 Supervision Direct Indirect Oversight With Supervision Immediately AvailableWith Supervision AvailableTelephonic or electronicallyOversightProvide review after care is delivered
25 New ACGME Program Requirement V.A. The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)ACGME Program Requirement V.A.
26 Seven ACGME Specialties Roll Out Milestones Diagnostic RadiologyEmergency MedicineInternal MedicineNeurosurgeryOrthopedicsPediatricsUrology
27 Milestones definedMeaningful, measurable markers of progression of competenceWhat abilities does the trainee possess at a given stage?What can the trainee be entrusted with?Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
29 When Do You Trust the Trainee? When is a professional activity mastered?Set thresholds / minimum standardsAllow unsupervised practiceDirect vs.. Indirect SupervisionFull entrustmentACGME requires Program Directors to attest to a trainee’s competence.Verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members
30 ACGME requires Program Directors to attest to a trainee’s competence.
31 Dreyfus ModelDreyfus Model of Skill Acquisition (2004)
32 Entrustable Professional Activities (EPAs) Define important clinical activitiesLink competencies / milestonesInclude professional judgment of competence by cliniciansEPAs together constitute the core of the professionMake “decisions of entrustment” for “entrustable activity”Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
33 EPA definedA core unit of work reflecting a responsibility that should only be entrusted upon someone with adequate competenciesOle ten CateMedical Teacher 1010;32:CONTEXT is key!More specific:Part of essential professional work in a given contextIndependently executable, within a time frameLeads to recognized output of professional laborObservable and measurable in process and outcome, leading to a conclusion (“well done” or “not well done”)Must require sufficient, specific knowledge, skill and attitude, generally acquired through trainingShould reflect competencies, important to be acquiredUsually confined to qualified personnel only
34 Building a Competency Based Workplace Curriculum around EPAs: The Case of PA TrainingMulder, ten Cate, Daalder and BerkvensMedical Teacher 2010; 32: e
35 Competency vs.. EPA Work Descriptors Person Descriptors Knowledge Skills, Attitudes and ValuesContent expertiseCollaboration abilityCommunication abilityManagement AbilityProfessional AttitudeScholarly ApproachWork DescriptorsEssential Parts of Professional PracticeDischarge PatientCounsel PatientLead Family DiscussionDesign Treatment PlanPerform ParacentesisResuscitate if neededSpecial thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate
36 Next Steps Refinement of Milestones Identify Assessment Methods Collection and Reporting Out on Data
37 ConclusionCompetency Based Education is here to stay for the foreseeable futureWolf in sheep’s clothes