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

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

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.

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

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

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

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

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

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

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

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

Competency Domains

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

Milestone Examples

Milestones in Action

E-value Assessment

Milestone Approach

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

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

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

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

The EPA Mapping Exercise

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 3/13 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

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