Competencies, Milestones & EPAs: What Does It All Mean? Susan B. Promes, MD, FACEP Professor and Program Director Department of Emergency Medicine Director, Curricular Affairs Office of GME

Historical Perspective ACGME Outcomes Project Initiative to increase emphasis on educational outcomes In 1999, Advisory committee identified six competencies and programs The 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.

Why Outcomes? Accountability Process vs. Product Department of Education Requirements Political Need The 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.

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?

Criticism of Modern Medical Education Is there a better way to ensure competence than just time spent in a training program?

We believe that in the future, expertise rather than experience will underlie competency-based practice and…certification. Aggarwal & Darzi, NEJM 2006 Competency based medical education is being discussed worldwide…even in major journals like the New England Journal of Medicine.

Competency Based Medical Education Flexibility for individuals Efficiency Less time-oriented Public accountability Relevance assured Transparent standards Logical progression

Six ACGME Competencies Medical Knowledge Patient Care Practice Based Learning and Improvement System Based Practice Professionalism Interpersonal and Communication Skills

Medical Knowledge Residents 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. Acquisition Analysis Application

Patient Care Residents 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 information Synthesis Partnering with patients/families

Professionalism Residents 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 behavior Ethical principles Cultural competence

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 system Cost effective practice Patient safety and advocacy/Systems causes of error

Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Communicating with patients and families Communicating with team members Scholarly Communication

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 learning Evidence based medicine Quality improvement Teaching skills

Measuring the unmeasurable “Domain independent” skills Does Shows how Miller’s pyramid Knows how Knows “Domain specific” skills Cees van der Vleuten Maastricht University

Measuring the unmeasurable Importance of domain-independent skills If 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 Vleuten Maastricht University

Measuring the unmeasurable Self assessment Peer assessment Patient assessment Multisource feedback Journals or logs Simulation Portfolio assessment Cees van der Vleuten Maastricht University

Competency defined An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes. KSA – knowledge skills and abilities Med Teach. 2010;32(8):638-45. 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 2009 Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competent defined Possesses the required abilities in all domains in a certain context at a defined stage of medical education or practice. The International CBME Collaborators 2009 Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competence defined Entails more than the possession of knowledge, skills and attitudes; it requires you to apply them in the clinical environment to achieve optimal results Medical competence: The interplay between individual ability and the health care environment TJO ten Cate, L Snell, C Carraccio Medical Teacher 32 (8), 669-675 Example of driving a car: Competency Can accelerate and brake smoothly Can approach an intersection and can turn left Competent Passes driver’s education classes Passes driver’s exam to get the license Competence Drives safely on interstate or during bad weather, avoids accidents, no traffic tickets Parents hand over the keys and walk away Ten Cate, Medical Teacher, 2010 Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competency Competent Competence Competency Can identify the various key cooking utensils Demonstrates appropriate hygeine and understanding of infection control in the kitchen Competent (Required KSA in that particular context) Passes each of the cooking exams Receives qualifications in each of their areas of distinction Competence Drives safely on interstate or during bad weather, avoids accidents, no traffic tickets Parents hand over the keys and walk away Competent Competence

Recent Events MedPac, IOM and Macy Foundation call for GME Reform Concern for Gov’t regulation of GME 2011 Macy Report: Ensuring an Effective Physician Workforce • IOM new initiative: Governance and Financing of Graduate Medical Education

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.

Supervision Direct Indirect Oversight With Supervision Immediately Available With Supervision Available Telephonic or electronically Oversight Provide review after care is delivered

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.

Seven ACGME Specialties Roll Out Milestones Diagnostic Radiology Emergency Medicine Internal Medicine Neurosurgery Orthopedics Pediatrics Urology

Milestones defined Meaningful, measurable markers of progression of competence What 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

© Copyright 2012 ACGME and American Board of Emergency Medicine

When Do You Trust the Trainee? When is a professional activity mastered? Set thresholds / minimum standards Allow unsupervised practice Direct vs.. Indirect Supervision Full entrustment ACGME 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

ACGME requires Program Directors to attest to a trainee’s competence.

Dreyfus Model Dreyfus Model of Skill Acquisition (2004)

Entrustable Professional Activities (EPAs) Define important clinical activities Link competencies / milestones Include professional judgment of competence by clinicians EPAs together constitute the core of the profession Make “decisions of entrustment” for “entrustable activity” Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

EPA defined A core unit of work reflecting a responsibility that should only be entrusted upon someone with adequate competencies Ole ten Cate Medical Teacher 1010;32:669-675 CONTEXT is key! More specific: Part of essential professional work in a given context Independently executable, within a time frame Leads to recognized output of professional labor Observable 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 training Should reflect competencies, important to be acquired Usually confined to qualified personnel only

Building a Competency Based Workplace Curriculum around EPAs: The Case of PA Training Mulder, ten Cate, Daalder and Berkvens Medical Teacher 2010; 32: e453-459

Competency vs.. EPA Work Descriptors Person Descriptors Knowledge Skills, Attitudes and Values Content expertise Collaboration ability Communication ability Management Ability Professional Attitude Scholarly Approach Work Descriptors Essential Parts of Professional Practice Discharge Patient Counsel Patient Lead Family Discussion Design Treatment Plan Perform Paracentesis Resuscitate if needed Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Next Steps Refinement of Milestones Identify Assessment Methods Collection and Reporting Out on Data

Conclusion Competency Based Education is here to stay for the foreseeable future Wolf in sheep’s clothes