1. RANZCP Competency-Based Fellowship Program – Overview John Crawshaw Chair, Board Of Education, RANZCP RANZCP Congress, 2012, Hobart, Tasmania

2. Presentation Overview Background to the competency-based 2012 Fellowship Program Program Elements Regulations Key Terms Transition Arrangements Questions

3. Background to the 2012 Fellowship Program- Why Change the Curriculum? Workforce demands Time spent in training Exam pass rate Lateral entry Increase flexibility – not one size fits all Trainee difference in prior knowledge Rate of competence attainment for different tasks Clinical opportunities

4. Focus Group Outcomes Focus groups held in 2007 identified the following: Key area of competence:Wanted: Clinical knowledge (general medical and psychiatric) Clearly defined requirements Management and leadership skills (team/colleague & patient/community) Less paperwork Language and communicationExam preparation program Ethical issues and knowledgeFlexibility Complete components more flexibly Sit exams earlier, if criteria are met Opportunity to pursue personal interests with the program

5. Competency-based Fellowship Program Aims Develop a competency-based curriculum and Fellowship training program that -integrates the concept of competent performance into the College’s educational philosophy -integrates contemporary adult education principles into the training program -is developed in line with international specialist medical education best practice -increases flexibility in training -allows for more timely progression

6. Competency-based Fellowship Program Aims The competency-based 2012 Fellowship training program –is developed to better reflect the complexity of contemporary professional practice of specialist psychiatrists –provides a broad range of clinical experience during training –addresses issues associated with competing demands for service provision and training requirements for trainees –provides for Recognition of Prior Learning (RPL) –maintains high standards of training Workplace-based assessments align to, and help assess, the development of competencies

7. Process of Development Commenced in 2007 as the Curriculum Improvement Project Much development undertaken since 2007 Moved to Competency Based Fellowship Program (2009) as implementation commenced

8. Process for CBFP Development Review of current curriculum –Focus groups with Trainees and DOTs –Online survey Literature review of international best practice Ongoing discussion with RCPsych (UK) and RCPSC (Canada) Development of key curriculum components and some associated resources Extensive consultation with relevant stakeholders in the development and review of work

9. Program Elements – CanMEDS roles and Fellowship Competencies Medical Expert Communicator Collaborator Manager Health Advocate Scholar Professional

10. Fellowship Competencies Example: Communicator Role Statement As Communicators, psychiatrists communicate effectively with a range of patients, carers, multidisciplinary teams, general practitioners, colleagues and other health professionals, using their interpersonal skills for the improvement of patient outcomes. Communication skills range from the ability to provide clear, accurate, contextually appropriate written communication about patients’ conditions, to being able to enter into dialogue about psychiatric issues with the wider community. Fellowship Competencies Demonstrate the ability to communicate effectively with a range of patients, carers, multidisciplinary teams, general practitioners, colleagues and other health professionals. Demonstrate the ability to provide clear, accurate, contextually appropriate written communication about the patient’s condition.

11. Fellowship Competencies Example: Communicator Learning outcomes – Communicator, Stage 1 Use effective and empathic verbal and non-verbal communication skills in all clinical encounters with the patient, their families and carers Recognise challenging communications, including conflict with patients, families and colleagues, and discuss management strategies in supervision to promote positive outcomes Recognise and incorporate the needs of culturally and linguistically diverse populations, including the use of interpreters and culturally appropriate health workers Provide accurate and structured verbal reports regarding clinical encounters, using a recognised communication tool Demonstrate comprehensive and legible case record documentation including discharge summaries and written liaison with referrers, primary care providers and community organisations (where relevant), under supervision

12. Program Elements – Developmental Trajectory BASIC PROFICIENT ADVANCED STAGE 1STAGE 2 STAGE 3 PGY 1/2 LOW INDEPENDENCE DEVELOPMENTAL TRAJECTORY HIGH INDEPENDENCE HIGH LEVELS SUPERVISION LOW LEVELS SUPERVISION JUNIOR CONSULTANT

13. Program Elements – Developmental Descriptors Developmental Descriptors: –are behavioural descriptors for the Fellowship Competencies –articulate how the Developmental Trajectory applies to the Fellowship Competencies through the training stages –the behaviours described for each aspect of practice is not an exhaustive list, but is intended as a guide –a developmental descriptor that articulates what is expected at each training stage is provided for each aspect of practice

14. Example: Aspect of Practice - Assessment By the end of each Stage, the trainee’s performance in this aspect of practice can be assessed using the following standards: Program Elements – Developmental Descriptors Stage 1 Basic level Stage 2 Proficient level Stage 3 Advanced level Conducts a standard assessment of a patient with typical psychiatric disorders, but requires supervision to elicit all necessary data and to understand the significance of data obtained. With supervision, performs a detailed and comprehensive assessment of a patient presenting with typical and atypical features Performs a detailed and comprehensive assessment of a patient presenting with complex or multiple problems, or in special groups.

15. Key Terms Stage competency levels reflect the Developmental Trajectory and move from low independence/high supervision levels to high independence/low supervision levels –Stage 1: Basic –Stage 2: Proficient –Stage 3: Advanced WBAs - Workplace-based Assessments EPAs – Entrustable Professional Activities

16. Regulations New regulations, policies and procedures for the 2012 Fellowship program are currently being drafted Example of new Regulation - Transition Trainees of the College who enrolled prior to December 2012 (New Zealand) and January 2013 (Australia) will transfer to training under the RANZCP Fellowship Regulations 2012 through the transitional arrangements determined by the Board of Education and detailed in the College Policy on Transition Arrangements for College Trainees. Transition to the RANZCP Fellowship Regulations 2012 shall minimise any disadvantage to College trainees enrolled under the previous regulations. The policy on transition arrangements will provide a mechanism for reviewing and amending individual transition decisions in which the trainee asserts disadvantage has occurred.

17. So, How Does It Work? Typically 60 months full-time equivalent Implementation begins: –Stage 1 (1 st year): December (NZ); January 2013 (Australia) –Stage 2 (2 nd and 3 rd years): December 2013 –Stage 3 (4 th and 5 th years): December 2015 Transition arrangements will apply for current trainees Transition of existing trainees will begin from the start of 2014 Progression between Stages dependent on: –Time spent in rotations –Attainment of Fellowship Competencies demonstrated through successful completion of mandatory assessments – WBAs, EPAs, In-Training Assessment Forms and Reports

20. 2012 Fellowship Program Framework

21. Formal Education Course All trainees must be enrolled in a Formal Education Course Syllabi have been developed for Stages 1 and 2 Syllabi defines the knowledge base that underpins the acquisition of competencies at each Stage Syllabi inform knowledge acquisition across the following settings: –Clinical –Formal –Informal –Self-directed learning Syllabi are not prescriptive, and local training schemes/FECs will provide greater levels of specification

22. Psychotherapies Trainees required to develop competence to a proficient level (standard for Stage 2) in psychotherapies Trainees must complete: –Psychotherapies Long Case of one long psychotherapy intervention (~1 year or 40 sessions) Write up of Long Case is a summative assessment requirement –A number of briefer interventions Trainees will be encouraged to treat low acuity/high prevalence disorders Treatment modality will be determined by patient need

23. Scholarly Project College-approved Scholarly Project must be completed Assessed at the Fellowship level Trainees encouraged to undertake the Scholarly Project earlier in training Scholarly Project Subcommittee will be established for government and assessment Examples of appropriate projects include: –Quality assurance project –Clinical audit –Literature review –Qualitative or quantitative original research project –Case series Other Scholarly Projects may be approved on a case-by-case basis

24. Workplace-based Assessments (WBAs) Formative assessment of competencies, NEVER a mechanism to ‘mark’ or ‘pass/fail’ Mechanism for supervisor to provide meaningful and effective feedback Minimum of 3 WBAs used to inform assessment of each EPA Supervisors are required to be competent in conducting WBAs WBA tools include: –Observed Clinical Activity (OCA) –Mini Clinical Evaluation Exercise (Mini-CEX) –Professional Presentation –Case-based Discussion (CbD) Outlined in more detail, with examples, in this afternoon’s session

25. Entrustable Professional Activities (EPAs) Summative assessment – trainees must be entrusted to perform specific EPAs to an appropriate standard for the stage of training to progress EPAs provide a snapshot of how a trainee is performing 2 EPAs should be assessed and achieved for each 6 month rotation In addition to EPAs in each rotation, 5 mandatory EPAs are to be entrusted by the end of Stage 2 Fellowship EPAs do not need to be signed off by a supervisor with a Certificate in the respective Area of Practice (unless the trainee is enrolled in an Advanced Certificate in that Area of Practice) Outlined in more detail, with examples, in this afternoon’s session

26. Supervisor In-Training Assessment – ITAs 2 ITAs: –Formative In-Training Assessment Forms Mid-rotation –Summative In-Training Assessment Reports End of rotation Must be submitted to the College The ITAs are currently in development

27. Examinations – Written Exam Knowledge level and application at junior consultant standard Threshold of Stage 2 and 3 (years 3 & 4) –May be sat from early in Stage 2, but this is not recommended –May be sat as late as the end of the first rotation in Stage 3 Attempted after acquiring specified competencies to the proficient level, demonstrated through satisfactory In- Training Assessments including EPAs Not a barrier to entering Stage 3 – trainees may complete first 6 month rotation of Stage 3, including the 2 required EPAs

28. Examinations – Clinical Exam Held in Stage 3 at junior consultant standard May be attempted after successful completion of Written Exam Observed Clinical Interview (OCI): –Trainees must pass 2 out of 3 OCIs Objective Structured Clinical Examination (OSCE): –12 stations

29. Stage 1 – 1 st Year of Training 12 months FTE Minimum 12 months in General Psych training; with 6 months in acute setting First intake: December 2012 (NZ) Supervision –4 hours/week for 40 weeks, including: 2hrs/week outside ward rounds and case review 1 hour minimum individual supervision of clinical work –WBAs typically occur in supervision time –EPAs may or may not be formally signed off in supervision time

30. Stage 1 – 1 st Year of Training continued Mandatory Stage 1 EPAs: 1.Producing discharge summaries and organising appropriate transfer of care. 2.Initiating an antipsychotic in a patient known to have schizophrenia. 3.Active participation in the multidisciplinary team meeting. 4.Providing an explanation to a family about a young adult’s major mental illness.

31. Stage 2 – 2 nd and 3 rd Years of Training 24 months FTE; first intake December 2013 (NZ) Supervision: –Minimum 4 hours/week for 40 weeks annually –1 hour/week individual supervision of clinical work Mandatory areas of practice rotations and Stage 2 EPAs: –Consultation-Liaison Psychiatry (6 months FTE) EPAs: a) Care for a patient with delirium. b) Manage clinically significant psychological distress in the context of a patient’s medical illness in the general hospital. –Child & Adolescent Psychiatry (6 months FTE) EPAs c) Develop a management plan for an adolescent where school attendance is at risk. d) Clinical assessment of a prepubertal child.

32. Stage 2 – 2 nd and 3 rd Years of Training continued Competence must be gained to a proficient level in the following mandatory Areas of Practice: Addiction Psychiatry EPAs e)Management of intoxication and withdrawal. f)Comorbid mental health and substance use problems. Psychiatry of Old Age EPAs g)Behavioural and psychological symptoms in dementia (BPSD). h)The appropriate use of antidepressants and antipsychotics in patients aged 75 years and over (or under 75 with excessive frailty).

33. Stage 2 – 2 nd and 3 rd Years of Training continued Elective rotations may be undertaken in the following Areas of Practice: –Addiction –Adult –Forensic –Indigenous –Psychiatry of Old Age –Rural –Other Areas of Practice as approved by the BOE

34. Stage 2 – 2 nd and 3 rd Years of Training continued Mandatory Stage 2 EPAs must be successfully attained by the end of Stage 2: 1.Demonstrating proficiency in all the expected tasks associated with prescription, administration and monitoring of ECT. 2.The application and use of the Mental Health Act. 3.Assessment and management of risk of harm to self and others. 4.The safe and effective use of clozapine in psychiatry. 5.Cultural competence

35. Stage 3 – 4 th and 5 th Years of Training 24 months FTE; first intake December 2015 (NZ) Supervision: –4 hours/week for 40 weeks annually –1 hour/week individual supervision of clinical work Certificate of Advanced Training –Trainees may apply and, if successful, enroll in a Certificate in a College-established Area of Practice Areas of Practice –Trainees may also stay in the Fellowship stream, and complete 24 months in a single Area of Practice or multiple Areas of Practice 2 EPAs must be entrusted at an advanced level for each rotation in Stage 3 Clinical exams: –OCI and OSCE – attempted in Stage 3 after trainees have passed the Written exam

36. Stage 3 – 4 th and 5 th Years of Training continued College-established Areas of Practice: –Addiction- Adult –Child & Adolescent- Consultation-Liaison –Forensic- Indigenous –Psychiatry of Old Age- Psychotherapies –Research/Academic- Rural –Others as approved by BOE Clinical currency – trainees undertaking 12 months Research/Academic or specialised administrative/managerial training in Stage 3 must retain clinical currency in a psychiatry area

37. Transition Arrangements - Regulation Transition Arrangements for College Trainees Enrolled Prior to the RANZCP Fellowship Regulations 2012 Trainees of the College who enrolled prior to December 2012 (New Zealand) and January 2013 (Australia) will transfer to training under the RANZCP Fellowship Regulations 2012 through the transitional arrangements determined by the Board of Education and detailed in the College Policy on Transition Arrangements for College Trainees. Transition to the RANZCP Fellowship Regulations 2012 shall minimise any disadvantage to College trainees enrolled under the previous regulations. The policy on transition arrangements will provide a mechanism for reviewing and amending individual transition decisions in which the trainee asserts disadvantage has occurred.

38. Transition Matrix

39. Transition Table [insert final doc here]

40. Transition Arrangements – Policy & Practice All trainees will have either completed under 2003 regulations or transitioned to 2012 Fellowship Regulations by December 2015 ** At this point, the Transition Policy expires Trainees will be able to transition into Stage 2 from December 2013 Two sets of Exams will be held in 2015 CFT manages the transition process Process –Eligible trainees receive the Transition Table and Matrix in the form of a 2012 Regulations Training Record which will clearly identify the components they are recognised as achieving comparable competency in, and those still to be completed.

41. Transition Arrangements – Policy & Practice Currency –Trainees with currency expiration dates within 12 months of transition may need to undertake WBAs and attain EPAs to achieve and maintain currency Appeals –Trainees may access College Reviews and Appeals process if they feel they have grounds to reconsider a CFT decision

42. Questions Any questions? Further resources: –CBFP website – new and updated: http://cbfp.ranzcp.org/ http://cbfp.ranzcp.org/ –CBFP email: cbfp@ranzcp.orgcbfp@ranzcp.org –Information is also available at the CBFP Booth