1. RANZCP Competency-Based Fellowship Program – Overview John Crawshaw Chair, Board Of Education, RANZCP RANZCP Congress, 2012, Wellington, New Zealand

2. Presentation Overview Program Elements Key Terms So, How Does it Work? WBAs and EPAs –How the EPA Handbook and RANZCP Certificate of Entrustment (COE) work –Process of entrusting an EPA –How WBAs may help gauge readiness to entrust an EPA Transition Arrangements Questions

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

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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, but, no longer a barrier to Stage 3 –A number of briefer interventions Trainees will be encouraged to treat low acuity/high prevalence disorders Treatment modality will be determined by patient need

13. 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

14. 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)

15. 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)

16. How do the EPA Handbook and RANZCP Certificate of Entrustment work? All EPAs are detailed in the EPA Handbook, which is available on the CBFP website EPA Handbook is helpful for supervisors and trainees The website version is always the most up-to-date Every EPA also has a RANZCP Certificate of Entrustment (COE) –Summary version of full EPA –Sign-off required on RANZCP COE to certify entrustment

17. Process of Entrusting an EPA EPA Handbook document contains a full description of the knowledge, skills and attitudes required to gain entrustment of that professional activity May or may not be attained in dedicated supervision time Entrustment decision draws on all data available to supervisor –WBA performance –Observation –Information from other staff/allied health/etc

18. Entrustment Example: Consultation–Liaison Psychiatry EPA Care for a patient with delirium Skill: Negotiates clinical role throughout the course of the delirium episode Trainee may assess patient, liaise with staff, etc. On the following day, trainee discusses this case with a supervisor in a CbD as Workplace-based Assessment Skill: Considers the patient’s capacity to consent and any implications Trainee may have consented a different patient with a different issue on another occasion and completed a CbD Knowledge: Accesses, appraises and applies best level of evidence. Supervisor has observed trainee working with a number of patients and considers their knowledge to be good.

19. How WBAs Help Gauge Readiness to Entrust EPAs WBAs provide an evidence base The structured feedback provided by a WBA highlights trainees’ strengths and weaknesses They can measure progress over time WBAs can be used to assess difficult or complex tasks

20. Process of Entrusting an EPA When the supervisor judges the trainee to be competent to perform the EPA with only distant, reactive supervision → entrustment achieved To document entrustment –Trainee prints the RANZCP COE –Supervisor completes RANZCP COE –RANZCP COE signed by supervisor, trainee and DOT –EPAs attainment will be reported to the College on the In-Training Assessment report at the end of each rotation

21. 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

22. 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 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 continue with rotations in Stage 3 The Failure to Progress policy will, when triggered, require a mandatory remedial plan to be submitted and ultimately the trainee to show cause to the CFT should they not be able to pass the exam.

23. Examinations – Clinical Exam Held in Stage 3 at junior consultant standard Observed Clinical Interview (OCI): –Trainees must pass 2 out of 3 OCIs Objective Structured Clinical Examination (OSCE): –12 stations The Failure to Progress policy will, when triggered, require a mandatory remedial plan to be submitted and ultimately the trainee to show cause to CFT, should they continue to be unable to pass the Clinical Exams.

24. 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

25. 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.

26. Stage 2 – Mandatory General Psychiatry EPAs (may be done in Stage 1) 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

27. 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.

28. 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).

29. 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

30. 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.

31. 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.

32. Questions Any questions? Further resources: –CBFP website – new and updated: http://cbfp.ranzcp.org/ http://cbfp.ranzcp.org/ –Training email: training@ranzcp.orgtraining@ranzcp.org