1. Director, Competency-based Assessment Programs
SCTC Meeting – May 23, 2012
Entrustable Professional Activities (EPAs): The Competencies and Milestones in Context
Carol Carraccio, MD,MA
Director, Competency-based Assessment Programs

2. Objectives
Answer the question: What are EPAs & why do we need them when we have competencies and milestones?
Explain the added value of EPAs to assessment
Discuss example EPAs- their descriptions and step by step mapping to competencies and milestones
Explain why identifying EPAs is a team sport

3. Setting the Stage
51 series of milestones that span the novice to expert continuum & contribute meaningfully to assessment by:
Providing descriptions of behaviors that ground the more abstract language of competencies
Informing us about learners at a granular level as we directly observe their behaviors
Providing substrate for formative feedback and a learning roadmap
BUT

4. Setting the Stage
Need to integrate the competencies/milestones for a more holistic assessment of learners to answer the question “Is he a good doctor?”
AND
Cluster the milestones to make assessment more practical & situate it in a clinical context to make it more meaningful (Entrustable Professional Activities- EPAs)

5. Where Do We Go From Here? The Good News About Milestones
Like the competencies they are context-free
The Bad News About Milestones
Translation: Current milestones span the continuum so no need to write new milestones for subspecialties but need to embed existing milestones into subspecialty EPAs

6. Context Matters
The Milestones as “Building Blocks” in the Context of Clinical Experience: Introducing EPAs .
As we said the milestones are helpful in understanding the language of the competencies and helping us to assess learners at a more granular level as they perform components of the competencies but there is still something missing- and that is the grounding of the competencies in a clinical context which helps us to assess learners in integrating competencies and milestones to provide actual care to patients. The missing link is the construct of entrustable professional activities or EPAs.
ten Cate O, Scheele F. Viewpoint: Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Academic Medicine. Jun 2007;82(6):

7. Entrustable Professional Activities
In aggregate- represent the essential professional work that defines a discipline
Lead to a recognized outcome
Are observable and measurable
Require integration of competencies (KSA) across domains
Map to competencies and their milestones

8. The Good Doctor: PUTTING IT ALL TOGETHER
Domains of
EPAs Competence Competencies Milestones
EPAs
DOMAINS OF COMPETENCE
COMPETENCIES
MILESTONES
The Good Doctor:
PUTTING IT ALL TOGETHER

9. The “Entrustable” in an EPA
Ability to perform an activity at a desired level of performance without direct supervision
Trust is (should be) based on directly observed, consistent performance over time
We constantly, often subconsciously, make entrustment decisions based on needed level of supervision- need to formalize this process

10. Why Focus on Entrustment?
Adds meaning to assessment
“Do you trust this person to provide care for a patient referred with an acute cardiac problem without direct supervision?”
Versus
“Is this person competent in PBLI, SBP, etc?” 10

11. Summary: Why EPAs? Make sense to faculty, trainees, and the public
Situate competencies and milestones in the clinical context in which we live
Align what we assess with what we do
Add meaning to assessment by focusing on integration of competencies in care delivery
Make assessment more practical by clustering 51 series of milestones into meaningful professional activities 11

12. Identifying EPAs: Begin With the End in Mind
What does a suspecialist do in everyday practice?
Translates into the EPAs for subspecialty training

13. EPAs for Subspecialties
Three Broad Categories
Common across the generalist/subspecialist role
Common across subspecialties
Subspecialty-specific

14. EPAs Common to Generalists/Subspecialists
Provide consultation to other health care providers caring for children
Provide consultation using a variety of media (e.g. telephone, , webcast, video conferencing)
Facilitate the transition from pediatric to adult health care
Perform operational functions in a group practice setting
Improve care for a population of patients
Lead a health care team
Facilitate handovers to another healthcare provider either within or across settings
Expectations are higher for fellows than residents and higher for residents than students

15. EPAs Common Across Subspecialties
Contribute to the scholarly work of the subspecialty
Engage in meaningful MOC to fill knowledge/skills gaps and demonstrate deliberate practice
Co-manage patients with generalists and other subspecialists
Effectively perform the procedures key to the subspecialty

16. Subspecialty Specific EPAs
Sub-categories
Care for patients with acute ______ problems
Provide a medical home for patients with
chronic _____ problems
Care for patients who require ______ (some unique non-procedural skill (e.g., management s/p transplantation)
For subspecialties like cardiology who require additional training for EP consider an EPA on EP for which general cardiology fellows are not expected to achieve entrustment
In the case of tiered subspecialties like cardiology, you may not expect entrustment for every EPA. You would not expect a general cardiology fellow to be entrusted to perform a cardiac cath without direct supervision but you may expect him to be able to know who to refer and how to interpret the data from a cath.

17. EPA Worksheet 1. EPA Title Improve care for a population of patients
2. Activity Description
The 21st century health care professional needs to understand population health in order to optimize care. Populations can be defined by socio-demographics, disease states, and/or active practice patients to name a few.
The functions required:
Apply knowledge of population health
Function in an interdependent health care team
Collaborate with others to improve systems
Recognize one’s professional responsibility to populations, communities and society at large
Utilize technology (e.g. patient registries and databases)
Demonstrate adaptability in developing and implementing improvement plans
Utilize risk/benefit and cost/benefit analysis

18. EPA Worksheet (continued)
3. Judicious Mapping to Domains of Competence
___ Patient Care
___ Medical Knowledge
_x_ Practice-Based Learning/Improvement
___ Interpersonal & Communication Skills
_x_ Professionalism
_x_ Systems-Based Practice
_x_ Personal & Professional Development
Modified from the work of ten Cate

19. EPA Worksheet (continued)
4. Judicious Mapping to Competencies
Practice-based Learning and Improvement
Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement
Use information technology to optimize learning and care delivery
Professionalism
Develop a professional identify, including understanding, appreciation, and internalization of the professional role as it relates to patient, community, or specialty

20. EPA Worksheet (continued)
4. Judicious Mapping to Competencies
Systems-based Practice
Incorporate considerations of cost awareness and risk-benefit analysis
Advocate for quality patient care and optimal patient care systems
Know how to advocate for the promotion of health and the prevention of disease and injury in populations
Personal & Professional Development
Flexibility and maturity in adjusting to change with the capacity to alter one’s own behaviors

21. EPA Worksheet (continued)
5. List specific knowledge, skills and attitudes that are needed to execute the EPA well?
Curriculum
KSA specific to:
Quality improvement methods
Information technology
Professional identity
Cost awareness
Risk-benefit analysis
Quality care and care systems
Advocacy
Flexibility and maturity in adjusting to change

22. Next Steps for EPAs: Assessment
Create a matrix (handout)
Using milestones for each competency at each level of performance
Synthesize behaviors across domains/competencies by level of performance
Create clinical vignettes that describe the integration of behaviors across competencies at each level of performance
Garner consensus about which level of performance correlates with “entrustment” of a learner and whether entrustment is required for that professional activity

23. Example Subspecialty EPA Worksheet
1. EPA Title
Provide care to patients who present with acute renal problems
2. Activity Description
The functions required:
Apply in-depth knowledge of the field in implementing a focused diagnostic work-up and management plan
Communicate with the patient and family and engage them to the extent possible in shared decision making
Communicate with the referring physician and other team members involved in care
Support the emotional response of patients and families to uncertain or fear inducing diagnoses, treatments, and/or prognoses
An iterative process will be needed to sort functions that are more important to patients with chronic renal disease from those with acute renal problems such as helping to navigate the health care system. Likely procedural competence is so critical to subspecialty care that this will be identified as its own EPA so I did not include it as a function of the given EPA.

24. Example Subspecialty EPA Worksheet
3. Judicious Mapping to Domains of Competence
_X__ Patient Care
_X__ Medical Knowledge
___ Practice-Based Learning/Improvement
_X__Interpersonal & Communication Skills
___ Professionalism
__ Systems-Based Practice
___ Personal & Professional Development
Modified from the work of ten Cate

25. Example Subspecialty EPA Worksheet
4. Judicious Mapping to Competencies
Patient Care
Make informed diagnostic & therapeutic decisions that result in optimal clinical judgment
Develop & carry out management plans
Medical Knowledge
Demonstrate sufficient knowledge of the basic & clinically supportive sciences in the subspecialty

26. Example Subspecialty EPA Worksheet
4. Judicious Mapping to Competencies
Interpersonal and Communication Skills
Communicate effectively with patients, families and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds
Communicate effectively with physicians, other health professionals, and health related agencies
Demonstrate the insight and understanding into the emotion and human response to emotion that allow one to appropriately develop and manage human interactions

27. Example Subspecialty EPA Worksheet
5. List specific knowledge, skills and attitudes that are needed to execute the EPA well?
Curriculum
KSA specific to:
Epidemiology, signs, symptoms, presenting features & up to date management of HUS, ATN…
Interpreting diagnostic imaging & testing…
Delivering bad news
Basic elements of emotional intelligence ….
Use your functions to help you inform your curriculum

28. Both are Critical to Meaningful Assessment
Take Home Messages
Milestones + EPAs:
Both are Critical to Meaningful Assessment

29. Take Home Messages Milestones: A granular approach to assessment
Address the learner at the level of a competency (e.g., gather essential information…)
Allow drill down to smaller elements of behavior that provide the substance of formative feedback, remediation, and a learning roadmap
EPAs: A holistic approach to assessment
Integrate competencies within a clinical context
Assess clusters of behaviors required to care for patients

30. Take Home Messages COLLABORATION IS KEY
Identifying EPAs for Subspecialties:
COLLABORATION IS KEY

31. Thank you!