SCTC Meeting – May 23, 2012

1. 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 • Like the competencies they are context-free • 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. The Milestones as “Building Blocks” in the Context of Clinical Experience:Introducing EPAs. Context Matters 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):542-547

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. Domains of EPAs Competence Competencies Milestones DOMAINS OF COMPETENCE EPAs 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?”

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

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, e-mail, 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

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

17. EPA Worksheet

18. EPA Worksheet (continued)

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

24. Example Subspecialty EPA Worksheet

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 ….

28. 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 Identifying EPAs for Subspecialties: COLLABORATION IS KEY

31. Thank you!