Transcript Part 2 - POGOe

Are They Practicing What You are
Preaching?
Entrustable Professional Activities (EPA) for the
Geriatrician
Kelly Caverzagie, MD
Department of Internal Medicine
University of Nebraska Medical Center
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Disclosures

A portion of my salary at the University
of Nebraska is reimbursed by the ABIM:
◦ Practice Improvement Module (PIM)
Development
◦ Academic Affairs
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Learning Objectives

Identify the basic principles of CompetencyBased Medical Education (CBME)

Understand the concept of an Entrustable
Professional Activity (EPA) as it relates to
trainee assessment

Apply lessons learned to advance work of
community in developing EPA’s
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Outline

Background review of CBME
◦ Need for meaningful assessment

Assessment of Competence
◦ Entrustable Professional Activities (EPA)

Small group activities
◦ Reflect upon draft set of Geriatric EPA’s and
recommend revisions
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Competency-Based Medical Education
CBME is an outcomes-based approach to
the design, implementation, assessment
and evaluation of a medical education
program using an organizing framework of
competencies.
The International CBME Collaborators, 2009
ACGME – Outcome Project
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Introduced 1999
Implemented 2001
6 General
Competencies

Medical Knowledge

Patient Care and
Procedural Skills

Professionalism

Interpersonal &
Communication Skills

Practice-based Learning &
Improvement

Systems-based Practice
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Struggles Moving Forward

Programs have had trouble moving from
traditional framework (structure/process) to
CBME framework (competence/outcomes)
◦ Unclear and complex ACGME general
competencies
◦ Difficulty in assessing and evaluating resident
competence
Ambulatory Clinic
Old Assessment System
Critical Care Medicine
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Average 4.32 / 5
for SystemsBased Practice
Traditional vs. CBME: Start with System Needs
Frenk
Lancet, 2010
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ACGME – Outcome Project



Introduced 1999
Implemented 2001
6 General
Competencies

Medical Knowledge

Patient Care and
Procedural Skills

Professionalism

Interpersonal &
Communication Skills

Practice-based Learning &
Improvement

Systems-based Practice
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IOM High Quality Care

Timely – reducing waits and harmful delay

Efficient – avoiding waste

Equitable – providing care that does not vary in quality
because of personal characteristics

Safe – avoiding injuries rom care

Effective – providing services based on scientific knowledge
to all who could benefit

Patient-centered – providing care that is respectful of and
responsive to patient preferences, needs and values
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Medicare-Determined Outcomes
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Work effectively in multiple settings
Coordinate care within and across settings
Understand cost and value of diagnostic and
treatment options
Work in inter-professional teams and multidisciplinary team-based models
Identify systematic errors and in implement
systematic solutions in case of errors
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Traditional vs. CBME
Educational Program
Variable
Structure/Process
Competency-based
Driving force: Curriculum
Content
Outcome
Goal of educ. encounter
Knowledge acquisition
Knowledge application
Typical assessment tool
Single subjective measure
Multiple objective measures
Proxy
Authentic
(mimic real tasks of profession)
Setting
Removed (gestalt)
Direct observation
Focus of Assessment
Norm-referenced
Criterion-referenced
Timing of assessment
Emphasis on summative
Emphasis on formative
Assessment tool
Adapted from Carracchio, et al. 2002
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Ambulatory Clinic
Old Assessment System
Critical Care Medicine
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Average 4.32 / 5
for SystemsBased Practice
Manage multiple meds
New Assessment
System
Resuscitate critically ill patient
Manage transitions of care
Perform musculoskeletal exam
Consult to non-medicine teams
Critically appraise literature
Goals of care discussion
Example
activities of
unsupervised
internist
OR
Inform steps
along the way to
becoming an
unsupervised
internist
How does
Brady get to
drive a car?
Competency
An observable ability of a health
professional, integrating multiple
components such as knowledge, skills,
values and attitudes.
The International CBME Collaborators, 2009
Competent
Possessing the required abilities in all
domains in a certain context at a defined
stage of medical education or practice.
The International CBME Collaborators, 2009
Competence
Competence entails more than the
possession of knowledge, skills and
attitudes; it requires you … to apply these
[abilities] in the clinical environment to
achieve optimal results.
ten Cate, Med Teach, 2010
Competenglish
Competency – the thing(s) they need to do
Competent – can do all of the things
Competence – does all of the things
consistently, adapting to contextual and
situational needs
How Does Brady get to Drive 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
◦ Dad gives him the keys and walks away
When do your fellows get the keys to
the car?
Lots of good evaluations …
 Absence of bad evaluations …
 Survived a year of fellowship…
 Didn’t commit any crimes …


Your program director followed the
rules…
CBME is a new paradigm
We must know the trainee has
demonstrated competence and is ready
to progress to the next stage of their
career:
◦ Requires clear definition of expected
competencies (i.e. thing they need to do)
◦ Requires assessment to determine whether
these things are done consistently and within
the contextual needs of the clinical
environment
Geriatric Curricular Competencies
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Potential Criticisms
•
There are too many!
◦ Programs cannot assess all of them

Reductionistic?
◦ Potential to deconstruct the learners’
performance into discreet tasks or checklists
◦ Checking off competencies does not equate
to competence
CBME Challenge

Ensure that the outcomes of the
assessment actually demonstrate
competence in the activities that define
the profession

Do they equate to the things that the
public trusts that geriatricians are doing?

Entrustable Professional Activities (EPA’s)
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Entrustable Professional Activities
“… identify the critical activities that
constitute a specialty … the activities of
which we would all agree should be only
carried out by a trained specialist.”
ten Cate et al.
Acad Med 2007; 82: 542-47
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An Entrustable Professional Activity
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Part of essential work for a qualified professional
Requires specific knowledge, skill, attitude
Acquired through training
Leads to recognized output
Observable and measureable, leading to a
conclusion
Reflects the competencies expected
EPA’s together constitute the core of the
profession
ten Cate et al.
Acad Med 2007; 82: 542-47
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Entrustable Professional Activities
“Patients’ and instructors’ … entrustment of
responsibility to a trainee is an essential
concept in this approach…”
ten Cate et al.
Acad Med 2007; 82: 542-47
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Entrustment in Residency Training

Attending physicians assess a multidimensional construct of
“trustworthiness” when deciding a level
of supervision

Entrustment implies a level of
competence
Kennedy, et. al.
Acad Med 2008; 83(10 Suppl): S89-92
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COMPETENCE
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“Windows to Competence”
Caverzagie and Iobst
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EPA - Lead and work within
interprofessional teams
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Accept feedback
EPA - Lead and work within
interprofessional teams
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EPA - Lead and work within
interprofessional teams
Manage diverse
opinions with
goal optimizing
patient care
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EPA - Lead and work within
interprofessional teams
Maintain
climate of
mutual respect
and shared
values
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EPA - Lead and work within
interprofessional teams
Engage in
collaborative
communication
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EPA - Lead and work within
interprofessional teams
Identify and
understand
roles of team
members
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Accept feedback
Maintain
climate of
mutual respect
and shared
values
Identify and
understand
roles of team
members
EPA - Lead and work within
interprofessional teams
Manage diverse
opinions with
goal optimizing
patient care
Engage in
collaborative
communication
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DRAFT Geriatricians EPA’s (v13)
1.
2.
3.
4.
5.
6.
7.
8.
Prevent, diagnose and treat conditions in older adults with attention to
multimorbidity, age-related changes in physiology, function, treatment efficacy
and response, medication management and psychosocial issues.
Prevent, diagnose and treat geriatric syndromes.
Provide and coordinate health care for older adults in all settings, during
transitions of care, and at end of life.
Provide geriatric consultation.
Conduct meetings with patients, families and caregivers to clarify goals of
care and make complex decisions in the context of prognosis, net benefit
and burden, preferences and values.
Collaborate effectively as a member or leader of a health care team.
Teach the principles of geriatric care and aging-related health care issues to
professionals and nonprofessionals.
Participate in quality improvement and other systems-based initiatives to
assure patient safety and improve outcomes for older adults.
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Group Activity #1 - Task

Using your assigned Geriatric EPA …
◦ Describe the activity
◦ Identify the tasks required for you to entrust the
fellow to do this activity at the end of training

Goals
◦ Develop ‘shared mental model’ of the EPA in
order to inform meaningful assessment
◦ Write down recommendations and provide to
________________.
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Considerations

Compare / contrast to Internal Medicine EPA’s

Use Geriatric Curricular Competencies as a guide

Balance between specific vs. vague / standardized vs.
flexible

Ideally, the description and tasks will be evidence-based
and informed by the knowledge, skills and attitudes
required of physicians to meet the outcomes expected
of the future health care system
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Group Activity #2 - Task

Consider the entire list of Geriatric EPAs
◦ Is anything missing? Is anything redundant?
◦ Do they reflect the expected outcomes?
 Profession
 Patient / Public
 Policy makers
 Goals
◦ Hand in recommend revisions
◦ Use your expertise to guide community
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Building Assessments for an EPA
Step 1 – Describe the activity. What tasks are
required for you to entrust the fellow to do this
activity at the end of training?
Step 2 – Identify the Curricular Competencies
that will help you assess a fellow performing this
activity
Step 3 – Identify specific assessment methods /
tools
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Clinical
Competency
Committee
Educational Milestones
Assessment
System
ADS Update
Self Study
Resident Survey
Faculty Survey
Board Pass Rate
CLER Visit
Clinical Experience
Log
Core Faculty
Scholarly Activity
Next Accreditation
System
Learning Objectives

Identify the basic principles of CompetencyBased Medical Education (CBME)

Understand the concept of an Entrustable
Professional Activity (EPA) as it relates to
trainee assessment

Apply lessons learned to advance work of
community in developing EPA’s
46
Thank You!
[email protected]
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