Transcript Presentation title goes here Subtitle of presentation

SCTC Meeting – May 23, 2012
Entrustable Professional Activities
(EPAs): The Competencies and
Milestones in Context
Carol Carraccio, MD,MA
Director, Competency-based Assessment Programs
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
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
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)
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
Context Matters
The Milestones as “Building Blocks”
in the Context of Clinical Experience:
Introducing 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):542-547
Entrustable Professional Activities
• In aggregate- represent the essential
•
•
•
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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
EPAs
EPAs
DomainsOFof
DOMAINS
Competence
COMPETENCE
COMPETENCIES
Competencies
MILESTONES
Milestones
The Good Doctor:
PUTTING IT ALL TOGETHER
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
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?”
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
Identifying EPAs:
Begin With the End in Mind
• What does a
suspecialist do in
everyday practice?
• Translates into the
EPAs for
subspecialty training
EPAs for Subspecialties
• Three Broad Categories
– Common across the generalist/subspecialist
role
– Common across subspecialties
– Subspecialty-specific
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
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
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 nonprocedural 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
EPA Worksheet
1. EPA Title
Improve care for a population of patients
2. Activity Description The functions required:
The 21st century health
care professional needs
to understand population
health in order to
optimize care.
Populations can be
defined by sociodemographics, disease
states, and/or active
practice patients to name
a few.
•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
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
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
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
EPA Worksheet (continued)
5. List specific knowledge, skills and attitudes that are
needed to execute the EPA well?
Curriculum
KSA specific to:
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•
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
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
Example Subspecialty EPA
Worksheet
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
1. EPA Title
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
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
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
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 ….
Take Home Messages
Milestones + EPAs:
Both are Critical to Meaningful
Assessment
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
Take Home Messages
Identifying EPAs for Subspecialties:
COLLABORATION IS KEY
Thank you!