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Competency Based Medical Education Lessons from the Trenches - The Basics Rob Anderson Christina Tremblay Catherine Cervin Northern Constellations March 28, 2015
Competency Based Medical Education
Lessons from the Trenches - The Basics
Rob Anderson Christina Tremblay Catherine Cervin
Northern Constellations March 28, 2015
Today's Learning Objectives
By the end of this session, participants will be able to:• Describe the two models of CBME that are
being implemented in Canada: CFPC competency assessment program and RCPSC competency by design.
• Build an assessment framework which will support the use of milestones, entrustable professional activities, and skill dimensions.
The Building Blocks
Design
DEFINED PROGRAM OUTCOMES
Competency-based and guided by CanMEDS-FM
Assess
Triple C Competency-based LEARNING OPPORTUNITIESClinical ExperiencesAcademic ProgramOther Activities
Design and providecurriculum
Triple C Competency-based teaching and learning STRATEGIES
Triple C Competency-based RESOURCESClinical resourcesTeaching Materials Faculty
Outcome-based PROGRAM EVALUATION
ON
GO
ING
ASSESSMEN
T of residents –
based on Evaluation objectives
5
Triple C Competency-based Curriculum
6
The Big Question
• How do we develop competency based training
AND
• ensureAND
• document
End of training competence?
Basic Principles
Define Behaviour Observe Behaviour
Assess BehaviourDecide where learner is on competencetrajectory
Competency Trajectory
Expert
PGY1 Start
PGY2 Start
End Residency
First 3-5 years of Practice
Beginning Professional
Knowledgeable Professional
Novice
TIME
SETT
ING SUMMATIVE
ASSESSMENT
RESIDENTOWNERSHIP!
Development of The Evaluation Objectives
• Asked to describe competence in terms of:
– Patient problems and situations– Clinical decision making and judgment– Other qualities and behaviours– Problem areas
Survey Results / Further Definition • 99 Topics
• 6 Skill Dimensions : Clinical Reasoning, Selectivity, Patient Centered Approach, Communication, Professionalism, Procedural/Psychomotor Skills
• 8 Phases of the Clinical encounter : History, Physical, hypothesis, Investigation, Diagnosis, Management, Referral, Follow-up
Further Definition of TopicsKey Features
• Definition- The critical steps in the resolution of a problem. Focused on the points where we are most likely to make errors and the areas that are the most difficult in practice.
Skills – Procedural• Decision to act- consider indications,
contraindications, your skills and context ( that day and time ability ), context of the procedure
• Informed Consent• Preparation: Review - anatomy, sequential
technical steps. potential complications and their management, appropriate equipment
• During Procedure: Keep patient informed (decrease anxiety), ensure comfort and safety
• If problems reevaluate ( ? Stop ? Ask for help)
• Aftercare/Follow-up
CANMedsRoles
Clinical Domains
Skill Dimensions
Clinical Contexts
CommunicatorCollaboratorProfessionalScholarManagerAdvocate
Care through the Life CycleWomen’s Health + Maternity
Surgical/Procedural Mental Health
Palliative Care/End of Life CareCare of the Underserved
Care of the Elderly
HospitalHomeOffice
Labour delivery wardNursing Home
Operating RoomEmergency Department
SelectivityClinical ReasoningProfessionalismProcedural skillsPatient CentredMethodCommunicator
FAMILY MEDICINEEXPERT
Community
Community
Levels of competence:
Low levels one well-defined taskdone repeatedly
the same way
High levels multiple tasks, ambiguous,uncertain end-points, partial data,
knows how and why, can justifycan abstract to new situations
Task 1: Picking a competency
• Work with your table to define:• A population• An observable behavior/task• Timeline of success
• For example: Anesthesia residents inserting a labor epidural in a healthy parturient by the end of 2nd year of residency.
“I am not interested in Competency Based Education”
Direct quote from Nov 2011 NOSM anesthesia retreat
slide presented byRob Anderson!
What Changed?
• CanMEDs 2015• Time free “softened” to time as a
resource. • ICRE 2012/13• Workshops (Sherbino and UofT)• CFPC SIFP Working group• Unmatched desire to not have to
completely rebuild … ever!
LESSON # 1: DON’T WORRY ABOUT THE EVOLVING DEFINITIONS…THEY WILL JUST TELL US!
Definitions relevant to CBD
• Entrustable Professional Activities (EPA): • A task in the clinical setting that may be
delegated to a resident by their supervisor once competence has been demonstrated
• Milestones: • An observable marker of an individual’s
ability along a developmental continuum
Competency by Design - Lots of Change!
• Increased resident ownership• Mainport ePortfolio• De-emphasize examinations• New accreditation structure• Competency committees and
coaches• Competency frameworks “Back
Office” vs “Front Office”
Back Office
• Comprehensive set of milestones created through a set of workshops at the specialty committee
• Defines what it means to be a competent physician
• Map to EPAs and assessments
• Define duration and content of stages
Front Office
• EPAs and specific milestone assessments
• Each EPA integrates multiple milestones
• Aggregated by ePortfolio• Bank of assessments that have
been identified for the programs• Implementing them is the key!
Early EPA discussion
• We do this anyway!• Assess what is important, not
everything• Multiple milestones captured per
EPA• Key milestones captured across
multiple EPAs
Labor Analgesia in the Healthy Parturient
Competency Committees
• Promotion is resident driven!• Demonstrate that they have met
the bar• The bar must be clear• EPAs, set by the specialty
committee/working groups, will be mapped to CBD stages
The FPA Journey
• CFPC extending CCC into enhanced skills programs
• Small working group created• Creation of Priority Topics
relevant to anesthesia –validated broadly
• Focus on discriminatory acts, or “key features”
Priority Topics
• General Anesthesia• Post-operative care• Teamwork• Equipment • Neuraxial Anesthesia• Airway: complex• OR Emergencies
and complications• Pre-anesthesia
assessment
• Acutely ill or injured• Vascular access• Acute pain
management• Procedural Sedation• Know and apply
limits of capacity• Self directed
learning
0
20
40
60
80
100
120
OR
emer
genc
ies a
nd…
Airw
ay: r
outin
e an
d co
mpl
ex
Acut
ely
ill o
r inj
ured
Pre-
anae
sthe
tic/s
urge
ry…
Obs
tetr
ical
ana
esth
esia
Regi
onal
ana
esth
esia
Vasc
ular
acc
ess
Pedi
atric
ana
esth
esia
Proc
edur
al se
datio
n
Anae
sthe
sia g
ener
al a
nd e
lect
ive
Post
-ope
rativ
e ca
re
Vent
ilatio
ns a
nd e
quip
men
t
New
born
resu
scita
tion
Pain
man
agem
ent
Anae
sthe
sia a
nd o
besit
y
Med
icat
ions
Tran
spor
t of a
cute
ly il
l or i
njur
ed
VG
WG*6
Top 5*10
Key Features (PT Manage the complex airway)
• Can perform direct laryngosocopy
VS
• Can assess and predict/anticipate the patient with a difficult airway and the stages in which those difficulties may occur.
Or• Perform endotracheal intubation effectively in
elective, urgent and emergent situations that require different approaches
LESSON # 2: YOU DO NOT HAVE TO ASSESS EVERYTHING, JUST THE RIGHT THINGS!
Synergistic messages
• Residents own learning and documentation
• Assess the important things• Subjective and workplace
assessment is going to be vital
Task 2: Defining what is important
• What are the key steps that one must demonstrate to complete the task?
• Keep in mind…• Where do the “incompetents” fall
down.• What is so essential it can’t not be
included
LESSON # 3: FOCUS ON SMALL WINS WHEN IMPLEMENTING CHANGE.
Don’t Try to Drink the Ocean!
Image source: www.istockphoto.com
1. Analyze current practices2. Use the big picture to identify
achievable tasks which will move you toward CBD
3. Identify tools & resources required to achieve those tasks
4. Do the work & create the process5. Implement 6. Evaluate & re-evaluate frequently
Look at what you have & what you need
Achievable Tasks
• Give residents real-time feedback on how they are doing in the program
• Set clear expectations for the residents & faculty
• Assess performance in the clinical setting
Curriculum & Assessment for CBD
Tools for Implementation
1
23
Mul
tiple
iter
atio
ns &
Con
tinuo
us Im
prov
emen
ts
Trying our best to wade through the muddy waters of CBD
Developing & facilitating a culture of real-time feedback
Resident LogBook Report p.1 of 6
Centralized Learning Space
Integration with MyCurriculum
Progress Reporting
Curriculum & Assessment for CBD
Tools for Implementation
1
23
Mul
tiple
iter
atio
ns &
Con
tinuo
us Im
prov
emen
ts
Gaining some additional clarity on resident & faculty expectations for CBD
Implementation of the new MicroCEXs in place of our Generic Daily Evaluation Card
LESSON # 4: FACULTY BELIEVE IN AND LIKE COMPETENCY BASED ASSESSMENT…IT MAKES SENSE!
MicroCEX - Checklist
MicroCEX – Global Rating Scale
Key Features inform the Global Rating Scale narratives!
Curriculum & Assessment for CBD
Tools for Implementation
1
23
Mul
tiple
iter
atio
ns &
Con
tinuo
us Im
prov
emen
ts
Further development to
support real time feedback.
Setting clear expectations &
consequences for residents.
Incorporating the Assessments
Checklist
Checklists & Reporting
Curriculum & Assessment for CBD
Tools for Implementation
1
23
Mul
tiple
iter
atio
ns &
Con
tinuo
us Im
prov
emen
ts
4?
For the Future
• Mapping to FPA priority topics & Royal College EPAs
• Program syllabus• Online assessment forms rather than
paper• Aggregation software to show overall
resident progress (needs assessment to determine program requirements)
Overview of Lessons Learned
Lesson # 1: Don’t worry about the evolving definitions…They will just tell us!Lesson # 2: You do not have to assess everything, just the right things!Lesson # 3: Focus on Small wins when implementing change.Lesson # 4: Faculty believe in and like competency based assessment…it makes sense!
What have you learned in this session?
What is one thing you will change because of this talk?
QUESTIONS?
Contact Information
Dr. Rob Anderson Program Director, [email protected]
Dr. Cathy CervinAssociate Dean, [email protected]
Christina TremblayAssistant Curriculum Instructional [email protected]
