are they practicing what you are preaching? entrustable professional activities (epa) for the...
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Are They Practicing What You Are They Practicing What You are Preaching?are Preaching?
Entrustable Professional Activities Entrustable Professional Activities (EPA) for the Geriatrician(EPA) for the Geriatrician
Kelly Caverzagie, MDDepartment of Internal MedicineUniversity of Nebraska Medical Center
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DisclosuresDisclosuresA 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 ObjectivesLearning ObjectivesIdentify the basic principles of
Competency-Based 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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OutlineOutlineBackground 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 revisions4
Competency-Based Medical Competency-Based Medical EducationEducation
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 ProjectACGME – Outcome Project
Introduced 1999Implemented
2001
6 General Competencies
Medical Knowledge
Patient Care and
Procedural Skills
Professionalism
Interpersonal &
Communication Skills
Practice-based
Learning &
Improvement
Systems-based Practice 6
Struggles Moving ForwardStruggles Moving ForwardPrograms 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
Critical Care Medicine
Ambulatory Clinic
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Average 4.32 / 5 for
Systems-Based
Practice
Old Assessment System
Traditional vs. CBME: Start with System Traditional vs. CBME: Start with System NeedsNeeds
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Frenk Lancet,
2010
ACGME – Outcome ProjectACGME – Outcome Project
Introduced 1999Implemented
2001
6 General Competencies
Medical Knowledge
Patient Care and
Procedural Skills
Professionalism
Interpersonal &
Communication Skills
Practice-based
Learning &
Improvement
Systems-based Practice 10
IOM High Quality IOM High Quality CareCare
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 Medicare-Determined OutcomesOutcomes
Work effectively in multiple settingsCoordinate care within and across settingsUnderstand cost and value of diagnostic
and treatment optionsWork in inter-professional teams and
multi-disciplinary team-based modelsIdentify systematic errors and in
implement systematic solutions in case of errors
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Traditional vs. CBMETraditional vs. CBME
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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
Assessment tool 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
Adapted from Carracchio, et al. 2002
Critical Care Medicine
Ambulatory Clinic
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Average 4.32 / 5 for
Systems-Based
Practice
Old Assessment System
Resuscitate critically ill patient
Manage multiple meds
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
New Assessment System
How does Brady get to drive a car?
CompetencyCompetency
An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.
The International CBME Collaborators, 2009
CompetentCompetent
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
CompetenceCompetence
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
CompetenglishCompetenglish
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 How Does Brady get to Drive a Car?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 When do your fellows get the keys to the car?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 paradigmCBME 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 Geriatric Curricular CompetenciesCompetencies
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Potential CriticismsPotential 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 ChallengeCBME ChallengeEnsure 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 Entrustable Professional ActivitiesActivities“… 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.”
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ten Cate et al. Acad Med 2007; 82: 542-47
An Entrustable Professional An Entrustable Professional ActivityActivityPart of essential work for a qualified
professionalRequires specific knowledge, skill, attitudeAcquired through trainingLeads to recognized outputObservable and measureable, leading to a
conclusionReflects 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 Entrustable Professional ActivitiesActivities“Patients’ and instructors’ … entrustment of responsibility to a trainee is an essential concept in this approach…”
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ten Cate et al. Acad Med 2007; 82: 542-47
Entrustment in Residency Entrustment in Residency TrainingTrainingAttending physicians assess a
multi-dimensional 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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COMPETENCECOMPETENCE
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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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Manage diverse opinions with
goal optimizing patient care
EPA - Lead and work within interprofessional teams
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Maintain climate of
mutual respect and
shared values
EPA - Lead and work within interprofessional teams
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Engage in collaborative communicatio
n
EPA - Lead and work within interprofessional teams
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Identify and understand
roles of team members
EPA - Lead and work within interprofessional teams
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EPA - Lead and work within interprofessional teams
Identify and understand
roles of team members
Engage in collaborative communicatio
n
Maintain climate of
mutual respect and
shared values
Manage diverse opinions with
goal optimizing patient care
Accept feedback
DRAFT Geriatricians EPA’s DRAFT Geriatricians EPA’s (v13)(v13)
1. 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.
2. Prevent, diagnose and treat geriatric syndromes.
3. Provide and coordinate health care for older adults in all settings, during transitions of care, and at end of life.
4. Provide geriatric consultation.
5. 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.
6. Collaborate effectively as a member or leader of a health care team.
7. Teach the principles of geriatric care and aging-related health care issues to professionals and nonprofessionals.
8. 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 - TaskGroup Activity #1 - TaskUsing 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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ConsiderationsConsiderationsCompare / 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 - TaskGroup Activity #2 - TaskConsider 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 Building Assessments for an EPAan EPAStep 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
Next Accreditation System
Learning ObjectivesLearning ObjectivesIdentify the basic principles of
Competency-Based 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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