competence by design - nosm · 2019-06-12 · •competence by design, our cbme initative, was...
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Competence by Design
Future Directions for Continuing Professional Development
Douglas Hedden MD, FRCSCViren Naik, MD FRCPC
Friday, May 3, 2019
Conflict of Interest Declaration
Douglas Hedden, MD FRCSC
I am a full-time Executive Director with the Royal College of Physicians and Surgeons of Canada
I have no relationships with any commercial interests to disclose
Future Directions for Continuing Professional Development 2
Conflict of Interest Declaration
Viren Naik, MD FRCPC
I am a full-time Director with the Royal College of Physicians and Surgeons of Canada
I have no relationships with any commercial interests to disclose
Future Directions for Continuing Professional Development 3
Learning objectives
• Describe the competency-based medical education model, including application to continuing professional development
• Identify potential future directions for Maintenance of Certification (MOC) within a competency-based medical education model
Future Directions for Continuing Professional Development 4
What is the role of the Royal College?• Accreditation – Residency programs and continuing professional
development activities
• Credentials – Verification that a physician has met all of the necessary requirements for certification
• Examination – Produce the national certification exams
• Maintenance of Certification – Continuing professional development program for Fellows
• CanMEDS Physician Competency Framework – Developed with the goal of improving patient care
• Awards and grants – Distribute more than $1 million in awards, grants, fellowships, and visiting professorships
• Research and innovation – Continually enhance our role in scholarship
Future Directions for Continuing Professional Development 5
Our vision and mission
• Vision
• The global leader in specialty medical education and care.
• Mission
• We serve patients, diverse populations, and our Fellows by setting the standards in specialty medical education and lifelong learning, and by advancing professional practice and health care.
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Medical education – a period of transition
7
Flexner, Halsted & Osler: 100 Years After
The most dangerous phrase in the language is,
“We've always done it this way.”
Rear Admiral Grace Hopper
Future Directions for Continuing Professional Development
Rationale for change
• While the medical education system in Canada was exceptional, there were gaps and challenges in the model that needed to be addressed
• One challenge was that we assumed that the more time a learner spends on an activity, the more they absorb and excel (time-based learning)
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Medical education for a changing world
• Increased complexity of care
• What do trainees need to learn?
• What do practitioners need to develop?
• Requirement for oversight and accountability
• Changing societal expectations of accountability
• Failure to fail in residency
• Changing learning/teaching environments
• New learning environments/locations
• Time pressures on faculty/supervision
• Resident duty hours
Future Directions for Continuing Professional Development
Enhancing patient safety and quality care must:
• …meet patient expectations and needs
• …recognize time spent on a learning rotation does not guarantee consistency in graduate abilities
Future Directions for Continuing Professional Development
Focusing on learning instead of time
• Ensures competence, but teaches for excellence
• Supports physicians’ skills and abilities to evolve throughout practice – enhancing care
• Responds to changing patient and societal needs
• Addresses gaps in the current system, like the “failure to fail” culture of resident education
• Reduces burden on faculties, promoting smoother credentialing and accreditation
• Increases accountability and promotes transparency in training
= Competency-based Medical Education (CBME)
Future Directions for Continuing Professional Development 12
Routes to Certification 13
What is Competency-Based Medical Education (CBME)?A model to prepare physicians for practice that is:
• oriented to outcomes desired in physician;
• based on patient needs;
• based on the needs of the learner, with more accountability and flexibility; and
• focused on achieving skills and performance, instead of time-spent in training.
Adapted from: Frank JR, Snell L, Dath, D, Sherbino, J, Holmboe ES, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45.
Future Directions for Continuing Professional Development
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We are not alone in this change,
CBME is a validated model growing around the world.
Future Directions for Continuing Professional Development
Competence by Design
16
CBD Model and Design
Future Directions for Continuing Professional Development
A medical education milestone
• Competence by Design, our CBME initative, was launched on July 1, 2017
• First two programs: Otolaryngology and Anesthesiology
• Iterative implementation, with new programs joining each year
• All disciplines will embark on transition to CBD by 2022
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CBD Model and Design:Hybrid model
Benefits of CBME while maintaining service learning and delivery imperatives at hospitals and the postgraduate funding structure
Future Directions for Continuing Professional Development
Competence by Design: Simplified
20Future Directions for Continuing Professional Development
Competence by Design: Simplified
21Future Directions for Continuing Professional Development
Competencies
•Defines the discipline
•Defines the competencies of the graduate
• High level view of final competencies to practice
•Add context of practice
• A description of the scope of practice of the specialty
Future Directions for Continuing Professional Development
Entrustable Professional Activities (EPAs)
• In the setting of residency training,
•An entrustable professional activity is a responsibility or task in the clinical setting that may be delegated to a resident by their supervisor once sufficient competence has been demonstrated.
Future Directions for Continuing Professional Development
Examples of EPAs
In medicine
• Running codes
In the real world
• Driving on G1
Images via: bing.com
Future Directions for Continuing Professional Development
EPA Example: Neurosurgery
Performing surgery for patients with spontaneous intracerebral hemorrhage with or without an underlying vascular malformation
25Future Directions for Continuing Professional Development
Milestones within an EPA
EPA
Milestone
Milestone
Milestone
Typically, each EPA integrates
multiple milestones.
Future Directions for Continuing Professional Development
Milestones Example:EPA - Performing surgery for patients with spontaneous intracerebral hemorrhage with or without an underlying vascular malformation
C ME 3.4 Prepare, position and drape the patient C ME 1.4 Apply knowledge of anatomy, key landmarks, and the surgical procedure C ME 2.2 Interpret intraoperative imagingC ME 3.4 Select appropriate instruments and sutures for each step of the procedureC ME 3.4 Independently perform craniotomy for exposure (NS-V) C ME 3.4 Open dura for exposure (NS-V)C ME 3.4 Open and close the incision C ME 3.4 Use optical magnification appropriately
C ME 3.4 Perform safe tissue dissection of relevant structures and tissue layers with gentle tissue handlingC ME 3.4 Recognize and address anatomical variants
C ME 3.4 Manage intraoperative hemostasis, including effective use of adjunctive agentsC COM 5.1 Document surgical clinical encounters in a complete and timely manner
C COL 1.2 Work effectively with the OR team
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Competence by Design: Simplified
28Future Directions for Continuing Professional Development
CBD coaching model
Facilitating learning and development of a residents’ competence
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Coaching in the moment: A process
1) RAPPORT
2) EXPECTATIONS
3) OBSERVE
4) CONVERSATION
5) DOCUMENT
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RX-OCDFuture Directions for Continuing Professional Development
Observation of an EPA
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EPA Observation Encounters- Point in time- Single rater- Specific context
Future Directions for Continuing Professional Development
Competence by Design: Simplified
32Future Directions for Continuing Professional Development
Assessment of EPA Achievement
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EPA Observation Encounters- Point in time- Single rater- Specific context
EPA Achievement- Multiple times- Multiple raters- Multiple contexts
Future Directions for Continuing Professional Development
Progression of competence: Curriculum
Future Directions for Continuing Professional Development
35Future Directions for Continuing Professional Development
Lessons learned so far
• General satisfaction with the educational design
• Need to listen to perceptions and address myths
• Assure manageability of number of specialty-specific competencies that require assessment
• Consideration for privacy
• Engage and develop all faculty who will be assessing residents
• Increase observations at “the bedside”
• Earlier identification of areas for improvement • Protecting patient safety, helping trainees succeed, decreasing trainees requiring additional
funding
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CBD and continuing professional development
37
Maintenance of Certification (MOC)
• The MOC Program supports the lifelong learning needs of Fellows and healthcare professionals
• Requirements:
• 5-year cycle• Minimum 40 credits/year
• Minimum 400 credits/cycle
• Minimum 25 credits/section/cycle (for cycles starting on or after Jan. 1, 2014)
• Enabling Tools:• Framework of CPD Activities
• MAINPORT ePortfolio
• CPD Accreditation system
• Educational Support
Future Directions for Continuing Professional Development
Consistent evolution
Future Directions for Continuing Professional Development
1994• Maintenance of competence (MOCOMP) program launches at the Royal College
1994-1999
• MOCOMP = Practice-based learning projects, self-assessment programs, performance audits
• CME transitioning to CPD
1999-2001
• MOCOMP discontinued to make way for mandatory Maintenance of Certification (MOC) Program
2001-2011 • MOC Program implementation, enhancement and evaluation phases
2011-present
• Program monitoring, enhancements, and revisions
Looking around: Global CPD – how do we compare?
COUNTRY CYCLE LENGTH REQUIREMENTS FOR CPD/CME CREDITS/HOURS
Canada (CFPC) 5 years 25 credits/year250 credits/cycle
USA (examples of ABMS boards) 10 years (“mini” cycles of 3 years)
Several moving to ‘continuous certification’
25 to 30 credits/year90 to 150 credits/3 years240 to 300 credits/cycle
Australia (ANZCA) 3 years 30 credits/year180 credits/cycle
Australia (RACS) 1 year 30 to 60 credits/cycle
Future Directions for Continuing Professional Development
Looking around: Global CPD – how do we compare?
COUNTRY CYCLE LENGTH REQUIREMENTS FOR CPD/CME CREDITS/HOURS
China 3 years 10 to 30 points/year90 points/cycle
Germany 5 years 250 points/cycle
Ireland (RCSI: Faculty of Radiologists) 5 years 50 credits/year250 credits/cycle
Kuwait 5 years 250 credits/cycle
Oman 3 years 40 credits/year120 credits/cycle
Future Directions for Continuing Professional Development
Looking around: Global CPD – how do we compare?
COUNTRY CYCLE LENGTH REQUIREMENTS FOR CPD/CME CREDITS/HOURS
Qatar 2 years 40 credits/year80 credits/cycle
Saudi Arabia 5 years 30 hours/year90 hours/3 years
150 hours/5 years
Singapore 1 or 2 years 25 points/1 year50 points/2 years
United Kingdom (RCP) 1 year 50 hours/cycle
United Kingdom (RCOG) 5 years 250 credits/cycle
Future Directions for Continuing Professional Development
Looking around: Global CPD – how do we compare?
Compared to the Royal College’s current MOC Program, CPD/CME programs worldwide have:
• Shorter cycles, with overall average cycle length of three years
• Fewer credits required overall for program compliance
• Similar minimum/maximum credit requirements
• Minimum number of credits per year and/or per cycle
• Minimum or maximum number of credits per specific section, category or activity
• Similar flexibility for activities eligible for credit
• Most programs do not mandate specialty, practice or content—specific requirements
Future Directions for Continuing Professional Development
Advancing CPD
Future Directions for Continuing Professional Development
Looking ahead
• Competence by Design (CBD)
• Transformational change in medical education for specialty medicine in Canada
• What are the competencies each resident must demonstrate:
• At each stage of training?
• Across each CanMEDS role?
• Continuing Professional Development (CPD)
• How can the principles of CBD be expressed in CPD for specialists in practice?
Competency-Based CPD (CB-CPD) Advancing CPD
Future Directions for Continuing Professional Development 45
Competency-based CPD
• Vision: A CPD system that uses competencies to continuously improve specialty practice, patient outcomes, and the health system
Future Directions for Continuing Professional Development 46
Educational principles
Enhanced Expertise
Enable Fellows to continuously enhance their expertise
Contiuous Quality Improvement
Satisfy licensure, privileging and Fellowship requirements
Interprofessional CPD
Embrace learning and assessment
of individuals, groups and teams
Scope of Practice
Promote physicians to pursue excellence throughout
their professional life
Patient Care
Be designed to address personal, patient
and population health needs
Future Directions for Continuing Professional Development 47
Competency-based CPD
1. Aligns learning and assessment activities with a specialist’s scope of practice;
2. Uses external sources of feedback to identify actionable goals across
the CanMEDS framework;
3. Achieves specific outcomes: competence, performance, and quality
of care experienced by patients; and
4. Addresses societal health needs.
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What makes CPD competency-based?
Competencies are linked to decisions specialists make regarding:
1. The goals for improvement they are intending to complete;
2. The learning and/or assessment activities that will enable them to achieve these goals; and
3. The outcomes that will be achieved – what was affirmed or improved.
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Competency-based CPD
Future Directions for Continuing Professional Development 50
Focus less on Focus more on
Personal needs Patient / Population health needs
Learning as the goal of CPD Competence, performance and health outcomes as the goals of CPD
Recording and reflecting on participation in CPD activities
Recording how engagement in CPD activities improved practice
Learning as an individual Learning within groups / teams
Competencies relevant to the Medical Expert Role Competencies across all CanMEDS Roles
Passive learning in a classroom Active learning in a workplace
General educational requirements Specialty specific requirements
Physician Practice Improvement (PPI)
• Approach to assessing and enhancing physician competence, laid out by FMRAC in 2016
• Helps practising physicians identify learning needs that can be addressed through professional development and education programs
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Aligning CPD with PPI
1. Describe your practice: Roles, responsibilities, and career aspirations in clinical practice, education, administration or research.
2. Develop practice improvement goals based on accessing external sources of data and feedback.
3 and 4. Identify and engage in CPD activities that sustain and continuously improve the core competencies of the specialty.
5. Use data and feedback to evaluate outcomes.
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Create and implement your learning plan: MOCIdentify and engage in CPD activities that sustain and continuously improve the core competencies of the specialty
Competencies that are
• Defined by the specialty across the CanMEDS Roles
• Integrated within one’s practice improvement plan
Demonstrated through participation in
• Group learning
• Self-learning
• Assessment
Future Directions for Continuing Professional Development 53
Create and implement your learning plan: MOCParticipate in CPD activities to acquire the competencies to pursue specific career goals or plans
Competencies that are
• Not expected to be achieved by residents to be certified
• Based on milestones within the CPD / Enhanced Expertise stage of the competence
continuum
• Reflect personal , academic interests within one’s scope of practice
Future Directions for Continuing Professional Development 54
Create and implement your learning plan: MOCParticipate in high quality CPD activities that meet annual/cycle requirements
Greater emphasis on documenting planned learning
Credits are relevant to learning/assessment activities selected to
• Practice improvement goals
• Sustaining and enhancing core competencies
• Career development plans
• Scanning activities to identify future needs
Future Directions for Continuing Professional Development 55
Initiatives for Advancing CPD
1. MOC Program Working Group
2. CB-CPD National Advisory Committee
3. Council Task Force on Reaffirmation of Ongoing Competence
4. FMEC-CPD
5. FMRAC Working Group on Physician Competence
6. CBD Steering Committee whiteboards
7. Regular feedback from Fellows and MOC Program participants through Royal College Services Centre, MAINPORT, booths, etc.
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Content creation and curation
•Collaboration with mdBriefCase to develop online self-assessment programs (SAPs)
•Prescribing Safely Canada pilot
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Royal College/mdBC SAPs
• 2,185 accesses since April 2018
• 1,238 accesses since April 2018
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Stats as of April 22, 2019
Prescribing Safely Canada
• Online assessment of prescribing skills
• Pilot by the numbers• November 1, 2017 to April 30, 2018
• 2695 registrants from 28 specialties, 10 provinces and 2 territories
• Target completions = 500 to 750
• Actual completions = 740
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Prescribing Safely Canada
• Outcomes• Prescribing Safely Canada Competency framework developed
• Prescribing Competency Assessments for 3 specialties developed, implemented and valued
• Prescribing Competency Assessments targets were met
• Three Prescribing Safely learning cases being produced
• A Prescribing Safely interim evaluation is completed, final to be completed end of June
• Scholarly activities have begun
Future Directions for Continuing Professional Development 60
Advancing CPD:Your input
1. Will you have the data you need to participate in a PPI cycle?
2. What would be a meaningful change in the MOC program for you?
3. What challenges do you have with the MOC program?
4. Are we meeting societal expectations by granting lifetime certification?
Future Directions for Continuing Professional Development
Thank Youroyalcollege.ca • collegeroyal.ca
Dr. Doug Hedden| [email protected] | 613-730-8177 ext 163Dr. Viren Naik| [email protected] | 613-730-8177 ext 162