from building competencies to developing capabilities … · from building competencies to...
TRANSCRIPT
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From Building Competencies to Developing Capabilities in Health Profession Education
Dr Lim Shih Hui
Group Director Education, SingHealth Professor and Senior Associate Dean, Duke-NUS Medical School
Senior Consultant, National Neuroscience Institute and Singapore General Hospital
23rd September 2017
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Why Education?
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Health profession education has been evolved from the old style of “structure / process” education to a competency-
based health profession education (CBHPE)
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Competence vs Competency
• Competence and competency are used in different contexts though both having similar meanings
– Competence refers to a person’s ability or skills and knowledge that he possesses to do a certain task
– Competency(ies) of a job refer to description of how things have to be done and at what level
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• An observable ability of a health professional
– Integrates and combine multiple components
including Knowledge, skills, values and attitudes
– Reflects a spectrum
– Measurable with respect to a defined outcome
Royal College and The International CBME Collaborators 2009
Competency & Competencies
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Traditional Education Competency-Based Education
Time-based Outcome-based
Passive learning Active learning
Fragmented curriculum Integrated curriculum
Isolation Collaboration
Textbook driven Research driven
Teacher-centred Learner-centred
Print Multimedia
Facts and memorization Higher-order thinking
Health Professions Education:
Traditional vs Competency-Based Model
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Health Professions Education:
Traditional vs Competency-Based Model
Frenk J et al: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4;376(9756):1923-58
• Health profession education has been evolved from the old style of “structure / process” education to a competency-based health profession education (CBHPE)
• Curriculum and assessment follows from the competencies and outcome, not vice versa !
• Requires
• Definition of milestones of competency
• Robust assessment methods, tools and systems
Then structure the curriculum, learners’ activities, assessment
tools, evaluation processes, etc, to achieve these
competencies
Defines the competencies that the learner must
demonstrate
Must know the trainee is truly competent to
progress to the next stage of their career
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To be competent so as to meet the needs of the aging population with multiple co-morbidities
• The profession?
– College of Family Physicians, Singapore?
– Academy of Medicine, Singapore?
– Others?
• The policy makers?
– MOH, SMC, SAB-JCST-RAC, FPAB, etc..?
– ACGME-I
• The public?
Who Determines the Outcomes?
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• Competent
– Possessing the required abilities in all domains at a specific stage of health profession education or practice
• Dyscompetent
– Relatively lacking in one or more domains of required abilities at a specified stage of education or practice
• Incompetent
– Lacking the required abilities in ALL domains in a certain context at a defined state of education or practice
• Supra-competent
Competent or Otherwise
2010 Royal College and The International CBME Collaborators
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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CanMeds Roles Framework
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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KSA Framework
• K = Knowledge
• S = Skill
– Information gathering skills • History taking, physical examination, communication
– Ability to use knowledge and information • Clinical judgement, problem solving
– Management skills • Diagnosis, treatment, patient education, counselling, procedural skills
• A = Attitudes
– Professionalism, humanism
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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RIME Model
• Synthetic Model
– Reporter
– Interpreter
– Manager
– Educator • Developed at Uniformed Services
University Health Services (USUHS) in 1980s
– Lou Pangaro and Goron Noel
– For use in 3rd year medical student clerkships in internal medicine it becomes a passing criterion or prerequisite for advancement
– For each level of performance, examples are given which illustrate the framework, but do not exhaust the category
*I = introduced in the curriculum, P = practice, repetition M= sufficient proficiency, mastery, for the next level of independence, M* = sophisticated, complex situations or procedures
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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Dreyfus Developmental Model
Master: Expert who relishes the unknown, or the situation that breaks the rules – who the experts go to for help – don’t know what they know
Don’t know what they don’t know
Know what they don’t know
Able to perform the tasks and roles of the discipline with
restricted breath and depth
Consistent and efficient in performance of the tasks and roles of the
discipline – know what they know and don’t know
In depth knowledge concerning the discipline – often rule based –
know what they know
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From Novice to Competent
Competent
Time
Training (3-8 yrs) Post-Training
What we imagine happens
With Support
Safety level
Level
Advance Beginner
Novice
Proficient
Expert
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Route to Dyscompetent / Incompetent
Competent
Time
Training (3-8 yrs) Post-Training
What we imagine happens
Without Support
Safety level
Level
Advance Beginner
Novice
Proficient
Expert
With Support
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From Competent to Proficient & Expert
Competent
Time
Training (3-8 yrs) Post-Training
What we imagine happens
Without Support
Safety level
Level
Advance Beginner
Novice
Proficient
Expert
With Support
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From being Competent to Mastery
Competent
Time
Training (3-8 yrs) Post-Training
Safety level
Level
Advance Beginner
Novice
Proficient
Expert
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Career Path for Medical Specialists
PGY
10 yrs 20 yrs 30 yrs 0
PGY1 HO
Junior Residents
Senior Residents
Associate Consultants
Consultants
Senior Consultants: Clinicians + Educators / Scientists / Administrators
Consultative Service in the Private Sector
Training Phase Practicing & Life-Long Learning Phase
Medical School’s Exam MBBS /
MD
DGMS’ / Overseas Colleges’ Exam M Med / MRCP, MRCS,
MRCOG & Others
Initial Specialists’ Certification with
Professional Qualification (FAMS)
Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. AMS)
HMDP
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PGY
10 yrs 20 yrs 30 yrs 0
PGY1 HO
Junior Residents
Senior Residents
Associate Consultants
Consultants
Consultative Service in the Private Sector
Training Phase Practicing & Life-Long Learning Phase
Medical School’s Exam MBBS /
MD
DGMS’ / Overseas Colleges’ Exam M Med / MRCP, MRCS,
MRCOG & Others
HMDP
Novice
Advance Beginner
Competent
Proficient Expert
Initial Specialists’ Certification with
Professional Qualification (FAMS)
Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. AMS)
Senior Consultants: Clinicians + Educators / Scientists / Administrators
Career Path for Medical Specialists
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PGY
10 yrs 20 yrs 30 yrs 0
PGY1 HO
Residents
Associate Consultants
Consultants
Family Medicine Practice in the Community
Training Phase Practicing & Life-Long Learning Phase
Medical School’s Exam MBBS /
MD
GDFM, M Med (FM) HMDP
Novice
Advance Beginner
Competent
Proficient
Expert
MCFPS, FCFPS, FAMS(Family Medicine)
Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. CFPS)
Senior Consultants: Clinicians + Educators / Administrators
Career Path for Family Physicians
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Competency Framework
• Each competency framework starts with broad
distinguishable areas of competence that, in the
aggregate, define the desired outcomes for a clinician
– CanMeds Roles Framework
– KSA Framework
– RIME Model
– Dreyfus Developmental Model
– ACGME & ABMS adopted competencies
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Competencies Framework
Adopted by ACGME and AMBS
• Patient Care
• Medical Knowledge
• Practice Based Learning and Improvement
• Interpersonal and Communication Skills
• Professionalism
• Systems Based Practice
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The Physician Competency
Reference Set (PCRS)
• Using the ACGME/ABMS framework as a reference, AAMC synthesized more than 150 competency lists for health professionals and developed a defining list of competencies for physicians
• This resulted in 58 competencies in 8 domains called “The Physician Competency Reference Set”(PCRS)
– These competencies define the desired outcomes across the continuum of education, training, and practice
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Domains of Competence (DoC) in the Physician
Competency Reference Set (PCRS)
1. Patient Care (PC)
2. Knowledge for Practice (KP)
3. Practice-based Learning and Improvement (PBLI)
4. Interpersonal and Communication Skills (ICS)
5. Professionalism (Prof)
6. Systems-based Practice (SBP)
7. Interprofessional Collaboration (IPC)
8. Personal and Professional Development (PPD)
http://journals.lww.com/academicmedicine/Fulltext/2013/08000/Toward_a_Common_Taxonomy_of_Competency_Domains_for.21.aspx
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Competency-based
Health Profession Education
• Four Components
– Identifying the outcomes
– Defining performance levels for each competency
– Developing a framework for assessing competencies
– Continuous evaluation of the program to see if it is indeed producing the desired outcomes
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Competency-based
Health Profession Education
• Four Components
– Identifying the outcomes
• e.g. competent clinicians
– Defining performance levels for each competency
– Developing a framework for assessing competencies
– Continuous evaluation of the program to see if it is indeed producing the desired outcomes
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Minimal Competencies
Professional Knowledge
Professional Skills
Professional Values and Behaviours
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Professional Values and Behaviours
• e.g. Ethics
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Professional Values and Behaviours
e.g. Integrity
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Importance of Integrity
• Hire and/or promote
– 1st on the basis of integrity
– 2nd motivation
– 3rd Capacity
– 4th Understanding
– 5th Knowledge
– 6th Experience
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Competency-based
Health Profession Education
• Four Components
– Identifying the outcomes
–Defining performance levels for each
competency Milestones
– Developing a framework for assessing competencies
– Continuous evaluation of the program to see if it is indeed producing the desired outcomes
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Defining Performance Levels for the
Competencies (Milestones)
• In US, reporting progress towards achieving desired competencies uses the language of milestones
– Markers of achievement of levels of performance in a developmental continuum
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Milestones Definition
• A significant point in development
Merriam-Webster
• A significant event or stage in the life, progress, development, or the like of a person, nation, etc
Dictionary.com
• Project management: Scheduled event that indicates the completion of a major deliverable event (or a set thereof) of a project. Milestones are measurable and observable and serve as progress markers (flags) but, by definition, are independent of time (have zero durations) therefore no work or consumption of resources is associated with them.
http://www.businessdictionary.com/definition/milestone.html
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Defining Performance Levels for the
Competencies (Milestones)
• Undergraduate medical education (UME) milestones
– AAMC defined two performance levels, corresponding to novice performance and the performance expected of a graduating MD
• Graduate medical education (GME) milestones
– In GME, as a result of the ACGME Milestones Project, each of the specialties generally defined five milestones for each competency, with the first designed to describe the entering resident and the last to define either the resident graduate or a practicing physician (called an “aspirational milestone”)
– Behavioral descriptions of performance roughly corresponding to a novice, advanced beginner, competent individual, proficient individual, and expert physician
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Milestone Reporting
• Level 1: The resident demonstrates milestones expected of a resident who has had some education in family medicine
• Level 2: The resident is advancing and demonstrating additional milestones
• Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency
• Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target
– Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director
• Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level
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Levels of Expectation
Milestone Reporting
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• The focus in Developmental
• Milestones should enable the trainee, programme and regulatory bodies to know an individuals trajectory of competency acquisition
Should allow the demonstration of competence in those activities that
define the profession
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The ACGME Milestones Initiative
• All specialties to develop milestones and recommend assessments to advance CBME
• Define developmental milestones and reliable, valid assessment tools for all training programmes by 2012
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ACGME Report Form
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Milestones for Patient Care
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Milestones for Patient Care
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Milestones for Patient Care
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Milestones for Medical Knowledge
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Milestones for Medical Knowledge
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Milestones for System-Base Practice
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Milestones for System-Base Practice
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Milestones for System-Base Practice
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Milestones for Practice-Base
Learning and Improvement
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Milestones for Practice-Base
Learning and Improvement
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Milestones for Professionalism
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Milestones for Professionalism
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Milestones for Communication
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Milestones for Communication
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Milestones for Communication
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Milestones for Communication
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Milestones Benefits
• Provide the leaners with a clear path of progression no surprises
• Allow for rich formative feedback learners know where they are and where they need to go
• Define specific behaviours that can focus assessment
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Milestones Criticisms
• They are reductionistic
• Checking off a milestones list does not equal to competent practice in a highly complex healthcare environment
• There are many milestones (e.g. 142 in IM) cannot assess them all, even over 3 years…
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Milestone Challenges
• Need to ensure that assessment and evaluation of these milestones actually demonstrate competence in those activies that define the profession
• Must resonate with learners, clinician educators, etc…
• One implementation strategy involves in building assessment and evaluation around activities learners are “entrusted” to do
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Competency-based
Health Profession Education
• Four Components
– Identifying the outcomes
– Defining performance levels for each competency
–Developing a framework for assessing competencies
– Continuous evaluation of the program to see if it is indeed producing the desired outcomes
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Developing a framework for assessing
competencies
e.g. traditional true/false MCQs
Other e.g. essays, extended matching type MCQs
Other e.g. OSCEs
Other e.g. through direct observation
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Entrustable Professional Activities
(EPAs)
• Describe routine activities of the clinician in specific contexts
• Require “work-based” application and assessment of skills (e.g. “OPA” Observed Practice Activities)
e.g. traditional true/false MCQs
Other e.g. essays, extended matching type MCQs
Other e.g. OSCEs
Other e.g. through direct observation
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EPAs
• The essential day-to-day activities of a specialty or a
profession that an individual must be trusted to perform
– Without direct supervision (for the undergraduate to graduate
medical education transition)
– In unsupervised practice (for the graduate medical education to
practice or fellowship transition)
• Activities are observable and measurable
• Require the integration of competencies—usually across
domains—and thus can be mapped to those competencies
and measured by their milestones that are critical to a
supervisor’s decision to entrust a learner
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Interrelationship among EPAs,
Competencies, and Milestones
It is the integration of those competencies and their milestones that ultimately determines a supervisor’s willingness to trust the learner to perform the EPA without supervision.
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Competency Curves For Trainees
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Outline of Presentation
• Competency and Competency-Based Education
• Various Models of Competency Frame Work
• Building Competencies
– Identifying Outcome
– Defining Performance Level for each Competency
– Developing Framework for Assessing Competency
• Developing Generic Professional Capabilities
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Is Being Competent Good Enough?
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“Good Enough” Test
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What is a “Good Enough” Test?
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Florence Laura Goodenough
• 1886 – Born August 6, 1886 in Honesdale, PA, USA; Youngest of 9
children; Parents were farmers; Never married
• 1921 – helped Lewis Terman conduct studies with the standford-Binet
I.Q. test for children he had developed
• Contributed to Terman’s book Genetic Studies of Genius
• 1924 – relocated to Minneapolis, Minnesota and worked in the
Minneapolis Child Guidance Clinic
• 1925 – appointed Assistant Professor at the University of Minnesota;
during this time she wrote her first book : Measurement of Intelligence
by Drawings
• 1931 – appointed Full Professor; during this time published Anger in
Yong Children
• 1933 – wrote her Handbook of Child Psychology
• 1942 – Appointed President of the National Counsel of Women
Psychologists
• 1946 – became President of the Society for Research in Child
Development
• 1947 – Retired early due to degenerative disease which eventually
caused her blindness
• 1957 – died of stroke
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Is Being Competent Good Enough?
Context Familiar
Context Unfamiliar
Task Familiar Task Unfamiliar
Certainties Competencies
Training
Routine
Complex Challenges
Modified from Prof Ian Curran
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Developing Capabilities
Far Beyond Competence
Context Familiar
Context Unfamiliar
Task Familiar Task Unfamiliar
Certainties
Uncertainties
Competencies
Capabilities
Training
Education
Being Competent is
NOT Good Enough !
We need to be Capable to handle Uncertainties and
Complex Challenges.
Modified from Prof Ian Curran
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Professional Knowledge
Professional Skills
Professional Values and Behaviours
Building Competencies
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GMC’s Generic Professional Capabilities
Professional Knowledge
Professional Skills
Professional Values and Behaviours
Health Promotion
& Illness Prevention
Research and
Scholarship
Leadership and Team Working
Patient Safety and Quality
Improvement
Education and
Training
Safeguarding Vulnerable
Groups
From Building Competencies
To Developing Capabilities
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Professional Knowledge
Professional Skills
Professional Values and Behaviours
Innovation & Entre-
preneurship
Research
Leadership and Team Working
Safety and
Quality
Education
Global Health
Capabilities of
Healthcare Professional+
Community Health
Ethics, Policy and Health
Law
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“Future Ready”
Healthcare Professionals
• HCP as Practitioners, Communicators, Collaborators
• HCP Plus – Educators
– Researchers / Scientists
– Administrators / Leaders
– Safety & Quality Champions / Advocates
– Community Health Promoters / Advocates
– Global Health Champion
– Innovators & Entrepreneurs
– Health Ethicist/Health Law & Policy Expert
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Framework for Developing “Future Ready”
Healthcare Professionals @ SingHealth
Stage 1: To Build Capabilities as
Healthcare Professionals (HCP)
Stage 2: To Develop More Capabilities & Grow into
HCP-Plus
Focus on core capabilities – Knowledge, Skills & Attitude
• ACP • CCM • CCN • CAH • CCD
• SIMS • CHeAL • AM.EI
• IPE/IPCP Committee
• SIMS • AM.EI
• Educator
• Researcher/Scientist
• Administrator/Leader
• Safety & Quality Champion/Advocate
• Community Health Promoter/Advocate
• Global Health Champion
• Innovator/Entrepreneur
• Health Ethicist/Health Law & Policy Expert
Healthcare Practitioner
Communicator Collaborator
Adapted from CanMEDs and GMC (UK)
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11th January 2017
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College of Allied Health (CAH)
College of Clinical Nursing (CCN)
Office of SingHealth Academy
Education Support & Corporate Services
College of Clinical
Dentistry (CCD)
College of Healthcare
Administration and Leadership
(CHeAL)
College of Clinical
Medicine (CCM)
SHA Executive Council
Academic Medicine Education Institute (AM•EI)
SingHealth Duke-NUS Institute of Medical Simulation (SIMS)
Role of SHA’s Colleges and
Institutes in Developing GPCs
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Integrate Simulation-based Training into Residency
Training & Undergraduate Education
Patients’ Safety
Practice Before Performing
Procedures On Patients
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Role of ACPs, SHA Colleges and
Institutes in Developing GPCs
GPC ACP SHA CAH (PGAHI)
CCD CCM (GME, PGMI)
CCN (ALIAN)
CHeAL SIMS AMEI AMRI IPSQ Others
Professional Knowledge
Professional Skills Professional Values
& Behaviours
Education and Training
Research & Scholarship
Patient Safety and Quality Improvement Leadership and Team
Working
Health Promotion and Illness Prevention
Safeguarding Vulnerable Groups
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Thank You