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Defining and Assessing Entrustable Professional
Activities
Karen E. Hauer, MD
H. Carrie Chen, MD, MSEd
John Q. Young, MD, MPP
Patricia S. O’Sullivan, EdD
With thanks to Olle ten Cate, PhD
UCSF
June 5, 2013
Agenda1-1:15 Welcome1:15 Introduction to EPAs1:45 individual writing of an EPA2:05 overview of EPA development2:35 small group activity, design an EPA (steps 1-4) Break3:15 small group reporting3:45 overview of steps 5-74:00 second activity, evidence for an EPA (steps 5-
7) 4:30 small group reporting and wrap up (all)
Workshop objectivesBy the end of this workshop,
participants will be able to:Define an entrustable professional
activity (EPA)Develop an entrustable professional
activity that can be used for assessment of medical trainees
What do you hope to learn today?
ACGME core competencies:Patient CareMedical Knowledge Practice-based Learning and
Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice
Current Assessment System
Practice-based Learning and Improvement (Housestaff) (Question 5 of 9 - Mandatory)
Assimilates evidence from scientific studies or consultants related to their patients' health problems. Participates in
organized transitions of care curriculum as specified at each site. Actively seeks out and acts on performance feedback from the supervising attending and other team members.
Insufficient Contact to
Judge
1 & 2 = Unsatisfactory3 = Marginal
Satisfactory/Meets Expectations
7 & 8 = Excellent9 = Outstanding
0 1 2 3 4 5 6 7 8 >> 9 <<
Current Assessment System
Current Assessment System
What are some limitations of current assessment systems?
Core competencies and sub-competencies: long checklists of behavioral descriptors
Relies on traditional but limited assessment methods – knowledge exams, ward evaluations
Not a holistic summative view of the trainee
CompetencyCompetency
An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.
The International CBME Collaborators, 2009
CompetentCompetent
Possesses 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.
does the job
ten Cate, Med Teach, 2010
Can you trust the learner to function independently?
How to Drive a CarHow to Drive a CarCompetency
Can accelerate and brake smoothlyCan approach an intersection and can turn left
CompetentPasses driver’s education classesPasses driver’s exam to get the license
CompetenceDrives safely on interstate or during bad
weather, avoids accidents, no traffic ticketsParents hand over the keys and walk away
What is the goal with assessment?
Integrated, longitudinal, learner-centered assessment system
Promote skill acquisition in multiple domains concurrently
Assess what learners actually do in practice
Be able to conclude: this is a trustworthy trainee
Features of genuine competency based medical
education
Outcome-based, not process-based: what is attained is key, not just what is done or taught
Integrates knowledge, skill, attitude
Time-independent: length of training for defined outcomes is not pre-set
Individualized: trainees and contexts vary
Workplace-learning based
Lifelong learning oriented
Competence. What criteria would you use
to select your doctor?
Passed all tests and exams?
Grades and scores?
Years of training?
Follows protocols and guidelines?
Trust that s/he will manage a case in the best possible way?
Entrustable Professional Activities
(EPAs)
Entrustable Professional Activity (EPA)
Define important clinical activitiesLink to competencies / milestonesInclude professional judgment of competence
by cliniciansMake “decisions of entrustment” for
“entrustable” activitiesSomething changes for the learner….
Build collection of mastered EPAs (portfolio) to document full competence
Definition of an Entrustable Professional
ActivityA core unit of work, reflecting a responsibility that
should only be entrusted upon someone with adequate competencies
More specific: Part of essential professional work in a given context Independently executable, within a time frame Leads to recognized output of professional labor Observable and measurable in process and outcome,
leading to a conclusion (“well done” or “not well done”) Must require sufficient, specific knowledge, skill and
attitude, generally acquired through training Should reflect competencies, important to be acquired Usually confined to qualified personnel only
Competencies versus EPAs
person-descriptors
knowledge, skills, attitudes, values
• content expertise• collaboration ability• communication ability• management ability• professional attitude• scholarly approach
work-descriptors
essential parts of professional practice
• discharge patient• counsel patient• lead family meeting• design treatment plan• perform paracentesis• resuscitate if needed
Competencies EPAs
Competencies and EPAs combined
Patie
nt C
are
Med
ical
Kn
ow
led
ge
PB
LI
Com
mu
ni-c
atio
n
Pro
fessio
-nalis
m
Syste
m-B
ased
P
ractic
e
Develop and implement a safe discharge plan for a patient from the acute care setting
xxx x xx xxx x xx
Lead a family meeting to discuss serious news with patient/family and other health providers
xxx x x xxx xx x
ExerciseComplete Worksheet A on your own
List good examples of essential EPAs your trainees should be able to do independently at the end of training.
List bad examples of EPAs
Pair Share: share your examples with one person next to you.
Recommended full EPA description
1. EPA Title (max 20 words, avoid skill and avoid adjectives)
2. Description of the activity (to serve universal clarity, include limitations)
3. Expected KSA (to serve trainee)
4. Link with competencies and predefined milestones (to embed within the existing framework)
5. Sources of information to determine progress (to serve observation and assessment)
6. Basis for formal entrustment decision (who will have a say in the decision -- signatures if formal and documented)
7. Post level-4 of entrustment (“unsupervised”) (what difference does it make for the trainee?)
Example from PediatricsOne of the 16 draft EPAs developed by AAMC and ABP team for pediatric residency training:
1.EPA Title: Manage patients with acute, common single system diagnoses in an ambulatory, emergency, or inpatient setting
2.Description: Merged with expected KSA and clarified in descriptive vignettes
Example EPA cont’d3. Expected KSA:
Gathering info thru hx, PE, and initial labs Sound clinical reasoning driving development of DDx
to allow proper diagnostic testing and initial therapy Knowledge of evidence related to primary problem Application of evidence to management plan Patient and family-centered care with bidirectional
communications Documentation of plan and reasoning that is
transparent to other members of health care team
Example EPA cont’d4. Link with competencies/milestones:
Patient care Perform complete and accurate PE Make informed diagnostic and therapeutic
decisions that result in optimal clinical judgment Develop and carry out management plan
Medical knowledge Interpersonal and communication skills
Communicate effectively with patients, families, and the public as appropriate, across a broad range of socioeconomic and cultural backgrounds
Maintain comprehensive, timely, and legible medical records
PE Sub-competencyPerforms essentially the same rote head-to-toe physical examination of the patient regardless of presenting complaint; does not use diagnostic hypotheses from the history to anticipate or look for specific positive or negative findings on physical examination.
With a broad list of diagnostic hypotheses after the history, uses a head-to-toe approach to the physical examination to anticipate and look for a myriad of potential positive and negative physical examination findings for multiple diagnostic considerations. This approach can lead to failure to identify pertinent and important physical findings that are present, misinterpretation of physical findings, and attribution of importance and meaning to irrelevant findings.
Uses a narrow list of diagnostic hypotheses generated through the history to anticipate and look for specific positive or negative physical examination findings of only the most relevant diagnostic considerations; open to new diagnostic possibilities in the process of performing a survey physical examination to elicit unexpected abnormalities but may dismiss these as unimportant when it is difficult to integrate these findings into the working differential diagnosis.
Uses a narrow list of diagnostic hypotheses generated through the history as well as through extensive clinical experience to anticipate and look for key specific physical examination findings that will discriminate between competing similar diagnoses; uses surprises that result from a survey physical examination to rethink and retest diagnostic hypotheses; actively looks for physical exam findings that disconfirm the working diagnosis or rule in or out rare but high-risk alternative diagnoses.
DescriptionBehaviors of early, more advanced, competent,
proficient, and expert learnerExpected elements from milestones
Vignette – 2 yo with wheezing, resp distressReassurance provided during hxHas FB aspiration on differential so focuses on
differential BS in addition to wheezing and WOBPresents focused hx/PE with reasoned assess/plan
consistent with family’s wishes and health literacy, including SW referral for loss of insurance
Small Group Activity: Design an EPA
Work in small groups
Use resources provided Internal medicine milestonesSOM milestones
Develop an EPA for Internal medicine
ORMedical students
Small Group Debrief
When is “competence” reached?
When you trust the traineeWhen a professional activity is mastered• on a threshold level• that permits unsupervised practice• and full entrustment
It happens all the time: when trainees work without direct supervision
Level of supervision
Level 1: not allowed to practice the EPA
Level 2: practice with full supervision
Level 3: practice with supervision on demand
Level 4: “unsupervised” practice allowed
Level 5: supervision task may be given
Recommended full EPA description
1. EPA Title (max 20 words, avoid skill and avoid adjectives)
2. Description of the activity (to serve universal clarity, include limitations)
3. Expected KSA (to serve trainee)
4. Link with competencies and predefined milestones (to embed within the existing framework)
5. Sources of information to determine progress (to serve observation and assessment)
6. Basis for formal entrustment decision (who will have a say in the decision -- signatures if formal and documented)
7. Post level-4 of entrustment (“unsupervised”) (what difference does it make for the trainee?)
Dreyfus and Dreyfus Model
• Novice – Don’t know what they don’t know
• Advanced Beginner – Know what they don’t know
• Competent – Able to perform the tasks and roles of the discipline – restricted breath and depth
• Proficient – In depth knowledge concerning the discipline – often rule based – know what they know
• Expert – Expert thrives with situations that break the rules – who the proficient practitioners go to for help
training deliberate professional practice
Dreyfus & Dreyfus, 1986
proficient
expert
competent
advancednovice
Development of Competence
training deliberate professional practice
EPA1
EPA4
EPA2
EPA3
EPA5
Competence
Threshold
Justified entrustment decisions
Sample Competency Curve
Small Group Activity:Choosing Evidence
What evidence will inform the EPA that you developed
Small Group Reporting
Wrap Up
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