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Are They Practicing What You are Preaching? Entrustable Professional Activities (EPA) for the Geriatrician. Kelly Caverzagie, MD Department of Internal Medicine University of Nebraska Medical Center. Disclosures. A portion of my salary at the University of Nebraska is reimbursed by the ABIM:

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Are They Practicing What You are Preaching? Entrustable Professional Activities (EPA) for the Geriatrician

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Are They Practicing What You are Preaching?Entrustable Professional Activities (EPA) for the Geriatrician

Kelly Caverzagie, MD

Department of Internal Medicine

University of Nebraska Medical Center


Disclosures

  • A portion of my salary at the University of Nebraska is reimbursed by the ABIM:

    • Practice Improvement Module (PIM) Development

    • Academic Affairs


Learning Objectives

  • Identify 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


Outline

  • Background 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 revisions


Competency-Based Medical Education

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 Project

  • Introduced 1999

  • Implemented 2001

  • 6 General Competencies

  • Medical Knowledge

  • Patient Care and Procedural Skills

  • Professionalism

  • Interpersonal & Communication Skills

  • Practice-based Learning & Improvement

  • Systems-based Practice


Struggles Moving Forward

  • Programs 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


Old Assessment System

Ambulatory Clinic

Critical Care Medicine

General Medicine Wards

Average 4.32 / 5 for Systems-Based Practice

Rheumatology

Cardiology Consult

Research Elective

Geriatrics


Traditional vs. CBME: Start with System Needs

Frenk

Lancet, 2010


ACGME – Outcome Project

  • Introduced 1999

  • Implemented 2001

  • 6 General Competencies

  • Medical Knowledge

  • Patient Care and Procedural Skills

  • Professionalism

  • Interpersonal & Communication Skills

  • Practice-based Learning & Improvement

  • Systems-based Practice


IOM High Quality Care

  • 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


Medicare-Determined Outcomes

  • Work effectively in multiple settings

  • Coordinate care within and across settings

  • Understand cost and value of diagnostic and treatment options

  • Work in inter-professional teams and multi-disciplinary team-based models

  • Identify systematic errors and in implement systematic solutions in case of errors


Traditional vs. CBME

Adapted from Carracchio, et al. 2002


Old Assessment System

Ambulatory Clinic

Critical Care Medicine

General Medicine Wards

Average 4.32 / 5 for Systems-Based Practice

Rheumatology

Cardiology Consult

Research Elective

Geriatrics


New Assessment System

Manage multiple meds

Resuscitate critically ill patient

Example activities of unsupervised internist

OR

Inform steps along the way to becoming an unsupervised internist

Manage transitions of care

Perform musculoskeletal exam

Consult to non-medicine teams

Critically appraise literature

Goals of care discussion


How does Brady get to drive a car?


Competency

An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.

The International CBME Collaborators, 2009


Competent

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


Competence

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


Competenglish

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 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 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 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 Competencies


Potential 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 Challenge

  • Ensure 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)


Entrustable Professional Activities

“… 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.”

ten Cate et al.

Acad Med 2007; 82: 542-47


An Entrustable Professional Activity

  • Part of essential work for a qualified professional

  • Requires specific knowledge, skill, attitude

  • Acquired through training

  • Leads to recognized output

  • Observable and measureable, leading to a conclusion

  • Reflects the competencies expected

  • EPA’s together constitute the core of the profession

ten Cate et al.

Acad Med 2007; 82: 542-47


Entrustable Professional Activities

“Patients’ and instructors’ … entrustment of responsibility to a trainee is an essential concept in this approach…”

ten Cate et al.

Acad Med 2007; 82: 542-47


Entrustment in Residency Training

  • Attending 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


COMPETENCE


“Windows to Competence”

Caverzagie and Iobst


EPA - Lead and work within interprofessional teams


EPA - Lead and work within interprofessional teams

Accept feedback


EPA - Lead and work within interprofessional teams

Manage diverse opinions with goal optimizing patient care


EPA - Lead and work within interprofessional teams

Maintain climate of mutual respect and shared values


EPA - Lead and work within interprofessional teams

Engage in collaborative communication


EPA - Lead and work within interprofessional teams

Identify and understand roles of team members


EPA - Lead and work within interprofessional teams

Accept feedback

Manage diverse opinions with goal optimizing patient care

Maintain climate of mutual respect and shared values

Engage in collaborative communication

Identify and understand roles of team members


DRAFT Geriatricians EPA’s (v13)

  • 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.

  • Prevent, diagnose and treat geriatric syndromes.

  • Provide and coordinate health care for older adults in all settings, during transitions of care, and at end of life.

  • Provide geriatric consultation.

  • 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.

  • Collaborate effectively as a member or leader of a health care team.

  • Teach the principles of geriatric care and aging-related health care issues to professionals and nonprofessionals.

  • Participate in quality improvement and other systems-based initiatives to assure patient safety and improve outcomes for older adults.


Group Activity #1 - Task

  • Using 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 ________________.


Considerations

  • Compare / 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


Group Activity #2 - Task

  • Consider 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


Building Assessments for an EPA

Step 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


Educational Milestones

Clinical Competency Committee

Assessment System

Next Accreditation System


Learning Objectives

  • Identify 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


Thank You!

[email protected]


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