Accreditation Council for Graduate Medical Education
© 2014 Accreditation Council for Graduate Medical Education
Competency-based Medical Education (CBME)
and Transformation
Future Directions of Credentialing Research in Nursing: A Workshop
© 2014 Accreditation Council for Graduate Medical Education
Disclosures
Eric Holmboe Employed by ACGME Formerly employed by ABIM Receives royalties for textbook from
Mosby-Elsevier
© 2014 Accreditation Council for Graduate Medical Education
Why CBME: System Needs
3
Frenk J. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010
© 2014 Accreditation Council for Graduate Medical Education
What Are The Outcomes?
• A competent (at a minimum) practitioner aligned with:
CMS Triple Aim
© 2014 Accreditation Council for Graduate Medical Education
The Assessment “System”
Assessments within Program:
•Direct observations•Audit and
performance data•Multi-source FB
•Simulation•ITExam
Qual/Quant “Data”
Synthesis:Committee
Residents
Faculty, PDs and others
Milestones and EPAs as Guiding Framework and Blueprint
Accreditation
Unit of Analysis:Program
Certification and Credentialing
Unit of Analysis:Individual
JUDGEMENT
D
FB
FB
DD FB
PUBLIC
Milestones
• By definition a milestone is a significant point in development.
• Milestones should enable residents, fellows and the training program to better determine an individual’s trajectory of competency acquisition.
© 2014 Accreditation Council for Graduate Medical Education
PC1. History (Appropriate for age and impairment)
Level 1 Level 2 Level 3 Level 4 Level 5Acquires a general medical history
Acquires a basic physiatric history including medical, functional, and psychosocial elements
Acquires a comprehensive physiatric history integrating medical, functional, and psychosocial elements Seeks and obtains data from secondary sources when needed
Efficiently acquires and presents a relevant history in a prioritized and hypothesis driven fashion across a wide spectrum of ages and impairments Elicits subtleties and information that may not be readily volunteered by the patient
Gathers and synthesizes information in a highly efficient manner Rapidly focuses on presenting problem, and elicits key information in a prioritized fashion Models the gathering of subtle and difficult information from the patient
CompetencyDevelopmental
Progression or Set of Milestones Sub-competency
Specific Milestone
Entrustable Professional Activities
• EPAs represent the routine professional-life activities of physicians based on their specialty and subspecialty
• The concept of “entrustable” means:• ‘‘a practitioner has demonstrated the necessary
knowledge, skills and attitudes to be trusted to perform this activity [unsupervised].’’1
1Ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and
clinical practice? Acad Med. 2007; 82(6):542–547.
© 2014 Accreditation Council for Graduate Medical Education
Competencies, Milestones and EPAs
COMPETENCY
Entrustable Professional Activity
MILESTONES
Characteristic Competencies Milestones EPAs
Granularity Low Moderate to High Low to Moderate
Synthetic/Integrated
Moderate Low to Moderate High
Practicality (application)
Low Moderate High
Conceptual High Low Low to Moderate
COMPETENCY
MILESTONES
COMPETENCY
MILESTONES MILESTONES
COMPETENCY
© 2014 Accreditation Council for Graduate Medical Education
Milestones and EPAs as Roadmap
Observations:
1)Journey not a straight line2)More than one path (but not infinite)3)“If you don’t know where you are going, any road will get you there”
© 2014 Accreditation Council for Graduate Medical Education
Dreyfus & Dreyfus Development Model
Dreyfus SE and Dreyfus HL. 1980Carraccio CL et al. Acad Med 2008;83:761-7
Time, Practice, Experience
Novice
Advanced Beginner
Competent
Proficient
Expert/Master
© 2014 Accreditation Council for Graduate Medical Education
Dreyfus & Dreyfus Development Model
Dreyfus SE and Dreyfus HL. 1980Carraccio CL et al. Acad Med 2008;83:761-7
Time, Practice, Experience
Novice
Advanced Beginner
Competent
Proficient
Expert/Master
MILESTONESCurriculum
Assessment
Curriculum
Assessment
Curriculum
Assessment
Curriculum
Assessment
Curriculum
Assessment
Effective Assessment System Processes
Most important component of curriculum is the clinical care clnicians provide and experience Clarity on right outcomes linked to curriculum Integration of the educational and clinical systems
Right combination and synthesis of assessment methods
Critical importance of shared understanding & mental models of competence Competencies, milestones, entrustable professional
activities (EPAs)
© 2014 Accreditation Council for Graduate Medical Education
Improvements We Can Implement Now
Observe, observe, observe There is currently no substitute for ongoing
observation and feedback from an expert clinician. Stop seeking the grail of assessment forms.
Assessment forms are only as good as the individual using them.
Align assessment forms with purpose & construct. Invest in assessor development. Refine use of work-based assessment methods. Treat local assessment practices as a continuous
quality improvement activity.
© 2014 Accreditation Council for Graduate Medical Education
Next Steps for Assessment
Need to advance development of work-based assessment (WBA) methods Interprofessional team care Effective use of clinical decision support Quality, systems-based practice, safety Sophisticated communication skills
Embed WBA into routine clinical work EMRs will need to evolve
Robust and longitudinal feedback loops
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