Entrustable Professional Activities (EPA) for the
Geriatrician
Kelly Caverzagie, MD
Department of Internal Medicine
University of Nebraska Medical Center
1


A portion of my salary at the University of Nebraska is reimbursed by the ABIM:
◦ Practice Improvement Module (PIM)
Development
◦ Academic Affairs
2


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
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
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
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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



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
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
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

Ambulatory Clinic
Critical Care Medicine
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Old Assessment System
Average 4.32 / 5 for Systems-
Based Practice

Traditional vs. CBME: Start with System Needs
Frenk
Lancet, 2010
9



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
10


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
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




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 multidisciplinary team-based models
Identify systematic errors and in implement systematic solutions in case of errors
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Variable
Driving force: Curriculum
Goal of educ. encounter
Typical assessment tool
Assessment tool
Setting
Focus of Assessment
Timing of assessment
Educational Program
Structure/Process Competency-based
Content Outcome
Knowledge acquisition
Single subjective measure
Proxy
Removed (gestalt)
Norm-referenced
Emphasis on summative
Knowledge application
Multiple objective measures
Authentic
(mimic real tasks of profession)
Direct observation
Criterion-referenced
Emphasis on formative
Adapted from Carracchio, et al. 2002
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Ambulatory Clinic
Critical Care Medicine
General Medicine Wards
Rheumatology
Cardiology Consult
Research Elective
Geriatrics
Old Assessment System
Average 4.32 / 5 for Systems-
Based Practice

Manage multiple meds
Resuscitate critically ill patient
Manage transitions of care
Perform musculoskeletal exam
Consult to non-medicine teams
Critically appraise literature
Goals of care discussion
New Assessment
System
Example activities of unsupervised internist
OR
Inform steps along the way to becoming an unsupervised internist

An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.
The International CBME Collaborators, 2009

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 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

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


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





Lots of good evaluations …
Absence of bad evaluations …
Survived a year of fellowship…
Didn’t commit any crimes …

Your program director followed the rules…

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

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• 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


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)
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“… 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
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
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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
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“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
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
Attending physicians assess a multidimensional 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
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“Windows to Competence”
Caverzagie and Iobst
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EPA - Lead and work within interprofessional teams
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Accept feedback
EPA - Lead and work within interprofessional teams
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EPA - Lead and work within interprofessional teams
Manage diverse opinions with goal optimizing patient care
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Maintain climate of mutual respect and shared values
EPA - Lead and work within interprofessional teams
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EPA - Lead and work within interprofessional teams
Engage in collaborative communication
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Identify and understand roles of team members
EPA - Lead and work within interprofessional teams
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Accept feedback
EPA - Lead and work within interprofessional teams
Maintain climate of mutual respect and shared values
Identify and understand roles of team members
Manage diverse opinions with goal optimizing patient care
Engage in collaborative communication
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1.
2.
3.
4.
5.
6.
7.
8.
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.
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
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
________________.
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
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
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
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
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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
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Assessment
System
Clinical
Competency
Committee
Educational Milestones
ADS Update
Resident Survey
Board Pass Rate
Clinical Experience
Log
Self Study
Faculty Survey
CLER Visit
Core Faculty
Scholarly Activity
Next Accreditation
System


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
46

kelly.caverzagie@unmc.edu
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