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Competence by Design (CBD) Overview:
2015-2018
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Journey of the Resident:
Current Model vs. Competence by Design
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Andrea’s Journey
Through Residency
Meet our
resident.
We’ll call her
“Andrea”.
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Andrea’s Journey:
Current Residency Model
Certification
Exams
Exam Preparation/Electives
Senior Residency
Junior Residency
Basic Clinical year
In-training
exams
ITERs
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Educational Tensions in
Andrea’s Current World
•
•
•
•
•
•
•
Residents can be disempowered
Great burden placed on faculty
Teacher-Learner exchange is corrupted
Failure to fail
Dichotomous judgements
Little direct observation
High stakes national exams
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System Challenges in
Andrea’s Current World
•
Learning judged by time spent, not ability
•
Trainees unprepared at stages
•
Variable workplace assessment/failure to fail
•
Concerns about patient harm
•
Missing content
•
Faculty overload & educational inefficiency
•
Resource imperatives
•
Lack of support for lifelong learning
•
Need for assessment for learning
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Change is Underway…
CBD
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New World:
Competence by Design (CBD)
Conceptual framework for performance assessment. Khan and Ramachandran, Medical Teacher 2012; 34: 920-928
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New World:
Competence by Design (CBD)
Competence is about performance –
the right thing, for the context,
at the right time
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New World:
Competence by Design (CBD)
• Multi-year, transformational change
initiative in specialty medical education;
• Focused on the learning continuum from
the start of residency to retirement;
• Based on a competency model of
education and assessment; and
• Designed to address societal health need
and patient outcomes.
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CBD: Not Time Free
• “Pure” competency-based medical education
(CBME) is time free;
• CBD is a hybrid model of CBME.
It is NOT time free.
• CBD will re-conceptualize time as a framework.
• The number of years of residency to remain the
same.
• Residents will be able to achieve competencies
(measured by milestones and Entrustable
Professional Activties (EPAs) at their own rate
within the defined residency program
timeframe.
Why CBD? Why Now?
We need a system that:
• Addresses changes to patient and societal
needs;
• Assesses competence, but teaches for
excellence;
• Ensures competencies in all domains evolve
across the continuum of medical education
(residency to retirement); and
• Enables flexibility; allows physicians to identify
when and how changes apply to practice.
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Commitments for
Implementation
• Communication
• Engagement
• Streamline workload
• Continuous improvement
• Work-flow integration
• Pilot testing
• Support
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CBD Competence Continuum
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Andrea’s Journey:
Proposed CBD Residency Model
Certification
Transition to Practice
Final
Competency
Assessment
Exams
Core / Electives
Foundation
Orientation / Assessment
Multi-facetted
assessment
Portfolios
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How Do We Get to This New World?
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CBD Identified Initiatives
For Residents
MAINPORT ePortfolio
For Fellows
Assessment
In-Training
Competency-Based
Assessment
In-Practice
Competency-Based
Assessment
Accreditation
Redesign Policy:
Outcome-Based
Focus
Change Exam
Governance
CBME
Re-Engineer
Accreditation
Process
Create Competency
Framework & Milestones
(Generic & Speciality-Specific)
Re-Engineer
Exam Delivery
Develop
Exam Content
Credentialing
Redesign Policy:
Competency-Based
Focus
CanMEDS 2015
Re-Engineer
Credentialing
Process
Deliver Phased,
Speciality-Specific
Roll-Out
Affirmation of Continued Competence
Faculty Development and Faculty/Education Support
Lifelong Learning
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CanMEDS 2015
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CanMEDS 2015
CanMEDS 2015 :
• Foundational project of CBD,
• Focused on updating the existing CanMEDS
Framework and introducing generic milestones
across the continuum
• Series IV of the Framework is now available
• The final version will be released at ICRE 2015
in October 2015 along with an updated version
of the evergreen Milestones Guide
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CanMEDS 2015 con’t…
Specialty Committees will use the updated
CanMEDS Framework and Milestones Guide to:
• Better integrate concepts like patient safety
into their curriculum,
• Help develop specialty-specific milestones and
Entrustable Professional Activities (EPAs).
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Milestones and EPAs
Milestones: for teaching
A defined, observable marker of an individual's
ability along a developmental continuum
• Demonstrate a commitment to patient safety
and quality improvement through adherence to
institutional policies and procedures
Entrustable Professional Activities (EPAs):
for assessment
An essential task of a "discipline" that an individual
can be trusted to perform independently in a given
context
• Recognize and manage conflicts of interest in
independent practice
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Key Concept of EPAs:
Entrustment
• “What can I safely delegate with
indirect supervision?”
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Example of Draft Leader
Milestones (generic)
Key & enabling
competencies
Requirements
for Residency
Transition
to Discipline
Foundations of
Discipline
1. Contribute to the improvement of health care delivery in teams,
organizations, and systems
1.1 Apply the
science of quality
improvement to
contribute to
improving systems
of patient care
Describe the relevance of
system theories in health
care at the practice,
organization, and health
system levels.
1.2 Analyze adverse
events and near
misses to enhance
systems of care
Describe the elements
of the health care
system that facilitate or
protect against adverse
events or near misses.
...etc
Describe quality
improvement
Methodologies.
Compare and contrast
the traditional
methods of research
design with those of
improvement
science…etc
Describe a patient’s
longitudinal exp. through
the health care system.
…etc
Describe the
process
for reporting
adverse
events and
near misses.
…etc
Report patient
safety hazards and
adverse events.
…etc
Medical Oncology Example:
Milestones and EPA
Milestones which make up the Medical Oncology EPA
(abilities needed to accomplish the task)
• Recognize urgent and emergent oncologic issues, including
but not limited to, pain crisis, febrile neutropenia,
uncontrolled diarrhea, hypocalcemia, epidural cord
compression and malignant bowel obstruction.
• Select and administer appropriate interventions for urgent
and emergent oncologic issues.
• Identify the limits of their own expertise and appropriately
seek assistance and supervision.
Medical Oncology EPA
(the task that must be accomplished)
• Initial care for urgent and emergent oncologic situations.
Benefits of Milestones and
EPAs
Curriculum
Abilities expected
of a resident at
a defined stage of
training
Assessment
Meaningful,
measurable markers
of progression
of competence
CanMEDS 2015: Milestones
and EPAs: Benefits to Andrea
• More frequent assessment and meaningful supervision;
• Greater engagement in the pursuit of abilities, not just
knowledge;
• Clearly defined targets for acquiring competency and
meeting standards throughout training;
• Better preparation to serve patients and communities;
• More flexible timeframe, focusing on personal
development; and
• Ability to continue to strive towards mastery of skills
and abilities beyond training and throughout practice.
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CBD MAINPORT ePortfolio and
eDiploma
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MAINPORT eDiploma:
Trainee Dashboard
First step in the development of a MAINPORT
ePortfolio for residents and in-practice physicians
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MAINPORT ePortfolio:
Benefits to Andrea
Scope of practice, goal
setting monitoring progress
Discussion forums,
blogs, social media
Discuss /
Collaborate
Share
Perspectives,
experiences
Goal Setting &
Monitoring
Planning tools, recording,
reflection templates
Planning and
Reflection
CBD MAINPORT
ePortfolio
Reporting
Licensure, privileging,
credentialing
Demonstrate /
Showcase
Assess knowledge,
skills, performance
SelfAssessment
External
Assessment
Formative and
summative strategies,
Demonstrate professional
development
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Phased Implementation
with Specialties
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Phased Implementation with
Specialities: Proposed Plan
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Phased Implementation:
First & Second Adopters
First round of adopters started in Fall
2014 (Cohort 1)
• Medical Oncology, and
• Otolaryngology – Head and Neck Surgery.
Second round of adopters starting in
2015 (Cohort 2)
• Anesthesiology,
• Internal Medicine,
• Forensic Pathology, • Surgical Foundations, &
• Gastroenterology,
• Urology.
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Proposed Implementation:
All Disciplines
2016
(Cohort 3)
2017
(Cohort 4)
2018
(Cohort 5)
2019
(Cohort 6)
2020
(Cohort 7)
Neurosurgery
Gen. Surg.
Orthopedic Surg.
Dermatology
Colorectal
Cardiac Surg.
Plastic Surg.
Vascular Surg.
Ophthalmology
Gen. Surg. Onc.
Pediatrics
Obs/Gyn
Neuro. Path.
Diag. Rad.
Thoracic Surg.
Anatomic Path.
PMR
Neurology
Medical Gen.
Interventional Rad.
Gen. Path.
Nuclear Med.
Hem. Path.
Public Health
Palliative Med.
Radiation. Onc.
Psychiatry
Hematology
Peds. EM
Pain Med.
Emerg. Med.
Respirology
Peds. Hem/Onc
GREI
Developmental
Peds.
CCM
Cardiology
Peds. Surg.
MFM
Neuro. Rad.
GIM
Rheumatology
Clin. Pharm/Tox
Gyne/Onc
Peds. Rad.
Nephrology
Geriatrics
Forensic Psych
ID
Occupational Med.
NPM
Child/Ado. Psych
Med. Micro.
Endo. and Met.
CIA
Geriatric Psych.
Med. Biochem.
Adolescent Med.
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CBD: Is It Really Worth It
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Summary:
CBD in the Coming Years
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Commitments for
Implementation
As we roll out CBD, we are committed to:
• Engagement,
• Open communications,
• Supporting our Fellows and stakeholders
through faculty development,
• Streamlining workload,
• Pilot testing, and
• Continuous improvement.
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CBD: Improving Andrea’s
Journey
Ultimately, a
move to CBME
is about a
better way to
train health
professionals.
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CBD: Next Steps
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CBD in the Coming Years
• Launch final version of the updated CanMEDS
Framework and the evergreen Milestones Guide at
ICRE 2015
• Update the CanMEDS diagram based on
stakeholder feedback
• Continue working work with CBD early adopters
(Medical Oncology and Otolaryngology – Head
and Neck Surgery).
• Develop & implement specialty-specific
milestones and EPAs,
• Evolve CBD ePortfolio to track achievements
against milestones, and
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CBD in the Coming Years
con’t…
• Plan new Accreditation, Credentialing and Exams
processes .
• Focusing on increasing ease-of-use,
reducing burden of work and implementing
electronic, work-reducing processes/tools.
• Pilot with adopters and medical schools,
• Build, test and refine infrastructure
• Craft and share education and faculty
development resources
• Engage and collaborate with Fellows and
stakeholders.
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Your Input Matters
How can we improve the CBD Program?
Let us know at:
• cbd@royalcollege.ca
• www.facebook.com/TheRoyalCollege
• https://twitter.com/Royal_College
• www.linkedin.com
For more information, visit our website:
• www.royalcollege.ca/cbd
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