Competence by Design - NOSM · 2019-06-12 · •Competence by Design, our CBME initative, was launched on July 1, 2017 •First two programs: Otolaryngology and Anesthesiology •Iterative

•••

Competence by Design

Future Directions for Continuing Professional Development

Douglas Hedden MD, FRCSCViren Naik, MD FRCPC

Friday, May 3, 2019

Conflict of Interest Declaration

Douglas Hedden, MD FRCSC

I am a full-time Executive Director with the Royal College of Physicians and Surgeons of Canada

I have no relationships with any commercial interests to disclose

Future Directions for Continuing Professional Development 2

Conflict of Interest Declaration

Viren Naik, MD FRCPC

I am a full-time Director with the Royal College of Physicians and Surgeons of Canada

I have no relationships with any commercial interests to disclose


Learning objectives

• Describe the competency-based medical education model, including application to continuing professional development

• Identify potential future directions for Maintenance of Certification (MOC) within a competency-based medical education model


What is the role of the Royal College?• Accreditation – Residency programs and continuing professional

development activities

• Credentials – Verification that a physician has met all of the necessary requirements for certification

• Examination – Produce the national certification exams

• Maintenance of Certification – Continuing professional development program for Fellows

• CanMEDS Physician Competency Framework – Developed with the goal of improving patient care

• Awards and grants – Distribute more than $1 million in awards, grants, fellowships, and visiting professorships

• Research and innovation – Continually enhance our role in scholarship


Our vision and mission

• Vision

• The global leader in specialty medical education and care.

• Mission

• We serve patients, diverse populations, and our Fellows by setting the standards in specialty medical education and lifelong learning, and by advancing professional practice and health care.


Medical education – a period of transition

7

Flexner, Halsted & Osler: 100 Years After

The most dangerous phrase in the language is,

“We've always done it this way.”

Rear Admiral Grace Hopper


Rationale for change

• While the medical education system in Canada was exceptional, there were gaps and challenges in the model that needed to be addressed

• One challenge was that we assumed that the more time a learner spends on an activity, the more they absorb and excel (time-based learning)


Medical education for a changing world

• Increased complexity of care

• What do trainees need to learn?

• What do practitioners need to develop?

• Requirement for oversight and accountability

• Changing societal expectations of accountability

• Failure to fail in residency

• Changing learning/teaching environments

• New learning environments/locations

• Time pressures on faculty/supervision

• Resident duty hours


Enhancing patient safety and quality care must:

• …meet patient expectations and needs

• …recognize time spent on a learning rotation does not guarantee consistency in graduate abilities


Focusing on learning instead of time

• Ensures competence, but teaches for excellence

• Supports physicians’ skills and abilities to evolve throughout practice – enhancing care

• Responds to changing patient and societal needs

• Addresses gaps in the current system, like the “failure to fail” culture of resident education

• Reduces burden on faculties, promoting smoother credentialing and accreditation

• Increases accountability and promotes transparency in training

= Competency-based Medical Education (CBME)


Routes to Certification 13

What is Competency-Based Medical Education (CBME)?A model to prepare physicians for practice that is:

• oriented to outcomes desired in physician;

• based on patient needs;

• based on the needs of the learner, with more accountability and flexibility; and

• focused on achieving skills and performance, instead of time-spent in training.

Adapted from: Frank JR, Snell L, Dath, D, Sherbino, J, Holmboe ES, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45.


15

We are not alone in this change,

CBME is a validated model growing around the world.


Competence by Design

16

CBD Model and Design


A medical education milestone

• Competence by Design, our CBME initative, was launched on July 1, 2017

• First two programs: Otolaryngology and Anesthesiology

• Iterative implementation, with new programs joining each year

• All disciplines will embark on transition to CBD by 2022


CBD Model and Design:Hybrid model

Benefits of CBME while maintaining service learning and delivery imperatives at hospitals and the postgraduate funding structure


Competence by Design: Simplified

20Future Directions for Continuing Professional Development



Competencies

•Defines the discipline

•Defines the competencies of the graduate

• High level view of final competencies to practice

•Add context of practice

• A description of the scope of practice of the specialty


Entrustable Professional Activities (EPAs)

• In the setting of residency training,

•An entrustable professional activity is a responsibility or task in the clinical setting that may be delegated to a resident by their supervisor once sufficient competence has been demonstrated.


Examples of EPAs

In medicine

• Running codes

In the real world

• Driving on G1

Images via: bing.com


EPA Example: Neurosurgery

Performing surgery for patients with spontaneous intracerebral hemorrhage with or without an underlying vascular malformation


Milestones within an EPA

EPA

Milestone

Milestone

Milestone

Typically, each EPA integrates

multiple milestones.


Milestones Example:EPA - Performing surgery for patients with spontaneous intracerebral hemorrhage with or without an underlying vascular malformation

C ME 3.4 Prepare, position and drape the patient C ME 1.4 Apply knowledge of anatomy, key landmarks, and the surgical procedure C ME 2.2 Interpret intraoperative imagingC ME 3.4 Select appropriate instruments and sutures for each step of the procedureC ME 3.4 Independently perform craniotomy for exposure (NS-V) C ME 3.4 Open dura for exposure (NS-V)C ME 3.4 Open and close the incision C ME 3.4 Use optical magnification appropriately

C ME 3.4 Perform safe tissue dissection of relevant structures and tissue layers with gentle tissue handlingC ME 3.4 Recognize and address anatomical variants

C ME 3.4 Manage intraoperative hemostasis, including effective use of adjunctive agentsC COM 5.1 Document surgical clinical encounters in a complete and timely manner

C COL 1.2 Work effectively with the OR team




CBD coaching model

Facilitating learning and development of a residents’ competence


Coaching in the moment: A process

1) RAPPORT

2) EXPECTATIONS

3) OBSERVE

4) CONVERSATION

5) DOCUMENT

30

RX-OCDFuture Directions for Continuing Professional Development

Observation of an EPA

31

EPA Observation Encounters- Point in time- Single rater- Specific context




Assessment of EPA Achievement

33

EPA Observation Encounters- Point in time- Single rater- Specific context

EPA Achievement- Multiple times- Multiple raters- Multiple contexts


Progression of competence: Curriculum



Lessons learned so far

• General satisfaction with the educational design

• Need to listen to perceptions and address myths

• Assure manageability of number of specialty-specific competencies that require assessment

• Consideration for privacy

• Engage and develop all faculty who will be assessing residents

• Increase observations at “the bedside”

• Earlier identification of areas for improvement • Protecting patient safety, helping trainees succeed, decreasing trainees requiring additional

funding


CBD and continuing professional development

37

Maintenance of Certification (MOC)

• The MOC Program supports the lifelong learning needs of Fellows and healthcare professionals

• Requirements:

• 5-year cycle• Minimum 40 credits/year

• Minimum 400 credits/cycle

• Minimum 25 credits/section/cycle (for cycles starting on or after Jan. 1, 2014)

• Enabling Tools:• Framework of CPD Activities

• MAINPORT ePortfolio

• CPD Accreditation system

• Educational Support


Consistent evolution


1994• Maintenance of competence (MOCOMP) program launches at the Royal College

1994-1999

• MOCOMP = Practice-based learning projects, self-assessment programs, performance audits

• CME transitioning to CPD

1999-2001

• MOCOMP discontinued to make way for mandatory Maintenance of Certification (MOC) Program

2001-2011 • MOC Program implementation, enhancement and evaluation phases

2011-present

• Program monitoring, enhancements, and revisions

Looking around: Global CPD – how do we compare?

COUNTRY CYCLE LENGTH REQUIREMENTS FOR CPD/CME CREDITS/HOURS

Canada (CFPC) 5 years 25 credits/year250 credits/cycle

USA (examples of ABMS boards) 10 years (“mini” cycles of 3 years)

Several moving to ‘continuous certification’

25 to 30 credits/year90 to 150 credits/3 years240 to 300 credits/cycle

Australia (ANZCA) 3 years 30 credits/year180 credits/cycle

Australia (RACS) 1 year 30 to 60 credits/cycle




China 3 years 10 to 30 points/year90 points/cycle

Germany 5 years 250 points/cycle

Ireland (RCSI: Faculty of Radiologists) 5 years 50 credits/year250 credits/cycle

Kuwait 5 years 250 credits/cycle

Oman 3 years 40 credits/year120 credits/cycle




Qatar 2 years 40 credits/year80 credits/cycle

Saudi Arabia 5 years 30 hours/year90 hours/3 years

150 hours/5 years

Singapore 1 or 2 years 25 points/1 year50 points/2 years

United Kingdom (RCP) 1 year 50 hours/cycle

United Kingdom (RCOG) 5 years 250 credits/cycle



Compared to the Royal College’s current MOC Program, CPD/CME programs worldwide have:

• Shorter cycles, with overall average cycle length of three years

• Fewer credits required overall for program compliance

• Similar minimum/maximum credit requirements

• Minimum number of credits per year and/or per cycle

• Minimum or maximum number of credits per specific section, category or activity

• Similar flexibility for activities eligible for credit

• Most programs do not mandate specialty, practice or content—specific requirements


Advancing CPD


Looking ahead

• Competence by Design (CBD)

• Transformational change in medical education for specialty medicine in Canada

• What are the competencies each resident must demonstrate:

• At each stage of training?

• Across each CanMEDS role?

• Continuing Professional Development (CPD)

• How can the principles of CBD be expressed in CPD for specialists in practice?

Competency-Based CPD (CB-CPD) Advancing CPD


Competency-based CPD

• Vision: A CPD system that uses competencies to continuously improve specialty practice, patient outcomes, and the health system


Educational principles

Enhanced Expertise

Enable Fellows to continuously enhance their expertise

Contiuous Quality Improvement

Satisfy licensure, privileging and Fellowship requirements

Interprofessional CPD

Embrace learning and assessment

of individuals, groups and teams

Scope of Practice

Promote physicians to pursue excellence throughout

their professional life

Patient Care

Be designed to address personal, patient

and population health needs



1. Aligns learning and assessment activities with a specialist’s scope of practice;

2. Uses external sources of feedback to identify actionable goals across

the CanMEDS framework;

3. Achieves specific outcomes: competence, performance, and quality

of care experienced by patients; and

4. Addresses societal health needs.


What makes CPD competency-based?

Competencies are linked to decisions specialists make regarding:

1. The goals for improvement they are intending to complete;

2. The learning and/or assessment activities that will enable them to achieve these goals; and

3. The outcomes that will be achieved – what was affirmed or improved.




Focus less on Focus more on

Personal needs Patient / Population health needs

Learning as the goal of CPD Competence, performance and health outcomes as the goals of CPD

Recording and reflecting on participation in CPD activities

Recording how engagement in CPD activities improved practice

Learning as an individual Learning within groups / teams

Competencies relevant to the Medical Expert Role Competencies across all CanMEDS Roles

Passive learning in a classroom Active learning in a workplace

General educational requirements Specialty specific requirements

Physician Practice Improvement (PPI)

• Approach to assessing and enhancing physician competence, laid out by FMRAC in 2016

• Helps practising physicians identify learning needs that can be addressed through professional development and education programs


Aligning CPD with PPI

1. Describe your practice: Roles, responsibilities, and career aspirations in clinical practice, education, administration or research.

2. Develop practice improvement goals based on accessing external sources of data and feedback.

3 and 4. Identify and engage in CPD activities that sustain and continuously improve the core competencies of the specialty.

5. Use data and feedback to evaluate outcomes.


Create and implement your learning plan: MOCIdentify and engage in CPD activities that sustain and continuously improve the core competencies of the specialty

Competencies that are

• Defined by the specialty across the CanMEDS Roles

• Integrated within one’s practice improvement plan

Demonstrated through participation in

• Group learning

• Self-learning

• Assessment


Create and implement your learning plan: MOCParticipate in CPD activities to acquire the competencies to pursue specific career goals or plans

Competencies that are

• Not expected to be achieved by residents to be certified

• Based on milestones within the CPD / Enhanced Expertise stage of the competence

continuum

• Reflect personal , academic interests within one’s scope of practice


Create and implement your learning plan: MOCParticipate in high quality CPD activities that meet annual/cycle requirements

Greater emphasis on documenting planned learning

Credits are relevant to learning/assessment activities selected to

• Practice improvement goals

• Sustaining and enhancing core competencies

• Career development plans

• Scanning activities to identify future needs


Initiatives for Advancing CPD

1. MOC Program Working Group

2. CB-CPD National Advisory Committee

3. Council Task Force on Reaffirmation of Ongoing Competence

4. FMEC-CPD

5. FMRAC Working Group on Physician Competence

6. CBD Steering Committee whiteboards

7. Regular feedback from Fellows and MOC Program participants through Royal College Services Centre, MAINPORT, booths, etc.


Content creation and curation

•Collaboration with mdBriefCase to develop online self-assessment programs (SAPs)

•Prescribing Safely Canada pilot


Royal College/mdBC SAPs

• 2,185 accesses since April 2018

• 1,238 accesses since April 2018


Stats as of April 22, 2019

Prescribing Safely Canada

• Online assessment of prescribing skills

• Pilot by the numbers• November 1, 2017 to April 30, 2018

• 2695 registrants from 28 specialties, 10 provinces and 2 territories

• Target completions = 500 to 750

• Actual completions = 740


Prescribing Safely Canada

• Outcomes• Prescribing Safely Canada Competency framework developed

• Prescribing Competency Assessments for 3 specialties developed, implemented and valued

• Prescribing Competency Assessments targets were met

• Three Prescribing Safely learning cases being produced

• A Prescribing Safely interim evaluation is completed, final to be completed end of June

• Scholarly activities have begun


Advancing CPD:Your input

1. Will you have the data you need to participate in a PPI cycle?

2. What would be a meaningful change in the MOC program for you?

3. What challenges do you have with the MOC program?

4. Are we meeting societal expectations by granting lifetime certification?


Thank Youroyalcollege.ca • collegeroyal.ca

Dr. Doug Hedden| [email protected] | 613-730-8177 ext 163Dr. Viren Naik| [email protected] | 613-730-8177 ext 162

Competence by Design - NOSM · 2019-06-12 · •Competence by Design, our CBME initative, was launched on July 1, 2017 •First two programs: Otolaryngology and Anesthesiology •Iterative

Documents