Competency Based Medical Education

Royal College Document Suite for Urology


Schulich Medicine Urology - CBME


Competence by Design (CBD) breaks training down into several different stages. Each stage has its own entrustable professional activities (EPAs) and milestones. A milestone is an observable marker of an individual's ability along a developmental continuum. An EPA is a task of the discipline. It can be delegated to a resident and observed by a supervisor. Typically, each EPA integrates multiple milestones as we use multiple abilities simultaneously when performing professional activities (e.g. we use our medical expertise, but also our communication skills).  EPAs and milestones can be used as a clear learning path for residents and clear teaching and assessment goals for educators.

Entrustable Professional Activities (EPAs)

EPAs are authentic tasks of a discipline. A supervisor can delegate a task to a resident and observe their performance in the workplace. Overtime, frequent observations of a trainee’s performance of an EPA, will provide a comprehensive image of their competence and inform promotion decisions.
Royal College EPAs are related to each stage of training (transition to discipline, foundations of discipline, core of discipline, transition to practice). EPAs are designed to be developmental — they go from smaller tasks to bigger tasks as trainees progress through stages of training. Each EPA integrates a number of milestones from different CanMEDS roles; a bigger task may include more milestones and/or more complex milestones.
The process of defining a series of EPAs at each stage provides residents with a clear understanding of the expectations at that stage. EPAs focus the supervisor on stage appropriate expectations, which helps supervisors pinpoint a learner’s achievements and areas for improvement. EPAs are also part of competence committee discussions about resident performance.

Each specialty or subspecialty carefully defines EPA’s that are best suited to ensure their residents progress through training appropriately. The number of EPAs for a specialty is determined by the specialty committee.
 

Milestones

Milestones provide learners and supervisors with discrete information about the relevant skills of the discipline. Milestones that have been linked to an EPA are the individual skills that are needed to perform that task. For the purposes of learning and improvement, a resident and supervisor can focus on the EPA as a whole, or examine the milestones linked to that EPA. Over time, this detail is needed to help guide feedback and coaching for improvement.  Milestones allow you as an observer to pinpoint areas that trainees need to improve, in order for them to successfully and reliably complete the EPA.
 

CBME - Urology

The Urology program initiated Competency Based Medical Education (CBME) in July 2018. Unlike other Urology programs all residents in our program (PGY1-5) will be assessed using the Royal College designed Entrustable Professional Activities (EPA’s). The EPA’s for Urology are divided into four phases of training; Transition to Discipline (4), Foundation (8), Core (21) and Transition to Practice (6).
 
EPA assessments are scored using the relevant milestones for each EPA and an overall O- score/O-CAT score on a likert scale of 1-5. A score of 4 or 5 is deemed as ‘achieved’ for the assessment while a score of 1-3 is deemed as ‘in progress’. Based on the number of successful assessments required (198), the Urology program expects the need for 1022 assessments spread over five years of training to allow achievement of the necessary number of assessments. The number of assessments required to be triggered for assessment when broken down by PGY year:  49 in PGY 1, 176 in PGY 2, 214 in PGY 3, 225 in PGY 4 and 358 in PGY 5. For the operating room, a minimum of 1 EPA assessment should be triggered by the resident on a case chosen in consultation with the faculty. The case chosen must be pre-decided to allow the faculty to perform a thorough and complete evaluation and provide specific feedback. For the clinic, a minimum of 1 EPA assessment should be triggered by the resident on a case decided by the faculty in the clinic.
 
The Competency Committee (CC) will be chaired by the current Assistant Program Director (APD) and include a minimum of three divisional faculty from the 3 clinical sites of the Urology Program who will act as faculty reviewers. The Program Director (PD) will be a non-voting observer. Membership shall also include the Program Administrator as recording secretary. The CC will meet quarterly to review the resident files (EPA assessments, ITERS, procedure logs, etc). The flow chart on the next page details the process of review and the metrics used.
 
The process of review will be initiated if the resident completes the minimum required EPA assessments required for the quarter. This number is based on the yearly total required and the rotations the resident has undertaken in the time period since the last CC meeting. Failure to trigger a sufficient number of EPA assessments will lead to a designation of “Unable to Assess” or “Failure to Progress”. If this is repeated, the resident will begin a process of remediation as there will be insufficient data for the CC to determine the resident’s progress.

PROCESS OF RESIDENT PROGRESS ASSESSMENT (click here)