from building competencies to developing capabilities … · from building competencies to...

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From Building Competencies to Developing Capabilities in Health Profession Education

Dr Lim Shih Hui

Group Director Education, SingHealth Professor and Senior Associate Dean, Duke-NUS Medical School

Senior Consultant, National Neuroscience Institute and Singapore General Hospital

23rd September 2017

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Outline of Presentation

• Competency and Competency-Based Education

• Various Models of Competency Frame Work

• Building Competencies

– Identifying Outcome

– Defining Performance Level for each Competency

– Developing Framework for Assessing Competency

• Developing Generic Professional Capabilities

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Why Education?

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Health profession education has been evolved from the old style of “structure / process” education to a competency-

based health profession education (CBHPE)

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Competence vs Competency

• Competence and competency are used in different contexts though both having similar meanings

– Competence refers to a person’s ability or skills and knowledge that he possesses to do a certain task

– Competency(ies) of a job refer to description of how things have to be done and at what level

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• An observable ability of a health professional

– Integrates and combine multiple components

including Knowledge, skills, values and attitudes

– Reflects a spectrum

– Measurable with respect to a defined outcome

Royal College and The International CBME Collaborators 2009

Competency & Competencies

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Traditional Education Competency-Based Education

Time-based Outcome-based

Passive learning Active learning

Fragmented curriculum Integrated curriculum

Isolation Collaboration

Textbook driven Research driven

Teacher-centred Learner-centred

Print Multimedia

Facts and memorization Higher-order thinking

Health Professions Education:

Traditional vs Competency-Based Model

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Health Professions Education:

Traditional vs Competency-Based Model

Frenk J et al: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4;376(9756):1923-58

• Health profession education has been evolved from the old style of “structure / process” education to a competency-based health profession education (CBHPE)

• Curriculum and assessment follows from the competencies and outcome, not vice versa !

• Requires

• Definition of milestones of competency

• Robust assessment methods, tools and systems

Then structure the curriculum, learners’ activities, assessment

tools, evaluation processes, etc, to achieve these

competencies

Defines the competencies that the learner must

demonstrate

Must know the trainee is truly competent to

progress to the next stage of their career

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To be competent so as to meet the needs of the aging population with multiple co-morbidities

• The profession?

– College of Family Physicians, Singapore?

– Academy of Medicine, Singapore?

– Others?

• The policy makers?

– MOH, SMC, SAB-JCST-RAC, FPAB, etc..?

– ACGME-I

• The public?

Who Determines the Outcomes?

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• Competent

– Possessing the required abilities in all domains at a specific stage of health profession education or practice

• Dyscompetent

– Relatively lacking in one or more domains of required abilities at a specified stage of education or practice

• Incompetent

– Lacking the required abilities in ALL domains in a certain context at a defined state of education or practice

• Supra-competent

Competent or Otherwise

2010 Royal College and The International CBME Collaborators

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Competency Framework

• Each competency framework starts with broad

distinguishable areas of competence that, in the

aggregate, define the desired outcomes for a clinician

– CanMeds Roles Framework

– KSA Framework

– RIME Model

– Dreyfus Developmental Model

– ACGME & ABMS adopted competencies

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– KSA Framework

– RIME Model



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CanMeds Roles Framework

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– KSA Framework

– RIME Model



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KSA Framework

• K = Knowledge

• S = Skill

– Information gathering skills • History taking, physical examination, communication

– Ability to use knowledge and information • Clinical judgement, problem solving

– Management skills • Diagnosis, treatment, patient education, counselling, procedural skills

• A = Attitudes

– Professionalism, humanism

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– KSA Framework

– RIME Model



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RIME Model

• Synthetic Model

– Reporter

– Interpreter

– Manager

– Educator • Developed at Uniformed Services

University Health Services (USUHS) in 1980s

– Lou Pangaro and Goron Noel

– For use in 3rd year medical student clerkships in internal medicine it becomes a passing criterion or prerequisite for advancement

– For each level of performance, examples are given which illustrate the framework, but do not exhaust the category

*I = introduced in the curriculum, P = practice, repetition M= sufficient proficiency, mastery, for the next level of independence, M* = sophisticated, complex situations or procedures

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– KSA Framework

– RIME Model



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Dreyfus Developmental Model

Master: Expert who relishes the unknown, or the situation that breaks the rules – who the experts go to for help – don’t know what they know

Don’t know what they don’t know

Know what they don’t know

Able to perform the tasks and roles of the discipline with

restricted breath and depth

Consistent and efficient in performance of the tasks and roles of the

discipline – know what they know and don’t know

In depth knowledge concerning the discipline – often rule based –

know what they know

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From Novice to Competent

Competent

Time

Training (3-8 yrs) Post-Training

What we imagine happens

With Support

Safety level

Level

Advance Beginner

Novice

Proficient

Expert

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Route to Dyscompetent / Incompetent

Competent

Time



Without Support

Safety level

Level

Advance Beginner

Novice

Proficient

Expert

With Support

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From Competent to Proficient & Expert

Competent

Time



Without Support

Safety level

Level

Advance Beginner

Novice

Proficient

Expert

With Support

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From being Competent to Mastery

Competent

Time


Safety level

Level

Advance Beginner

Novice

Proficient

Expert

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Career Path for Medical Specialists

PGY

10 yrs 20 yrs 30 yrs 0

PGY1 HO

Junior Residents

Senior Residents

Associate Consultants

Consultants

Senior Consultants: Clinicians + Educators / Scientists / Administrators

Consultative Service in the Private Sector

Training Phase Practicing & Life-Long Learning Phase

Medical School’s Exam MBBS /

MD

DGMS’ / Overseas Colleges’ Exam M Med / MRCP, MRCS,

MRCOG & Others

Initial Specialists’ Certification with

Professional Qualification (FAMS)

Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. AMS)

HMDP

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PGY


PGY1 HO

Junior Residents

Senior Residents


Consultants

Consultative Service in the Private Sector



MD

DGMS’ / Overseas Colleges’ Exam M Med / MRCP, MRCS,

MRCOG & Others

HMDP

Novice

Advance Beginner

Competent

Proficient Expert

Initial Specialists’ Certification with

Professional Qualification (FAMS)

Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. AMS)

Senior Consultants: Clinicians + Educators / Scientists / Administrators

Career Path for Medical Specialists

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PGY


PGY1 HO

Residents


Consultants

Family Medicine Practice in the Community



MD

GDFM, M Med (FM) HMDP

Novice

Advance Beginner

Competent

Proficient

Expert

MCFPS, FCFPS, FAMS(Family Medicine)

Subsequent Maintenance of Specialists’ Competencies (MOC) and Practicing Standard by the public healthcare institutions and professional organization (e.g. CFPS)

Senior Consultants: Clinicians + Educators / Administrators

Career Path for Family Physicians

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– KSA Framework

– RIME Model



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Competencies Framework

Adopted by ACGME and AMBS

• Patient Care

• Medical Knowledge

• Practice Based Learning and Improvement

• Interpersonal and Communication Skills

• Professionalism

• Systems Based Practice

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The Physician Competency

Reference Set (PCRS)

• Using the ACGME/ABMS framework as a reference, AAMC synthesized more than 150 competency lists for health professionals and developed a defining list of competencies for physicians

• This resulted in 58 competencies in 8 domains called “The Physician Competency Reference Set”(PCRS)

– These competencies define the desired outcomes across the continuum of education, training, and practice

http://academicmedicineblog.org/understanding-competency-based-medical-education/#comp

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Domains of Competence (DoC) in the Physician

Competency Reference Set (PCRS)

1. Patient Care (PC)

2. Knowledge for Practice (KP)

3. Practice-based Learning and Improvement (PBLI)

4. Interpersonal and Communication Skills (ICS)

5. Professionalism (Prof)

6. Systems-based Practice (SBP)

7. Interprofessional Collaboration (IPC)

8. Personal and Professional Development (PPD)

http://journals.lww.com/academicmedicine/Fulltext/2013/08000/Toward_a_Common_Taxonomy_of_Competency_Domains_for.21.aspx



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Competency-based

Health Profession Education

• Four Components

– Identifying the outcomes

– Defining performance levels for each competency

– Developing a framework for assessing competencies

– Continuous evaluation of the program to see if it is indeed producing the desired outcomes

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Competency-based


• Four Components


• e.g. competent clinicians




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Minimal Competencies

Professional Knowledge

Professional Skills

Professional Values and Behaviours

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• e.g. Ethics

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e.g. Integrity

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Importance of Integrity

• Hire and/or promote

– 1st on the basis of integrity

– 2nd motivation

– 3rd Capacity

– 4th Understanding

– 5th Knowledge

– 6th Experience

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Competency-based


• Four Components


–Defining performance levels for each

competency Milestones



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Defining Performance Levels for the

Competencies (Milestones)

• In US, reporting progress towards achieving desired competencies uses the language of milestones

– Markers of achievement of levels of performance in a developmental continuum

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Milestones Definition

• A significant point in development

Merriam-Webster

• A significant event or stage in the life, progress, development, or the like of a person, nation, etc

Dictionary.com

• Project management: Scheduled event that indicates the completion of a major deliverable event (or a set thereof) of a project. Milestones are measurable and observable and serve as progress markers (flags) but, by definition, are independent of time (have zero durations) therefore no work or consumption of resources is associated with them.

http://www.businessdictionary.com/definition/milestone.html

http://www.businessdictionary.com/definition/milestone.html

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Defining Performance Levels for the

Competencies (Milestones)

• Undergraduate medical education (UME) milestones

– AAMC defined two performance levels, corresponding to novice performance and the performance expected of a graduating MD

• Graduate medical education (GME) milestones

– In GME, as a result of the ACGME Milestones Project, each of the specialties generally defined five milestones for each competency, with the first designed to describe the entering resident and the last to define either the resident graduate or a practicing physician (called an “aspirational milestone”)

– Behavioral descriptions of performance roughly corresponding to a novice, advanced beginner, competent individual, proficient individual, and expert physician

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Milestone Reporting

• Level 1: The resident demonstrates milestones expected of a resident who has had some education in family medicine

• Level 2: The resident is advancing and demonstrating additional milestones

• Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency

• Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target

– Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director

• Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level

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Levels of Expectation

Milestone Reporting

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• The focus in Developmental

• Milestones should enable the trainee, programme and regulatory bodies to know an individuals trajectory of competency acquisition

Should allow the demonstration of competence in those activities that

define the profession

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The ACGME Milestones Initiative

• All specialties to develop milestones and recommend assessments to advance CBME

• Define developmental milestones and reliable, valid assessment tools for all training programmes by 2012

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ACGME Report Form

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Milestones for Patient Care

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Milestones for Medical Knowledge

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Milestones for Medical Knowledge

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Milestones for System-Base Practice

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Milestones for Practice-Base

Learning and Improvement

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Milestones for Practice-Base

Learning and Improvement

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Milestones for Professionalism

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Milestones for Professionalism

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Milestones for Communication

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Milestones Benefits

• Provide the leaners with a clear path of progression no surprises

• Allow for rich formative feedback learners know where they are and where they need to go

• Define specific behaviours that can focus assessment

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Milestones Criticisms

• They are reductionistic

• Checking off a milestones list does not equal to competent practice in a highly complex healthcare environment

• There are many milestones (e.g. 142 in IM) cannot assess them all, even over 3 years…

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Milestone Challenges

• Need to ensure that assessment and evaluation of these milestones actually demonstrate competence in those activies that define the profession

• Must resonate with learners, clinician educators, etc…

• One implementation strategy involves in building assessment and evaluation around activities learners are “entrusted” to do

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Competency-based


• Four Components



–Developing a framework for assessing competencies


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Developing a framework for assessing

competencies

e.g. traditional true/false MCQs

Other e.g. essays, extended matching type MCQs

Other e.g. OSCEs

Other e.g. through direct observation

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Entrustable Professional Activities

(EPAs)

• Describe routine activities of the clinician in specific contexts

• Require “work-based” application and assessment of skills (e.g. “OPA” Observed Practice Activities)

e.g. traditional true/false MCQs

Other e.g. essays, extended matching type MCQs

Other e.g. OSCEs

Other e.g. through direct observation

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EPAs

• The essential day-to-day activities of a specialty or a

profession that an individual must be trusted to perform

– Without direct supervision (for the undergraduate to graduate

medical education transition)

– In unsupervised practice (for the graduate medical education to

practice or fellowship transition)

• Activities are observable and measurable

• Require the integration of competencies—usually across

domains—and thus can be mapped to those competencies

and measured by their milestones that are critical to a

supervisor’s decision to entrust a learner

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Interrelationship among EPAs,

Competencies, and Milestones

It is the integration of those competencies and their milestones that ultimately determines a supervisor’s willingness to trust the learner to perform the EPA without supervision.

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Competency Curves For Trainees

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Is Being Competent Good Enough?

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“Good Enough” Test

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What is a “Good Enough” Test?

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Florence Laura Goodenough

• 1886 – Born August 6, 1886 in Honesdale, PA, USA; Youngest of 9

children; Parents were farmers; Never married

• 1921 – helped Lewis Terman conduct studies with the standford-Binet

I.Q. test for children he had developed

• Contributed to Terman’s book Genetic Studies of Genius

• 1924 – relocated to Minneapolis, Minnesota and worked in the

Minneapolis Child Guidance Clinic

• 1925 – appointed Assistant Professor at the University of Minnesota;

during this time she wrote her first book : Measurement of Intelligence

by Drawings

• 1931 – appointed Full Professor; during this time published Anger in

Yong Children

• 1933 – wrote her Handbook of Child Psychology

• 1942 – Appointed President of the National Counsel of Women

Psychologists

• 1946 – became President of the Society for Research in Child

Development

• 1947 – Retired early due to degenerative disease which eventually

caused her blindness

• 1957 – died of stroke

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Is Being Competent Good Enough?

Context Familiar

Context Unfamiliar

Task Familiar Task Unfamiliar

Certainties Competencies

Training

Routine

Complex Challenges

Modified from Prof Ian Curran

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Developing Capabilities

Far Beyond Competence

Context Familiar

Context Unfamiliar

Task Familiar Task Unfamiliar

Certainties

Uncertainties

Competencies

Capabilities

Training

Education

Being Competent is

NOT Good Enough !

We need to be Capable to handle Uncertainties and

Complex Challenges.

Modified from Prof Ian Curran

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Professional Skills


Building Competencies

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GMC’s Generic Professional Capabilities


Professional Skills


Health Promotion

& Illness Prevention

Research and

Scholarship

Leadership and Team Working

Patient Safety and Quality

Improvement

Education and

Training

Safeguarding Vulnerable

Groups

From Building Competencies

To Developing Capabilities

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Professional Skills


Innovation & Entre-

preneurship

Research

Leadership and Team Working

Safety and

Quality

Education

Global Health

Capabilities of

Healthcare Professional+

Community Health

Ethics, Policy and Health

Law

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“Future Ready”

Healthcare Professionals

• HCP as Practitioners, Communicators, Collaborators

• HCP Plus – Educators

– Researchers / Scientists

– Administrators / Leaders

– Safety & Quality Champions / Advocates

– Community Health Promoters / Advocates

– Global Health Champion

– Innovators & Entrepreneurs

– Health Ethicist/Health Law & Policy Expert

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Framework for Developing “Future Ready”

Healthcare Professionals @ SingHealth

Stage 1: To Build Capabilities as

Healthcare Professionals (HCP)

Stage 2: To Develop More Capabilities & Grow into

HCP-Plus

Focus on core capabilities – Knowledge, Skills & Attitude

• ACP • CCM • CCN • CAH • CCD

• SIMS • CHeAL • AM.EI

• IPE/IPCP Committee

• SIMS • AM.EI

• Educator

• Researcher/Scientist

• Administrator/Leader

• Safety & Quality Champion/Advocate

• Community Health Promoter/Advocate

• Global Health Champion

• Innovator/Entrepreneur

• Health Ethicist/Health Law & Policy Expert

Healthcare Practitioner

Communicator Collaborator

Adapted from CanMEDs and GMC (UK)

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11th January 2017

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College of Allied Health (CAH)

College of Clinical Nursing (CCN)

Office of SingHealth Academy

Education Support & Corporate Services

College of Clinical

Dentistry (CCD)

College of Healthcare

Administration and Leadership

(CHeAL)

College of Clinical

Medicine (CCM)

SHA Executive Council

Academic Medicine Education Institute (AM•EI)

SingHealth Duke-NUS Institute of Medical Simulation (SIMS)

Role of SHA’s Colleges and

Institutes in Developing GPCs

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Integrate Simulation-based Training into Residency

Training & Undergraduate Education

Patients’ Safety

Practice Before Performing

Procedures On Patients

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Role of ACPs, SHA Colleges and

Institutes in Developing GPCs

GPC ACP SHA CAH (PGAHI)

CCD CCM (GME, PGMI)

CCN (ALIAN)

CHeAL SIMS AMEI AMRI IPSQ Others


Professional Skills Professional Values

& Behaviours

Education and Training

Research & Scholarship

Patient Safety and Quality Improvement Leadership and Team

Working

Health Promotion and Illness Prevention

Safeguarding Vulnerable Groups

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Thank You

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