1. Entrustable Professional Activities
AFMRD EPA TASK FORCE

2. Outline and Objectives
Understand what an Entrustable Professional Activity is and IS NOT.
Recognize the differences and similarities between EPAs and subcompetencies.
Understand implementation opportunities for EPAs in your residency.
Understand examples of how to use EPAs in residency education.

3. Working Definitions
Competencies: Six core competencies as defined by ACGME
Subcompetencies: 22 Family Medicine subcompetencies as defined by the Family Medicine Milestone Project
Milestones: “Developmentally-based family medicine-specific attributes that family medicine residents can be expected to demonstrate as they progress through their programs.”
CCC: Clinical Competency Committee

4. Subcompetency
Developmental progression or set of MILESTONES
General
Competency
Milestone Description
Milestone Level

5. What is an EPA?
A task or responsibility ENTRUSTED to unsupervised execution by a trainee once sufficient specific competence is obtained
Independently executable, observable, and measurable
Written to describe activities that family physicians will perform when they are in independent practice

6. Why EPAs?
The implementation of subcompetency and milestone evaluations focused evaluations and observations on specific dimensions of resident abilities, rather than integrated performance.
The EPA scale allows for developmental enstrustment (independence) in these abilities.
However, this determination is too often based on insufficient direct observation of behaviors and inadequate assessment methods that focus on specific dimensions of residents’ abilities rather than their integrated performance.3,4
EPA assessment allows for the evaluation of whole clinical tasks, providing an oppor­tunity to observe, and intentionally entrust, residents to practice important clinical tasks independently.1

7. EPA Entrustment is Context Dependent
Trainee Factors:
Fatigue
Confidence
Resident experience
Supervisor:
Lenient vs strict
FM vs non-FM
Care Setting:
Out patient vs hospital
Night shift vs days
EPA type
Rarely occur
Frequent/common
Complexity
Global vs specific
Program Setting
Rural vs urban
Community vs university
Large vs small
Single vs multiple residencies
In practice, entrustment decisions are affected by 4 groups of variables: (1) attributes of the trainee (tired, confident, level of training); (2) attributes of the supervisors (eg, lenient or strict); (3) context (eg, time of the day, facilities available); and (4) the nature of the EPA (rare, complex versus common, easy).

8. Entrusting the EPA Scale of Evaluation Observation only
Execution with direct, proactive supervision
Execution with direct, reactive supervision
Supervision at a distance and/or post hoc
Trainee supervises more junior colleagues
ten Cate, O. Nuts and Bolts of Entrustable Professional Activities, JGME March 2013,

9. EPA and Subcompetency EPA Subcompetency
Observed patterns, actions, and behaviors that may overlap several different competency areas
Knowledge, skills, attitudes, and behaviors within one competency area
Evaluated based on level of independence.
Evaluated on a developmental scale
Related to many subcompetencies
Specific to one competency with little overlap
Develops over time

10. EPAs for Family Medicine
Provide a usual source of comprehensive, longitudinal medical care for people of all ages.
Care for patients and families in multiple settings.
Provide first-contact access to care for health issues and medical problems.
Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable stages.
Provide care that speeds recovery from illness and improves function.
Evaluate and manage undifferentiated symptoms and complex conditions.
Diagnose and manage chronic medical conditions and multiple co- morbidities.
Diagnose and manage mental health conditions.
Diagnose and manage acute illness and injury.

11. Perform common procedures in the outpatient or inpatient setting.
Manage prenatal, labor, delivery and post-partum care.
Manage end-of-life and palliative care.
Manage inpatient care, discharge planning, transitions of care.
Manage care for patients with medical emergencies.
Develop trusting relationships and sustained partnerships with patients, families and communities.
Use data to optimize the care of individuals, families and populations.
In the context of culture and health beliefs of patients and families, use the best science to set mutual health goals and provide services most likely to benefit health.
Advocate for patients, families and communities to optimize health care equity and minimize health outcome disparities.
Provide leadership within inter-professional health care teams.
Coordinate care and evaluate specialty consultation as the condition of the patient requires.

12. EPAs Mapped to Subcompetency and Milestone Level
EPA Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PC1
Cares for acutely ill patients -
Lvl 3
Lvl 2
Lvl 4
PC2
Cares for patients with chronic conditions
Lvl 5
PC3
Disease prevention and health promotion
PC4
Manages unclear diagnoses
PC5
Performs appropriate procedures
MK1
MK2
Applies critical thinking
SBP1
Cost conscious care
Lvl 3/4
SBP2
Emphasizes patient safety
SBP3
Advocates for individual and community health
SBP4
Coordinates team based care
PBL1
Locates, appraises and assimilates evidence
PBL2
Self-Directed learning
PBL3
Improves systems
Prof1
Completes process of professionalization
Prof2
Professional conduct and accountability
Prof3
Demonstrates humanism
Prof4
Maintain emotional, physical and mental health C1
Develops relationships with pts and families C2
Communicates effectively with pts and families C3
Relationships within Medicine C4
Use Technology

13. Entrustment for Independence in an EPA Maps to Specific Milestone Levels
Competency
Subcompetency
Milestone
Patient Care
PC-1: Cares for acutely ill or injured patients in urgent and emergent situations in all settings
Level 2
PC-2 Cares for patients with chronic conditions
Medical Knowledge
MK-2: Applies critical thinking skills in patient care
Systems Based Practice
SBP-1: Provides cost-conscious medical care
SBP-4: Coordinates team-based care
Professionalism
PROF-3: Demonstrates humanism and cultural proficiency
Level 3
Communication
COMM-1: Develops meaningful, therapeutic relationships with patients and families
COMM-2: Communicates effectively with patients, families, and the public

14. Specific Methods for Using EPAs
Resident evaluation
Resident education plan development
Curriculum evaluation and design
See separate documents and PowerPoint presentations for each of these areas

15. References
ten Cate O. Trusting graduates to enter residency: what does it take? JGME, March 2014
ten Cate O. Competency-based education, entrustable professional activities, and the power of language. JGME, March 2013
ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Academic Medicine, June 2007
ten Cate, O. Nuts and Bolts of Entrustable Professional Activities, JGME March 2013,

16. Case #1 Ready Resident
March, CCC meeting: Evaluating an R1 who is receiving comments on his evaluations that he is consistently not evaluating emergencies on the hospital service well. Overall his evaluations are above average, in management of the patients, presentations, notes, communication with peers and patients and professionalism. However there are several comments under PC1 sub-competency and MK1 sub-competency and C1 subcompetency regarding need for direct senior resident supervision for these situations.
Get EPA from roger and flesh out defninition

17. CCC Action
The CCC recognizes that despite passing all of the rotations this resident still had one global area that needs to be improved before supervising other residents.
The CCC gives feedback to the resident and PD that this resident needs to focus on EPA #14 “Manage care for patients with medical emergencies”
Resident is currently meeting this level
Observation only
Execution with direct, proactive supervision
Execution with direct, reactive supervision
Supervision at a distance and/or post hoc
Trainee supervises more junior colleagues

18. CCC Recommendation
In order to supervise as an R2, resident needs to be at
Observation only
Execution with direct, proactive supervision
Execution with direct, reactive supervision
Supervision at a distance and/or post hoc
Trainee supervises more junior colleagues
A specific remediation plan is recommended by the CCC in order to increase skills in emergent care.
Needs to grow from direct supervision to supervision at a distance before he will be a second year supervising on In Patient service.

19. EPA #14
Definition: Graduates of family medicine residencies will be able to intervene in an abrupt change in patient status. This EPA applies to situations that are more emergent and are higher risk for morbidity and mortality than those described in EPA #9.
These are the corresponding subcompetencies:
MK1 PC1 SBP1 SBP4 C1 C2 C3

20. Case #2 Specialist Situations
As the Chair of your CCC you have been tasked with updating your off site evaluations from the surgery subspecialists. When you added the subcompetencies to the forms last year, the preceptors stopped returning them altogether. You are trying to come up with meaningful questions to add to the evaluation form.

21. Evaluation Update
You create an evaluation form that asks the level of independence for the following EPAs
EPA 20 Coordinate care and evaluate specialty consultation as the condition of the patient requires
EPA 10 Perform common procedures in the outpatient or inpatient setting.
You could provide the specialist with examples where each of these may fit into their interactions with the resident.

22. Case #3 PD Problems
As the PD you have been asked by the GME office to update a summative (biannual evaluation) of residents in the out patient setting. You have recently transitioned to subcompetency based evaluations to support your CCC process but don’t want to add just subcompetencies to this evaluation as this is what you are doing for the other evaluations.

23. The addition of several EPAs could enhance this evaluation form.
You develop a summative evaluation that includes the following rated on resident levels of independence.
EPA1 Provide a usual source of comprehensive, longitudinal medical care for people of all ages.
EPA3 Provide first-contact access to care for health issues and medical problems.
EPA4 Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable stages
EPA6 Evaluate and manage undifferentiated symptoms and complex conditions.
EPA 7 Diagnose and manage chronic medical conditions and multiple co-morbidities.

24. Each of the EPAs, once entrusted, maps to specific milestones levels achieved
Eg. EPA3– “Provide first-contact access to care for health issues and medical problems” entrustment maps to:
PC3 Level 4 Integrates disease prevention and health promotion seamlessly in the ongoing care of patients
MK2 Level 3 Recognizes and reconciles knowledge of patient and medicine to act in patient’s best interest.
SBP-3 Level 3 Identifies specific community characteristics that impact specific patients’ health.
PBLI-1 Level 2 Evaluates evidence-based point-of-care resources
PBLI-3 Level 3 Uses an organized method, such as a registry, to assess and manage population health
Prof-3 Level 3 Incorporates patients’ beliefs, values, and cultural practices in patient care plans
Comm-1 Level 3 Respects patients’ autonomy in their health care decisions and clarifies patients’ goals to provide care consistent with their values
Comm-2 Level 4 Educates and counsels patients and families in disease management and health promotion skills. Maintains a focus on patient-centeredness and integrates all aspects of patient care to meet patients’ needs

25. The addition of these 5 EPAs could inform the CCC based on level of entrustment
Any ”fully entrusted” activity provides additional milestone level data for the CCC review of resident progress.