As the Royal College’s Competence by Design (CBD) initiative gains momentum, stakeholders are learning more and they’re eager to participate. If you are not part of a discipline that is scheduled to implement CBD in the next two years, there are still meaningful opportunities for you to prepare your entire faculty or program. This Meantime Guide describes those opportunities in practical steps that you can take.
The Competence by Design (CBD) initiative is gaining momentum. Some disciplines are already actively engaged in CBD, and many other disciplines are scheduled to make the change in the next few years. People in these “later cohorts” tell us they are keen to get involved in CBD sooner rather than later. If you are part of a discipline that has not yet started the Royal College CBD transition workshops there are still meaningful opportunities to prepare yourself, your faculty and your program. The Meantime Guide describes these opportunities in a series of practical steps. You asked, we listened.
Using this guide
If you are a clinical supervisor, residency program committee member, program director or specialty committee member whose discipline has not yet officially started the CBD process, the Meantime Guide was written for you. It is meant to provide an initial introduction to the CBD process and to help you start thinking about and preparing for this change. Although you can read the guide from start to finish if you’d like, we know you’re busy, so we’ve designed it to allow you to quickly scan the material and identify the content you need most.
All of the activities described in this guide are optional until your discipline starts the CBD transition workshops. The more you tackle now, though, the easier the CBD transition is likely to be down the line.
Where to find additional information
In this guide we introduce key concepts that will help get you started in CBD. You can find more information on the Royal College website. Your specialty committee will also dive into much greater detail once your discipline starts to plan for its CBD workshops.
Competency-based medical education (CBME) and the Competence by Design (CBD) initiative
Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies (e.g., CanMEDS 2015).
In a CBME system, a curriculum is organized around the outcomes expected of a resident, and that resident’s advancement is dependent on having achieved those outcomes. In some cases, CBME is designed as a time-free system (i.e., residents progress from one stage of their training to the next as soon as they achieve a certain set of competencies).
Many people have trouble distinguishing between CBME and CBD. Many countries are implementing CBME, but each one is doing it somewhat differently. CBD is the Royal College’s version of CBME.
In a nutshell, CBD has these characteristics:
It focuses on expected outcomes.
Competencies required of a clinician are now the organizing principle of postgraduate curricula.
CBD moves away from the assumption that time is a surrogate for competency (competence is no longer assumed, and promotion is no longer guaranteed, on the basis of time spent).
Residents must now demonstrate competencies and abilities to progress through their training.
It finds a balance between a fully time-dependent and a fully time-free mode of training.
As a hybrid model, CBD de-emphasizes time based training — time is instead used as a guideline and resource.
It promotes greater accountability, flexibility and learner centredness.
Residents will play a greater role in planning their learning and tracking their progress, which will promote development of lifelong learning skills.
It includes broader system-level changes in areas such as assessment and accreditation.
The Lingo
There are two key terms that will help you as you navigate this guide and the CBD process.
An EPA (Entrustable Professional Activity) is a task in the clinical or work setting that may be delegated to a resident by their supervisor once sufficient competence has been demonstrated. Typically, each EPA integrates multiple milestones.
A milestone is an observable marker of an individual’s ability or competence along a developmental continuum, used for planning and teaching.
For example, you might think of the ability to safely drive a car in reverse as one of the milestones related to an EPA of parallel parking. Similarly, the ability to assess and protect the airway can be one of the milestones related to the EPA of running a code in medical practice.
CBD organizes residency training into four developmental stages and clearly lays out markers for teaching and learning at each stage (see figure 1 below).
Each stage of training, and each learning experience, focuses on the identified outcomes for that stage.
In CBD, the first stage in residency is known as Transition to Discipline. It emphasizes the orientation and assessment of new trainees.
Foundations of Discipline, the second stage, covers broad-based competencies that every trainee must acquire before moving on to the third stage.
The third stage, which is known as Core of Discipline, covers more advanced, discipline-specific competencies. As part of CBD, the Royal College is exploring moving the Royal College exam to the end of this stage
The fourth and final stage of residency education is known as Transition to Practice. During this stage the trainee demonstrates readiness for autonomous practice.
The Competence by Design (CBD) initiative is a multi-partner, multi-phase, multi-project enterprise designed to improve residency education, the exam process, the accreditation system and continuing professional practice. Change on this scale does not happen one person at a time. Rather, it occurs as people who share a common purpose develop networks and then reach out to others to make the change together.
The path to a new way of doing things rarely follows a straight line and usually involves a “dip” that includes discomfort and setbacks. It’s natural for there to be tension as people adapt. Fortunately, there are a number of things you can do to moderate the dip. As you read through the list of practical suggestions in this section, keep in mind that one of the best ways to support change is to help people to engage in new ways of thinking and behaving.
Here are some things you can do now to help your program to prepare for the transition to CBD.
Improve your knowledge and skills so that you can become a local resource person, a role that we’re calling “CBD champion.”
Make CBD your own: prepare a “story” about how you relate to CBD as a program director, CBD or CBME lead, resident or teacher. If you present the case for change with a motivating story or cause that your listeners care about, they are more likely to respond positively than if you simply present them with numbers and statistics.
As you prepare your story, consider these questions:
Demonstrate the gap between what is and what could be.
What could CBD fix?
Educational needs of learners
Care needs of patients
Accountability to the public
Think about your key messages. How do you think CBD will most benefit your program? For example:
We want to design our program to meet patient care and societal needs.
We want to ensure that residents are safe, ready for practice and have the competencies they need.
We want to provide more timely coaching feedback to residents.
We want to identify struggling learners at an earlier stage, when interventions are more likely to be effective.
We want to chip away at the culture of “failure to fail.”
We want to support residents to take ownership of their own learning and to develop lifelong learning skills.
Use your CBD story as a conversation starter in your community.
Show how CBD is relevant to your program’s success.
You don’t always have to host special CBD meetings; sometimes it’s just about getting onto existing agendas and using existing communication channels.
Host local conversations at your regular meetings (divisional business meetings, grand rounds, program retreats, etc.) to share your CBD story and ensure that your colleagues see CBD as being relevant to your program’s success
Lead by example. Be a CBD resource or champion and inspire other people to become champions by modelling the change and making progress visible.
Invite local CBD champions from other programs to talk with your program faculty and other stakeholders about why change is needed and why CBD is so important.
Invite some of your colleagues to develop talking points about CBD and to engage in discussions about how CBD supports lifelong learning.
Share and make explicit the design of CBD, emphasizing key activities and language (e.g., direct observation, coaching feedback and documentation).
Begin to explore what it might take to implement CBD in your program.
Consider how to adapt the new behaviours and activities associated with CBD for your setting, then test them out on a small scale (e.g., try requiring a single documentation of observation and feedback per rotation in your program).
Share and celebrate early successes.
Build broader ownership and commitment
Think about how you will enlist your local stakeholders. What new or existing mechanisms can you use to build support for CBD (e.g., departmental meeting, postgraduate education committee, faculty retreat, grand rounds, resident meetings, regular emails and newsletters)?
Facilitate peer-to-peer conversations about CBD and what it will mean for each person (e.g., how it will impact their role).
Gather feedback so that you and your colleagues can learn from each other. People support what they have helped to create and have actually tried.
Tailor your methods: there is no-one-size-fits-all approach to change.
Ease the way for change.
Review the concepts of CBD and make sure enablers are in place for your program (e.g., give your faculty information on how to provide coaching feedback to residents according to the principles of CBD, help support your program’s new CBD competence committee).
Consider which elements of your program will need to be reviewed when your program transitions to CBD (e.g., policies, processes, systems, supports).
Other recommended resources
CBD early cohort materials – videos, slide decks, handouts all designed to help build understanding around CBD among early cohort disciplines
Review the CanMEDS Special Addendum to the Objectives of Training Requirements (OTR)
By: Cynthia Abbott
Rationale
Implementation of the CanMEDS 2015 Framework will happen gradually as disciplines develop their new competency-based standards with the help of the Royal College. In the meantime, the Royal College has introduced a CanMEDS 2015 Special Addendum to the Objectives of Training Requirements (OTR) for any discipline that will transition to CBD after July 1, 2018. The purpose of the special addendum is to ensure that the new elements of CanMEDS 2015 are incorporated efficiently into training programs, without overburdening stakeholders who are also dealing with significant changes as their programs transition to CBD.
Here are some things you can do now to help your program to incorporate the CanMEDS 2015 changes.
Plan the specific changes needed to address any gaps you identified in Step 2.
Obtain feedback.
Share your plan with your program committee, faculty and/or other educators and get their input.
Incorporate their suggestions and revise your plan
Other recommended resources
CanMEDS Interactive allows you to manipulate the CanMEDS framework and milestones to generate a fully customized and exportable file; sort through Royal College generic milestones easily to find what you need, when you need it; and access practical tips and sample tools to help you to teach and assess the seven CanMEDS Roles.
One of the changes that will be most notable for clinical teachers as they transition to Competence by Design (CBD) is the expectation for teachers to observe residents more frequently, provide regular coaching feedback and document these suggestions.
Rather than simply describing observations, coaching feedback supports the resident in their learning and development process, with the intention of performance improvement1. Preceptors can serve as coaches to help a resident to do some tasks better, develop a skill they don’t yet possess or achieve a specific goal.
Within education, coaching has been defined as “a one-to-one conversation focused on the enhancement of learning and development through increasing self-awareness and a sense of personal responsibility, where the coach facilitates the self-directed learning of the coachee through questioning, active listening, and appropriate challenge in a supportive and encouraging climate.1
Athletes rely on their coaches to provide development feedback that is designed to improve their performance. Coaches are able to provide helpful critique in part because they observe how the athlete executes the task(s), either in practice or on game day. But in medicine, observation can be limited, random, and/or unstructured. To embrace coaching as part of our toolbox to promote resident growth and success, we must better embed observation in our daily routines and practices (Coaching in the Moment) and create opportunities for longitudinal partnerships that assure residents are progressing and developing over time (Coaching over Time)2. In both cases, coaching requires mutual trust and understanding of roles so that residents can appreciate that feedback is given in the spirit of helping them to succeed. Click here for more information on the CBD Coaching Model.
In residency education, some clinical teachers are already using regular, direct observation of trainees as an effective tool to provide feedback to help learners improve (i.e. assessment for learning or formative assessment). CBD requires an increased emphasis on direct and indirect workplace-based observation to facilitate resident learning. Our role as faculty will need to evolve from one of supervision to one that includes more observation of the work residents are doing day to day3, 4, 5. Regular observation will help us, as faculty, to coach residents toward optimal performance, milestone after milestone and EPA after EPA.
Here are some things you can do now to help prepare your program’s clinical teachers to coach for excellence.
1. Build a coaching mindset.
Embrace a “growth mindset”6. This means believing that an individual’s intelligence, personality and character can be developed; true potential is not predetermined at birth, but rather develops over time with appropriate effort and guidance dedicated to such growth.
Review the concepts of coaching and think specifically about how these concepts can be applied in a clinical environment. Publications about coaching in medicine are increasing7, 8, 9, 10.
Consider how coaching is different from supervising a resident’s work.
Consider attending a workshop that will allow you to practice the skills and strategies that you’ve been reading and thinking about. Coaching is a process that requires practice.
2. Make a specific plan for observation in your practice setting(s).
The workplace is ideally suited for learning by doing, so identify opportunities in your clinical environment(s) that are conducive to resident observation. While direct observation isn’t always possible, it’s important whenever possible to find a time and place for it. Observation allows for a rich conversation about how to improve the execution of the task (i.e. “coaching feedback”).
If your discipline doesn’t have entrustable professional activities (EPAs) yet, identify a couple of competencies within one or two CanMEDS Roles that you can readily observe in your practice setting(s). For example, you could watch a resident give handover (Collaborator), obtain informed consent (Communicator) or perform a physical exam or procedure (Medical Expert). While physicians are more than the sum of a series of milestones or EPAs, focused coaching allows teachers to make concrete suggestions for improvement.
Be realistic and practical about what you take on. Direct observation doesn’t have to require a huge amount of your time: sometimes your observation can be based on a partial encounter (e.g., you might observe only part of the physical exam). Short, focused assessments are more likely to be completed and result in specific suggestions for improvement.
Emphasize the benefits of observation and coaching for learning.
Build an educational alliance or agreement with your resident(s) where your shared goal is their learning and development. Help them to see that your role is to supervise patient care and to act as their learning coach.
Be intentional about creating a positive learning culture in your clinical setting(s).
Encourage residents to regularly solicit suggestions for improvement from you and your colleagues. Help residents learn to treat constructive recommendations as a valued element of their ongoing development. This will help your residents create habits for ongoing life-long learning.
Encourage residents to provide you with feedback. This will facilitate and promote a learning culture.
4. Embrace Coaching as a PROCESS for learning
Practice Coaching In the Moment and follow the RX-OCR step-by-step process: R: Establish educational Rapport with the resident (an educational alliance or partnership). X: Set eXpectations for an encounter (discuss learning goals). Plan when and where you can observe a particular resident by matching the resident’s learning needs to the clinical opportunities for observation. Eventually, these discussions may revolve around what milestones or EPAs the resident is working on. O: Observe the resident (directly or indirectly). C: Coach the resident with the goal of improving performance. Follow each observation with a timely, specific, constructive conversation to facilitate the resident’s development. R: Record a summary of the encounter: Help each resident build a portfolio of observations by taking a few minutes to record the key points of your coaching. If your program doesn’t have encounter coaching/feedback forms, use a simple framework that identifies;
something the resident did well and should continue;
something you observed that needs correction, further development or improvement (be specific about the correction); and
a time to revisit the task requiring improvement.
5. Be realistic about the change: you won’t adjust to the new aspects of your role as a coach overnight.
Set realistic expectations for the frequency of observations. Depending on your program, the frequency of desired observations will vary.
Keep in mind that your observations will form part of a larger picture of resident performance that takes into account the input of many observers. Using a program of assessment (i.e., multiple assessors and multiple assessments over time) allows for all relevant domains to be assessed over the course of a training program. No one needs to observe everything, all the time — nor can they.
Van Nieuwerburgh C: Coaching in Education: Getting Better Results for Students, Educators and Parents. London, Karnac Books, 2012.
Watling, C., Driessen, E.,van der Vleuten, C., Lingard, L. Learning culture and feedback: an international study of medical athletes and musicians Medical Education 2014; 48: 713–723
Voyer, S., et al. (2016). "Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme." Medical Education 50(9): 943-954.
Pelgrim, E. A., et al. (2012). The process of feedback in workplace-based assessment: organisation, delivery, continuity. Medical Education 46(6): 604-612.
Watling, C J. Lingard, L. Toward meaningful evaluation of medical trainees: the influence of participants’ perceptions of the process. Adv in Health Sci Educ (2012) 17:183–194
Dweck C.S.: Mindset: The New Psychology of Success. New York, Ballentine Books, 2008.
Van Nieuwerburgh C: Coaching in Education: Getting Better Results for Students, Educators and Parents. London, Karnac Books, 2012.
Deiorio, N. M., et al. (2016). Coaching: a new model for academic and career achievement. Medical Education Online 21: 33480.
Ross S, Huie M, Schipper S. Use words that count: A content analysis to identify words and phrases that commonly appear in effective formative feedback. International Conference on Residency Education, October 22-24, 2015, Vancouver BC.
Ross, S., Dudek, N., Halman, S., Humphrey- Murto, S. Context, time, and building relationships: bringing in situ feedback into the conversation. Medical Education 2016 50: 889–895
http://www.businessballs.com/coaching.htm
Pelgrim, E. A., et al. (2012). The process of feedback in workplace-based assessment: organisation, delivery, continuity. Medical Education 46(6): 604-612.
Telio, S., et al. (2016). Feedback and the educational alliance: examining credibility judgements and their consequences. Medical Education 50(9): 933-942.
Watling, C., Driessen, E., van der Vleuten, C., Lingard, L. Learning culture and feedback: an international study of medical athletes and musicians Medical Education 2014; 48: 713–723
The competence committee is an important element of Competence by Design (CBD). This committee uses data integrated from a variety of sources and observations to make informed and transparent decisions about a learner’s performance and progression. In CBD, promotion decisions are made by the competence committee away from the individual teacher-learner interactions. Shifting broader promotion decisions to the competence committee frees teachers up to focus on giving coaching feedback for improved resident performance (i.e., assessment for learning).
The competence committee identifies patterns of performance revealing a broader picture of a resident’s progression to support his/her learning over time. Competence committees will be able to identify residents who are not meeting their milestones. In these cases, the competence committee can help to arrange support and coaching for residents before they get too far off their trajectory (e.g., assigning special mentors, extra readings or modified rotations).
Your discipline’s official transition to CBD may be years away, but in the interim your program is free to pilot a competence committee. This committee can meet to review collated resident assessment data and make recommendations to guide resident learning and development as a supplement to the discussions that happen at your existing progress decision meetings.
Some programs have asked for advice on setting up and running a competence committee. There isn’t one “right” way to set up this committee: there are guidelines and sample terms of reference on the Royal College website that will help you to set up your committee in the way that will work best for your program.
Here are some things you can do now to pilot a competence committee.
Review the purpose and role of a competence committee.
Familiarize yourself and others with CBD, its scope, the new terminologies and the new assessment strategies.
Review the Royal College’s sample guidelines and terms of reference documents for setting up a competence committee.
Consider how your competence committee might look.
Define your competence committee’s terms of reference and procedures, including membership (e.g., voting vs. non-voting members), frequency of meetings, plans for collating and presenting assessment data, and methods for decision making (e.g., majority, unanimous, consensus).
Identify the skill sets your committee members will need.
Recruit committee members. You may decide to recruit members from your current residency program committee or you may decide to choose other members, depending on the skills of your group.
Pilot your competence committee.
Consider engaging your residency program committee in piloting activities related to their coming competence committee.
Even if you don’t yet have entrustable professional activities (EPAs) and/or other CBD specialty requirements for your discipline, you can identify current assessment inputs and outcomes that will inform promotion decisions.
Identify gaps in your program’s assessment system: What data are you currently collecting? What are you missing?
Make plans to address gaps.
Meet regularly to systematically review individual residents’ performance on the basis of collated assessment data and synthesize existing data on patterns of competence.
Plan how you will communicate this information back to your trainees to give them feedback and direction on their progress.
Your program’s transition to Competence by Design (CBD) will take time and effort, but the outcome will be worth it. You are not alone in this journey: there are teams of people across the country working to make the implementation of CBD as smooth as possible.
As you probably know, the Royal College has developed a series of interactive, in-person workshops to guide and support each discipline as it transitions to CBD. These CBD cohort transition workshops (CBD workshops) will help prepare you for the changes you will face as your cohort moves to CBD. They will also highlight work that will need to happen back at your local program.
What can you expect at the Royal College CBD workshops?
Each discipline will typically have three workshops (three days each) facilitated by a Royal College clinician educator.
Workshop 1
will start with an introduction to CBD. The facilitator(s) will then help you to review and/or reimagine the scope of your discipline, determine how the stages of training apply to your discipline, and draft entrustable professional activities (EPAs) for those stages. You may also start to consider the training experiences needed to achieve those EPAs.
Workshop 2
will focus on achieving consensus on the EPAs as developed by the specialty committee during and after workshop 1. It will also focus on developing assessment plans for the individual EPAs.
Workshop 3
will usually focus on finalizing the EPAs and assessment plans. EPAs will be examined individually and they will also be reviewed to ensure that they fit together as a group (i.e., to avoid gaps and/or redundancies). In addition, the specialty committee will work to validate milestones linked to the EPAs and finalize the full document suite.
Throughout each of the workshops participants will discuss strategies to prepare for implementation.
If you’re invited, try to attend all three workshops as it will make it easier for you to understand, contribute to and implement these changes.
What “homework” can you expect?
Workshop 1
BEFORE: Participants will be asked to carefully consider the scope of their discipline (see specialty committee chapter 9 in this guide).
AFTER: Members will usually work on EPAs in small groups through teleconferences and/or electronic document sharing (e.g., Dropbox, Alfresco).
Workshop 2
AFTER: Members will usually work on EPAs in small groups through teleconferences and/or electronic document sharing (e.g., Dropbox, Alfresco).
Workshop 3
AFTER: Members will usually focus on finalizing all of the documents they’ve created and on preparing for implementation, which may include field tests and faculty development.
What will your program and faculty be responsible for doing at the local level?
Local curriculum and assessment mapping, adjustment of curriculum and assessments to meet national standards, local communication, local faculty development and change management will largely happen at the school and program level.
Consider brushing up on your curriculum mapping skills, as you will need to map your specialty’s/subspecialties national EPAs to your local training experiences and assessments.
Start considering the strengths and weaknesses in your program when it comes to implementing CBD. Where do you anticipate changes may be needed? How might you address any gaps in curriculum or assessment?
Think about the discussions you’ll need to have with your colleagues and residents as your program moves to CBD. What can you do before and after the workshops to ease the transition process? For example, you might introduce the rationale for CBD and its concepts and terms at a local business meeting, you might introduce new assessment tools to document short observations with feedback, you might pilot a competence committee and you might consider how you will prepare residents for new expectations.
Think about who can help you with these tasks. Many schools have assigned CBME leads, faculty development leads or communications teams who will help with local implementation. Find out if your school has people in these roles and reach out to them.
Find colleagues from other disciplines who are further along in their transition. Connect with them and learn from them. Chat about the lessons they’ve learned.
Review the composition of your specialty committee.
By: Anna Oswald
Rationale
In Competence by Design (CBD), the specialty committee will have new roles in assessment as well as an expanded role in educational design. For this reason, you may want to revisit your committee’s composition to make sure you have the right mix of skills.
Here are some things you can do now to review your committee’s composition.
Review the changing role of the specialty committee.
Familiarize yourself and your committee members with CBD, its scope, the cohort rollout plan for your disciplines and the new terminologies, assessment strategies, and so on, involved in CBD.
Review the Royal College’s document on the terms of reference for specialty committees.
Identify gaps and redundancies in the skill sets of your committee members.
Identify the skill sets of your committee members and the perspective they bring to committee work.
Review the scope of practice of your specialty / subspecialty.
By: Jolanta Karpinski
Rationale
Royal College specialties and subspecialties evolve over time as new treatments and technologies enter practice; as practice in the discipline moves into new locations or care settings; and/or as the patient population ages, becomes more complex and/or changes in other ways. An ongoing mandate of a specialty committee is to adapt its standards as the discipline transforms, but sometimes changes in standards lag behind changes in practice patterns.
Competency-based medical education is an outcomes-based approach to teaching, learning and assessment. This means that specialty committees start with the end in mind and design programs that will achieve that end goal. For individual specialties/subspecialties, program design requires a clear understanding of the societal need for, and expectations of, the discipline. Consider how you might answer the following questions:
What is the role our specialty/subspecialty plays in the Canadian health care system?
What services do the public expect from a graduate of our program?
What effect does practice location have on the skills required of a graduate?
Questions like these will guide your early transition work, so start the discussion early with colleagues in your discipline. Give yourself time to consult widely before your first CBD cohort transformation workshop. This pre-work will make your workshops run more smoothly, and the consultations you do at this preliminary stage should help with engagement and uptake later on.
Here are some things you can do now to review your discipline’s scope of practice.
Engage your specialty committee in a discussion about the scope of practice in your discipline.
Put this on the agenda for an upcoming committee meeting.
Gather information about practice patterns in your discipline.
Sources of information may include
the most recent Committee on Specialties review (done every six years),
data from your national specialty society and
recent publications in the field (e.g., epidemiological studies, reports on new technological advances).
Plan to address any gaps in that information.
Consider additional sources of information. For example, are there key billing codes used in your specialty that do not map to the described scope of practice?
Consider whether you need to survey current practitioners and recent graduates to gather more information.
Continue planning until all identified gaps have been addressed.
Obtain feedback.
Share your findings within your specialty committee, with your national specialty society and with other stakeholders.
Ensure your national standards documents are updated to reflect this review process.
