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Competence by Design (CBD) Overview:
2015-2018

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 Journey of the Resident:
Current Model vs. Competence by Design

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Andrea’s Journey
Through Residency

Meet our
resident.

We’ll call her

“Andrea”.

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Andrea’s Journey:
Current Residency Model

Certification Exams

Exam Preparation/Electives

Senior Residency
In-training
exams
Junior Residency

Basic Clinical year

ITERs

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 Educational Tensions in
Andrea’s Current World

• Residents can be disempowered

• Great burden placed on faculty
• Teacher-Learner exchange is corrupted
• Failure to fail
• Dichotomous judgements
• Little direct observation
• High stakes national exams

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 System Challenges in
Andrea’s Current World

• Learning judged by time spent, not ability

• Trainees unprepared at stages
• Variable workplace assessment/failure to fail
• Concerns about patient harm
• Missing content
• Faculty overload & educational inefficiency
• Resource imperatives
• Lack of support for lifelong learning
• Need for assessment for learning

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Change is Underway…
CBD 8
 New World:
Competence by Design (CBD)

Conceptual framework for performance assessment. Khan and Ramachandran, Medical Teacher 2012; 34: 920-928 9
 New World:
Competence by Design (CBD)

Competence is about performance –

the right thing, for the context,
at the right time

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 New World:
Competence by Design (CBD)

• Multi-year, transformational change

initiative in specialty medical education;
• Focused on the learning continuum from
the start of residency to retirement;
• Based on a competency model of
education and assessment; and
• Designed to address societal health need
and patient outcomes.

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 CBD: Not Time Free

• “Pure” competency-based medical education (CBME)

is time free;
• CBD is a hybrid model of CBME.
It is NOT time free.
• CBD will re-conceptualize time as a framework.
• The number of years of residency to remain the
same.
• Residents will be able to achieve competencies
(measured by milestones and Entrustable
Professional Activties (EPAs) at their own rate
within the defined residency program timeframe.
 Why CBD? Why Now?

We need a system that:

• Addresses changes to patient and societal
needs;
• Assesses competence, but teaches for
excellence;
• Ensures competencies in all domains evolve
across the continuum of medical education
(residency to retirement); and
• Enables flexibility; allows physicians to identify
when and how changes apply to practice.

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Commitments for
Implementation

• Communication
• Engagement
• Streamline workload
• Continuous improvement
• Work-flow integration
• Pilot testing
• Support

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CBD Competence Continuum

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Andrea’s Journey:
Proposed CBD Residency Model

Certification Final
Competency
Assessment
Transition to Practice

Exams
Core / Electives

Multi-facetted
Foundation assessment

Orientation / Assessment Portfolios

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How Do We Get to This New World?

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 CBD Identified Initiatives

For Residents
MAINPORT ePortfolio For Fellows

Assessment
In-Training In-Practice Change Exam Re-Engineer Develop
Competency-Based Competency-Based Governance Exam Delivery Exam Content
Assessment Assessment

Accreditation Credentialing
CBME
Redesign Policy: Re-Engineer Redesign Policy: Re-Engineer
Outcome-Based Accreditation Competency-Based Credentialing
Focus Process Focus Process

Create Competency
Framework & Milestones
CanMEDS 2015 Deliver Phased,
Speciality-Specific
(Generic & Speciality-Specific) Roll-Out

Affirmation of Continued Competence

Faculty Development and Faculty/Education Support

Lifelong Learning
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CanMEDS 2015

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 CanMEDS 2015

CanMEDS 2015 :
• Foundational project of CBD,
• Focused on updating the existing CanMEDS
Framework and introducing generic milestones
across the continuum
• Series IV of the Framework is now available
• The final version will be released at ICRE 2015
in October 2015 along with an updated version
of the evergreen Milestones Guide

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 CanMEDS 2015 con’t…

Specialty Committees will use the updated

CanMEDS Framework and Milestones Guide to:
• Better integrate concepts like patient safety
into their curriculum,
• Help develop specialty-specific milestones and
Entrustable Professional Activities (EPAs).

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 Milestones and EPAs

Milestones: for teaching

A defined, observable marker of an individual's
ability along a developmental continuum
• Demonstrate a commitment to patient safety
and quality improvement through adherence
to institutional policies and procedures
Entrustable Professional Activities (EPAs):
for assessment
An essential task of a "discipline" that an individual
can be trusted to perform independently in a given
context
• Recognize and manage conflicts of interest in
independent practice

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 Key Concept of EPAs:
Entrustment

• “What can I safely delegate with

indirect supervision?”

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 Example of Draft Leader
Milestones (generic)
Key & enabling Requirements Transition Foundations of
competencies for Residency to Discipline Discipline
1. Contribute to the improvement of health care delivery in teams,
organizations, and systems
1.1 Apply the Describe the relevance of Describe quality
science of quality system theories in health improvement
improvement to care at the practice, Methodologies.
contribute to organization, and health
improving systems system levels. Compare and contrast
of patient care the traditional
Describe a patient’s methods of research
longitudinal exp. through design with those of
the health care system. improvement
…etc science…etc
1.2 Analyze adverse Describe the elements Describe the Report patient
events and near of the health care process safety hazards and
misses to enhance system that facilitate or for reporting adverse events.
systems of care protect against adverse adverse …etc
events or near misses. events and near
...etc misses.
…etc
 Medical Oncology Example:
Milestones and EPA

Milestones which make up the Medical Oncology EPA

(abilities needed to accomplish the task)
• Recognize urgent and emergent oncologic issues, including
but not limited to, pain crisis, febrile neutropenia,
uncontrolled diarrhea, hypocalcemia, epidural cord
compression and malignant bowel obstruction.
• Select and administer appropriate interventions for urgent
and emergent oncologic issues.
• Identify the limits of their own expertise and appropriately
seek assistance and supervision.

Medical Oncology EPA

(the task that must be accomplished)
• Initial care for urgent and emergent oncologic situations.
 Benefits of Milestones and
EPAs

Curriculum Assessment
Abilities expected Meaningful,
of a resident at measurable markers
a defined stage of of progression
training of competence
 CanMEDS 2015: Milestones
and EPAs: Benefits to Andrea

• More frequent assessment and meaningful supervision;

• Greater engagement in the pursuit of abilities, not just
knowledge;
• Clearly defined targets for acquiring competency and
meeting standards throughout training;
• Better preparation to serve patients and communities;
• More flexible timeframe, focusing on personal
development; and
• Ability to continue to strive towards mastery of skills
and abilities beyond training and throughout practice.

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CBD MAINPORT ePortfolio and
eDiploma

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 MAINPORT eDiploma:
Trainee Dashboard

First step in the development of a MAINPORT

ePortfolio for residents and in-practice physicians

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 MAINPORT ePortfolio:
Benefits to Andrea

Scope of practice, goal Planning tools, recording,

setting monitoring progress reflection templates

Discussion forums, Goal Setting & Planning and Assess knowledge,

blogs, social media Monitoring Reflection skills, performance

Discuss / Self-
Collaborate CBD MAINPORT Assessment

Share
ePortfolio External
Assessment

Demonstrate /
Perspectives, Reporting Showcase Formative and
experiences
summative strategies,

Licensure, privileging, Demonstrate professional

credentialing development
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Phased Implementation
with Specialties

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Phased Implementation with
Specialities: Proposed Plan

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 Phased Implementation:
First & Second Adopters

First round of adopters started in Fall

2014 (Cohort 1)
• Medical Oncology, and
• Otolaryngology – Head and Neck Surgery.

Second round of adopters starting in

2015 (Cohort 2)
• Anesthesiology, • Internal Medicine,
• Forensic • Surgical Foundations, &
Pathology,
• Gastroenterology, • Urology.
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 Proposed Implementation:
All Disciplines
2016 2017 2018 2019 2020
(Cohort 3) (Cohort 4) (Cohort 5) (Cohort 6) (Cohort 7)
Neurosurgery Gen. Surg. Orthopedic Surg. Dermatology Colorectal
Cardiac Surg. Plastic Surg. Vascular Surg. Ophthalmology Gen. Surg. Onc.
Pediatrics Obs/Gyn Neuro. Path. Diag. Rad. Thoracic Surg.
Anatomic Path. PMR Neurology Medical Gen. Interventional Rad.

Gen. Path. Nuclear Med. Hem. Path. Public Health Palliative Med.
Radiation. Onc. Psychiatry Hematology Peds. EM Pain Med.
Emerg. Med. Respirology Peds. Hem/Onc GREI Developmental
Peds.
CCM Cardiology Peds. Surg. MFM Neuro. Rad.
GIM Rheumatology Clin. Pharm/Tox Gyne/Onc Peds. Rad.
Nephrology Geriatrics Forensic Psych ID Occupational Med.
NPM Child/Ado. Psych Med. Micro. Endo. and Met.
CIA Geriatric Psych. Med. Biochem.

Adolescent Med.
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CBD: Is It Really Worth It

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Summary:
CBD in the Coming Years

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 Commitments for
Implementation

As we roll out CBD, we are committed to:

• Engagement,
• Open communications,
• Supporting our Fellows and stakeholders
through faculty development,
• Streamlining workload,
• Pilot testing, and
• Continuous improvement.

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CBD: Improving Andrea’s
Journey

Ultimately, a
move to CBME
is about a
better way to
train health
professionals.

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CBD: Next Steps

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 CBD in the Coming Years

• Launch final version of the updated CanMEDS

Framework and the evergreen Milestones Guide at
ICRE 2015
• Update the CanMEDS diagram based on
stakeholder feedback
• Continue working work with CBD early adopters
(Medical Oncology and Otolaryngology – Head and
Neck Surgery).
• Develop & implement specialty-specific
milestones and EPAs,
• Evolve CBD ePortfolio to track achievements
against milestones, and
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 CBD in the Coming Years
con’t…

• Plan new Accreditation, Credentialing and Exams

processes .
• Focusing on increasing ease-of-use,
reducing burden of work and implementing
electronic, work-reducing processes/tools.
• Pilot with adopters and medical schools,
• Build, test and refine infrastructure
• Craft and share education and faculty
development resources
• Engage and collaborate with Fellows and
stakeholders.
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 Your Input Matters

How can we improve the CBD Program?

Let us know at:
• cbd@royalcollege.ca
• www.facebook.com/TheRoyalCollege
• https://twitter.com/Royal_College
• www.linkedin.com
For more information, visit our website:
• www.royalcollege.ca/cbd

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