Competence by Design Innovators

Big change is a well-studied phenomenon and due diligence needs to be given to the multi-step, and often multi-year, process and large number of stakeholders involved. Big change should be an iterative process that evolves over time from its original plan so that it aligns with the lived experiences of stakeholders. Piloting as much as possible ahead of time, developing a shared collective vision of the change, leveraging the existing medical champions to help lead the change, taking strategic pauses to reassess future directions of the big change, and embracing critical appraisal from stakeholders that remain skeptical are some important concepts to prioritize throughout the process.

The phrase “nothing about us without us” is an important concept. A master plan can look great on paper, but the magic is in the implementation of the pieces within the context of each specialty at each institution. Leveraging the early implementation work of champions, front-line faculty and resident trainees across all specialties and incorporating their feedback into the master plan with local customizations is important to get buy-in and develop a sustainable CBD system. For those who resist, or don’t value CBD, it’s important to engage with them through dialogue on what they do value and how this can be embedded into their CBD plans. Often their priorities align well with what CBD is trying to accomplish – and making these connections helps ease some of their apprehensions or resistance to change.

There are many supports that are critical to CBME implementation success. The most important support is a unified commitment to a systems-based approach by the decanal leadership at each institution. This commitment ensures all programs are supported equitably with shared central resources. Big change CBME implementation requires additional resource investment for all PGME programs regardless of size. Every institution will have unique challenges based on their contexts. This includes educational personnel, faculty protected time for education, IT and faculty development infrastructure, resident and front-line faculty engagement, program leader workshops, simulation facilities, and communication feedback loops. Big change CMBE also requires comprehensive planning, policy and funding at each institution to create a wide array of supports that are accessible to all postgraduate medical education leaders – with an end-goal of enhancing coaching and assessment of trainees through increased direct and indirect observation by faculty in the clinical realm. Built-in systems-based feedback loops from the frontlines can then help refine each program’s implementation strategy and progress can be shared with institutional stakeholders to achieve successful implementation across the institution.