Competence by Design Innovators

Change is difficult for all of us. Give yourself and your faculty time to prepare and adapt. To help manage the change, we held three ‘CBD faculty retreats’ prior to launch. Identical sessions were offered twice per year and I’m pleased to say we were able to achieve 100 percent faculty attendance. The retreats focused on what faculty needed to effectively implement CBD in our program: introduction to the concept of CBD, how to provide valuable feedback, completing EPAs, and how to set up a functioning Competence Committee. I’ve also learned that clear communication and managing expectations for both residents and faculty are essential to implementation. We took a team approach by messaging that this was a necessary change, but we ‘were in it together and could make it work. Although we are only six months into the CBD launch, things have been going well so far

In keeping with our slow and steady approach, we started introducing EPAs to residents and faculty years before launch. We began with Transition to Discipline EPAs, as there are only two. The PGY1s completed them in the first blocks of their residency. The evaluations were on paper, and our goal was to figure out the challenges to implementation. Starting the pilot before our first CBD retreat allowed for faculty discussion and brainstorming around observing residents. Our different sites came up with unique solutions including a ‘teaching clinic’ in Sudbury where the faculty book two or three new consults and observe the residents for the entire encounter. We were also able to provide feedback sessions, both verbal and written. As part of the pilot over the next several years, all residents were expected to complete EPAs at the stage most appropriate for their year. We gradually increased the number of EPAs that each PGY year needed to complete. We moved from paper documentation to electronic documentation that could be reviewed by the Competence Committee. One year we provided a prize for the first resident to complete their EPAs and then progressed to holding back promotion for several residents until the EPAs were completed. Residents then managed to get them completed quite quickly and they were subsequently promoted. This emphasized to both residents and faculty that the program was serious about implementation and completion improved the subsequent year.

Clear communication with the whole program was essential. To communicate to both faculty and residents, we used CBD retreats, email updates to faculty, house staff meetings with residents, and a resident newsletter. During one retreat we taped our residents completing EPAs and then had faculty use the EPA to assess the encounter. We then discussed where faculty would place the residents on the entrustment scales and milestones. This helped create clearer expectations around entrustment for the whole faculty. We have also encouraged open communication with the residents as we made this transition. Some of the barriers they identify are different from faculty and by recognizing them early we could adjust.

As mentioned above, our teaching clinic was suggested by the faculty themselves, which made it much easier to implement. The faculty at each site have individualized the operation of the teaching clinics to best meet their needs. For example, at one site, each faculty runs a half day clinic once a month, while at another site, faculty have blocked off the first consult of the afternoon several days a week for the teaching clinic. I think giving faculty the opportunity to be involved in the implementation process made it much smoother.

The program director has to be the CBD champion for the program. I can honestly say I have seen an improvement in the feedback we provide our residents as we have piloted and launched CBD, which makes it easier to champion the change. The program director must be prepared to listen to concerns and adjust as needed. It is important to remember change takes time and there are always bumps along the way. The earlier you start preparing the better.

The following four things were helpful in preparing our program for launch: 1) We conducted mock Competence Committee meetings so faculty and residents could understand the process and importance of providing detailed and specific feedback. 2) Competence Committee review has identified gaps in resident evaluation, including not enough written feedback on the EPAs. Knowing this early allowed us to target this skill at the CBD retreats. 3) We need refreshers on an ongoing basis. The members of the Competence Committees have also advocated at their own sites for discussing and encouraging faculty to provide rich feedback. 4) One fun innovation was the creation of a video that highlighted the common EPA challenges.