Entrustable Professional Activities (EPAs) in Residency Training in Anesthesiology

Suwannee Suraseranivongse, MD

Professor in Anesthesiology

Deputy Dean & Director of Siriraj Medical School

Faculty of Medicine Siriraj Hospital, Mahidol University

Outline

•Rationale of change

•Competency, EPAs, Milestones

•How to develop EPAs

Medical Council of Thailand

Royal College of Anesthesiologists of Thailand

Board Committee of Residency training in Anesthesiology

14 Training institutes n =140 / year

Previous curriculum • Traditional time-based curriculum • Summative evaluation • Informal formative evaluation & development • Suitable for small training center with few trainers & trainees

Current curriculum • Competency-based curriculum

• Formal formative evaluation & development

Increased number of trainee

History of EPAs in residency training in Anesthesiology

Policy 2017

Pilot model

Sharing

Brainstorming 2015

Competency based curriculum Entrustable professional activity (EPAs)

Milestones

Competency

•An observable ability of a health professional integrating multiple components such as knowledge, skills, values, and attitudes. •Observable & measurable, they can be assessed to

ensure their acquisition

Competency

• Patient care

• Medical knowledge & skills

• Practice-based learning & improvement

• Interpersonal & communication skills

• Professionalism

• System-based practice

Competency Definition Learning process Assessment

Patient care Clinical skills Authentic learning,

simulation

Workplace-based

assessment, Mini-CEX,

DOPS, PBA,

Medical knowledge &

skills

Basic Science & Clinical

knowledge

Lecture, SDL, Seminar MCQ, Essay, MEQ, SAQ,

CRQ, WBA, etc

Practice base learning

& improvement

Research skills, IT skills

Procedural skills, etc

Research project, authentic

practice, simulation

Research progress

DOPS, PBA, OSCE

Interpersonal &

communication skills

Presentation skills

Communication skills

Presentation, workshop,

authentic practice

Multisource feedback (360

degree assessment)

Professionalism Ethics, non-technical

skills

Workshop, authentic

practice

WBA, MSF

System based practice Patient safety, Rational

drug use, Quality

development, Risk

Seminar, workshop,

simulation, authentic

practice

WBA, project-based

assessment

Competency / Outcome based training

Entrustable professional activities (EPA) Prof. Olle ten Cate

•A unit of professional practice that can be fully entrusted to a trainee, as soon as he or she has demonstrated the necessary competence to execute this activity unsupervised”

Benefit of EPAs

• Trust • Guide learning, teaching & coaching • Assessment • Specific feedback

Milestone: A behavioral descriptor that marks a level of performance for a given competency L1 not allowed to practice the EPA

L2 practice the EPA with full supervision

L3 practice the EPA with supervision on demand

L4 unsupervised” practice allowed

L5 supervision task may be given

EPAs in Anesthesiology…trainee should be able to provide… 1. proper perioperative care including complication management for

patients undergoing general anesthesia (WPBA)

2. proper perioperative care including complication management for patients undergoing regional anesthesia (WPBA)

3. appropriate airway management (WPBA)

4. cardiopulmonary resuscitation (simulation)

5. respiratory care and crisis management (simulation, WPBA)

6. pain management (WPBA)

Overview of EPAs –Competency matrix Competency EPA1 EPA2 EPA3 EPA4 EPA5 EPA6

Patient care

Medical knowledge

Practice based learning & improvement

Interpersonal & Communication skills

Professionalism

System based practice

Workplace based assessment

Clinical skills

X Perioperative care in general( non subspecialty), simple patients, simple procedure

Y Perioperative care in complicated patients, complicated procedures

Milestones: entrustment level

Level of

resident

Type of clinical

skills (MUST)

Milestone: level

6 mo 12 mo

1 X 2 3

2 X

Y

3-4

2

4

3

3 X

Y

4-5

3-4

4-5

4

EPA 1: Perioperative care including complication management for patients undergoing general anesthesia Title of the EPA Perioperative care including complication management for

patients undergoing general anesthesia Specifications 1.Providing preop. evaluation & preparation

2.Providing plan & conduct 3.Use and interpretation of monitoring and equipment 4.Providing intra and post anesthetic care 5.Managing airway 6.Providing technical skills 7.Manage crisis 8.Manage peri-anesthetic /peri-procedural complications 9.Communicating & team working 10.Demonstrate professionalism & non-technical skills

EPA 1: Perioperative care including complication management for patients undergoing general anesthesia Title of the EPA Perioperative care including complication management for

patients undergoing general anesthesia

Context Operating theater setting

Domains of competence Patient care / Medical knowledge and skills / Practice-based learning / Interpersonal and communication skills / Professionalism / System-based practice

EPA 1: Perioperative care including complication management for patients undergoing general anesthesia Title of the EPA Perioperative care including complication management for

patients undergoing general anesthesia

Knowledge, skills, attitude and behavior and required experience for entrustment

Knowledge: preop.evaluation & preparation, choice of anesthesia, intraoperative and postoperative care, potential complications & management Skills: clinical reasoning and decision making, communication with patients and family, IV access, airway management, fluid & ventilator management, pain management Attitude and behavior: professionalism. Experience:

- Demonstrate experience coping with 2 simple patients undergoing general

anesthesia for uncomplicated surgery within 1st year of training

- Demonstrate experience coping with 2 complicated patients undergoing general

anesthesia for complicated surgery within 2nd year of training

EPA 1: Perioperative care including complication management for patients undergoing general anesthesia Title of the EPA Perioperative care including complication management for patients

undergoing general anesthesia

Assessment information source to assess progress and ground for a summative entrustment decision

- Direct observation, Anes-CEX

- Information from colleagues (multisource feedback)

- Medical records

Check list EPA Item correct Partial

correct incorrect Note for

feedback

1.Providing preop. evaluation & preparation

2.Providing plan & conduct

3.Use and interpretation of monitoring and equipment

4.Providing intra and post anesthetic care

5.Managing airway

6.Providing technical skills

7.Manage crisis

8.Manage peri-anesthetic /peri-procedural complications

9.Communicating & team working

10.Demonstrate professionalism & non-technical skills (responsibility, situation awareness)

Global assessment L1not allowed to practice the EPA L2practice the EPA with full supervision L3 practice the EPA with supervision on demand L4 unsupervised” practice allowed L5 supervision task may be given

Feedback…………………………………………………………………………………

E- Anes CEX for EPAs assessment in Mobile phone

ANESLOG

Global entrustment level

Comment

Self reflection

Brainstorming: selection of mandatory neonatal cases & procedures Co-morbidity/ Congenital anomalies Must Should May

Common congenital heart diseases:

ASD, VSD, PDA, TOF

Complicated congenital heart

diseases: TGA, Single ventricle

Common congenital anomalies:

Down syndrome

Rare/Complicated congenital

anomalies

URI

Laryngospasm

Airway obstruction

Laryngeal edema

Emergence delirium

Neonates

Premature babies

Difficult airway

Hypothermia

Malignant hyperthermia

Muscular dystrophy

Glucose, fluid, electrolyte

management

Massive bleeding

Postoperative pain management

Chronic/cancer pain management

Anesthetic procedures Must Should May

Inhalation induction

Mask ventilation

Under mask technique

Endotracheal intubation in

infant and children

Endotracheal intubation in

neonate

LMA in pediatric patients

Fiberoptic intubation in

pediatric patients

Ventilator setting in

neonate and infant

Peripheral nerve block

- Ilioinguinal,

iliohypogastic nerve

block

- Penile block

- Brachial block

- TAP block

Caudal block

Lumbar epidural block

Diagnosis/type of operation Must Should May

Gastroschisis/omphalocele

Congenital diaphragmatic hernia

Tracheoesophageal fiatula

Pyloric stenosis

Necrotizing enterocolitis

Retinopathy of prematurity

Strabismus & muscle correction

Adenotonsillectomy

Tympanoplasty

Craniotomy

Craniofacial reconstruction

Thoracotomy

Endoscopic surgery

Frenulotomy (tongue tie)

Muscle biopsy

Upper abdominal surgery

Lower abdominal surgery

Groin, perineal and anorectal

surgery

R1 R2 R3

Asse

ssm

en

t fo

r E

ntr

usta

ble

pro

fessio

na

l a

cti

vit

y

(EP

A)

1 Basic RA L4 #1

2 Basic GA ETT L4 #2

3 Basic GA under mask L4 #1

4 Complicated surgery L4 #1

5 Basic OB GA L4 #1

6 Basic OB RA L4 #1

7 Complicated OB L4 #1

8 GA supraglotic device L4 #1

9 Pediatrics L4 #1

10 Intracranial surgery L4 #1

11 Airway procedure L4 #1

12 Painless labor L4 #1

13 Neonate/infant L4 #1

14 Simple open cardiac surgery L4 #1

15 Thoracic surgery L4 #1

16 Acute pain L4 #1

17 Cancer/neuropathic pain L3 #1

Selection of Clinical skills, EPA & Milestones

Questions

• Minimum number of EPAs to assess for competency achievement

• Practicality

Thank you