CompetencyBased Health Professions Education: Why Should We Do It

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Competency-Based Health Professions Education
Why Should We Do It?

• Ruth B. Hoppe, MD, FACP, Director
• MSU Health Professions Colleges
• Learning and Assessment Center

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Congratulations

• On your commitment to quality nursing education
• On your efforts on behalf of quality for patients
  and health systems

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Medical Education Nursing Education
Medical Education
Nursing Education
Differences in Content, Process, Assessment,
Focus on the Patient, Focus on Education,
Willingness to Change
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Medical Education Nursing Education
Medical Education
Nursing Education
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Local Experience Acid-Base Disorders

• Students could answer
• The distal nephron is the principle site for
  reabsorption of
• a. Bicarbonate
• b. Chloride
• c. Hydrogen ion
• d. Potassium
• e. Sodium

• But couldnt figure out
• A patient presents with hypertension, serum
  potassium of 2.9 and a serum bicarbonate of 33
  (meq/L respectively). Which area of the nephron
  is most likely involved in this process?

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National Experience USMLE Step 2 Clinical Skills
Examination

• Highly interrogatory approach to communication
  just the facts maam
• Little attention to patient feelings even when
  directly expressed
• Inefficient data collection unfocused approach
  lack of hypothesis- driven questioning
• Cursory physical examinations
• Poor technique
• Inappropriate conclusions based on data aortic
  stenosis murmur

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More Evidence

• Deficiencies in medical interviewing performance
  (students)
• Deficiencies in cardiac auscultation skills
  (internal medicine and family practice residents)
• Deficiencies in procedural skills (practicing
  internists)
• Deficiencies in recognizing physical findings
  associated with HIV infection (practicing primary
  care physicians)

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• Are Our Graduates Competent?
• Do We Know?

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Competence

• the habitual and judicious use of
  communication, knowledge, technical skills,
  clinical reasoning, emotions, values, and
  reflection in daily practice for the benefit of
  the individual and the community being served.
• Epstein and Hundert
• JAMA, 2001

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Our educational focus has been

• KNOWS
• KNOWS HOW

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Traditional Educational Approaches

• Lecturing/
• Demonstrating
• Testing Command of
• Knowledge
• Experiencing Clinical Apprenticeships

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Does Knowing Imply Competency?

• KNOWS
• KNOWS HOW
• SHOWS HOW
• DOES COMPETENTLY
• DOES PROFICIENTLY

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Questions for Educators

• What levels are our responsibility as educators?
• How adequate are our curricula AND ASSESSMENT
  techniques given these tasks?
• Do we have the right data to tell?

• KNOWS
• KNOWS HOW
• SHOWS HOW
• DOES COMPETENTLY
• DOES PROFICIENTLY

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Problems with Traditional Approaches

• Focus on isolated knowledge bits students dont
  see and arent motivated by BIG PICTURE also,
  the bits leave
• much of task for INTEGRATION and APPLICATION
  to the student
• Student Engagement lecture attendance,
  participation, hyper-focus on exam
• Faculty focused on teaching less emphasis on
  discerning impact of their efforts on learning
• Students progress at different paces
• Faculty arent knowledgeable enough about
  aggregate results of instruction relative to
  broad curricular goals little data
• Employers unhappy with products want more
  practice-ready graduates

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Clinical environments degrading as educational
sites

• Low rates of hospitalization for many problems
• High intensity of illness make patients less
  available
• Short stays make patients less available
• Ambulatory settings have become high volume due
  to reimbursement problems
• Patients less willing to participate as
  educational subjects
• Bottom Line too hit and miss

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Is There a Cascade Effect?

• Does inadequate education at one level of
  training affect skills at subsequent levels? If
  so, then _______ school may be the most
  critical period for developing important habits,
  attitudes, and clinical reasoning
  approaches.and may influence subsequent
  clinical competencies
• Goldstein et al, AcadMed. 200580423-433.

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Lots of calls for curriculum reform

• Focus has been on modernizing content usually
  means INCREASE
• Driven by contemporary health care environment
  (e.g. health care financing)
• Little attention to BASIC competencies

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Era of Accountability

• The competency standards movement in Britain,
  Australia, New Zealand, and the United States is
  closely tied to political initiatives for global
  competitiveness and accountability (Chappell
  1996 Jackson 1994). The fundamental issue is
  whether and to what extent vocationalism should
  drive education.
• S. Kerka, 1998, Competency Based Education and
  Training Myths and Realities, Clearinghouse on Ad
  ult, Career,and Vocational Education  (ACVE)
  www.cete.org/acve/docgen.asp?tblmrID65

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A Breath of Fresh Air
Three decades of focus on assessments and outcomes
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Alvernos Ability-Based Curriculum

• The distinctive feature of an ability-based
  approach is that we make explicit the expectation
  that students should be able to do something with
  what they know

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Alvernos Specific Abilities

• Communication
• Analysis
• Problem Solving
• Valuing in Decision-Making
• Social Interaction
• Developing a Global Perspective
• Effective Citizenship
• Aesthetic Engagement

Six levels of achievement for each ability. Each
level serves as a gateway
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Competency Based Education (CBE) How is it
Different?

• Begin with the end in mind
• Main focus should always be on the
• outcome of the education, rather than
• the process.
• The process is important, but should
• be planned and carried out with the
• outcome of competency in mind.

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Competency-Based Instruction

• Ability to assess competency at the end of stages
  of the program to allow promotion, graduation
• Ability to assess competency development as
  students learn

Learning
Assessment
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Whats Really New?

• The articulation of competencies that can be
  measured
• The act of measurement
• The modification of trainee experience and/or
  programs based on assessment results
• The relationships that evolve during the act of
  measurement

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Criticisms of Competency Based Education

• Too reductionistic with behaviors measured
  yes/no with a checklist (monkey-like)
• Doesnt take into context into account
• More holistic views see competence not as
• trained behavior but thoughtful capabilities
  and a developmental process
• See Kerka

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WHY CBE?

• Society has the right to know that physicians
  who
• graduate from medical school and subsequent
• residency training programs are competent and
  can
• practice their profession in a compassionate and
• skillful manner. It is the responsibility of the
  medical
• school to demonstrate that such competence has
• been achieved and the responsibility of the
• accreditation agencies to certify that the
  educational
• programs in medical schools can do what they
• promise.
• Assessment is of fundamental importance because
  it is central to public accountability.
• Shumway,J.M, Harden, R.M. AMEE Guide No. 25
  The
• assessment of learning outcomes for the competent
  and reflective
• physician. Medical Teacher, 2003, 25, 569-584).

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Medicine Meets Competency Based Education and
Training

• LCME seeking program-wide evidence
• ACGME rolling out six competencies
• Licensure adopting new assessment methods looking
  at SKILLS
• Mandatory RE-certification now ubiquitous and is
  performance oriented
• Credentialing processes seeking evidence of
  competence
• CME starting to move toward practice-based
  learning needs

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Commitment to competency-based education ushers
in the need

• To articulate clearly the things needing to be
  assessed not easy!
• For help with assessment new tools
• The ability to simulate technology to the rescue

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Simulation Tools

• Synthetic models and mannequins
• Animal models
• Standardized patients
• Computer simulations
• Virtual reality
• Computer-driven synthetic models and mannequins

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This was the first time I had any standardized
patient contact. I feel that this should be a
part of all advanced practice programs (medical,
nursing etc.). It was probably the best and most
real learning situation I have ever been involved
in. I wish there had of been this type of
environment in my midwifery education
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MSUs Learning and Assessment Center
Opens Winter 2006 6th Floor Fee Hall
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The LAC A Joint Venture by CON, CHM, COM, CVM

Purpose To enhance health professions education,
increase patient safety, stimulate the
development of performance-based curriculum, and
serve as a regional resource for the continuous
development of practicing professionals. www.lac
.msu.edu
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Potential Advantages of CBE

• Makes the curriculum to take on a more holistic
  appearance and coherence be more than a string
  of beads
• Gets whole faculty to address and assume
  ownership for the basic competencies
• Makes clear to students what the expectations are
• Improves the system of feedback to students
• Gets the learner more engaged and acting
  responsibly
• Provides data for decisions about students,
  about program effectiveness, about value added.
• Opens focused dialogue with employers and
  external environment

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Challenges of CBE

• Requires College investment workshops,
  simulation tools, electronic portfolios
• Time challenge requires faculty to spend time to
  alter old products and methods
• Requires faculty to learn new concepts
  (assessment methods) and new skills (feedback)
  may threaten experts
• Is very hands on which challenges larger
  programs

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Elements of Success

• Learn the basic principles but be creative about
  adaptation for local circumstances
• Focus on integrated core competencies
• Start slow build on strengths
• Innovate dont be afraid to try something
  different
• Avoid perfectionism the perfect is the enemy of
  the good
• Dont reinvent the wheel collaborate
• Involve faculty in conduct of assessments its
  motivating!

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Your strengths

• You have a mandate need for nurses
• You have an opportunity new programs
• You have assets Gardner Center, Learning and
  Assessment Center, Distance Learning resources

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The Goal

• Graduates that are more practice ready

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In Summary

• Congratulations about your vision and about your
  accomplishments to date
• Hang in there this CAN be done
• Good luck!