Residency programs face the important task of determining whether their trainees have acquired the necessary competencies to provide high-quality, safe patient care. Historically, readiness for practice was defined by the completion of a prescribed number of years of training within an accredited residency program.Reference Hauer, Chesluk and Iobst1 However, in today's era of greater social accountability, the public has come to expect that programs have a process in place to ensure that their graduating physicians are adequately prepared for independent practice.Reference Cruess and Cruess2 Specifically, there have been calls for increased transparency in confirming the competence of graduating residents.Reference Frank, Snell and Cate3 In response, specialty training programs in Canada are undergoing a fundamental transformation from a time-based to an outcomes-based approach to delivering medical education, aptly named Competence By Design.Reference Frank, Snell and Cate3,4 The emergence and widespread adoption of a Competence By Design framework are in their earliest stages with novel innovations, curricular architectures, and various assessment strategies still in development, focusing on increased accountability and underscoring the importance of individualized learning.
Canadian emergency medicine (EM) specialty training programs implemented Competence By Design on July 1, 2018. With this transition, the responsibility for monitoring resident progress and making promotion decisions no longer falls solely on residency program directors. Instead, synthesis of resident assessment data and decisions about resident progress and promotions occur through a group process at the competence committee.5 Despite a year of experience formally implementing competence committees in Canadian EM specialty training programs, there remain many unanswered questions about how these committees should best approach their work of rendering judgments of competence.Reference Hauer, ten Cate and Boscardin6 What information sources should be used? What group processes should be applied to synthesize this information? How can one be sure that judgments and decisions about progress are trustworthy? Although some research on competence committees in the American context exists,Reference Hauer, Chesluk and Iobst1,Reference Hauer, ten Cate and Boscardin6 there is a paucity of literature to guide the work of competence committees specific to the Canadian context.
The purpose of the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education was to identify a consensus set of high-yield recommendations for educators and residency programs to enhance EM residency training. In this study, we describe the results of the consensus recommendations to optimize the function and decisions of competence committees in Canadian EM training programs.
Formation of our expert panel
The CAEP Academic Section assembled an expert working group including EM physicians from across the country, with attention to geographic representation, language, scope of practice, and experience in education scholarship and leadership. Final expert working group composition included nine Canadian emergency physicians representing eight medical schools in five provinces, and one content expert in competence committee scholarship from the University of California, San Francisco (K.E.H.). The expert working group included emergency physicians with certification from the College of Family Physicians of Canada through the Special Competence in Emergency Medicine (CCFP-EM) or EM certification through the Royal College of Physicians and Surgeons of Canada (FRCPC). The group had representation from a variety of education leadership positions and a mix of advanced training in medical education. They met monthly over 1 year by means of teleconference to design and implement the study and ultimately develop preliminary recommendations on EM competence committee best practices.
Study design and ethics
This qualitative study involved semistructured interviews of all competence committee chairs at each of the 14 FRCPC EM programs, including their satellite sites, to explore the purpose, structure, operations, and best practices of competence committees. Thematic analysis of the semi-structured interviews informed a set of preliminary recommendations which were presented, discussed, refined, and voted on at the 2019 CAEP Academic Symposium on Education in Halifax, Nova Scotia. This study was approved by the Ottawa Health Science Network Research Ethics Board (ID: 20180186-01H).
Development of interview guide
With the aid of a university librarian, we conducted a literature review regarding competence committee structure, processes, and best practices by searching PubMed, Embase, and Medline databases for related content.Reference Arksey and O'Malley7 Search terms included competence committee, clinical competency committee, clinical competence, committee membership, group decision making, progression decisions, competence assessment, workplace-based assessment, resident progression, resident competence. This review informed development of the interview guide for the semistructured interviews of competence committee chairs. All expert working group members participated in construction of the interview guide, and a content expert (K.E.H.) ensured that all relevant and emerging literature was captured. Interview questions addressed successes, challenges, and typical discussions occurring during competence committee meetings. W.J.C. and T.M. piloted the interview guide with five competence committee members who were known to the expert working group but were not participants in the study. Based on feedback from pilot participants, minor modifications were made to the wording of the interview guide for clarity and comprehensibility. The final interview guide is available as Online Supplemental Appendix A.
Data collection and analysis
Seven expert working group members conducted individual phone interviews with participants. All participants provided verbal consent. Interviews were audio recorded using Zoom Video Communications (San Jose, CA, USA) and were professionally transcribed. Interviews were deidentified during the transcription process. Three members (W.J.C., T.M., and T.M.C.) conducted an inductive thematic analysis using a qualitative approach described by Braun and Clarke: (a) become familiar with the data, (b) develop initial codes, (c) collate codes into themes, (d) review each theme, (e) define each theme, and (f) finalize the analysis.Reference Braun and Clarke8 Through joint discussions, the three members synthesized the codes from each interview and identified larger themes. They compared themes with the original transcripts to ensure that no themes were missed and to confirm that the themes accurately reflected the content of the interviews. All three investigators iteratively discussed differences in thematic interpretation until they reached agreement.
The expert working group reviewed the preliminary themes through a series of teleconferences and email correspondences. They collectively synthesized them into five dominant themes: (1) Competence Committee Membership, (2) High-Quality Data, (3) Competence Committee Meeting Process, (4) Competence Committee Decision Outcomes, and (5) Continuous Quality Improvement, and 11 preliminary recommendations within these five themes. These recommendations were presented to 60 emergency physicians at the 2019 CAEP Academic Symposium on Education in Halifax, Nova Scotia on May 25, 2019. Through a live presentation and survey poll guided by an expert working group member (TM), the audience engaged in a facilitated discussion of the recommendations to provide feedback on wording and organization. Revisions were made to the recommendations and the audience used an online platform (www.polleverywhere.com) to vote on the inclusion of revised recommendations based on a predetermined consensus threshold of 80%. Two recommendations did not achieve consensus (supplemental Material Appendix B). Here we present a final set of nine best practice recommendations to optimize the function of, and decisions made by, competence committees in Canadian EM training programs (Box 1).
SUMMARY OF RECOMMENDATIONS
Recommendation 1 Competence committee members should participate in regular faculty development addressing how the committee functions within the larger structure of their local postgraduate medical education system, its intrinsic processes and expected outputs.
Committee members may vary in their experience and knowledge of different assessment methods, competency frameworks, and committee processes.Reference Ekpenyong, Baker and Harris9,Reference Oudkerk Pool, Govaerts, Jaarsma and Driessen10 Frame of reference training can help members develop a shared mental model of the purpose of the committee and the performance expectations at each stage of training.Reference Holmboe and Hawkins11 Faculty development that focuses on group process can also help members mitigate the potential influences of personal cognitive biases and groupthink on committee decisions and outputs.Reference Hauer, ten Cate and Boscardin6,Reference Dickey, Thomas, Feroze, Nakshabandi and Cannon12 Member turnover and the expected evolution of committee processes (see recommendation 8) make it essential that new and longstanding members receive regular training. Such training can be scheduled during committee meetings or may occur as separate faculty development sessions that are organized locally or by national stakeholders.
Recommendation 2 Postgraduate training programs should establish well-defined descriptions of competence committee member qualifications, terms of service, and statements of work in the committee's Terms of Reference.
Committee member characteristics can influence the diversity and representativeness of information available during committee deliberations.Reference Hauer, ten Cate and Boscardin6 Individuals with a demonstrated commitment to improving trainee education should be recruited,Reference Holmboe, Rodak, Mills, McFarlane and Schultz13 and locally determined qualifications should be clearly outlined in the committee's Terms of Reference. Rotating members can help introduce new and diverse opinions and minimize groupthink.Reference Lewis, Belliveau, Herndon and Keller14 This can be accomplished by defining terms of service. The work of competence committees may require members to give of their time and energy outside of meetings (e.g., to review resident data). The member's statement of work should outline these expectations and supports available. To help streamline decision-making processes, the statements of work should also define individual member roles within the committee (e.g., Chair, Program Director) and delineate who are voting and nonvoting members.Reference Kinnear, Warm and Hauer15
Recommendation 3 The competence committee should be provided with data from multiple sources and contexts to generate a comprehensive overview of resident progression.
To make summative judgments of resident competence, the committee must incorporate multiple assessment methods that provide data that is sampled across content and clinical contexts, as well as over time.Reference Van Der Vleuten, Schuwirth and Driessen16 Competence is specific, not generic. Performance in one context does not predict performance in another. Regardless of what is being measured, or how it is being measured, assessment of resident competence and the observed performance are specific to the context.Reference van der Vleuten, Sluijsmans, Joosten-ten Brinke and Mulder17 Additionally, the concern over rater idiosyncrasies in workplace-based assessment can be mitigated by ensuring that data are collected from multiple observers.Reference Carraccio, Englander and Van Melle18 Designing a program of assessment, in which each competency domain is intentionally informed by multiple assessment sources and each source can be used to inform multiple competency domains, can help programs ensure that adequately sampled performance data inform competence committee decisions.Reference Schuwirth and Van Der Vleuten19
Recommendation 4 Discussion of trainee competence should follow clear processes and procedures to ensure fair and transparent resident progress decisions.
Applying structured group procedures facilitates information sharing among members and improves decision quality.Reference Hauer, ten Cate and Boscardin6,Reference Lu, Yuan and McLeod20 Committees should follow clear processes that outline what information is reviewed before and during meetings, how information is shared, and the defined goals of committee discussions. Structured procedures that enable sufficient time for discussion, solicit multiple perspectives, and encourage discussion of alternatives can also help to mitigate biased outcomes.Reference Mesmer-Magnus and Dechurch21,Reference Kerr and Tindale22 Competence committees should develop a “Process and Procedures” document that details the approach to group decision-making, including steps and requirements to reach a final decision (e.g., definition of quorum, process for reaching consensus or majority vote). Ensuring a transparent deliberation and decision-making process will enhance the credibility of the committee's outputs for stakeholders.Reference Donato, Alweis and Wenderoth23
Recommendation 5 Competence committee progress decisions should be based on documented data presented to the committee with specific avoidance of undocumented personal attestations.
The high-stakes decisions made by the competence committee must be credible and trustworthy.Reference Van Der Vleuten, Schuwirth, Driessen, Govaerts and Heeneman24 The introduction of undocumented personal attestations threatens to obscure the committee's decision-making process and introduce potential bias. Dickey et al., have highlighted several cognitive biases that committee members are susceptible to (e.g., bandwagon bias),Reference Dickey, Thomas, Feroze, Nakshabandi and Cannon12 which can emerge when discussions center around undocumented personal experiences. While data from informal sources, such as hallway conversations, may warrant further consideration, they may not always be captured by the formal program of assessment. Therefore, programs should have a process to document these informal data and reconcile them with other resident performance data at the competence committee. Ultimately, the judgments of the committee should stem from a transparent process that relies on data that can be audited by outsiders, if ncessary.Reference Donato, Alweis and Wenderoth23
Recommendation 6 Outcomes and decisions of competence committee proceedings should be promptly communicated to the residents.
Regular communication and performance feedback are powerful learning tools for medical trainees and are essential for personal and professional development.Reference Renting, Gans, Borleffs, Van Der Wal, Jaarsma and Cohen-Schotanus25 Residents with identified deficiencies in certain core knowledge areas, procedural dexterities, attitudes or any CanMEDS competencies should receive high-quality and detailed feedback to guide clinical and academic focus and remediation when needed.Reference Holmboe, Sherbino, Long, Swing and Frank26 Early identification and correction of perceived deficiencies promote clinical advancement, resident well-being, and improved patient care.Reference Carraccio, Wolfsthal, Englander, Ferentz and Martin27,Reference Bing-You and Trowbridge28 Regular feedback is equally important for residents progressing on track and those identified on an accelerated path to provide support and nurture them on a continued path toward mastery in EM.Reference Hauer, Chesluk and Iobst1 Regular communication should include not only the resident cohort, but also relevant stakeholders including their academic advisors and faculty coaches, when applicable.Reference Kinnear, Warm and Hauer15
Recommendation 7 Competence committee progress decisions should inform residents’ development of individualized learning plans with guidance from a faculty coach.
Reflective practice, essential for critical thinking and professional development, is an important skill residents must develop to achieve competence and progress through their training.Reference Albanese29,Reference Ericsson30 Transparency of progress decisions and consistent communication facilitate the development of trainee self-regulation and can inform individualized learning plans. These learning plans can help to close the gap between current and desired performance, and for those on an accelerated path, help them achieve mastery.Reference Nicol and Macfarlane-Dick31 Ensuring the trainee's faculty advisor or academic coach is also given timely access to the committee's findings enhances the utility of feedback, encourages reflective practice, and ensures the trainee has a point of contact to help maintain their developmental trajectory.Reference Gonzalo, Wolpaw, Krok, Pfeiffer and McCall-Hosenfeld32 An effective coach can help advance the trainee's potential and maximize clinical, professional, and academic performance.Reference Lovell33
Recommendation 8 Postgraduate training programs and local competence committees should engage in processes of continuous quality improvement to ensure high-quality data informs valid and defensible progress decisions.
Evaluation of individual competence committee processes and practices is crucial to reduce undesired resident assessment variability and to maintain a transparent, innovative and effective system for progress decisions.Reference Baartman, Prins, Kirschner and van der Vleuten34 Both internal and external stakeholders can be involved in systematically addressing and prioritizing gaps and challenges in the system with regular feedback from administration, faculty, and residents.Reference Brateanu, Thomascik, Koncilja, Spencer and Colbert35 The use of structured continuous quality-improvement practices can empower training programs with an approach to evaluate their processes and effectively restructure their procedures as necessary.Reference Kinnear, Warm and Hauer15,Reference Brateanu, Thomascik, Koncilja, Spencer and Colbert35
Recommendation 9 The national EM community should work collaboratively to share best practices and innovations in competence committee structure and process.
Competence committees across the country should engage in collaborative efforts and share information regarding challenges, best practices, and innovations. We live in the era of technological advancement where cross-program communication and collaboration by means of multiple online platforms is possible. Collaboration between programs will lead to increased efficiency, decreased time and effort on program assessment and redesign, and added mentorship and coaching from programs with greater infrastructure and resources. This collaboration has the potential to enhance the national standard for competence committee procedures and practices.Reference Gill, West, Watzak, Quiram, Pillow and Graham36
Competence committees are the cornerstone of a program of assessment within a competency-based medical education framework. In this study, we describe nine key consensus recommendations for EM competence committees addressing: committee membership, meeting processes, decision outcomes, as well as the use of high-quality performance data and engaging in processes of continuous quality improvement. Implementing these recommendations can optimize the function and decisions of competence committees in Canadian EM training programs.
The supplemental material for this article can be found at https://doi.org/10.1017/cem.2019.480.
The authors thank the competence committee chairs for their time and for sharing their insights and experiences. We also thank all of the many dedicated EM educators within our community who participated in the consensus conference in Halifax, Nova Scotia.
Transcription costs for this study were kindly supported by the Academic Section of the Canadian Association of Emergency Physicians.