that are characteristic of CBME.These include focusing on outcomes, emphasizing abilities, de-emphasizing time-based training, and promoting greater learner-centeredness (Table11.2). Education that follows these principles ensures that every graduate is prepared for practice.

are essential activities for the learner: planning phase, learn­ing phase, assessing phase, and adjusting phase. During the planning phase, learners identify gaps in their knowledge/ skills/ attitudes, prioritize opportunities for learning, create a goal, and search for resources. Throughout the learning phase, residents employ active learning strategies and criti­cally appraise resources. In the assessment phase, the resi­dents implement what was learned or “try it out.” Next, they compare their unguided self-assessment with an informed self-assessment utilizing external feedback such as feedback from faculty, patients, staff, colleagues, and patient outcomes [16]. Lastly, in the adjustment phase, the learner incorporates what was learned into their practice.

cal education curriculum design and assessment is a hierar­chical creation of curriculum implemented upon learners with minimal variation to address individual learner needs. In contrast, CBME requires the co-production of the curricu­lum and assessment between learners and instructors. The informed self-assessment required for learners to identify and plan their learning “requires that learners proactively seek out assessment from faculty and members of the health­care team, perform aspects of their own assessment such as clinical performance reviews or evidence-based practice and actively engage their assessment data for professional devel­opment as part of their own accountability.” Clinicians with this type of engagement in continual learning are essential to the improvement in healthcare quality that CBME promises.

Given the new terminology necessary for the implementa­tion of CBME, educators can get confused about the differ­ence between competencies, sub-competencies, milestones, EPAs and core outcomes. The ACGME Core Competencies, patient care; medical knowledge; practice-based learning and improvement; professionalism; interpersonal skills and communication; and systems-based practice are general characteristics of a learner that imply knowledge, skills and attitudes that a learner in any medical specialty must have to be successful in practice [10, 70]. Each discipline has parsed the core competencies into sub-competencies that describe the critical components of practice for that discipline (Family med milestones). For example, within the patient care com­petency in family medicine, the rst sub-competency is “Patient care 1: Care of the acutely ill patient” (Fig.11.2). Other patient care sub-competencies in family medicine include care for patients with chronic illnesses, health pro­motion, care of patients with undifferentiated signs and sys­tems, and procedural care. Within each sub-competency, each discipline has dened a series of milestones, which are observable descriptions of the knowledge, skills, attitudes, and other attributes of elements of a sub-competency orga-

nized in a developmental framework (Family med mile­stones). The sequenced progression of sub-competency acquisition within the milestones describes a common path to growth in learners of every discipline. Indeed, most chil­dren do crawl before they walk. However, outliers exist in normal development. Therefore, learners might acquire more advanced skills prior to demonstrating basic skills. Similarly, a normal learning curve might include a delay in a given sub­competency. The milestones detail a common path to skill acquisition. They are not a perfect description of the learning journey for every student.

ReviewCommittee for review on the individual and pro­gram levels.

The Critical Question: What Happens When aLearner Does Not Meet Core Outcomes?

must consider this fact. Bowe and Armstrong [11] offer a holistic framework for such evaluation, which is simple and elegant.

health care system.” The ACGME’s NAS included a require­ment for a 10-yr Self-Study that was an excellent example of level 3 analysis [47, 49, 58, 62]. However, the ACGME logistically was unable to continue site visits associated with these Self-Studies [1]. The future of ACGME-mandated Self-Studies remains unclear. Regardless, level 3 processes remain an important step for the success of CBME.Therefore, the steps of the ACGME Self-Study will serve as an example of a level 3 process. Philibert and Lieh-Lai [58] recommend that an evaluation group, which could be the program’s PEC or another subset of stakeholders within the residency, assembles and aggregates data from Annual Program Evaluations (APEs). The APE analysis can simply be a review of the documents themselves with an eye toward trends that inform a longitudinal assessment of the program’s improvement efforts. Using the initial analysis as back­ground, the evaluation group meets with stakeholders within and external to the residency to consider the program’s aims. Once the aims are reviewed and updated (as necessary), the evaluation team performs a SWOT analysis, identifying strengths, weaknesses, opportunities, and threats for the pro­gram [22]. The evaluation team then presents the ndings of the Self-Study with the program leadership and constituents to come to consensus on improvement priorities for the next several years. The process is completed by documenting the ndings and recommendations of the study. As an example, the PEC for a residency program could schedule an extra meeting to review the APEs from the last several years. This could be followed by a resident-faculty meeting to review the identied trends and discuss the aims of the program. A SWOT analysis could be conducted by the residents and fac­ulty at that meeting. External stakeholders such as the DIO, leaders of key off-service rotations, and operational leaders at the FMP could review the SWOT analysis asynchronously and offer additional suggestions. The PEC chair could create a document listing all the ndings to date and share it with the program leadership, working together to draft a list of key improvement goals for the next several years. These goals could be shared with the PEC at its next meeting. Following a discussion, the APE for the next year could include an action plan reecting those goals. This process could occur over a year and would only require a few hours of time from the PEC, the PD, and a resident-faculty meet­ing. However, the power of such a process to anticipate future changes and prepare the program to seize opportuni­ties and respond to threats allows programs to excel, even amidst uncertain times.