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be required as long as needed.
Finally, another form of an entrustment decision is the
scheduled or planned entrustment. For example, many
postgraduate medical education programs use night float
systems where learners cover patient services overnight,
often without direct faculty supervision (e.g., on-site
supervision) being readily available. These night float
rotations are usually baked into the learners’ rotational
schedule regardless of whether they are truly ready for this
responsibility. This “level 4” entrustment decision is
sometimes called “level 4a,” meaning that a supervisor is on
call and accessible through telephone if needed. As another
example, changes in supervision are often based on the
learner’s year of postgraduate training regardless of whether
the learner is truly ready. These types of entrustment
decisions should ideally be based on robust assessment data
and treated more as a summative type of assessment. In fact,
entrustment decisions based on merely the time period in
training contradicts the philosophy of competency-based
education.
Use Multiple Sources of Information to
Support Entrustment Decisions
While ad hoc decisions to trust a trainee are usually taken by
individuals and are very much situated in time and place,
summative and planned entrustment decisions must be
grounded in multiple identifiable sources of information
(Table 1.7). The sources of information to inform entrustment
decisions are not necessarily different for other WBAs.
Chapter 3 provides guidance on programmatic assessment.
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Table 1.7
Sources of Information to Support Summative Entrustment
Decisions
Sources Examples
1.
Knowledge
testing
Written or e-tests, case-based discussions,
assessment of clinical reasoning in vivo, casebased discussions, chart-stimulated recall
2. Short
practice
observations
Mini-CEX, DOPS, handoffs, video, and other (119)
3. Long
practice
observations
Multisource feedback, review of shifts and
rotations, daily shift cards
4.
Simulation
tests
OSCE, OSATS,a standardized patient tests
5. Work
product
evaluation
EHR entries, presentations, papers, reports, event
analysis, review of quality and safety performance
measures
a
Can also be used as a direct observation tool.
CEX, Clinical evaluation exercise; DOPS, direct observation of procedural skills;
EHR, electronic health record; OSATS, objective structured assessment of
technical skill; OSCE, objective structured clinical examination.
Entrustment Is an Approach to
Assessment Requiring a Prospective
Outlook
In most of education, the primary question is: Has the
student met all the objectives and requirements that a school
or program has set? In health professions education, an
important additional question is: Is the learner ready to be
licensed for practice? This essentially is an entrustment
question. It is a question that forces one to stop and think of
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future situations, and not just look back at what a learner has
done. Schools, programs, and clinical educators should, for
instance, not graduate health professionals if they would not
trust them to attend to their own family members.
175
Making
entrustment decisions for smaller units of practice than a
license means both weighing everything that is important for
autonomous practice and a deliberate willingness to accept
the risks that adverse events could happen. The breadth of
healthcare with which graduates are entrusted may be more
than supervisors have been able to observe, and could even
be more than the graduate has encountered in training. This
requires a shift in traditional thinking, from retrospective to
prospective, and arguably even extending the “does” level of
Miller’s pyramid. Ready to be trusted with unfamiliar
situations has led to suggest a fifth level of the pyramid
176
(see Fig. 1.12).
FIG. 1.12 “Extended” Miller’s pyramid with entrustment.
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The evaluation of learners at this level includes features
that many clinicians have acknowledged as important when
trusting them with critical care tasks. Ten Cate and Chen
reviewed several studies with this focus and concluded that,
besides specific capability (knowledge and skill, experience,
adaptive expertise), additional areas to assess include
reliability (conscientious, predictable, accountable,
responsible), integrity (truthful, good intentions, patient
centered), humility (observing limits, willing to ask for help,
receptive to feedback), and agency (self-confident; proactive
toward work, team, safety, and development). To remember
this with an acronym, they suggested thinking, prospectively,
of A RICH entrustment decision (A = Agency; R = Reliability;
I = Integrity; C = Capability; H = Humility).
177
Systems of Assessment
(See Chapters 3 and 18.)
As the section on Competency milestones and EPAs clearly
highlights, regardless of whether your program decides to
utilize these developmental concepts, all medical education
programs need a robust assessment program (i.e.,
programmatic assessment) using a multifaceted array of
assessment methods embedded in an effective educational
system. The movement toward outcomes-based education
and assessment presents many challenges for medical
educators. Educational leaders will need to integrate
traditional and new assessment methods into their
educational programs to ensure that individual trainees meet
important educational and professional goals and to inform
continued quality improvement of their programs.
Assessment approaches must be clearly aligned with
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educational objectives and congruent with teaching and
learning methods as highlighted by the core components
framework. Assessment should be closely intertwined with
instructional activities to optimize efficient use of resources
and to consolidate learning. The assessment system will need
to include multiple methods to capture each general
competency and ideally to provide for the assessment of
different aspects of each competency by different methods.
Program and clerkship directors will need to prepare the
assessors, through implementation of robust faculty
development programs, and inform and engage trainees for
the assessment system to succeed.
Beyond the performance of individual trainees, the
assessment system will need to support the continuous
collection and analysis of aggregate data to provide feedback
regarding the quality of the educational program. This
includes information from more traditional assessment
methods, such as program-level subscores on MCQ
examinations or aggregate case–level data from clinical skills
examinations, as well as composite scores or ratings from
newer methods such as multisource feedback, computer
simulation–based exercises, and a robust combination of
work-based assessments. It also involves collection and
analysis of clinical information, such as adherence with
evidence-based healthcare processes or patient health
outcomes that can provide the impetus for curricular change
or feedback on the quality of educational interventions.
Establishing such a connection, at least at the institutional
level, will facilitate conduct of needed research to elucidate
the relationships between educational activities and
healthcare practices and outcomes. Competency milestones
and EPAs were created to facilitate this integration and
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connection.
In addition to compiling aggregate data within programs to
inform quality improvement initiatives, assessment systems
will need to enable information gathering regarding the
performance of program graduates. As with concurrent
measures, educational leaders will need to access and
incorporate into their assessment systems information about
the performance of the program’s graduates to guide quality
improvement efforts (see Chapter 18). Some information,
such as licensure actions, in-training or board certification
examination scores, or program director ratings, is available
in some jurisdictions. For example, medical schools in the
United States can access their graduates’ first-year
competency milestones data as one measure. Obtaining other
sources of information, such as specific performance
measures or clinical data, to provide additional feedback
regarding educational program quality will require more
effort. The formation of collaborative projects and networks
linking professional and clinical outcomes across the
spectrum of education and practice will facilitate
understanding and incorporation of information critical to
the continuous quality improvement of educational
programs.
Conclusion
Public and professional pressure to increase accountability
and quality improvement in clinical care has resulted in
important changes in medical education and assessment.
Delineation of essential physician competencies and
widespread implementation of outcomes-based medical
education, to varying degrees, has led to a critical review of
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the quality and methods used in the assessment of
competence and performance. Advances in technology and
psychometrics have supported continued refinement of
traditional assessment modalities and the development of
new approaches. Educational leaders now face challenges in
developing and integrating assessment programs embedded
within an effective system and overall educational program.
The core components framework is a good place for
programs to start examining their own “outcomeness”
42
(see
Appendix 1.3
for worksheet). They must understand the
psychometric and utility properties of various assessment
tools, consider their relevance to trainee level as well as to
instructional methods and educational objectives, and then
balance these factors against program culture and resource
availability in deciding what methods to use in their
assessment system. Educators need to understand the
evolving science of workplace-based assessment such as
quality and safety measures, patient experience surveys, and
PROMs. The use of qualitative assessments and judgment
techniques, combined with group process, is also growing in
importance for assessment programs. Finally, health
professions educators must understand and use systems
thinking (see Chapters 3 and 18). The chapters that follow are
intended to help guide educational leaders in designing their
assessment programs and systems to support evaluation of
individual trainees and continuous quality improvement of
their educational programs for the benefit of the trainee,
program, and most importantly, patients and the public.
Acknowledgments
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The authors wish to sincerely thank Dr. John Norcini for
donating content from the first edition to this chapter.
Finally, we wish to thank Dr. Rich Hawkins, one of the
book’s editors of the first and second editions. We are very
appreciative of their graciousness and contributions to
previous versions of this chapter and their contributions to
medical education.
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