By: Mabel Yap, Kantharaj Reddy and Cedric Poh
Admin note: This blog is Part 2 in a series! Click here for Part 1
The Ministry of Health, Singapore (MOH) adopted the ADKAR model as a lens to frame our change management initiatives over the years as we transit to CBME anchored on EPAs (Figure 1).1 The ADKAR model is a framework for understanding change at an individual level and has been extended to show how businesses and government agencies can increase the likelihood that their changes are implemented successfully. It comprises five elements that must be in place for a change to be realised.
The ADKAR Model
Building Awareness
The first step of the ADKAR model was to raise awareness of the need to change through multiple communication channels. We invited to various workshops, stakeholders who were heavily involved in training and curriculum development and would likely be early adopters and supporters. These workshops include the “Ins and Outs of Entrustable Professional Activities” international workshop led by Prof Olle ten Cate and his international team of facilitators, as well as in-house EPA workshops conducted by trained local facilitators led by MOH’s Professional Training and Assessment Standards Division. We also presented the plans at the in-house town halls and education conferences of our healthcare institutions, to increase awareness amongst the early majority of faculty members and residents.
Creating Desire
The next step was to create desire amongst the relevant stakeholders after they learned of the upcoming changes. We appointed clinicians, usually faculty members from the programmes, to be EPA champions. They act as change leaders within their specialties to coordinate the change efforts. As they have been actively involved in the training processes, they were best equipped to assess risks, anticipate resistance, and remove obstacles unique to each specialties’ context.
To gain buy-in from specialties, we first embarked on a pilot study involving five specialties and Post-graduate Year 1s (PGY1s) [see note] ahead of the main transition. Representatives from these specialties often shared their achievements and successes from their pilot study with the rest. This allowed the other specialties to understand how much change was already happening and the Ministry’s commitment to this change. The message and desire were further strengthened when high-stakes examinations required for progression were cancelled or postponed due to the COVID-19 pandemic, prompting the need to establish a competency-based conditional progression framework to promote competent and deserving trainees.
Note: In Singapore, Post Graduate Year 1 (“PGY1”) serves as the transition year between basic medical education and full / conditional medical registration. The PGY1 training allows PGY1 doctor-trainees to gain the necessary clinical experience and skills as they assume increasing responsibilities and autonomy for patient care.
Developing Knowledge
After building awareness and creating desire, we proceeded to conduct a series of in-depth training sessions and developed job aides to facilitate knowledge acquisition.
Effective Training Programs
Trained MOH and local facilitators delivered structured workshops via a two-part series – EPA development and EPA implementation. The workshops were planned based on the andragogical model and adapted from the EPA International Course. We acknowledged the role of learning experiences in adult learning and how specialties come into the workshops with heterogenous knowledge of EPAs. Specialties accredited by the ACGME-I were familiar with using Milestones to guide curriculum development and forming Clinical Competency Committees as a form of accountability as medical educators to the public. On the other hand, the specialties that remained in the traditional basic/advanced/seamless training structure were less acquainted with these concepts and required more rigorous training and exposure to these concepts.
As a result, we needed to curate a learning experience that would be customised to each specialty based on their progress with support from our local facilitators. For instance, we embedded consultation sessions within the workshops for trainers to exercise flexibility in the learning outcomes for the respective specialties.
Job Aides
The provision of templates and checklists allowed the specialties to retain knowledge from their training and guided them in their EPA development. We adapted our EPA template from the work of ten Cate and Taylor.2 Most non-ACGME-I-accredited specialties did not have any existing frameworks of competencies. Therefore, these specialties were encouraged to elaborate on the template’s “knowledge, skills, and attitudes” section to capture critical features that learners must possess before a confident decision can be made to decrease supervision.
Furthermore, as most of the specialties were not using workplace-based assessment (WBA) tools to make summative decisions, efforts were made to guide specialties in listing the appropriate WBA tools in the EPA template to inform entrustment decisions. MOH also developed video resources to create a shared mental model within the specialty when adopting WBA tools such as entrustment-based discussions.
Fostering Ability
Training does not always lead to the ability to change or to adopt new processes and tools. Hence, we employed several strategies to develop the specialties’ ability to effect these changes. During the workshops, local facilitators were paired with their respective specialties. The facilitators then supported these specialties through their EPA development and implementation, and gradually reduced their assistance as specialties became more independent.
To further empower the specialties in the move towards CBME, a national level IT system and mobile application, MedHub, was adopted to support the timely capture and analysis of performance data for feedback provision, and promote learner agency and growth. Following the system roll-out, we have continued to communicate with the stakeholders to understand their IT-system needs and work with MedHub on national-level enhancements so that there is optimal usage of the system to support the needs.
Reinforcing Change
It is imperative to build reinforcement mechanisms to sustain change. From a system point of view, the attainment of requisite entrustment levels for residents is one of the key requirements for trainees to exit the training programme successfully. This policy highlights the importance of the change effort and the commitment towards it. The continual effort to train new trainers as subject matter experts to roll out national-level faculty development initiatives will help to further reinforce the change.
Conclusion
Singapore is now in the process of transiting all medical disciplines to use EPAs. The EPA movement in Singapore also includes other healthcare professions like nursing, dentistry, and the allied health disciplines. The resultant cross-exchange of knowledge and experiences has provided many valuable insights and highlighted some key areas for future work. These include strengthening faculty development and phasing in the use of EPAs while seeking feedback along the way, so as to smoothen the transition towards competency-based training. We will continue to support specialties in their transition to CBME anchored on EPAs.
ABOUT THE AUTHORS:
ADJUNCT ASSOCIATE PROFESSOR MABEL YAP IS DIRECTOR OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE AS WELL AS ADJUNCT ASSOCIATE PROFESSOR AT NATIONAL UNIVERSITY HOSPITAL SYSTEM AND DUKE-NUS MEDICAL SCHOOL.
MR KANTHARAJ REDDY IS ASSISTANT DIRECTOR OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE.
MR CEDRIC POH IS MANAGER OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE.
MINISTRY OF HEALTH SINGAPORE
References
1.Hiatt JM. ADKAR: A Model for Change in Business, Government, and Our Community. Prosci Learning Center Publications; 2006.
2. Ten Cate O, DR Taylor. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Med Teach. 2021;43(10):1106-1114.
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