CBME, by the ICBME Collaborators, Competency-based medical education
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Why Readiness Matters Before Moving to Competency-Based Education: The Case of Pharmacy Education

By: Krisy Thornby, PharmD, BCPS; Denise H. Rhoney, PharmD, FCCP, FNCS, MCCM; Aleda M. H. Chen, PharmD, MS, PhD, FAPhA

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Anyone who has engaged in curricular reform knows that approving a new curriculum is rarely enough to produce meaningful change. The Rider, Elephant, and Path metaphor offers an intuitive way to understand why.1 The Rider needs a clear direction: people must understand the rationale for the reform and what they are expected to do differently. The Elephant needs energy and commitment: faculty and leaders must believe the change matters, feel capable of contributing, and be willing to persist when the work becomes difficult. The Path must make change possible through supportive policies, resources, infrastructure, workflows, and relationships. Sustainable curriculum reform requires attention to all three. A clear plan cannot overcome a lack of commitment, and even highly committed people may be unable to act when the surrounding system does not support them. 

Competency-based pharmacy education (CBPE) is no exception. Since 2021, the American Association of Colleges of Pharmacy (AACP) has led efforts to explore what it would take to move from traditional, time-based curricula to a model that prioritizes learners’ competence and the progressive development of knowledge, skills, and abilities needed for practice.2 

Using implementation science to understand change

Much of the conversation surrounding CBPE implementation has focused on what a competency-based curriculum should look like, and the essential elements needed to support it. Published frameworks in both medical and pharmacy education describe a similar stepwise approach that begins with defining competencies, designing curricula, selecting assessment strategies, investing in faculty development, and continuously evaluating outcomes.3,4 Although these steps are important, implementation science shifts the focus from what should be implemented to what needs to happen for this type of change to be sustainable and successful.

Readiness must be considered at two interdependent levels: whether the organization provides the conditions needed for change and whether people in key roles have the capability, opportunity, and motivation to perform the behaviors CBPE requires. One widely used framework in healthcare research is the Behavior Change Wheel (BCW), developed by Michie and colleagues.5,6 The BCW begins by defining the implementation problem in behavioral terms, identifying and specifying the behaviors that must change, and determining what must change in Capability, Opportunity, and Motivation to support those Behaviors (COM-B). We applied this approach to examine readiness for CBPE implementation by identifying the behaviors needed to implement the five core components of CBE described by Van Melle and colleagues.7 The Rider, Elephant, and Path metaphor introduced earlier helps make COM-B intuitive, although it is not a direct substitute for the model. The Rider aligns most closely with aspects of Capability, including understanding CBPE and knowing how to perform the required behaviors. The Elephant aligns most closely with Motivation, including beliefs, confidence, professional identity, perceived value, and willingness to initiate and sustain change. The Path aligns most closely with Opportunity, including time, resources, workflows, policies, authority, technology, and social support. A constraint in any one of these may prevent a required CBPE behavior from occurring. The Theoretical Domains Framework (TDF) provides a more detailed set of domains for identifying the barriers and facilitators that influence the target behaviors, including knowledge and skills, professional roles, beliefs, goals, social influences, and environmental context.5,8,9 Together, COM-B and the TDF can help identify what may need to change and inform the selection of appropriate implementation strategies.8,9

Developing the readiness instruments

Before developing the readiness instruments, we first asked a simple question: What behaviors need to change for CBPE to be successfully implemented? Our earlier work included 35 focus groups representing seven stakeholder groups, including faculty, preceptors, students, practitioners, residency directors, and academic and CEO deans. These conversations explored the beliefs, barriers, and conditions that influence readiness for change and revealed three recurring themes: student strengths and challenges, gaps in pharmacy education, and the need to better align the profession with the needs of society.10

Building on these findings, we developed readiness instruments grounded in COM-B, the TDF, and the five core components of competency-based education (CBE).7 We then refined the instruments through a Delphi process, cognitive interviews, and expert review to ensure they were both theory-informed and practical for use. The resulting instruments assess readiness through the lens of capability, opportunity, and motivation, with separate instruments developed for faculty and deans.

What we learned and what’s next

As we tested the instruments with 32 deans and 36 faculty, one of our biggest takeaways was that readiness looks different depending on the role. Faculty, academic leaders, and CEO deans all contribute to CBPE implementation, but they do so in distinct ways. 

Participants emphasized that readiness involves much more than educating people about CBPE; shared terminology, clear expectations, and actionable feedback help institutions understand their current state and identify the next steps. Future work will focus on developing scoring guidance, implementation resources, and tailored strategies that help programs address identified readiness gaps and support successful CBPE implementation.

Although this approach began in pharmacy education, it has implications across health professions considering CBE or large-scale curricular transformation.

Summary

Cultivating readiness for change begins long before a new curriculum is introduced. It starts with understanding the behaviors that need to change, identifying the stakeholders who will make that change possible, and keeping the five core components of CBE at the center of the conversation.7 There is no one-size-fits-all roadmap. Every institution has its own culture, priorities, strengths, and challenges.Rather than assuming every program needs the same solution, readiness assessment helps identify where support is needed so that strategies can be tailored to the people and systems responsible for making change happen.

Transforming pharmacy education is a collective effort, and the BCW provides a structured way to understand readiness and the barriers and facilitators that influence change. This helps institutions move beyond asking “Are we ready?” to answering “What do we need to do next?”

Refrences:

  1. Heath C, Heath D. Switch: How to Change Things When Change Is Hard. New York, NY: Broadway Books; 2010. 
  2. Rhoney DH, Meyer SM. AACP’s Strategic Commitment to Improving Pharmacy Education: Past, Present, and Future. Am J Pharm Educ. 2024;88(2):100636. doi:10.1016/j.ajpe.2023.100636
  3. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645.
  4. Koster A, Schalekamp T, Meijerman I. Implementation of competency based pharmacy education (CBPE). Pharmacy (Basel). 2017;5(1):10.
  5. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. doi:10.1186/1748-5908-6-42
  6. Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing Interventions. Silverback Publishing; 2014
  7. Van Melle E, Frank JR, Holmboe ES, et al. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Acad Med. 2019;94(7):1002-1009. doi:10.1097/ACM.0000000000002743 
  8. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. Published 2017 Jun 21. doi:10.1186/s13012-017-0605-9
  9. Dyson J, Cowdell F. How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review. Int J Qual Health Care. 2021;33(3):mzab106. doi:10.1093/intqhc/mzab106 
  10. Rhoney DH, Chen AMH, Daugherty KK, et al. Identifying stakeholder behaviors for competency-based pharmacy education: A stage 1 behavior change wheel analysis. Res Social Adm Pharm. Published online June 18, 2026. doi:10.1016/j.sapharm.2026.06.006

About the Authors:

Krisy Thornby, PharmD, BCPS, is a Professor of Pharmacy Practice at Palm Beach Atlantic University’s Gregory School of Pharmacy. She has served on AACP’s Academic Affairs Committee since 2023, working alongside committed colleagues to advance competency-based pharmacy education (CBPE) initiatives, and currently serves as committee chair. 

Denise H. Rhoney, PharmD, FCCP, FNCS, MCCM, is the Ronald and Nancy McFarlane Distinguished Professor at the UNC Eshelman School of Pharmacy and President of ACCP. A nationally recognized leader in critical care and educational innovation, her scholarship spans neurocritical care, competency-based education, and implementation science. 

Aleda M. H. Chen, PharmD, MS, PhD, FAPhA is Director of Assessment and Professor of Pharmacy Practice at the University of Arkansas for Medical Sciences. She has worked on CBPE with AACP since 2020, and her research interests include CBHPE, implementation science, and assessment

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