By: David A. Turner, MD, Meghan O’Connor, MD and Michael A. Barone, MD MPH
Competency-Based Health Professions Education (CBHPE) represents a transformational change to education and assessment in the health professions, and this transition began more than half a century ago. (1,2) As we continue to advance this work as a global community, we often refer to CBHPE implementation as an endpoint – from which we can move on to the next important thing. We talk about education outcomes, entrustable professional activities (EPAs), competencies, coaching, programmatic assessment, and many other elements, but what we often do not explicitly discuss, particularly for those earlier in their CBHPE implementation efforts, is the fact that CBHPE implementation is indeed a journey, rather than a destination.
Helpful framing in this context, as each of us considers where we are in our CBHPE journey, is considering the implementation of CBHPE through a lens of Quality Improvement (QI). The overlap between the core tenets of QI and CBHPE is striking, with the starting assumption that the system can be improved, along with a focus on outcomes, systems-level thinking, local adaptation, and cycles of improvement. (3) This mindset – that we can continuously be doing better – is what our patients and their caregivers deserve. Thinking about this from a global perspective, implementation of CBHPE likely represents the largest QI project ever undertaken.
This perspective of viewing CBHPE through a QI lens also helps explain why implementation can feel messy, nonlinear, and sometimes frustrating. It reminds us that the goal is not perfection at launch. Like any complex improvement effort, CBHPE evolves through continuous learning, adaptation, and refinement over time.
The CBHPE Plan-Do-Study-Act Cycle
While there are many approaches to QI and organizing thinking around improvement, one well-described model is the “Plan-Do-Study-Act” (PDSA) approach. (4) The principles of this model are apparent when exploring almost every CBHPE implementation described, whether that is a national specialty or a single program advancing this work.
As an example:
Plan: Programs define desired outcomes using EPAs or another framework, design assessment systems, and prepare faculty and learners.
Do: New tools, curricula, coaching structures, assessment processes, and committee practices are introduced into real-world clinical learning environments.
Study: Data are collected. Faculty and learners provide feedback. Assessment patterns are examined. Outcomes are evaluated. Unintended consequences are identified.
Act: Programs refine assessment tools, modify faculty development efforts, adjust expectations, strengthen coaching relationships, and improve system processes based on what they have learned, and the cycle begins again….
Importantly, the cycles do not end. Each adaptation becomes the starting point for the next round of improvement as we collectively work to provide the best possible outcomes for our patients, through interventions in education and assessment.
Scaling Improvement Across Systems
One of the most interesting aspects of CBHPE is that PDSA cycles occur at multiple levels simultaneously.
A trainee may adapt how they approach clinical encounters and requests for feedback based on their experiences. An individual faculty member may refine how they provide feedback after each learner encounter and how they teach in the moment to the competencies. A training program may revise its overall approach to assessment to address systemic gaps based on competency committee discussions. Institutions may redesign faculty development programs that apply broadly across programs and disciplines. National organizations may adjust policies, frameworks, and regulatory requirements based on learnings across disciplines.
Over time, these nested improvement cycles create a powerful learning system.
There are many examples across the globe of these small tests of change – sometimes led in a grassroots manner starting with individual programs and pilots, and other times being led nationally at scale – that are driving us toward a better future in health professions education. The result is a growing body of experience and evidence that informs future iterations of CBHPE.
The Long View
Perhaps the most important implication of viewing CBHPE as a QI project is that it changes how we define success.
Success is not the absence of challenges.
Success is stepwise growth and the presence of learning.
When programs identify opportunities, gather data, engage stakeholders, and make evidence-informed adaptations, they are demonstrating that CBHPE is functioning as intended. In fact, a system that never identifies opportunities for improvement may be less healthy than one that continuously evolves.
This perspective also requires patience. Educational transformation unfolds over years, not weeks or months. The most meaningful outcomes of CBHPE, including improved assessment practices, enhanced feedback cultures, stronger readiness judgments, and ultimately better care for patients, emerge through repeated cycles of experimentation, learning, and refinement.
Looking Ahead
As CBHPE continues to mature globally, program evaluation and continuous improvement are essential. The future of CBHPE will not be shaped by a single innovation or implementation strategy. Rather, it will emerge through thousands of local and system-level PDSA cycles conducted by learners, educators, institutions, and professional organizations around the world.
Viewed this way, CBHPE is more than an educational paradigm shift. It is a commitment to continuous improvement for the sake of our current and future patients. It challenges us to ask not whether our systems are perfect, but whether they are evolving in meaningful ways.
And, like the best QI efforts, the ultimate measure of success is not where we started, but how effectively we continue to improve over time. In CBHPE, the intervention is the journey. Each PDSA cycle brings us closer to educational systems and learning environments that better prepare health professionals to meet the needs of our patients and communities they serve.
Refrences:
- Elam, Stanley. 1972. Performance-Based Teacher Education: What Is the State of the Art? American Association of Colleges for Teacher Education. https://eric.ed.gov/?id=ED058166.
- McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency-based curriculum development in medical education: an introduction. Public Health Papers. 1978
- Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.
- Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety. 2014;23(4):290-298. doi:10.1136/bmjqs-2013-001862.
About the Authors:
David A. Turner, MD is the Vice President of Innovation and Competency-Based Education at the American Board of Pediatrics. He is a recognized leader in competency-based education and assessment. He serves in a number of national leadership roles in the US focused on advancing CBHPE and is committed to helping lead the continued transition to a competency-based approach to learning and assessment across the education continuum in pediatrics and beyond.
Meghan O’Connor, MD is an Associate Program Director for the Pediatric Residency Program and Vice Chair of Education at the University of Utah. She is a member of the Competency Based Medical Education Committee at the American Board of Pediatrics. She was an investigator for the Education in Pediatrics Across the Continuum (EPAC) Project and has been a leader in CBME implementation and research in pediatrics for many years.
Michael A. Barone, MD MPH is the President and CEO of the American Board of Pediatrics. He has been a leader in education and assessment for decades and is committed to leading the work of the American Board of Pediatrics in setting standards of excellence, improving child health outcomes, and engaging trainees and pediatricians to continuously improve learning and care.
Disclosure
Microsoft CoPilot was used in the writing of this blog and creation of the accompanying image. Drs. Barone and Turner are employed by the American Board of Pediatrics. The opinions expressed in this blog are their own and do not represent the official position of the American Board of Pediatrics or the American Board of Pediatrics Foundation.
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