Building Capacity for CBME Implementation at Queen’s University

Medical education in Canada is currently in a state of transition. In 2013, the Royal College of Physicians and Surgeons of Canada launched Competency by Design (CBD), an initiative which will see all specialty and subspecialty programs in Canada begin transitioning to competency-based medical education (CBME) by 2022. At Queen’s University, we intend that beginning July 2017, residents entering any of our 29 postgraduate specialty programs will be integrated into CBME residency programs. This paper shares Queen’s University’s experience of an accelerated, institutional implementation of CBME in advance of the Royal College’s competency by design (CBD) program.


Introduction
In 2012, a consortium of the Association of Faculty of Medicine of Canada (AFMC) and a collection of postgraduate agencies came together for a project entitled the Future of Medical Education in Canada. Among their recommendations was to "develop, implement, and evaluate competency-based, learner-focused education to meet the diverse learning needs of residents and the evolving healthcare needs of Canadians" (AMFC Report p. 18). A relatively new approach to medical education, competency-based medical education (CBME), as defined by Frank and Snell (2010), "is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It deemphasizes time-based training and promises greater accountability, flexibility, and learner-centredness" (pg. 636). As a form of outcomes-or criteria-based learning, CBME provides an alternative to program structures organized around knowledge objectives, which may not always ensure that future physicians acquire competence in all required areas, and time-based training which may emphasize time spent on particular aspects of training as opposed to the acquisition of abilities during that training (Frank & Snell, 2010).
In 2013, the Royal College of Physicians and Surgeons of Canada launched Competency by Design (CBD), an initiative which will see all specialty and subspecialty programs in Canada begin transitioning to CBME by 2022. Disciplines are divided into seven cohorts, and the Royal College is currently transitioning its first and second group of adopters (Medical Oncology and Otolaryngology; and Anesthesiology, Forensic Pathology, Gastroenterology, Internal Medicine, Surgical Foundations, and Urology). According to the Royal College, "the greater goal of CBD is to enhance patient care by improving learning and assessment across the continuum from residency to retirement" (Royal College).
At Queen's University we have fully embraced the concept of moving from a time-based system to one based on competence. Furthermore, we felt there was merit in moving forward with the transformation of all of our specialty programs synchronously and collectively. To begin such a large undertaking, we applied to the Royal College's Fundamental Innovations in Residency Education (FIRE) program for permission to go forward with this educational initiative. Our successful FIRE application allowed us to diverge from the Royal College specialty transitioning schedule and training requirements for our 29 postgraduate specialty residency programs. This enabled our CBME leadership team to move forward with our goal of an accelerated institutional implementation of CBME. In July 2017, we will welcome all new Queen's residents into CBME specialty programs. This unique institutional approach will be the first of its kind in Canada and we have engaged all stakeholders (residents, program directors, faculty, hospitals and community partners) in the transition process.
There have been several advantages to our adopting an institutional approach to CBME implementation, including by-in from the decanal leadership. Support for CBME as an educational initiative at Queen's has involved martialing resources for one time costs associated with the transition, including making CBME a strategic priority for our alternate funding plan organization, the South Eastern Academic Medical Association of Ontario (SEAMO). Without the decision to do this centrally, these costs would have been prohibitive for many of our specialty programs. Additionally, an institutional approach has allowed the dean to incorporate deliverables for CBME in the performance plans of department heads, and it has enabled us to create a central team to provide guidance and leadership throughout the implementation process.
Finally, our institutional approach at Queen's has allowed us to engage the University by making this transformation one of the priorities of the School of Medicine, and as such, an identifiable deliverable in the strategic matrix for the university. Our accelerated institutional implementation plan for CBME is in keeping with our strategic plan in the School of Medicine, which identifies developing and piloting new models of training as a priority.
As our CBME leadership team began to envision what implementation would look like institutionally and across each program in terms of resources, supports and scholarship, we knew that we wanted our focus to be on collaboration and cooperation between and among the programs and with various educational support units on campus. Our Queen's model imagines a community of teachers, learners and knowledge sharers working together to sustain a high level of continued, ongoing evaluation. To this end, we created working groups that support and enable capacity building required for the successful implementation of CBME. The foci of our community includes academic scholarship, curricular reform, assessment, system reform, faculty development, project leadership, information technology support, and communication. These integrated networks create opportunities to bridge and connect the various programs involved in the implementation of CBME on Queen's campus, thus allowing us to build a community based approach to the project; one in which residents, program directors and working groups are all actively engaged in research, and in which all groups assume ownership for scholarship.

Curricular approach
As Queen's transitions to CBME, our curricular approach will be aligned with the vision, principles, definitions, and planned iterative processes for all Royal College specialty programs across Canada. This includes the transition to defined stages of postgraduate training within the competence continuum, the creation of stage specific entrustable professional activities (EPAs) that incorporate key and enabling competencies across all CanMEDS roles, and the alignment of appropriate assessment systems to assess specific EPAs.
Our programs will be divided into the four defined stages of the RCPSC Competence Continuum corresponding with postgraduate training (Transition to Discipline, Foundations of Discipline, Core of Discipline, and Transition to Practice). A central component of our curricula will be the creation of stage specific entrustable professional activities (EPAs) that meaningfully bundle enabling competencies and milestones across CanMEDS roles. These will be linked with required training experiences and robust assessment plans to support and track resident development both within and across stages of competence. Each specialty program will implement a comprehensive CBME curriculum with an integrated/accompanying assessment system by July 2017.
Each specialty residency program at Queen's will mirror the Royal College iterative process of CBME implementation. By maintaining an alignment with the vision of the Royal College, our transition to CBME can facilitate knowledge sharing by disseminating the results of our experience.

Faculty development
Ultimately, the success of CBME implementation will be dependent on faculty engagement and involvement. It is the faculty who are responsible for the details of the transition to CBME in each of their specialty programs.
Recognizing that faculty will need support and training to feel comfortable facilitating learning within this new curriculum, we have designed a comprehensive faculty curriculum for CBME to ensure that all faculty leaders and educators possess the knowledge, skills, and attitudes required for the implementation of CBME. The faculty development opportunities currently being provided include CBME workshops -that include all specialty CMBE leads; a rotating faculty development series; rotating administrative assistant development sessions; simulation faculty trainer course; assessment tool development sessions; information technology development sessions; and program specific implementation workshops.
These faculty development opportunities provide guidance and training for faculty as programs move through this transition, while also bringing together individuals from multiple programs in ways that are collaborative and rewarding. These sessions provide opportunities for faculty to engage in collaborative learning, while also giving them a voice in the transition process.
Currently, all faculty development programs are for 2016 and 2017. As we continue to move forward with the implementation process, we will identify and develop additional faculty development opportunities in an ongoing, needs-based time frame.

Stakeholder communication
For an innovation as large-scale as the Queen's transition to CBME, there are a vast number of stakeholders who need to be kept informed of changes, and who must have opportunities to voice concerns throughout the implementation process. At Queen's University, these groups include the decanal leadership, CBME team leadership, program directors, CBME program leads , resident trainees in both the new and existing systems, program administrative assistants, Department Heads and Division Chairs, information technology staff, faculty development and continuing professional development leaders, undergraduate medical education leaders, and all administrators and staff at our affiliated teaching hospitals, including regional providers and hospitals. At the centre of the stakeholders at our institution are the patients and their families.
The CBME leadership team has devised multiple strategies to maintain open and receptive communication throughout the transition. At the centre of these strategies is a focus on partnership and collaboration as the keystones to a successful implementation.