Division of Family and Community Medicine, Department of Humanities, Health, and Society, Florida International University Herbert Wertheim College of Medicine, Miami.
Department of Neurology, Yale University School of Medicine, New Haven, Connecticut.
JAMA Netw Open. 2022 Sep 1;5(9):e2233342. doi: 10.1001/jamanetworkopen.2022.33342.
Gaps in readiness for indirect supervision have been identified for essential responsibilities encountered early in residency, presenting risks to patient safety. Core Entrustable Professional Activities (EPAs) for entering residency have been proposed as a framework to address these gaps and strengthen the transition from medical school to residency.
To assess progress in developing an entrustment process in the Core EPAs framework.
DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study in the Core EPAs for Entering Residency Pilot, trained faculty made theoretical entrustment determinations and recorded the number of workplace-based assessments (WBAs) available for each determination in 2019 and 2020. Four participating schools attempted entrustment decision-making for all graduating students or a randomly selected subset of students. Deidentified, individual-level data were merged into a multischool database.
Schools implemented EPA-related curriculum, WBAs, and faculty development; developed systems to compile and display data; and convened groups to make theoretical summative entrustment determinations.
On an EPA-specific basis, the percentage of students for whom an entrustment determination could be made, the percentage of students ready for indirect supervision, and the volume of WBAs available were recorded.
Four participating schools made 4525 EPA-specific readiness determinations (2296 determinations in 2019 and 2229 determinations in 2020) for 732 graduating students (349 students in 2019 and 383 students in 2020). Across all EPAs, the proportion of determinations of "ready for indirect supervision" increased from 2019 to 2020 (997 determinations [43.4%] vs 1340 determinations [60.1%]; 16.7 percentage point increase; 95% CI, 13.8-19.6 percentage points; P < .001), as did the proportion of determinations for which there were 4 or more WBAs (456 of 2295 determinations with WBA data [19.9%] vs 938 [42.1%]; 22.2 percentage point increase; 95% CI, 19.6-24.8 percentage points; P < .001). The proportion of EPA-specific data sets considered for which an entrustment determination could be made increased from 1731 determinations (75.4%) in 2019 to 2010 determinations (90.2%) in 2020 (14.8 percentage point increase; 95% CI, 12.6-16.9 percentage points; P < .001). On an EPA-specific basis, there were 5 EPAs (EPA 4 [orders], EPA 8 [handovers], EPA 10 [urgent care], EPA 11 [informed consent], and EPA 13 [patient safety]) for which few students were deemed ready for indirect supervision and for which there were few WBAs available per student in either year. For example, for EPA 13, 0 of 125 students were deemed ready in 2019 and 0 of 127 students were deemed ready in 2020, while 0 determinations in either year included 4 or more WBAs.
These findings suggest that there was progress in WBA data collected, the extent to which entrustment determinations could be made, and proportions of entrustment determinations reported as ready for indirect supervision. However, important gaps remained, particularly for a subset of Core EPAs.
在住院医早期遇到的基本职责中，已经确定了在间接监督准备方面的差距，这对患者安全构成了风险。核心可委托专业活动（EPA）已被提议作为解决这些差距和加强从医学院到住院医过渡的框架。
评估在核心 EPA 框架中发展委托过程的进展。
设计、设置和参与者：在这项核心 EPA 进入住院医试点的质量改进研究中，经过培训的教师进行了理论委托决策，并记录了在 2019 年和 2020 年为每个决策提供的工作场所评估（WBA）数量。四所参与学校尝试为所有毕业学生或随机选择的学生子集做出委托决策。对去识别的个体水平数据进行了合并，纳入了一个多校数据库。
学校实施了与 EPA 相关的课程、WBA 和教师发展；开发了汇总和显示数据的系统；并召集小组进行理论总结性委托决策。
在 EPA 特定的基础上，记录了可以做出委托决策的学生比例、准备接受间接监督的学生比例和可用 WBA 数量。
四所参与学校对 732 名毕业学生（2019 年 349 名学生，2020 年 383 名学生）进行了 4525 项 EPA 特定准备度决定（2019 年 2296 项决定，2020 年 2229 项决定）。在所有 EPA 中，“准备接受间接监督”的决定比例从 2019 年增加到 2020 年（2019 年有 997 项决定[43.4%]，2020 年有 1340 项决定[60.1%]；增加了 16.7 个百分点；95%置信区间，13.8-19.6 个百分点；P<0.001），而有 4 个或更多 WBA 的决定比例也有所增加（2019 年有 2295 项决定的数据中有 456 项[19.9%]，2020 年有 938 项[42.1%]；增加了 22.2 个百分点；95%置信区间，19.6-24.8 个百分点；P<0.001）。在 2019 年有 1731 项数据集（75.4%）被认为可以做出委托决策，而在 2020 年则有 2010 项数据集（90.2%）被认为可以做出委托决策（增加了 14.8 个百分点；95%置信区间，12.6-16.9 个百分点；P<0.001）。在 EPA 特定的基础上，有 5 项 EPA（EPA 4[医嘱]、EPA 8[交接]、EPA 10[急救]、EPA 11[知情同意]和 EPA 13[患者安全]）只有很少的学生被认为准备接受间接监督，而且每个学生的可用 WBA 数量也很少。例如，在 EPA 13 中，2019 年有 0 名学生被认为准备好，2020 年有 0 名学生被认为准备好，而这两年中都没有 4 个或更多 WBA 的决定。
这些发现表明，在收集 WBA 数据、可以做出委托决策的程度以及报告为准备接受间接监督的委托决策比例方面都取得了进展。然而，重要的差距仍然存在，特别是对于核心 EPA 的一个子集。
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