Entrustable Professional Activities as a Framework for Continued Professional Competence: Is Now the Time?

Achallenge in health professions education is finding ways to structure and assess the essential integration of knowledge, skills, values, and attitudes that results in a professional (entry-level) graduate becoming self-aware and trusted to practice without direct supervision. This challenge extends to developing clinicians, residents, and fellows as they strive for advanced professional competence. Since the publication of the Institute of Medicine's To Err Is Human in 2000,1 patient safety has continued to be a critical driver of new standards for health professions competence. Billett2 argues that a fundamental “competency” for work safety is workers’ dispositions, that is, whether they have the attitudes, values, or predictable habits of behavior that demonstrate self-awareness and trustworthiness. Building on this premise, current medical education reform efforts are including an assessment framework grounded in identification of entrustable professional activities (EPAs). Medical education's framework connects EPAs across domains of competence to competencies with milestones specific to residency education (Fig. 1). Medical education's framework connects EPAs across domains of competence to competencies with milestones specific to residency education. Entrustable professional activities represent a unit of professional practice that can be entrusted to a sufficiently competent learner or professional and that requires proficiency in multiple competencies simultaneously. This approach provides a broad, practice-based focus for assessment rather than looking at individual, often isolated, competencies. Entrustable professional activities assessments are linked to decisions of entrustment—that is, assessing whether the learner can carry out these critical practice activities under a designated level of supervision.3,4 The pharmacy profession also is developing an EPA model for pharmacy education and for the continuum of advanced practice experiences. They envision that EPA statements may be considered for framing high-stakes performance assessment for graduation.5 Education as a field, including physical therapist professional education, has long struggled with finding the best strategies for identifying and assessing learner outcomes through valid outcome measures.6–12 Tyler's13 structures for curriculum and Bloom's14 classification system for learning domains have long focused on behavioral objectives and the challenge of measurability of learner outcomes. Identifiable professional competencies, with emphasis on measurable behavioral units, are limited in their ability to assess important dimensions of competence such as high-order thinking and the handling of uncertainty.15,16 A paradox in the measurability of learning is that the measurement often leads to more specificity through the creation of more objectives, which in turn may have less relevance to the whole situation and context of clinical care.17 As Jette8(p7) questioned, “What do students and graduates actually need to know for best practice?” Is now the time for the physical therapy profession to determine professional competencies and work expectations across the learner continuum? If so, how could we harness the power of partnership between academic and clinical communities to create these competency expectations and facilitate broad implementation within the profession? The physical therapy profession has identified various designated outcome expectations for students, residents, fellows, and clinicians through accreditation standards,18 APTA’s Guide to Physical Therapist Practice,19 APTA’s Clinical Performance Instrument (CPI),20,21 other clinical performance assessments, and the descriptions of specialty practice (DSPs)22 and residency practice (DRPs).23 Is there value in developing an assessment framework grounded in the essential components of what physical therapists do in practice (EPAs), linked to these tools to gauge clinical performance throughout professional development (Tab.)? Although the answer to this question will vary among the various stakeholders (eg, clinicians, consumers, educators, learners, licensure boards, payers, researchers), as a doctoring profession, the profession's response should acknowledge the professional obligation to ensure that physical therapists provide society with the highest level of clinical competence across a career. Three important questions for the profession's consideration are: What is the importance of partnering within the profession to develop valid, patient-centered EPAs that meet the needs of the profession and society? Is there quantifiable value in establishing EPAs that standardize professional competence expectations at different points along the professional continuum? Will the development of EPAs provide the profession with opportunities to promote education research as an essential strategy to advance education and practice? Currently, the profession does not have a comprehensive assessment framework, nor does it have the necessary tools to measure current and continued competency across the professional continuum. Development of EPAs is one way the physical therapy profession could create competency-based outcomes of performance as a developmental expectation. The implications of developing EPAs across the learner continuum are significant for physical therapist education, practice, and research. The need to establish measurable performance expectations has been highlighted by multiple sources, including APTA’s task forces on Excellence in Education and Best Practices for Physical Therapist Clinical Education, the American Council of Academic Physical Therapy's (ACAPT) Clinical Education Summit, and the National Study of Excellence and Innovation in Physical Therapist Education in the 21st Century.24,25 One thing is clear: in order for this initiative to be successful, the profession must work collaboratively to improve learning throughout the continuum of professional development. For example, the Education Leadership Partnership (ELP)—an alliance between ACAPT, APTA, and the Education Section of APTA—is working collaboratively to help reduce unwarranted variation in practice by focusing on best practices in education. Formally created in June 2016, the ELP has prioritized considering the development of EPAs and currently has 2 subgroups, Educational Research and Outcome Competencies, working to appraise opportunities. The impact of this work has implications not only for learners but for academic and clinical faculty, as incorporating EPAs into the professional development framework will require learning by all involved in the communities of practice. Is the physical therapy profession ready to engage in the complex cycle of education, practice, and research that can help achieve its goals of setting patient-centered clinical competency expectations? The path of professional development for physical therapists suggests the need to consider multiple EPAs at different points on the learning continuum (Fig. 2). For example, the profession may consider developing EPAs for prelicensure part-time, full-time, and terminal integrated clinical education experiences and for postlicensure clinical residency and fellowship experiences. Furze and colleagues,26 in a paper on physical therapist residency and fellowship education, have started that conversation, proposing the need for the profession to develop a framework for common domains of competence as we look across the professional continuum. Representation of application of EPAs across the learner continuum. Adapted with permission from: Association of American Medical Colleges. Core Entrustable Activities for Entering Residency: Curriculum Developers Guide.4 Key Concepts for Building a Working Framework for Professional Competence in Physical Therapy.a Adapted from Association of American Medical Colleges’ Core Entrustable Activities for Entering Residency: Curriculum Developers Guide4 and from Furze et al.26 Key Concepts for Building a Working Framework for Professional Competence in Physical Therapy.a Adapted from Association of American Medical Colleges’ Core Entrustable Activities for Entering Residency: Curriculum Developers Guide4 and from Furze et al.26 With a focus in physical therapist education on ensuring that graduates hit the ground running upon obtaining licensure, there are opportunities for education programs to begin this effort. The ELP, ACAPT’s Benchmarks for Excellence Task Force, the Graduate Outcomes Task Force, post-Summit clinical education panels, and other consortia and task forces have identified that measuring performance expectations is a priority. Similarly, the Federation of State Boards of Physical Therapy's efforts to address ongoing clinical competence could lead to further opportunities, and opportunities exist within clinical specialty practice and residency and fellowship education, where DSPs, DRPs, and DFPs exist or are being developed. The results of this work will inform future decisions about efforts to improve clinical performance expectations at a specific point in one's professional development. Additionally, any effort to develop and implement EPAs as a component of professional development would contribute to a more comprehensive view of best practices in physical therapist education and practice to increase learner outcomes and societal gains. Although few from medicine or pharmacy are likely to suggest that EPAs are a perfect measure for determining clinical competence or that the return on investment is immediately known, there is little doubt that competency-based assessment of practice performance will continue to be a priority. The development, implementation, and outcomes assessment of EPAs provides an opportunity for the profession to use education research as a central strategy. Medicine's implementation of EPAs in the United States includes a dynamic and rigorous research plan that is grounded in professional practice expectations, applies concepts from the learning sciences, and studies the process of development and implementation. This is an effort that the physical therapy profession should adapt. Developing a framework for implementing EPAs using education research approaches will ensure that EPAs are valid, grounded in units of practice, defendable, and reproducible. The Association of American Medical Colleges was intentional in its initial approach of launching 13 EPAs for graduate medical education to only 10 schools and embedding research as an ongoing activity. This approach ensured that the evolution of EPAs and their use was developmental, intentional, meaningful, and grounded in evidence. Similarly, Haines and colleagues27 described the development of EPAs for the pharmacy profession as “merely the first step” and noted that “EPAs are intuitively understood by patients, practitioners, and policymakers,” suggesting that “the profession of pharmacy needs a core set of EPAs—not only to describe what pharmacists do but also to set expectations and guide future action.”27(p1) Any consideration of developing EPAs within the physical therapy profession must intentionally build education research assessment into the process.28 Medicine's effort at developing EPAs for graduate medical education,29–32 as well as in specialty areas,33–35 provides a good model for the physical therapy profession. There are numerous experts in medicine who have helped drive the development and use of EPAs; the physical therapy profession would do well to use medicine's expertise to guide physical therapy's initial stages of adopting this concept. As a doctoring profession, physical therapy is more entrusted with the health and well-being of society, including having a moral obligation to seek strategies to meet societal needs. We believe now is the time for the profession to establish an assessment framework that includes an EPA model, achieved through collaborative work, built on the synergy of current and past efforts to address student and clinician competency expectations, and harnessed through collaboration among many stakeholder groups. The ELP is ideally situated to facilitate this effort for professional education, as are the various groups vested in the development and growth of residency and fellowship education for postprofessional learners. Constructing seminal EPAs that assess essential expectations for physical therapist development across the learning continuum, using process and product models described by educators in medicine and pharmacy, would be a good place to begin. Our response to this need should not only build on the synergy created by the multiple efforts already well underway within the profession, but should infuse principles of education research in our collective efforts—keeping a focus on improving quality of care and ensuring we are meeting the needs of society. The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest. W.G. Boissonnault and S.B. Chesbro disclose that they are employees of APTA. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.