The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education

Figures & data

Figure 1. Competency-based education. Reprinted by permission from Frenk et al. (2010).

Table 1. Implementation of CBME at exemplar sites aligned with the core components framework.

Core components (Van Melle et al., International Competency-Based Medical Education Collaborators. 2019)	Vanderbilt University School of Medicine	Oregon Health & Science University School of Medicine	University of Michigan Medical School	University of California, San Francisco, School of Medicine
Outcome competencies	Institutionally-created UME competencies aligned with ACGME framework (Lomis et al. 2017) plus AAMC Core EPAs	Institutionally-created UME competencies aligned with ACGME framework plus AAMC Core EPAs	Eight Institutionally – created UME competency domains aligned with ACGME framework + 2 additional domains (leadership, teamwork, & interprofessionalism; critical thinking & discovery) for a total of 31 competencies	Seven UME competencies aligned with the 6 competencies in the ACGME framework plus interprofessional collaboration
Sequenced progression	Competencies are allocated and tracked across courses and years of training Greater focus on EPAs in the post-clerkship phase	Competencies are allocated and tracked across courses and years of training EPA achievement tracked only in clinical phase	Focus on 4 competency domains during first preclinical year (MK, PC, Comm, Prof); other competencies assessed in clerkship and post-clerkship years.	Competencies have 35 milestones for the 3 phases of the curriculum; curriculum and assessment activities are mapped to the milestones
Tailored learning experiences	Evidence-driven digital portfolio Structured individualized coaching program Student-led individualized learning plans, with scheduling flexibility in post-clerkship phase (years 3 & 4)	Students have great flexibility in timing and choice of clerkships Each student assigned to academic coach who provides guidance based on student performance	Three years of workplace-based learning (clinical) Post-clerkship competency committee reviews competency development and provides guidance to learners and their coaches/advisers (Keeley et al. 2019) Individualized development plans and coaches	Each student has a faculty coach for the entire curriculum; students and coaches have 8 progress and planning meetings to review progress in student dashboard and discuss student’s individual SMART goals for learning planning
Competency-focused instruction	All courses and clerkships have learning objectives and assessments mapped to competencies New course structures created to emphasize differing competency needs	All courses and clerkships have learning objectives and assessments mapped to competencies	All courses and clerkships have learning objectives and assessments mapped to competencies	All courses and clerkships have learning objectives and assessments mapped to competencies
Programmatic assessment	All courses assess in standardized competency language and provide frequent formative and fully transparent feedback Individual competency development is tracked and informs progression independently of course grades Aggregate competency outcomes for cohorts of students inform curricular and assessment improvements	All courses and clerkships have a standardized assessment framework based on competencies Aggregate competency outcomes for cohorts of students inform curricular and assessment improvements	Learners are assessed primarily based on competencies using a number of assessment strategies Competency committee reviews learner data in dashboard and makes determination of competency progression (Monrad et al. 2019)	All assessments are centrally coordinated (Hauer et al. 2018) Multiple competency-focused assessment tools are used longitudinally Group decision making is required for course and clerkship grading and overall progress
Time variable approaches * the Van Melle model does not name time-variability as a core component	Graduation is not variable; however variable use of time in the post-clerkship phase based on individual’s competency development	Time-variable progression as well as graduation A few students have begun GME training ∼ 2 months early and early graduation is increasingly common	Graduation is not variable; however variable use of time in post-clerkship phase based on individual’s competency development	Time variability allowed for exams and in required medicine sub-internship

Figure 2. The integral relationships between competency-based medical education, the Master Adaptive Learner model, coaching practices, and the learning environment. Competency based medical education (left) provides clarity of competency expectations and evidence of performance. The Master Adaptive Learner model (center circle) provides a repeating, cyclical process for learners to reflect on performance and plan learning. Coaches (outer circle) wrap around the Master Adaptive Learner, leveraging questioning, accountability, and other strategies to guide them. The entire process relies upon a supportive learning environment (right), with appropriate technology to track and visualize data, as well as a social and organizational culture that encourages a mastery orientation. Used with permission of the American Medical Association.

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