Entrustable Professional Activities (EPAs)
In CBD, Entrustable Professional Activities (EPAs) are defined by the Royal College as “authentic tasks of a discipline. A supervisor can delegate a task to a resident and observe their performance in the workplace. Over time, frequent observations of a trainee’s performance of an EPA, will provide a comprehensive image of their competence and inform promotion decisions.” EPA example: Develop and implement a management plan in a patient with a common mental health concern.
EPAs are related to each stage of training (see competency stage graphic here). EPAs are designed to be developmental — they go from smaller tasks to bigger tasks as trainees progress through stages of training. Each EPA integrates a number of milestones from different CanMEDS roles; a bigger task may include more milestones and/or more complex milestones.
The Department of Psychiatry adopted the Royal College's EPAs in July 2020.
- Transition to Discipline (first 1-3 months) has 2 EPAs.
- Foundations of Discipline (end of the Transition to Discipline through to the end of PGY2) has 5 EPAs.
- Core of Discipline (essentially PGY3 and PGY4) has 12 EPAs. Both COD6 and COD7 have two parts.
- Transition to Practice (PGY5) has 6 EPAs. TTP1 has two parts (A, and B) and TTP3 has three parts (A, B, and C).
An overview of the existing EPAs is available here: EPAs Overview. Detailed information regarding specific EPAs can be below in the Royal College EPAs section.
How are EPAs Assessed?
EPAs are completed using the University of Toronto's Elentra system. Faculty and Residents can login using their UTORid and password. If you are experiencing issues logging on, or require help resetting an EPA please contact Tammy Mok (firstname.lastname@example.org).
EPA General Guidelines
- Residents and faculty can initiate EPAs. In most cases, residents have been initiating EPAs but faculty are permitted to do so as well. The majority of EPAs can be completed by psychiatry faculty/staff and senior/subspecialty residents. There are a few EPAs that can also be completed by allied health professionals. At least 51% of each EPA must be completed by staff and up to 49% of each EPA can be completed by senior/subspecialty residents or allied health professionals.
- EPAs are to be initiated within a week of an encounter as they are meant to be brief, low-stakes, “in the moment” assessments. Retroactive submission of EPAs beyond 7 days of the encounter will not be counted. Assessors should be completing these assessments within the week of initiation. Faculty EPA completion rates will be monitored by the program. Residents are discouraged from sending multiple EPAs to a single supervisor (i.e. an EPA “bolus”) for completion.
- As per July 1, 2022, and UofT PGME guidelines, EPAs expire 14 days after the date of initiation. The program will allow for one additional extension of another 7 days. The duration of completion should be no more than 3 weeks from the date of initiation. Residents/faculty can reach out to Tammy Mok (email@example.com) for an extension.
- Residents are encouraged to concentrate on EPAs corresponding to their current stage of training. Residents are permitted to reach forward to EPAs in the next stage of training. i.e. a resident in FOD can reach forward and attempt EPAs in COD but should not be attempting TTP EPAs.
Please see our user guide for supervisors below:
What does Entrustment mean?
Contextual Variables (CVs)
Starting in 2022-2023, the Psychiatry Competence Subcommittee (PCS) is responsible for looking at whether or not PGY1-2 residents are able to meet the various contextual variables included in the Royal College EPA Guide. Contextual variables are the context of observations (e.g., setting, case complexity, etc.) assess trainee’s competence in varying scenarios that mirror the reality of independent practice. At this time, we are monitoring whether these are achievable or not. At this time, decisions on progression and promotion will not be based on whether residents are able to meet all contextual variables.
Refer to "Understanding Contextual Variables" for more information on how to interpret Contextual Variable tracking on Elentra.
View October 2022 Program Director Message - Contexual Variables
Generally, residents should aim to complete at least 1 EPA a week.
The Psychiatry Competence Subcommittee (PCS) calculates EPA expectations based on the above guideline. EPA targets may be adjusted accordingly for each resident due to leaves, redeployment, or other events.
EPA Entrustment requirements will differ depending on when a resident began residency.
Residents who began residency prior to the official RCPSC launch of CBD for psychiatry on July 1, 2020 (2018, 2019 - current PGY4s-5s) need to have 3 entrustments for each EPA unless the RC requirement is less than 3. An overview is available for download.
Residents who began residency from 2020 onwards (current PGY1s-3s) are required to complete entrustments per RC requirements. A summary table is available for download.
As of July 2020, all Psychiatry training programs adopted the Royal College of Physicians and Surgeon's Entrustable Professional Activities. The EPAs are available for download and viewing below.
Transition to Discipline
TTD1 OBTAINING A PSYCHIATRIC HISTORY to inform the preliminary diagnostic impression
TTD2 COMMUNICATING CLINICAL ENCOUNTERS in oral and written/electronic form
Foundations of Discipline
FOD1 Assessing, diagnosing and participating in the management of patients with MEDICAL PRESENTATIONS relevant to psychiatry
FOD2 PERFORMING PSYCHIATRIC ASSESSMENTS referencing a biopsychosocial approach, and developing basic differential diagnoses for patients with mental disorders
FOD3 Developing and implementing MANAGEMENT PLANS for patients with presentations of low to medium complexity
FOD4 Performing RISK ASSESSMENTS that inform the development of an acute safety plan for patients posing risk for harm to self or others
FOD5 Performing CRITICAL APPRAISAL and presenting psychiatric literature
Core of Discipline
COD1 Developing COMPREHENSIVE treatment/management PLANS for adult patients
COD2 Performing psychiatric assessments and providing differential diagnoses and management plans for CHILDREN AND YOUTH
COD3 Performing psychiatric assessments, and providing differential diagnoses and management plans for OLDER ADULTS
COD4 Developing comprehensive biopsychosocial FORMULATIONS for patients across the lifespan
COD5 Identifying, assessing, and managing emergent situations in psychiatric care across the lifespan (EMERGENCIES)
COD6-A Integrating the principles and skills of psychotherapy into patient care (PSYCHOTHERAPY MODALITY)
COD6-C Applying and integrating psychosocial skills and principles in general psychiatric care (INTEGRATING PSYCHOTHERAPY SKILLS)
COD7A-B Integrating the principles and skills of NEUROSTIMULATION into patient care
COD8 Integrating the principles and skills of PSYCHOPHARMACOLOGY into patient care
COD9 Applying relevant legislation and LEGAL principles to patient care and clinical practice
COD10 Providing TEACHING to students, residents, public and other health care professionals
Transition to Practice
TTP1-A Managing the clinical and administrative aspects of a psychiatric practice: patient care (PRACTICE MANAGEMENT - PATIENT)
TTP1-B Managing the clinical and administrative aspects of a psychiatric practice: working with the team (PRACTICE MANAGEMENT - TEAM)
TTP3-A Developing and implementing personalized learning experiences geared to career plans or future practice: DEVELOPING A LEARNING PLAN
TTP3-B Developing and implementing personalized learning experiences geared to career plans or future practice: IMPLEMENTING A TRAINING EXPERIENCE
TTP3-C Developing and implementing personalized learning experiences geared to career plans or future practice: REFLECTING ON LEARNING PLAN EFFICACY
EPA Maps and Rotation Cards
Overview: Psychiatry EPAs by Stage
PGY5 (applicable to learners who began residency in July 2019)
What is an EPA?
The Royal College defines EPAs as “authentic tasks of a discipline. A supervisor can delegate a task to a resident and observe their performance in the workplace. Over time, frequent observations of a trainee’s performance of an EPA, will provide a comprehensive image of their competence and inform promotion decisions.
What is the purpose of EPAs?
EPAs are workplace-based assessments that provide residents with feedback ‘in the moment’. Each EPA is intended to serve a formative, developmental purpose for the learner. Taken together with other assessments, EPAs are reviewed by the Psychiatry Competence Subcommittee to inform holistic decisions about progression and promotion towards independent practice.
It may be important here to distinguish between competencies and EPAs. Competencies refer to the abilities of an individual whilst EPAs refer to the work or tasks of a discipline. For a brief explication of the differences, Olle ten Cate provides a cogent overview in the When I say… series in Medical Education: https://onlinelibrary.wiley.com/doi/full/10.1111/medu.14005
What is the entrustment scale and how is this different from the Likert scale on an ITAR/ER?
EPAs are formative assessments (i.e. assessments for learning) rated on an entrustability scale that uses behaviourally anchored criteria to rate the resident’s workplace-based performance on the observed task. Observers (i.e. faculty supervisors) rate the level of support that was needed to complete the task (e.g. direction, support, competent). This differs from the Likert scale on ITARs which provide a summative assessment of learning during the course of a rotation aligned with the rotation plan and goals & objectives for each rotation. For a comprehensive list of goals and objectives and rotation plans for rotations please refer to the Rotation Plan Booklet.
Are there different EPAs for each stage of training?
Yes. EPAs are designed to be developmental and are intended to increase in complexity from Transition to Discipline to Transition to Practice. The Royal College Psychiatry Speciality Committee has created a complexity table that has informed Competence by Design requirements, including EPAs – https://www.royalcollege.ca/rcsite/documents/ibd/psychiatric-complexity-table-e.pdf.
Can residents complete EPAs from a different stage of training?
Residents are encouraged to focus on EPAs from their current stage of training.
Residents can reach ahead to EPAs from the next stage. They cannot, however, complete EPAs from two stages ahead of their current stage. For example, a resident currently in the Foundations of Discipline (FOD) stage of training should focus on FOD EPAs; however, they may also complete EPAs from Core of Discipline (COD). They may not complete EPAs in the Transition to Practice (TTP) stage of training.
Residents may complete EPAs from a stage preceding their current stage if it most appropriately reflects the task they are performing. For example, a senior resident in the Transition to Practice (TTP) stage of training doing a research elective will likely be completing FOD5 (Performing CRITICAL APPRAISAL and presenting psychiatric literature) on this rotation as it is the EPA most relevant to their work in that rotation.
How many EPAs do residents need to complete?
The residency program requires that residents achieve a minimum number of EPA attempts as well as meet Royal College defined EPA targets for all residents who began training on July 1, 2020 or later.
Residents are expected to attempt at least one EPA per week. EPA attempt targets are adjusted for residents due to leaves, redeployment, or other events that may impact on a resident’s capacity to participate in residency training.
Please refer to rotation cards for EPAs that are recommended for both off-service and core and elective/selective psychiatry rotations: https://psychiatry.utoronto.ca/entrustable-professional-activities-epas .
Residents must meet EPA entrustability targets as defined by the Royal College for their stage of training in order to be promoted to the next stage. The Psychiatry Competence Subcommittee, in collaboration with the Program Director, can modify EPA targets if there are extenuating circumstances that affect residents’ capacity to meet the defined targets.
Please note that residents who started residency training before July 1, 2020 have different EPA targets as they were not part of the official Royal College launch of CBD for Psychiatry.
If a resident has achieved the EPA targets for their stage of training, do they need to continue to complete EPAs?
Yes, residents are expected to complete at least one EPA per week and to “work ahead” to the next stage. As we welcome our first full cohort of residents entering PGY5 and the Transition to Practice (TTP) stage of training in the 2022-23 academic year, the Assessment Subcommittee and PRPC will have further guidance for our TTP residents as we support a growth mindset and the spirit of continuous improvement in our residency program. If residents or faculty members will like to provide feedback or suggestions about the TTP stage of training, please contact our TTP Curriculum Lead, Michael Mak (firstname.lastname@example.org).
Who can assess an EPA?
EPAs may be completed by faculty (staff psychiatrists), health professionals, and senior residents. Some EPAs indicate specifically who should complete the EPA. For example, COD10 requires direct observation by a psychiatrist. Overall, >50% of EPAs must be completed by staff psychiatrists.
How and when should EPAs be documented?
EPAs are documented through Elentra and may be triggered by either the resident or their assessors. Assessors completing an EPA should complete the entrustment scale as well as provide specific and/or actionable qualitative feedback to support resident development. https://psychiatry.utoronto.ca/sites/default/files/inline-files/elentra_how_to_v4_0.pdf
EPAs are to be initiated within 7 days of an encounter. They are meant to be brief, low stakes, “in the moment” assessments.* Retroactive submission of EPAs beyond 7 days of the encounter will not be counted. Assessors should be completing EPAs within 7 days of initiation. Faculty EPA completion rates are monitored by the program. Residents are discouraged from sending multiple EPAs at once (i.e. an EPA “bolus”) for completion.
Please note that as per UofT PGME guidelines, EPAs expire 7 days after the date of initiation. The program will allow for one additional extension of another 7 days. The duration of completion should be no more than 2 weeks from the date of initiation. Residents/faculty can contact Tammy Mok (email@example.com) for an extension.
EPAs that were triggered but not completed do not count towards EPA attempt requirements. It is therefore important that residents trigger and faculty complete EPAs in a timely manner.
*For EPAs that involve documentation review in an outpatient clinic setting where it may take more than 7 days to complete and review the documentation, the EPA should be triggered within 7 days of the documentation being ready for the supervisor to review (e.g. after resident review/edits of consult or follow-up note).
What are contextual variables? Do they “count”?
Each EPA indicates contextual variables around setting, demographic, case type or complexity and may indicate the number of observations of achievement required for each context. Although Elentra records and counts contextual variables, we are not currently using contextual variables when adjudicating promotion decisions at PCS. Nevertheless, some rotations have specific requirements regarding contextual variables for EPA achievement (e.g. Child Psychiatry rotation).
Where can I get more information about EPAs?
- University of Toronto, Department of Psychiatry, Entrustable Professional Activities (EPAs)
- Royal College, Competence By Design, EPAs and CANMeds Milestones