Entrustability Scales

Abstract

Meaningful residency education occurs at the bedside, along with opportunities for situated in-training assessment. A necessary component of workplace-based assessment (WBA) is the clinical supervisor, whose subjective judgments of residents' performance can yield rich and nuanced ratings but may also occasionally reflect bias. How to improve the validity of WBA instruments while simultaneously capturing meaningful subjective judgment is currently not clear. This Perspective outlines how "entrustability scales" may help bridge the gap between the assessment judgments of clinical supervisors and WBA instruments. Entrustment-based assessment evaluates trainees against what they will actually do when independent; thus, "entrustability scales"-defined as behaviorally anchored ordinal scales based on progression to competence-reflect a judgment that has clinical meaning for assessors. Rather than asking raters to assess trainees against abstract scales, entrustability scales provide raters with an assessment measure structured around the way evaluators already make day-to-day clinical entrustment decisions, which results in increased reliability. Entrustability scales help raters make assessments based on narrative descriptors that reflect real-world judgments, drawing attention to a trainee's readiness for independent practice rather than his/her deficiencies. These scales fit into milestone measurement both by allowing an individual resident to strive for independence in entrustable professional activities across the entire training period and by allowing residency directors to identify residents experiencing difficulty. Some WBA tools that have begun to use variations of entrustability scales show potential for allowing raters to produce valid judgments. This type of anchor scale should be brought into wider circulation.

Entrustable Professional Activities: Correlation of Entrustment Assessments of Pediatric Residents With Concurrent Subcompetency Milestones Ratings

“…13 Entrustable professional activities (EPAs) require observable behaviors and skills that support decisions to trust a trainee to independently perform within a particular field. [13][14][15][16] In the context of competency-based medical education, EPAs represent an attractive assessment tool for several reasons: they are easily observed and reliably assessed 4,9,10,17 ; entrustment incorporates supervision and safety considerations [18][19][20] ; and competence is implicit in the eventual entrustment of trainees to perform EPAs. 13,21,22 Because EPAs are directly observable, they may serve as a potential link between the theoretical framework of subcompetencies and point-of-service clinical practice.…”

Trainee Satisfaction with Feedback provided using an Entrustment Scale: A Survey of Internal Medicine Residents

“…(Vleuten & Schuwirth, 2005) Our findings suggesting trainee preference for the entrustment scale likely reflects the challenges learners face interpreting traditional assessment scales within competency-based medical education, as noted by prior critics of these scales. (Hauer et al, 2016;Rekman et al, 2016) Theoretically, these challenges in interpretation of traditional metrics might limit the impact of formative feedback on trainee development. As trainee satisfaction and acceptability is crucial in an assessment's ultimate educational impact, our finding of resident preference for the entrustment scale may have broader implications in graduate medical education.…”

“…(Holmboe, 2015;Williams, Dunnington, Mellinger, & Klamen, 2015) To address this issue, entrustment scales have been proposed to bridge the gap between the theoretical aspect of competency-based education and real world clinical practice. (Englander & Carraccio, 2014;Kwan et al, 2016;Rekman, Gofton, Dudek, Gofton, & Hamstra, 2016;Olle Ten Cate, 2013a, 2013bO. Ten Cate et al, 2016) Entrustment-based assessment aims to evaluate trainees against what they will actually do when independent.…”

“…Therefore, entrustment scales align with the construct of competency-based education when compared to more traditional evaluation scales, such as ordinal scales with adjectives or normative scales, and reflect a judgment with relevant clinical meaning for assessors. (Crossley, Johnson, Booth, & Wade, 2011;Rekman et al, 2016;Williams, Klamen, & McGaghie, 2003;Yeates, O'Neill, Mann, & Eva, 2013) In addition to intuitiveness for assessors within clinical evaluation, early uses of entrustment scales suggest improved inter-rater reliability as compared to alternative evaluation scales (Gofton, Dudek, Wood, Balaa, & Hamstra, 2012;Kogan, Conforti, Iobst, & Holmboe, 2014;Mink et al, 2017), particularly as these scales provide an assessment structured around the way evaluators already make day-to-day clinical entrustment decisions. In response, residency programs have begun to institute these as an adjunct to their traditional milestone evaluations.…”

The Reliability of Rater Variability

“…Entrustment, entrustability, and level of supervision scales promised to better mimic the judgments and decisions supervisors make in the workplace. 22,23 The construct of entrustment resonated with the essence of supervision. 24,25 It offered to systematically track subjective expert judgments of overall performance to complement the competence judgments based on observed behaviors that were already being collected and analyzed.…”