Fremen Chihchen Chou

Health professions education is experiencing a paradigm shift, from a focus on the structures and processes of education to a focus on the outcomes health professionals must demonstrate to meet the healthcare needs of the public served. The Competency-based Health Professions Education (CBHPE) movement now has two decades of implementation experience in some contexts. Educators across health professions working on the design, planning, implementation, or maintenance of competency-based systems can benefit from the lessons learned through implementation efforts to date. In this manuscript, the authors capitalize on the experiences of the International Competency-based Health Professions Educators Collaborative (ICBHPE), a multinational and interprofessional group of educators, to summarize some of the common challenges faced and adaptations made after implementation. The lens of post-implementation challenges allows a view of CBHPE programs as they have matured. The challenges are organized by the five core components of CBHPE: outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment. For each component, the authors review those challenges that are most common and provide examples of adaptations that have been successful. The challenges and their adaptations are synthesized through “lessons learned” to provide practical insights for designing, planning, implementing, and maintaining CBHPE programs to continue driving the evolution of CBHPE globally.

Assessments serve several purposes in competency-based medical education (CBME) and competency-based health professions education (CBHPE) programs. These purposes are commonly termed ‘assessment for learning’ and ‘assessment of learning.’ Historically, educational scholars have advised against using an assessment for multiple purposes, arguing that doing so undermines its primary purpose. However, at times, such an approach may be required from a pragmatic standpoint. In this Eye Opener, the authors consider the competing purposes of assessment in CBHPE programs from a practical lens. They propose specific strategies to maximize benefits and minimize risks of dual-purposing when such an approach is necessary. First, the authors describe the importance of setting the stage for dual-purposing by creating a culture of trust, which requires clear institutional commitment to learner orientation and faculty development, infrastructure, and appropriate channels of communication with all constituents. Second, data considerations are discussed. The authors focus on adoption of programmatic assessment principles, opportunities for frequent formative observations, and strategies for leveraging available technology. Finally, the focus turns to the learner, highlighting their essential function as a key agent in driving their own growth and development. Balancing learner- and supervisor-initiated assessments, implementing longitudinal coaching programs, and considering “ultra-low-stakes” assessments are identified as mechanisms to support learner agency and development. Taken together, these specific design conditions may be used to promote learner growth and acquisition of competence when practical constraints require assessment data to serve a dual purpose.

Competency-based medical education (CBME) positions workplace-based assessment and feedback as developmental processes, yet translating these principles into clinical practice is challenging. CBME often becomes administratively driven rather than developmentally meaningful. Learner studies consistently report superficial feedback, diminished psychological safety, and variable engagement, but most evidence comes from Western contexts and in the early stages of CBME adoption. Limited research has examined how residents in mature systems interpret and enact assessment and feedback. This study explored these interpretive processes to identify mechanisms that shape learner engagement in CBME. We conducted a constructivist grounded theory study using semi-structured interviews with emergency medicine residents. Data were analyzed iteratively through initial, focused, and theoretical coding, supported by constant comparison, memo-writing, and team triangulation across learner, program, and system levels within a fully implemented CBME system in East Asia. Residents' engagement with CBME was dynamic and context-dependent, shaped through ongoing interpretation of assessment encounters. Theme 1 described forces shaping navigation, including learner orientations or mindsets, supervisory interactions, and structural and cultural conditions, such as workload, assessment design, and the social weight of assessment. Theme 2 illustrated how system adaptations shaped enactment: shared educational literacy supported clarity and alignment; structured direct observation enabled focused feedback; and responsiveness in assessment content and processes influenced whether documentation felt meaningful. Across themes, engagement emerged through the interplay of learner orientations, supervisory interactions, structural conditions, and system responsiveness, with alignment supporting authentic engagement. These findings are synthesized into a mechanism-oriented framework in which system responsiveness acts as a key driver shaping how structures and interactions support learners' meaningful engagement. We further conceptualize learner engagement as situated agency, an interpretive and context-sensitive process through which learners calibrate their orientations and participation in response to evolving relational and structural conditions within implemented CBME systems.

Background: Competency-Based Health Professions Education (CBHPE) is increasingly implemented; however, CBHPE outcomes research remains difficult to interpret and synthesize when studies incompletely report the CBHPE model and other elements. Objective: To develop structured reporting guidelines for CBHPE outcomes studies to improve transparency, interpretability, and transferability across educational contexts and professions. Methods: A multi-phase, iterative consensus-development process was used to create a CBHPE outcomes reporting checklist aligned with a CBHPE Outcomes Theory of Change. Draft reporting elements were generated and refined through structured writing-group deliberations, broad stakeholder feedback gathered through interactive town hall sessions within the ICBHPE Collaborative, and iterative revision cycles. The checklist was then pilot-tested with non-expert users to assess clarity, feasibility, and usability, and revisions were made to reduce redundancy, harmonize terminology, and strengthen guidance for high-impact reporting domains. Results: The final product is a structured reporting checklist, organized by manuscript section, accompanied by brief item descriptions and rationales, and registered with EQUATOR. The guidelines prioritize reporting elements that support causal interpretability in CBHPE outcomes research, including specification of the CBHPE intervention architecture and core components, program theory and intended mechanisms, implementation fidelity and adaptations, assessment system design and governance for progression decisions, multi-level outcomes and indicators across developmental timeframes, contextual enablers and constraints, and equity considerations. Conclusions: These CBHPE outcomes reporting recommendations provide a practical tool and guideline for authors, reviewers, and editors to strengthen the completeness and consistency of CBHPE outcomes reporting and should be considered before beginning a study. Adoption of this checklist may improve interpretability and evidence synthesis across programs and accelerate actionable learning about what works in CBHPE, for whom, in what contexts, and why.

Introduction: Competency-Based Health Professions Education (CBHPE) is an outcomes-based approach to planning and conceptualizing the training of health professionals to serve population needs. Despite its uptake, ongoing debate persists regarding the assumptions underpinning CBHPE, its intended purposes, and how success should be defined and evaluated. This contributes to variable implementation and difficulty aligning core features with meaningful outcomes. To date, no published theory of change has articulated how CBHPE’s core components provide a framework for later evaluation of intended outcomes.Methods: Using Funnell and Rogers’ purposeful program theory, the authors, all members of the International Competency-based Education Health Professions Educators Collaborative (ICBHPE), developed a model theory of change. The authors conducted a broad review of CBHPE literature, supplemented by CBE frameworks from adjacent educational contexts to strengthen underdeveloped constructs in implementation and evaluation. Findings were iteratively synthesized into a program theory and refined through repeated cycles of large-group feedback, consensus building, and member checking within ICBHPE.Results: The authors developed a CBHPE Outcomes Theory of Change that articulates key assumptions, mechanisms of impact, and expected outcomes associated with CBHPE implementation. The framework specifies how van Melle’s CBHPE core components are theorized to function across phases of implementation and identifies proximal and distal outcomes that can reasonably be expected, based on intentional, deliberate program evaluation at each implementation and evaluation stage.Discussion: The CBHPE Outcomes Theory of Change offers scholars and implementers a practical guide to enhance the quality and fidelity of implementation, evaluation, and research efforts related to CBHPE worldwide. Using this guide as a framework, programs can plan, implement, and then examine whether the intended outcomes of CBHPE have been realized.

Competency-based medical education (CBME) is widely adopted in numerous countries, but many programs struggle to translate its conceptual promises into routine educational and clinical practice. Entrustable Professional Activities (EPAs), a key mechanism to operationalize CBME, have been implemented in different ways with substantial variation across contexts. While implementation challenges are well described, the field lacks explanatory approaches to understand why such variation occurs and how it shapes practice. In this Show-and-Tell contribution we apply Normalization Process Theory (NPT), an implementation theory, to analyze how EPA-based curriculum reforms are taken up, enacted, and sustained across settings. We conducted a comparative, theory-informed analysis of implementation experiences from five regions (in Latin America, Asia, North America, Europe) drawing on materials from an international EPA symposium (Barcelona, 2025). Data sources include a pre-symposium survey, invited presentations, transcripts of plenary discussions, and follow-up reflections. Using NPT’s four core constructs (coherence, cognitive participation, collective action, and reflexive monitoring), we examined how stakeholders make sense of EPAs, engage with implementation, integrate practices into clinical routines, and adapt them over time. The analysis revealed recurring mechanisms shaping implementation across contexts. Challenges included conceptual ambiguity, variable engagement, workflow pressures, and misalignment with existing practices. At the same time, enabling conditions emerged across settings: clear communication of purpose, phased implementation strategies, coordinated faculty development, leadership support, and context-sensitive adaptation. By foregrounding implementation mechanisms rather than outcomes alone, NPT offers a transferable analytic lens to guide, evaluate, and refine curriculum reforms.

Faculty development, trainee orientation and stakeholder engagement are essential elements of change management in the implementation of EPAs. An effective strategy addresses stakeholder needs over the various stages of planning, piloting, and implementation of EPAs. It encompasses faculty and all other stakeholders, i.e., clinical supervisors and assessors, non-workplace-based teaching faculty, coaches or advisers for trainees’ portfolios, members of clinical competence committees, administrators, program directors and other leaders. Best practices involve engaging with stakeholders as essential partners working toward a shared vision, building a sense of a community of practice, planning a range of activities in a continuous, dynamic, and enabling process, and including trainee development alongside faculty development. This chapter introduces evolving conceptions of faculty development and identifies key principles and strategies to guide the design of an effective plan. A range of approaches is outlined from passive to active, with various modes of delivery including face-to-face and hybrid and self-directed learning. Factors to consider are discussed and the significance of context is acknowledged. The importance of resourcing faculty and other stakeholders and the need to make a business case supported by ongoing evaluation are highlighted. Three examples of strategies in practice illustrate some key ideas. An analysis of the specific needs of different stakeholder groups, with potential approaches and a directory of accessible digital resources to support faculty development, trainee orientation, and engagement with other stakeholders, is also provided.

Entrustable professional activities (EPAs) form the cornerstone of competency-based health professions education, focusing on the critical tasks trainees must master for their future unsupervised clinical practice. Recognizing the challenges in assessing EPAs, especially those caused by the rarity of some clinical events and the dynamic nature of health care settings, there is an increasing interest in utilizing simulation as a complementary approach. Using simulation modalities, educators can design controlled and relevant settings for learning and assessment, allowing students to apply theoretical knowledge, practical skills, and professional attitudes in a risk-free environment. This chapter delves into whether and how simulation can be integrated into EPA-based curricula to enhance training and preparation for performing EPAs, as well as to provide a controlled setting for assessing trainees’ entrustment levels. We explore the theoretical underpinnings for applying simulation in an EPA-based curriculum, highlighting its potential dual roles in bridging educational experiences with assessment activities, and relating both to real-world clinical practice. While we propose a model for the promising integration of simulation into EPA-based curriculum, we also note that the evidence supporting its efficacy remains preliminary. Further research must substantiate the role and value of simulation in an EPA-based training and assessment modality. Our model describes the possible application of EPAs that progresses from an individual’s basic skill acquisition to their becoming capable of acting in complex, broader team-based clinical challenges. Incorporating simulation meaningfully into EPA-based curricula represents a transformative approach in preparing health care professionals for the challenges of clinical practice.

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The quality of health professions education is socially determined and closely linked to the quality of health care. Entrustable professional activities (EPAs) add strength to and operationalize curricula for competency-based education for health professions by focusing on both the patient and trainee, bringing health professions education together with patient care. This social accountability within an EPA-based curriculum emphasizes measurable enhancements to local health services through EPAs. As such, both external quality assurance (QA) and internal QA are crucial for implementing and improving an EPA-based program. External QA involves guidance from the regulating body regarding training policies, procedures, and practices. Internal QA entails self-auditing, utilizing mechanisms like program evaluation (PE) to monitor, evaluate, and improve the assessment and attainment of EPAs. Continuous quality improvement (CQI) can be used to augment PE by serving as a system for accountability and transparency. This section introduces the concepts of PE and CQI to be used within an EPA-based curriculum, models to support PE and CQI processes, examples of actual cases where PE and CQI were beneficial, and solutions to address challenges specific to EPA-based curricula.