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Competency Based Medical Education

PA CBME Orientation

This Program Administrator’s CBME Orientation guide is meant to serve as a launching point for your role as a Program Administrator. While the content here will serve as a basis for your journey into CBME as a PA, feel free to tweak/tailor the material for your own needs. If you have any additional questions after viewing the content, please do not hesitate to reach out to us. 

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Competency based medical education

Competency Based Medical Education is an outcomes based model designed to ensure that physicians graduate with the competencies required to meet local health needs. It aims to enhance patient care by improving learning and assessment in residency.

As stated by the Royal College of Physicians and Surgeons of Canada:

Competence by Design (CBD) is the Royal College of Physicians and Surgeons of Canada’s major change initiative to reform the training of medical specialists in Canada. It is based on a global movement known as Competency-based medical education (CBME), and is led by the medical education community. The objective of CBD is to ensure physicians graduate with the competencies required to meet local health needs. It aims to enhance patient care by improving learning and assessment in residency.

While we will be typically focusing on the CBD model, the College of Family Physicians of Canada (CFPC) has a similar model entitled “Triple C”. Triple C is a competency-based curriculum for family medicine residency training, and is based on the CanMEDS–Family Medicine framework and the Evaluation Objectives in Family Medicine.

In a nutshell, the CBME model is assessing learner’s individual competencies (I.e. procedures/tasks) within a clinical/surgical environment. These individual procedures/tasks are broken down into what is called EPAs and Milestones (Please see the video in Module 2). 

Acronyms to remember: 

CBME = Competency Based Medical Education 

CBD = Competence by Design 

EPA = Entrustable Professional Activity 


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Competence by design

As per the Royal College, in Competence by Design (CBD) “supervisors make use of authentic clinical oversight to engage in the workplace-based assessment (WBA) of each resident’s performance. WBA should be feasible; put simply, it involves documenting the verbal feedback that many supervisors already give to their residents. The goals of WBA are to provide specific feedback for trainee development as well as sufficient practice performance data to inform the EPA achievement decisions of the competence committee.”

Competence by Design (CBD) requires that trainees demonstrate ability at all stages along the competence continuum.

It is important to remember WBA’s track feedback over time. Not just a specific task/procedure.

Acronyms to Remember: WBA = Workplace Based Assessment

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Workplace-based assessment

Workplace based assessment is based on direct and indirect observation. Narrative feedback is a cornerstone of the CBD assessment strategy.

As per the Royal College, “Frequent and timely coaching conversations between a learner and observer are a critical element of WBA. This is known as Coaching in the Moment and it follows the RX-OCR step-by-step process:

  1. R: Establish educational Rapport between the resident and the clinician (an educational alliance or partnership).
  2.  X: Set eXpectations for an encounter (discuss learning goals).
  3.  O: Observe the resident. With CBD, the role of clinical teacher is evolving from supervisor to frequent observer and coach. When clinical teachers directly or indirectly observe the work residents do more often, their observations provide greater learning opportunities and a more comprehensive image of trainees’ competence.
  4. C: Engage in a Coaching conversation for the purpose of improvement of that work. As part of this conversation, the clinical teacher gives the trainee “coaching feedback,” focusing on specific actionable suggestions for improvement and how such improvements can be accomplished.
  5. R: Record a summary of the encounter, including observation specifics and performance ratings, using an observation form.”

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The entrustability scale allows us to rate a resident’s workplace-based performance. This entrustability scale, known as the O-Score Scale, contains a series of five anchors.  

  1. “I had to” 
    1. I.e. The physician had to perform the clinical activity while the resident observed. 
  2.  “I had to talk them through” 
    1. I.e. The resident required constant direction. 
  3.  “I had to prompt them from time to time” 
    1. I.e. The resident required frequent direction. 
  4. “I had to provide minor direction” 
    1. I.e. The resident required minor direction. 
  5. “I did not need to provide direction for safe and independent care” 
    1. I.e. No direction was required for safe independent care. 

Program Committees, Competence Committees and Faculty will need to collaborate on what constitutes a 4 or a 5 on the entrustability scale so that the Program is all on the same page.  

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CBD Coaching model

Coaches are the supervisors and faculty who work within the clinical learning environment. There are two key approaches to coaching. 

  1. Coaching in the moment 
    1. The Royal College states that “Coaching in the Moment requires clinicians to establish rapport and set expectations with their residents, observe the residents doing their daily work, provide coaching feedback, and record the encounter. Frequent observation is a key ingredient in resident learning and assessment. 
  2. Coaching over time 
    1. The Royal college states that “Coaching over Time requires a longitudinal relationship between a clinical faculty member and a resident. This educational partnership lasts longer than any one clinical experience. It requires regularly scheduled face-to-face discussions about the resident’s progression toward competence. Learning opportunities are planned to address any recognized performance patterns. For an educational partnership to work well, residents must feel confident that the clinician has the resident’s best learning interests in mind. 

Faculty will have different approaches to coaching. Creating or using a standardized template/form for Coaches to complete their review of the trainee will make their review/report for the Competency Committee streamlined and efficient.  

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Support for program administrators

CBME runs a series of committees, each with a variety of goals. CBME aims to have PA representation on each committee, so that your unique voice and ideas can be heard.

A specific Program Administrator (PA) Subcommittee exists to:

  • Support PAs in their roles in programs at various stages of transition
  • Contribute to the development of resources and learning opportunities
  • PA NAC (long form Program Assistant National Advisory Committe)

CBME also runs a series of lunch and learns, which can be found on our events page.

Acronyms to Remember:  PA NAC – Program Assistant National Advisory Committee 


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Competence continuum diagram

The Competence Continuum Diagram provides a high-level overview of the resident’s transition from residency to professional practice.

The diagram/process is broken into seven stages.

  1. Entry to residency
  2. Transition to discipline (orientation and assessment)
  3.  Foundation of discipline
  4.  Core of discipline
    1.  Followed by Royal College Examination
  5.  Transition to practice
    1.  Followed by Certification
  6.  Continuing professional development (maintenance of competence and advanced expertise)
  7.  Transition out of professional practice

It should be noted that every trainee move through the above-mentioned stages at their own pace.


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keeping informed

The CBME office has multiple means of keeping you informed. We distribute a monthly newsletter detailing the latest happenings in our Office, which includes a section dedicated to Program Administrators. You can find the latest newsletter, and a collection of previous newsletters, on our news page.

We also utilize Microsoft Teams to organize the various CBME committees, and involve those who are part of implementation. If you have not been added to the PA channel yet, please reach out to us.


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the role of the pa in CBMe

  1. Connect with other programs transitioning to CBD.
    1. The CBME office utilizes Microsoft Teams to organize the various CBME committees and involve those who are part of implementation. Teams will allow you to quickly identify who else is involved in the CBME process, and allow you to reach out to them. If you have not been added to the PA Channel yet, please reach out to us.
  2. Attend PGME and MEDSIS Workshops
    1. A full list of upcoming workshops can be found on our events.
  3. Read and re-read literature from workshops – create a “how to” folder of information
    1. We maintain a directory of helpful material via our resources.

We also recommend that you keep a simple list of objectives during the process, and identify a timeline for completion. It’s important to remember to be flexible though, and allow for changes in the process. You’ll likely also find that many of the things your program is doing is already CBD. 

 It is also important to keep the steps manageable, and to keep the big picture in mind. Keep your goals simple and easily achievable. It may be helpful to use your Outlook Calendar to create “meeting times” to track specific weekly, monthly, and yearly tasks (such as rotation scheduling, program activities, CARMS interviews, etc.).  

Ask! Ask! Ask! The CBME Office is happy to assist with any questions you may have and point you in the right direction to our PA CBME Experts. 

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CBME across program roles

CBME is championed across four key program roles.

The Competence Committee Chair

  • Determine optimal ways to stay in touch – Chair/PA
  • Set and circulate meeting dates which should coincide with Residency Trainee/Program Committee Meetings
  • Set meeting agendas – PA
  • Circulate and collect documents – PA
  • Meeting minutes – PA

The Competence Committee

  • Maintain Terms of Reference
  • Watch for role changes that impact the committee – PA
  • Assign MedSIS access – PA
  • Provide pre-meeting documentation – PA
  • Distribute Competence Committee results to residents – PA
  • Assist with meeting follow up – PA

Academic Coaches

  • Maintain terms of reference
  • Provide timeline for meeting prep – PA
  • Assign MedSIS Access – PA
  • Maintain Coach Assignment list – PA
  • Distribute Competence Committee results to coaches – often, role of PA as Coaches/Faculty have difficulty “uploading” documents to MedSIS (or refuse)


  • Ensure access to EPA data – PA
  • Provide ‘Year at a Glace’ (a road map) – PA
  • Remind about lead time before CC meetings – PA
  • Assist with MedSIS issues and questions – PA/MedSIS
  • Reassure/assist residents so that they feel supported – PA

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CBME Program Administrator SUBCOMMITTEE

The CBME Program Administrator Subcommittee aims to create a forum for the PAs to meet and share information. There we discuss and share best practices for the Program and Administrators, and how it relates to Competency by Design (CBD). The CBME PA Subcommittee also identifies resources and infrastructure that enables the successful adoption of CBD, and promotes scholarly work within the Program Administrator system.

The CBME Program Administrator Subcommittee meets monthly, and new PAs are always welcome to join.

Please reach out to us if you’re interested in joining!

Additional Links/Resources


We maintain a list of frequently asked questions that can be found on our FAQ Page.