Making Entrustment Decisions Research Articles

OWIED System to Facilitate the Entrustment Decision in EPA Implementation.

Entrustable professional activities (EPAs) are gaining attention as an approach for adequate implementation of a competency-based evaluation framework in nursing education. This study sought to develop an Online Web-assessment Interface for Entrustment Decision (OWIED) to facilitate the entrustment decision in EPA implementation. A participatory qualitative action research design consisting of two phases was used for this study. The exploration phase was conducted in close collaboration with stakeholders. Following the exploration phase, the primary researcher and a team of subject-matter experts in academic and information technology developed the OWIED system according to the exploration phase results. The necessary features that met the expectations of the stakeholders were identified and assisted in developing the OWIED system. OWIED may provide a valid tool to track and validate nursing student acquisition of core competencies and assist in making entrustment decisions as students fulfill their training requirements in their academic program. [J Nurs Educ. 2024;63(6):356-365.].

Unintended consequences of technology in competency-based education: a qualitative study of lessons learned in an OtoHNS program

BackgroundFormative feedback and entrustment ratings on assessments of entrustable professional activities (EPAs) are intended to support learner self-regulation and inform entrustment decisions in competency-based medical education. Technology platforms have been developed to facilitate these goals, but little is known about their effects on these new assessment practices. This study investigates how users interacted with an e-portfolio in an OtoHNS surgery program transitioning to a Canadian approach to competency-based assessment, Competence by Design.MethodsWe employed a sociomaterial perspective on technology and grounded theory methods of iterative data collection and analysis to study this OtoHNS program’s use of an e-portfolio for assessment purposes. All residents (n = 14) and competency committee members (n = 7) participated in the study; data included feedback in resident portfolios, observation of use of the e-portfolio in a competency committee meeting, and a focus group with residents to explore how they used the e-portfolio and visualize interfaces that would better meet their needs.ResultsUse of the e-portfolio to document, access, and interpret assessment data was problematic for both residents and faculty, but the residents faced more challenges. While faculty were slowed in making entrustment decisions, formative assessments were not actionable for residents. Workarounds to these barriers resulted in a “numbers game” residents played to acquire EPAs. Themes prioritized needs for searchable, contextual, visual, and mobile aspects of technology design to support use of assessment data for resident learning.ConclusionBest practices of technology design begin by understanding user needs. Insights from this study support recommendations for improved technology design centred on learner needs to provide OtoHNS residents a more formative experience of competency-based training.Graphical abstract

Variable or Fixed? Exploring Entrustment Decision Making in Workplace- and Simulation-Based Assessments.

Many models of competency-based medical education (CBME) emphasize assessing entrustable professional activities (EPAs). Despite the centrality of EPAs, researchers have not compared rater entrustment decisions for the same EPA across workplace- and simulation-based assessments. This study aimed to explore rater entrustment decision making across these 2 assessment settings. An interview-based study using a constructivist grounded theory approach was conducted. Gastroenterology faculty at the University of Toronto and the University of Calgary completed EPA assessments of trainees' endoscopic polypectomy performance in both workplace and simulation settings between November 2019 and January 2021. After each assessment, raters were interviewed to explore how and why they made entrustment decisions within and across settings. Transcribed interview data were coded iteratively using constant comparison to generate themes. Analysis of 20 interviews with 10 raters found that participants (1) held multiple meanings of entrustment and expressed variability in how they justified their entrustment decisions and scoring, (2) held personal caveats for making entrustment decisions "comfortably" (i.e., authenticity, task-related variability, opportunity to assess trainee responses to adverse events, and the opportunity to observe multiple performances over time), (3) experienced cognitive tensions between formative and summative purposes when assessing EPAs, and (4) experienced relative freedom when using simulation to formatively assess EPAs but constraint when using only simulation-based assessments for entrustment decision making. Participants spoke about and defined entrustment variably, which appeared to produce variability in how they judged entrustment across participants and within and across assessment settings. These rater idiosyncrasies suggest that programs implementing CBME must consider how such variability affects the aggregation of EPA assessments, especially those collected in different settings. Program leaders might also consider how to fulfill raters' criteria for comfortably making entrustment decisions by ensuring clear definitions and purposes when designing and integrating workplace- and simulation-based assessments.

Who can do this procedure? Using entrustable professional activities to determine curriculum and entrustment in anesthesiology – An international survey

Introduction As competency-based curricula get increasing attention in postgraduate medical education, Entrustable Professional Activities (EPAs) are gaining in popularity. The aim of this survey was to determine the use of EPAs in anesthesiology training programs across Europe and North America. Methods A survey was developed and distributed to anesthesiology residency training program directors in Switzerland, Germany, Austria, Netherlands, USA and Canada. A convergent design mixed-methods approach was used to analyze both quantitative and qualitative data. Results The survey response rate was 38% (108 of 284). Seven percent of respondents used EPAs for making entrustment decisions. Fifty-three percent of institutions have not implemented any specific system to make such decisions. The majority of respondents agree that EPAs should become an integral part of the training of residents in anesthesiology as they are universal and easy to use. Conclusion Although recommended by several national societies, EPAs are used in few anesthesiology training programs. Over half of responding programs have no specific system for making entrustment decisions. Although several countries are adopting or planning to adopt EPAs and national societies are recommending the use of EPAs as a framework in their competency-based programs, few are yet using these to make “competence” decisions.

How Clinical Supervisors Conceptualize Procedural Entrustment: An Interview-Based Study of Entrustment Decision Making in Endoscopic Training.

Entrustment is central to assessment in competency-based medical education (CBME). To date, little research has addressed how clinical supervisors conceptualize entrustment, including factors they consider in making entrustment decisions. The aim of this study was to characterize supervisors' decision making related to procedural entrustment, using gastrointestinal endoscopy as a test case. Using methods from constructivist grounded theory, the authors interviewed 29 endoscopy supervisors in the United States and Canada across multiple specialties (adult and pediatric gastroenterology, surgery, and family medicine). Semistructured interviews, conducted between April and November 2019, focused on how supervisors conceptualize procedural entrustment, how they make entrustment decisions, and what factors they consider. Transcripts were analyzed using constant comparison to generate an explanatory framework and themes. Three themes were identified from the analysis of interview transcripts: (1) entrustment occurs in varying degrees and fluctuates over time; (2) entrustment decisions can transfer within and across procedural and nonprocedural contexts; (3a) persistent static factors (e.g., supervisor competence, institutional culture, legal considerations) influence entrustment decisions, as do (3b) fluctuating, situated dynamic factors (e.g., trainee skills, patient acuity, time constraints), which tend to change from one training encounter to the next. In the process of making procedural entrustment decisions, clinical supervisors appear to synthesize multiple dynamic factors against a background of static factors, culminating in a decision of whether to entrust. Entrustment decisions appear to fluctuate over time, and assessors may transfer decisions about specific trainees across settings. Understanding which factors supervisors perceive as influencing their decision making has the potential to inform faculty development, as well as competency committees seeking to aggregate faculty judgments about trainee unsupervised practice. Those leading CBME programs may wish to invest in optimizing the observed static factors, such that these foundational factors are tuned to facilitate trainee learning and achievement of entrustment.

Assessing Trainees and Making Entrustment Decisions: On the Nature and Use of Entrustment-Supervision Scales.

Clinical teachers are continuously entrusting trainees with care responsibilities in health care settings. Entrustable professional activities employ entrustment decision making as an approach to assessment in the workplace.Various scales have been created to measure "entrustment," all basically expressing the level or type of supervision a trainee requires for safe and high-quality care. However, some of these scales are only weakly related to the purpose of making decisions about the autonomy trainees will be granted. The authors aim to increase understanding about the nature, purpose, and practice of supervision scales aimed at entrustment.After arguing for entrustment as a component of workplace-based assessment, the distinction between ad hoc entrustment decisions (daily decisions in health care settings) and summative entrustment decisions (with a certifying nature) is clarified. Next, the noncontinuous nature of entrustment-supervision (ES) scales, as opposed to most workplace-based assessment scales, is explained. ES scales have ordinal, rather than interval, properties and focus on discrete decisions. Finally, some scales are retrospective ("how much supervision was provided?"), and others are prospective ("how much supervision will be needed in the near future?"). Although retrospective scales reflect observed behavior, prospective scales truly focus on entrustment and ask for more holistic judgment, as they include a broader evaluation and a risk estimation to enable a decision about increase of autonomy.The analysis concludes with a discussion about entrustment for unsupervised practice and supervision of others, as well as the program, context, and specialty specificity of scales.

The ingredients of a rich entrustment decision

Entrustment decision-making has become a topic of interest in workplace-based assessment in the health professions and is germane to the use of entrustable professional activities. Entrustment decisions stem from judgments of a trainee’s competence and include the permission to act with a higher level of responsibility or autonomy and a lower level of supervision. Making entrustment decisions differs from regular assessment of trainees, which usually has no consequences beyond marking trainee progress. Studies show that clinicians generally weigh more factors in making an entrustment decision than when merely assessing trainee competence or performance without direct consequences for patient care. To synthesize the varying factors reported in literature, the authors performed a thematic analysis of key qualitative studies that investigated trainee features clinical supervisors find important when making entrustment decisions. Five themes emerged from the 13 publications: Capability (specific knowledge, skills, experience, situational awareness), Integrity (truthful, benevolent, patient-centered), Reliability (conscientious, predictable, accountable, responsible), Humility (recognizes limits, asks for help, receptive to feedback), Agency (proactive toward work, team, safety, personal development). Thoughtful entrustment decisions, made either by individual clinical supervisors or by clinical competency committees, may be enriched by taking into account these five features.

Entrustment within an objective structured clinical examination (OSCE) progress test: Bridging the gap towards competency-based medical education

Purpose Progress testing aligns well with competency-based medical education (CBME) frameworks, which stress the importance of continuous improvement. Entrustment is a useful assessment concept in CBME models. The purpose of this study was to explore the use of an entrustability rating scale within the context of an objective structured clinical examination (OSCE) Progress Test. Methods A 9-case OSCE Progress Test was administered to Internal Medicine residents (PGYs 1–4). Residents were assessed using a checklist (CL), global rating scale (GRS), training level rating scale (TLRS), and entrustability scale (ENT). Reliability was calculated using Cronbach's alpha. Differences in performance by training year were explored using ANOVA and effect sizes were calculated using partial eta-squared. Examiners completed a post-examination survey. Results Ninety one residents and forty two examiners participated in the OSCE. Inter-station reliability was high for all instruments. There was an overall effect of training level for all instruments (p < 0.001). Effect sizes were large. 88% of examiners completed the survey. Most (62%) indicated feeling comfortable in making entrustment decisions during the OSCE. Conclusions An entrustability scale can be used in an OSCE Progress Test to generate highly reliable ratings that discriminate between learners at different levels of training.

Entrustment trends in orthotic and prosthetic residencies.

Orthotic and prosthetic residency preceptors have little guidance transitioning residents between observing and performing patient care. Understanding current entrustment trends and factors can help guide resident progression during residency. To identify entrustment trends and factors within an orthotics and prosthetics residency affecting a supervisor's decision to entrust residents with independent patient care. Cross-sectional study. In this cross-sectional study, 831 National Commission of Orthotic and Prosthetic Education preceptors were invited to complete a 26-question, online questionnaire that examined possible entrustment factors. A total of 77 preceptors completed the questionnaire. The top-reported behavioral qualities impacting entrustment were recognition of limitations and willingness to ask for help (n = 45) and competence (n = 37). Preceptors ranked evaluation (n = 27) as the professional skill which most affected entrustability; technical skill least affected entrustability (n = 4). Preceptors of 12-month residencies entrust residents to indirect supervision when they have completed approximately 75% (i.e. 9 months) of the program. Preceptors of 18-month residencies reported that they entrust their residents by the time they reach 50% (i.e. 9 months) of their training. A small number of preceptors (n = 19) never allow a resident to independently perform practice management. Residency supervisors value interpersonal and evaluation skills when making entrustment decisions. Residency mentors can use these findings to inform their entrustment decisions and support a resident's progression toward independent practice. This study presents information which can inform clinical preceptors and residents on what factors contribute to the decision to progress a resident from observation to independent patient care. These findings may influence clinical education standards which aim to promote both resident training and patient access to quality care.

Developing an Entrustment Process: Insights from the AAMC CoreEPA Pilot.

One of the main goals of the CoreEPA pilot has been to determine the feasibility of developing a process to make summative entrustment decisions regarding entrustable professional activities (EPAs). Five years into the pilot, we report results of a research study we conducted to explore approaches to the entrustment process undertaken by our ten participating schools. We sought to identify the choices that participating schools made regarding the entrustment process and why these decisions were made. We are sharing these results, highlighting ongoing challenges that were identified with the intent of helping other medical schools that are moving toward EPA-based assessment. We conducted semi-structured interviews with representatives of all 10 medical schools in the CoreEPA pilot to understand their choices in designing the entrustment process. Additional information was obtained through follow-up communication to ensure completeness and accuracy of the findings. Several common themes are described. Our results indicate that, while approaches to the entrustment process vary considerably, all schools demonstrated consistent adherence to the guiding principles of the pilot. Several common barriers to the entrustment process emerged, and there was a consensus that more experience is needed with the process before consequential entrustment decisions can be made. The CoreEPA pilot schools continue to address challenges identified in implementing entrustment processes and making entrustment decisions for our students graduating in the Class of 2020.

The viability of interprofessional entrustable professional activities.

Interprofessional education (IPE) and entrustable professional activities (EPAs) represent two topics in health professions education that have attracted significant attention in recent years. IPE (when different health professionals learn with, from and about each other with the aim of optimal care) has an inherent focus on the collective. EPAs (units of professional practice that can be fully entrusted to a trainee, once he or she has demonstrated the necessary competence to execute this activity unsupervised) have a focus on the individual. Attempts to relate the two may cause friction and the question is: can they be reconciled? Are interprofessional EPAs or team-EPAs useful concepts and if so what should they look like? The authors argue that most work in modern healthcare involves interprofessional collaboration. Some EPAs have an inherent strong interprofessional nature, such as emergency teamwork, running multidisciplinary team meetings, and surgery. Other EPAs are less inherently dependent on interprofessional collaboration. The authors conclude that neither interprofessional team-EPAs (for which a team can or should be certified), nor IP-EPAs for individuals, as opposed to other EPAs, are viable concepts. However, the authorsdo not question that certifying health care professionals and entrusting trainees with most clinical tasks will require to ascertain their competence in interprofessional collaboration. This must be included when assessing learners for most EPAs and making entrustment decisions. This can help to strengthen interprofessional competence in the clinical workplace.

Mitigating “Educational Groundhog Day” – The Role of Learner Handoffs Within Clinical Rotations: A Survey of Pediatric Educational Leaders

BackgroundMedical students decry frequent changes in faculty supervision, leading to the experience of “educational groundhog day.” The discontinuity in supervision, cursory relationships, and uncoordinated feedback impede students’ skill acquisition and delay entrustment decisions. Whereas patient handoff bundles are common, little is known about similarly structured approaches to learner handoffs (LHs). ObjectiveTo describe current LH procedures and practices within pediatric clerkships and subinternships and to gauge interest in a future LH bundle. MethodsNine items included in the 2016 Council on Medical Student Education in Pediatrics annual member survey were analyzed using mixed-methods. ResultsThe response rates were 66% (101 of 152) and 40% (165 of 411) for institutions and individuals, respectively. After limiting data to complete responses to programs with traditional block rotations, 54% of individual respondents (76 of 141) identified as inpatient faculty and about a quarter endorsed providing LHs. Inpatient faculty most commonly supervise medical students for 5 to 7 days. Most endorsed needing 1 to 3 days to determine a student's baseline performance and 5 days or more to make entrustment decisions. Three-quarters of inpatient faculty endorsed interest in LHs, while fewer than 16% of course directors currently provide LH expectations. Four themes emerged: instrument features, stakeholder buy-in, impact, and utility. ConclusionsTypical inpatient faculty service days approximate the time required for making entrustment decisions about clinical students. While most inpatient faculty desire a LH bundle for use within a clinical rotation, few institutions and faculty currently use LHs. LHs could accelerate entrustment decisions by allowing coordinated feedback that might hasten learner clinical-skill development.

Combining Scores Based on Compensatory and Noncompensatory Scoring Rules to Assess Resident Readiness for Unsupervised Practice: Implications From a National Primary Care Certification Examination in Japan.

Competence decisions in health professions education require combining scores from multiple sources and identifying pass-fail decisions based on noncompensatory (required to pass all subcomponents) and compensatory scoring decisions. This study investigates consequences of combining scores, reliability, and implications for validity using a national examination with subcomponent assessments. National data were used from three years (2015, 2016, and 2017) of the Japan Primary Care Association Board Certification Examination, with four subcomponent assessments: Clinical Skills Assessment-Integrated Clinical Encounter (CSA-ICE), CSA-Communication and Interpersonal Skills (CSA-CIS), Multiple-Choice Questions (MCQ), and Portfolio. Generalizability theory was used to estimate variance components and reliability. Kane's composite reliability and kappa decision consistency were used to examine the impact of using compensatory and noncompensatory scoring. Mean performance (n = 251) on the CSA-ICE, CSA-CIS, MCQ, and Portfolio subcomponent assessments were, respectively, 61% (SD = 11%), 67% (SD = 13%), 74% (SD = 8%), and 65% (SD = 9%); component-specific Φ-coefficient reliability ranged between, respectively, 0.57 and 0.67; 0.50 and 0.60; 0.65 and 0.76; and 0.87 and 0.89. Using a completely noncompensatory scoring approach on all four subcomponents, decision-consistency reliability was 0.33. Fully compensatory scoring yielded reliability of 0.86. Assessing a range of abilities in making entrustment decisions requires considering the balance of assessment tools measuring distinct but related competencies. These results indicate that noncompensatory pass-fail decision making, which seems more congruent with competency-based education, may lead to much lower reliability than compensatory decision making when several assessment subcomponents are used.

Competencies, Milestones, and a Level of Supervision Scale for Entrustable Professional Activities for Scholarship.

Scholarship is an important element of both undergraduate and graduate medical education, and scholarly activity is required for all pediatric fellows. However, despite the creation of entrustable professional activities (EPAs) for scholarship, the specific progressive levels of performance and the appropriate level of supervision for a given performance level have not been defined. The authors developed competencies and milestones for the scholarship EPA to provide a framework for assessment across the continuum; a level of supervision scale was also developed. The Vitae Researcher Development Framework served as a template to create the competencies and milestones for the scholarship EPA. Beginning in September 2015 and using a modified Delphi approach, three drafts were circulated to individuals with expertise in various types of scholarship until broad agreement was achieved. Then, in October 2016, the Steering Committee of the Subspecialty Pediatrics Investigator Network created a level of supervision scale, modeled after one it had previously developed. Eight competencies were identified as important in making entrustment decisions related to scholarship. For each competency, five milestone levels that span the continuum from novice to expert were created. A supervision scale with five progressive levels of entrustment was also created. Next steps include a study to obtain validity evidence for the supervision scale and determine the correlation between milestone and supervision levels. These competencies, milestones, and supervision levels can potentially serve as a road map for trainees and junior faculty and also play a role in the assessment of physician-scientists.

Entrustment of the on-call senior medical resident role: implications for patient safety and collective care

BackgroundThe on-call responsibilities of a senior medicine resident (SMR) may include the admission transition of patient care on medical teaching teams (MTT), supervision of junior trainees, and ensuring patient safety. In many institutions, there is no standardised assessment of SMR competency prior to granting these on-call responsibilities in internal medicine. In order to fulfill competency based medical education requirements, training programs need to develop assessment approaches to make and defend such entrustment decisions.The purpose of this study is to understand the clinical activities and outcomes of the on-call SMR role and provide training programs with a rigorous model for entrustment decisions for this role.MethodsThis four phase study utilizes a constructivist grounded theory approach to collect and analyse the following data sets: case study, focus groups, literature synthesis of supervisory practices and return-of-findings focus groups.The study was conducted in two Academic Health Sciences Centres in Ontario, Canada. The case study included ten attending physicians, 13 SMRs, 19 first year residents and 14 medical students. The focus groups included 19 SMRs. The later, return-of-findings focus groups included ten SMRs.ResultsFive core on-call supervisory tasks (overseeing ongoing patient care, briefing, case review, documentation and preparing for handover) were identified, as well as a range of practices associated with these tasks. We also identified challenges that influenced the extent to which SMRs were able to effectively perform the core tasks. At times, these challenges led to omissions of the core tasks and potentially compromised patient safety and the admission transition of care.ConclusionBy identifying the core supervisory tasks and associated practices, we were able to identify the competencies for the on-call SMR role. Our findings can further be used by training programs for assessment and for making entrustment decisions.

P075: Constructing entrustment: understanding clinical supervisor dynamics in the oral case presentation

Introduction: The Oral Case Presentation (OCP) has been described as a unique form of inter-physician communication integral to the practice of medicine and represents the foundation of trainee-supervisor interactions. In recent years, entrustment has been identified as an essential element of trainee supervision and learning. Despite the growing body of knowledge concerning entrustment in medical education, the influence of trust on the educational dynamic surrounding the OCP remains unknown. The objectives of this study were to (1) describe the complex nature of the OCP from the perspective of the supervisor and (2) explore the central role the OCP plays in the dyadic relationship between supervisor and trainee during the delivery of patient care. Methods: Using a constructivist grounded theory approach, semi-structured interviews were conducted from 2015 to 2016 with a purposive sample of attending Emergency Medicine (EM) physicians from the University of Ottawa. Transcripts were reviewed independently by two investigators using line-by-line coding and constant comparative analysis. Emerging concepts were coded and key themes identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Results: Twenty-one attending EM physicians participated in this study (71% male). The mean number of years in practice was 14. The mean percentage of shifts with a trainee assigned was 86%. Factors relating to entrustment were identified as the principal influences on both the content of the OCP and decisions relating to trainee supervision during the OCP process. These factors included the trainee level, the trainee-supervisor relationship, the context and the task. The OCP was also found to play several important roles as supervisors balanced the delivery of patient care and trainee education. These roles were related to communication, teaching and trainee assessment. Conclusion: The OCP represents a core activity within the supervisor-trainee relationship in which trust plays a central role. Clinical supervisors value the OCP as a form of authentic assessment of skills and perceive it to be a key determinant in making entrustment decisions. Future studies designed to evaluate the utility of the OCP as an educational tool should consider entrustment as an essential element.

Using Backward Design to Align the Core Clerkships with the EPAs

Since the publication of the Entrustable Professional Activities (EPAs) project by the Association of American Medical Colleges (AAMC), institutions have been exploring how to integrate and assess EPAs into a pre-existing medical education curricular structure. Here, we describe a systematic approach for achieving this task using the third year Core Clerkships as a model. We utilized the process of Backward Design to integrate the EPAs into our existing third year Core Clerkship Curriculum by creating common student learning outcomes and implementing a standardized assessment strategy. Specifically, our manuscript shares the process we used, barriers we faced, methods to evaluate the changes, our ideas to continue to improve this process in the future, and how other institutions can generalize this process. Our redesign efforts revealed that many perceptors were unable to evaluate student performance on key EPA-based outcomes we identified as appropriate to the third year. This finding has implications for how to begin making Entrustment decisions by helping to better establish where key entrustable performances are best observed and assessed.

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

Essential Facets of Competence That Enable Trust in Graduates: A Delphi Study Among Physician Educators in the Netherlands

There is a need for valid methods to assess the readiness for clinical practice of recently graduated physicians. To develop these methods, it is relevant to know the general features of trainees' performance that facilitate supervisors' trust in their ability to perform critical clinical tasks. To discover such essential facets of competence (FOCs), based on the opinion of experienced physician educators. We conducted a Delphi study, consisting of 2 rounds, among 18 experienced physician educators in the Netherlands. Mean, standard deviation, level of agreement, and skewness were calculated for the importance of FOCs for making entrustment decisions. The study yielded a list of 25 FOCs. In the first round, means were between 6.50 and 7.00 on a 7-point Likert scale (SD, 0.42-2.18); in the second round, means ranged from 5.45 to 6.90 (SD, 0.3-2.02). The level of agreement was high for 92% of the FOCs in the first round and 100% of the FOCs in the second round. Our Delphi study found consensus among experts about FOCs that are important for clinical entrustment decisions.

Nuts and bolts of entrustable professional activities.

The entrustable professional activity (EPA) concept allows faculty to make competency-based decisions on the level of supervision required by trainees. Competency-based education targets standardized levels of proficiency to guarantee that all learners have a sufficient level of proficiency at the completion of training.1–6 Collectively, the competencies (ACGME or CanMEDS) constitute a framework that describes the qualities of professionals. Such a framework provides generalized descriptions to guide learners, their supervisors, and institutions in teaching and assessment. However, these frameworks must translate to the world of medical practice. EPAs were conceived to facilitate this translation, addressing the concern that competency frameworks would otherwise be too theoretical to be useful for training and assessment in daily practice.Trust is a central concept for safe and effective health care. Patients must trust their physicians, and health care providers must trust each other in a highly interdependent health care system. In teaching settings, supervisors decide when and for what tasks they entrust trainees to assume clinical responsibilities. Building on this concept, EPAs are units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence. EPAs are independently executable, observable, and measurable in their process and outcome, and therefore, suitable for entrustment decisions. Sequencing EPAs of increasing difficulty, risk, or sophistication can serve as a backbone for graduate medical education.6An EPA must be described at a sufficient level of detail to set trainee expectations and guide supervisor's assessment and entrustment decisions (see table 2 for guidelines).Milestones, as defined by the ACGME, are stages in the development of specific competencies. Milestones may link to a supervisor's EPA decisions (eg, direct proactive supervision versus distant supervision). The Pediatrics Milestone Project provides examples of how milestones can be linked to entrustment decisions.7,8Entrustment decisions involve clinical skills and abilities as well as more general facets of competence, such as understanding one's own limitations and knowing when to ask for help. Making entrustment decisions for unsupervised practice requires observed proficiency, usually on multiple occasions.In practice, entrustment decisions are affected by 4 groups of variables: (1) attributes of the trainee (tired, confident, level of training); (2) attributes of the supervisors (eg, lenient or strict); (3) context (eg, time of the day, facilities available); and (4) the nature of the EPA (rare, complex versus common, easy). Entrustment decisions can be further distinguished as ad hoc (eg, happening during a night shift) or structural (establishing the recognition that a trainee may do this activity at a specific level of supervision from now on). In the clinical context, many ad hoc entrustment decisions happen every day. Structural entrustment decisions formally acknowledge that a trainee has passed a threshold that allows for decreased supervision. The certificate awarded at such occasions has been called a statement of awarded responsibility (STAR) and should be carefully documented.2Linking an EPA with a competency framework emphasizes essential competency domains when observing a trainee executing the EPA.Decide how many EPAs are useful for training.While there can be many EPAs that serve to make ad hoc entrustment decisions, EPAs that lead to structural entrustment decisions (ie, certification or STARs) should involve broad-based responsibilities and be limited in number. For a graduate medical education program, no more than 20 to 30 EPAs are recommended.EPAs can be the focus of assessment. The key question is: Can we trust this trainee to execute this EPA? The answer may be translated to 5 levels of supervision for the EPA: