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Identify Key Encounter Types for Patient Log
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Keep a Procedure Log, Where Applicable
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Assess PA Progress on EPAs and Patient Logs to Inform Clinical Ramp-Up Prospectively
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Include a Clinical Skills Essentials Checklist
Keep in mind that by having defined expectations of role, EPAs, foundational knowledge, schedule of progression through training - it helps give dual responsibility to both supervisiors/preceptors and APP to track their progress.
Assess PA Progress on EPAs and Patient Logs to Inform Clinical Ramp-Up Prospectively
The preceding sections have described how to outline a clear road map for what is expected during your new APP’s first several months. However, even the most carefully thought-out plan will require refinements along the way. Each APP will bring a unique set of strengths and weaknesses, and the clinical demands of the moment can always shift. Making a shared plan for assessment with your APP can ensure progress is being made and help refine your plan in real-time.
Regular competency assessments are mandated by law. After initial hire, PAs must be evaluated using a Focused Professional Performance Evaluation (FPPE) at 30 days, 60 days, and 90 days. Thereafter, Ongoing Professional Performance Evaluations (OPPE) must be completed once per year by the supervising MD. These reviews are meant to offer a holistic appraisal of the PA’s competence. High quality feedback, however, is specific and actionable.
It is challenging to (1) achieve accurate assessment in the clinical environment and (2) find the time and comfort to deliver it. Another advantage of utilizing EPAs in your training paradigm is that specific areas for assessment and targets for achievement are pre-specified. Supervisors will have an easier time knowing what to look out for. APPs will be more empowered to seek out feedback on specific content areas. Both parties may be more comfortable with feedback in general, since the areas of focus at each time point are agreed upon ahead of time. The feedback generated from this process will also be highly actionable: entrustment decisions can be made, and the APPs clinical responsibilities tailored accordingly. The EPA schedule be accelerated or slowed as appropriate based on these assessments.
Ideally, assessment of the new APP should be informed by multiple sources. Make a plan for who will formally evaluate the APP, and how often. While the supervising/collaborating MD will certainly be instrumental in these evaluations, anyone who is working frequently with the APP can be a valuable resource. Ensure that those who are expected to evaluate the APP know this in advance, and share the schedule of EPAs you have devised for their training period (if you elect not to use EPAs, at least share the intended ramp-up plan and key patient groups that the APP will log). This will allow for more specific feedback.
As the APP gains more independence, supervisors and near-peer evaluators will inherently rely less on direct observation to evaluate the APP. Make a plan for a designated supervisor to conduct regular chart reviews of independent encounters as this occurs (for example, review five charts per week for documentation and orders). Some departments might plan more formal assessments at milestone timepoints. Simulation sessions, formal clinical skills examination, or even a mini-OSCE could be considered. Finally, ensure that your new APP gets in the practice of self-evaluation. It can be particularly instructive to compare self-rated EPA entrustments with those obtained by supervisors and near-peers.
Patient Log
Patient logs can be help in racking the general progress and experience of an APP, to determine when they have experienced sufficient volume/complexity/acuity to take on more patients/encounters/complexity/acuity, new types of patients/encounters/complexity/acuity and shift to more independent models of practice; and/or
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Tracking the experience an APP has with specific conditions, to determine when they are ready to admit or serve as responding clinician for certain types of patients. (See complexity ramp-up, above)
In most circumstances, tracking the general progress of an APP can be accomplished by selecting:
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2-3 common reasons for admissions/consultations (for inpatient APPs) or clinic visits (for outpatient PAs); and
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2-3 common emergencies (for inpatient APPs) or reasons for an urgent visit (for outpatient APPs)
Tracking a greater range of conditions may be useful when (1) there is a large diversity of patient complaints admitted to this service and/or (2) there are other providers on the service, so the workload can be divided based on the graded responsibility the APP in training has achieved.
To select which types of patient encounters to track, it is therefore essential to define:
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What are the most common reasons for which patients are admitted to this unit or seen in this clinic?
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What are the most common emergencies that might arise among patients seen?
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How similar are the individual patients admitted to this service or seen in this clinic?
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One extreme: post-operative patients on a highly specialized surgical service. The focus and common issues for each patient will be quite similar.
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Another extreme: a general medical service. Patients may be admitted for extremely different reasons, and the issues that arise may be less predictable
It may be challenging to prospectively determine how many patient encounters should be completed before additional independence is warranted. Accordingly, it most useful to keep notes that inform this progression and inform assessment of your EPAs. For example, “APP’s supervised exam was accurate and did not need any correction, but needed input from MD on plan.”
Tracking APP Progress and Clinical Skills
Keep in mind that by having defined expectations of role, EPAs, foundational knowledge, schedule of progression through training - it helps give dual responsibility to both supervisiors/preceptors and APP to track their progress.
Example: Commmon Patient Encounter - Patient Admitted with heart failure exacerbation
Example: Commmon Patient Emergency - Acute chest pain
Keep a Procedure Log (where applicable)
If your APP will be expected to perform any procedures independently, it will be useful to keep a log for each procedure performed to determine when they are ready to shift to independent performance.
For each procedure, define ahead of time:
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What should the APP know about this procedure before they begin to attempt performing it? For example, is there a safety time-out to review that outlines what needs to be completed before the procedure it?
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How many procedures should the APP observe before they can start performing it?
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How many supervised procedures does the APP need to do before they can attempt one unsupervised?
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What circumstances should prompt the APP to pause the procedure and check with a supervisor?
Similar to above will have snapshot of example with link to blank pdf template
EDIT PAGE
Keep in mind that by having defined expectations of role, EPAs, foundational knowledge, schedule of progression through training - it helps give dual responsibility to both supervisiors/preceptors and APP to track their progress.
Example: Commmon Patient Encounter - Patient Admitted with heart failure exacerbation
Example: Commmon Patient Emergency - Acute chest pain
Keep a Procedure Log (where applicable)
If your APP will be expected to perform any procedures independently, it will be useful to keep a log for each procedure performed to determine when they are ready to shift to independent performance.
For each procedure, define ahead of time:
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What should the APP know about this procedure before they begin to attempt performing it? For example, is there a safety time-out to review that outlines what needs to be completed before the procedure it?
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How many procedures should the APP observe before they can start performing it?
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How many supervised procedures does the APP need to do before they can attempt one unsupervised?
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What circumstances should prompt the APP to pause the procedure and check with a supervisor?