Use of entrustable professional activities for reliable overall entrustment decisions

Abstract – Purpose – Entrustable professional activities (EPAs) detail essential activities within a given specialty. Although 17 general pediatrics EPAs have been defined, it is not known how many are needed to make high-reliability overall entrustment decisions about resident readiness for practice at the time of graduation and initial certification. This study sought to determine how many general pediatrics EPAs are needed. Method – During the 2021 to 2022, 2022 to 2023, and 2023 to 2024 academic years, the authors collected entrustment-supervision levels, determined by clinical competency committees biannually, for the 17 general pediatrics EPAs for residents at 48 U.S. pediatric residency training programs. Midyear reports were collected between November and January of each year, and end-of-year reports were collected between May and July. The authors conducted generalizability and decision studies to determine the number of EPAs needed to make a reliable overall entrustment decision. Results – A total of 166, 077 individual entrustment-supervision levels were collected for 4, 250 pediatric residents across the 17 general pediatrics EPAs. Across all data reporting cycles, the authors found that assessing 6 EPAs yields a generalizability coefficient of 0.8 and assessing 12 EPAs yields a generalizability coefficient of 0.9. However, results differed for midyear compared with end-of-year data collection timepoints as well as by postgraduate year. At graduation, 9 to 13 EPAs are needed to make a highly reliable (generalizability coefficient of 0.9) overall decision about degree of entrustment for unsupervised practice. Conclusions – This study provides rich insight into the number of EPAs needed to make reliable entrustment decisions about resident readiness to provide patient care. Although readiness can be determined with as few as 9 general pediatrics EPAs (an assessment task), more may be needed to inform a comprehensive curriculum that ensures focus in all areas important to developing general pediatricians during residency training (a curricular task).