Competence by Design (CBD)

July 1, 2019 Programs Launching with CBD: Obstetrics & Gynecology, Anatomic Pathology, Cardiac Surgery, Critical Care Medicine, Gastroenterology, General Internal Medicine, General Pathology, Geriatric Medicine, Internal Medicine, Neurosurgery, Radiation Oncology and Rheumatology.

CBD 101 PowerPoint


CBD is a multi-year initiative launched to transform medical education. CBD has introduced a hybrid model of competency-based medical education (CBME) to learning and assessment in residency and specialty practice across Canada. The goal of CBD is to enhance patient care by improving specialist training and lifelong learning, ensuring physicians demonstrate the skills and behaviors required to continuously meet evolving patient needs.

Entrustable Professional Activity (EPA):

EPAs are authentic tasks of a discipline. Each specialty or subspecialty carefully defines EPAs that are best suited to ensure their resident's progress through training. Either a resident or a supervisor can initiate an observation for an EPA assessment in the workplace. Over time, frequent observation and documentation of a trainee's performance will provide a comprehensive image of their competence and inform promotion decisions by their competence committee.


Milestones provide discrete information about the individual skills that are needed to perform a specific EPA task. The resident and supervisor can focus on the EPA as a whole or examine the milestones linked to that EPA. Over time, this detail will help guide feedback and coaching for improvement.

Roles and Responsibilities

Academic Advisors:

Academic Advisors support and supervise residents' progress throughout residency training. Each Academic Advisor has an assigned resident and meets with them regularly to discuss EPA completion, provide guidance and support with learning barriers, and facilitate the implementation of individualized learning plans. Additionally, the Academic Advisor prepares recommendations for the Competence Committee regarding residents' on-going development and readiness to progress to the next stage of training. Advisors liaise with the program director or delegate.

Competence Committee:

The role of the Competence Committee is to review all low-stakes assessments and other assessment data to make progress decisions and guide learning activities. Preceptors no longer make progression decisions with their residents; this is now the role of the Competence Committee and the Residency Program Committee.

The Competence Committee is empowered to make recommendations for the following:

  • Resident EPA achievement
  • Resident progression from one stage to the next
  • Readiness for RCPSC exams
  • Readiness for unsupervised practice
  • May monitor and suggest individual learning plans

Recommendations made by the Competence Committee need to be ratified by the Residency Program Committee.

Residency Program Committee (RPC):

The RPC is responsible for ratifying recommendations made by the Competence Committee (resident status, progression and setting individual learning plans). The RPC is also responsible for setting the residency curriculum, conducting curriculum program evaluations and determining improvements.

Resident Progression: (Post Graduate Year (PGY) Level vs. Stage):

CBD breaks training down into several different stages defined by EPAs and Milestones. EPAs and milestones are used to create a clear learning path for residents and clear teaching and assessment goals for educators.

Residents are no longer defined by their post-graduate year (PGY). They are now described by the stage in their residency program (as seen in the diagram below), which identifies the level of competence and ability to complete a task. These stages describe what residents can and should be allowed to do by evaluating their competency level through observation, and EPAs achieved. Residents may work on EPAs that are assigned to stages above their classification.

Each resident is required to achieve specific EPAs per rotation and stage to progress to the next stage in their residency program. Each rotation has assigned mandatory EPAs which can be viewed on the curriculum map and rotation objectives (pending).

It is the resident's responsibility to complete the EPAs assigned to each rotation. If a resident does not achieve the mandatory EPAs specific to a rotation, they may not be able to progress to the next stage in their residency program. To help mitigate this, learning plans are developed for residents who require additional support to achieve their EPA's and ensure they are competent to progress to the next stage.


Competence Continuum (Stages)