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Competency-based education in the health professions: Implications for

improving global health

Article in Human Resources for Health · November 2012

DOI: 10.1186/1478-4491-10-43 · Source: PubMed

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Gruppen et al. Human Resources for Health 2012, 10:43
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REVIEW Open Access

The promise of competency-based education in

the health professions for improving global
health
Larry D Gruppen1*, Rajesh S Mangrulkar1,2 and Joseph C Kolars2

Abstract
Competency-based education (CBE) provides a useful alternative to time-based models for preparing health
professionals and constructing educational programs. We describe the concept of ‘competence’ and ‘competencies’
as well as the critical curricular implications that derive from a focus on ‘competence’ rather than ‘time’. These
implications include: defining educational outcomes, developing individualized learning pathways, setting
standards, and the centrality of valid assessment so as to reflect stakeholder priorities. We also highlight four
challenges to implementing CBE: identifying the health needs of the community, defining competencies,
developing self-regulated and flexible learning options, and assessing learners for competence. While CBE has been
a prominent focus of educational reform in resource-rich countries, we believe it has even more potential to align
educational programs with health system priorities in more resource-limited settings. Because CBE begins with a
careful consideration of the competencies desired in the health professional workforce to address health care
priorities, it provides a vehicle for integrating the health needs of the country with the values of the profession.

Improvements in global health can only be realized acknowledging that learning objectives are often requis-
through the development of a workforce that has been ite but typically in and of themselves insufficient).
educated to promote health and to care for those with There have been many definitions of ‘competence’ and
disease [1]. Increased attention is being placed on ‘competencies’, all sharing many common features [6-9].
competency-based education as a means for optimizing For this paper, we use Albanese et al.’s [10] five charac-
the preparation of health professionals. Competency- teristics to define a competency:
based education (CBE) is a framework for designing and
implementing education that focuses on the desired per-
formance characteristics of health care professionals. Al- A competency focuses on the performance of the
though ‘competence’ has always been the implicit goal of end product or goal state of instruction
more traditional educational frameworks, CBE makes Traditional education tends to focus on what and how
this explicit by establishing observable and measurable learners are taught and less so on whether or not they
performance metrics that learners must attain to be can use their learning to solve problems, perform proce-
deemed competent. By contrast, more traditional frame- dures, communicate effectively, or make good clinical
works have delineated the intended learning objectives decisions. By emphasizing the results of education rather
of instruction [2-7] Learning objectives often focus on than its processes, CBE provides a significant shift in
what the learner should ‘know’ whereas competencies what educators and policy makers look for in judging
focuses on what the learner should be able ‘to do’, (while the effectiveness of educational programs. Figure 1 illus-
trates Miller’s pyramid [11], which describes the differing
levels of educational goal states. For early learners, out-
* Correspondence: lgruppen@[Link] comes at the level of ‘knows’ and ‘knows how’ may be
1
Department of Medical Education, University of Michigan Medical School, sufficient, but for more advanced learners, educational
G1113 Towsley Center, 1500 E. Medical Center Drive, Ann Arbor, MI
48109-5201, USA
goals are more typically at the levels of ‘shows’ and
Full list of author information is available at the end of the article ‘does’. These higher levels of the pyramid reflect
© 2012 Gruppen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Gruppen et al. Human Resources for Health 2012, 10:43 Page 2 of 7
[Link]

Figure 1 Miller’s pyramid [11].

performance in practice, not just in the classroom. In the performance of other learners (that is, not graded on a
CBE, the critical issue is that the learner reaches the speci- ‘curve’) but by the expert judgment of practitioners and
fied level of performance in a competency; how he or she educators in the field. Thus, it is desirable that ALL lear-
reaches that point (the educational process) is secondary. ners will achieve ‘competence’ after training.

A competency reflects expectations that are A competency informs learners, as well as other
external to the immediate instructional program stakeholders, about what is expected of them
Traditional educational programs too often have an in- By focusing on the outcomes of education, CBE is often
sular character in which the expectations of learners are much more transparent and therefore accountable to
based on what has been taught in the past. In CBE, suc- learners, policy makers and other stakeholders. Indeed,
cess is determined by the ability to perform to expecta- defining a discipline’s values, goals and priorities is an
tions that are largely determined by stakeholders outside implicit part of defining competencies, which enables
of the educational program itself. the competencies to communicate these values and
expectations to various stakeholders within and outside
A competency is expressible in terms of the discipline.
measurable behavior
Although traditional education does assess learner Defining the curriculum for competency-based education
knowledge and progress, CBE places a much higher pre- The curriculum, or what is to be learned, is at the heart
mium on learner performance of tasks and activities rep- of all educational models. It is the genesis or origin of
resentative of the competencies. These assessments the curriculum that differentiates traditional models
emphasize behavioral measures that depend on integrat- from CBE. Traditional curricula often become anchored
ing knowledge and skills derived from an aggregate of to historical legacies that codify the traditions, priorities,
educational experiences and parts of the curriculum [4]. and values of the faculty in that profession. Learning
objectives are often defined to reflect what the faculty
A competency uses a standard for judging desire to teach or deem important rather than the other
competence that is not dependent upon the way around. This ‘curriculum driven’ definition of learn-
performance of other learners ing outcomes often fails to coincide with the needs of
Each performance assessment of competence must be ac- society. For example, curricula designed in resource-rich
companied by an explicit criterion for determining whether settings may be projected or perceived as ‘gold stan-
or not a given learner has or has not attained the required dards’ for resource-poor settings, to the exclusion of
level of performance to be considered ‘competent’. These other necessary topics that are more likely to address
criteria or performance standards are not determined by local health needs. Competency-based education places
Gruppen et al. Human Resources for Health 2012, 10:43 Page 3 of 7
[Link]

the curriculum as an ‘end product’ of a needs assess- stakeholders, and to focus learners in these health pro-
ment rather than as the structure that constrains educa- fessions on aligning their own performance with the
tional objectives and assessments (see Figure 2). health expectations of society.
When comparing CBE to a traditional model of educa- Needs assessments that reflect available health data,
tion (Figure 2), three fundamentally different characteris- input from the community and the public health per-
tics emerge. First, CBE explicitly maps the specific health spective are necessary to inform this process. A multi-
needs of the populations to a set of competencies for the tude of approaches have been used for this, including a
workforce to be trained. For example, the United States carefully designed needs analysis of key informants [12],
National Board of Medical Examiners, which is respon- direct observation of health care providers in practice
sible for the licensing of all graduating physicians in the along with surveys of practitioners regarding perceived
United States, has adopted a plan to realign its licensure need [13], multilateral expert panels [14], and national
processes to more substantially reflect the expectations of consensus-building processes [15].
patients [9]. Second, CBE uses these expectations to then Still, there is a tendency for educational institutions to
develop and implement learning experiences (the curricu- focus on their own narrow mission and definition of
lum) designed to produce the requisite knowledge, values, competence. In order to incorporate the health needs of
and skills in the learners to achieve these competencies. the larger community into the competency definition,
Finally, CBE uses the same set of competencies to develop several models to explicitly elicit these needs are pos-
critical assessment programs to determine the extent to sible. One could be establishing a national health com-
which they are reached. petency board with broad stakeholder representation,
which would set competencies for the country as a
The practical steps in implementing a competency-based whole. A second might include explicit partnerships with
educational system health workers in the field as a means of validating the
The past several years have seen considerable growth in relevance of competencies and ensuring key domains are
the development of competencies in different health not neglected. A third could be a responsive feedback
professional fields, including medicine, nursing, midwif- system in which graduates report back to the school the
ery, and public health. However, many of these efforts adequacy of their preparation in regard to the compe-
fall short of a fully implemented CBE model because of tencies and the need for modifications. The specific
challenges in four domains. methods for incorporating community health needs will
necessarily depend on the unique characteristics of the
Defining the health needs of the community country or region, but educators and health care practi-
A CBE program has the potential to improve the health tioners must be creative in ensuring that this critical step
of the community it serves only to the extent that it uses takes place and that it reflects the input of wide
context-specific health issues to determine the desired spectrum of stakeholders.
competencies [1]. Explicitly defining the health needs of
the community is necessary in order to identify outcome Defining competencies
variables that can be mapped to desired changes in The central step in shifting from a traditional to a
health, to ensure program accountability to relevant competency-based educational framework is to define
the learner competencies. These competencies reflect
specific goals of education, but also express institutional,
disciplinary, or national priorities. Competency defini-
tions are intended, among other things, to communicate
these priorities in memorable and meaningful ways.
Schools, licensing agencies, and professional societies
may each define the competencies differently or use dif-
ferent terminology for similar domains or even have dif-
ferent conceptions of what constitutes a ‘competent’
professional. For example, each of five published compe-
tency frameworks includes ‘communication skills’. How-
ever, only two contain competencies related to
‘managing information’ or ‘lifelong learning’. Other com-
petencies, such as ‘clinical skills’ are represented in each
set but under somewhat different labeling.
Figure 2 Comparing traditional and competency-based
Competency descriptions typically operate at multiple
educational modelsa.
levels of detail. ‘Communication skills’, as a description
Gruppen et al. Human Resources for Health 2012, 10:43 Page 4 of 7
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of a target competency, does not provide clear guidance professionals. Checkbox education is not, however, an
for educators or learners. To make competencies rele- inherent limitation of CBE. For example, proficiency in
vant to education, they must be translated into much patient care, medical knowledge and communication all
more specific statements that include the context, con- might readily be assessed through the observation of a
tent, and criteria for the competency to be attained. This learner performing a normal delivery of a newborn. This
results in a hierarchy of competency specificity within reflects the proposal of ten Cate and colleagues that we
any single domain. use a more integrative framework for assessing compe-
For example, the University of New South Wales [16] tencies that centers around ‘entrustable professional ac-
identifies ‘effective communication’ as one of its eight tivities’, those that reflect day-to-day professional
competencies, but then goes on to refine this to include activities appropriate to the level of learner [4].
three more detailed competencies: ‘communicates effect-
ively with patients and their families’, ‘communicates ef- Self-regulated and flexible learning options
fectively with peers and tutors’, and ‘communicates with Competency-based education promotes a necessary flexi-
communities’. There is then further specificity with bility in the time and sequence of what is to be learned that
more operational competencies such as ‘counsels is regulated by the needs of the learner [17]. Therefore,
patients appropriately on a range of health risks includ- CBE allows for a highly individualized learning process ra-
ing poor nutrition, smoking cessation, drug and alcohol ther than the traditional, lock-step, one-size-fits-all cur-
management, and refers to community programs and riculum [18]. Ideally, students would have an opportunity
services if appropriate’. It is easier to develop educa- to explore a menu of choices in learning activities and
tional activities and assessment tools for the more spe- methods that could allow them to achieve competency.
cific, detailed competency statements than for the more By way of example, Table 1 depicts competencies
broad domains. mapped to the global health problem of managing ma-
This example illustrates a major challenge in CBE, ternal obstructed labor, formulated within the 10 compe-
which is the rapid expansion of the number of compe- tency domains specified by the Indiana University
tencies as they become more focused on teachable and School of Medicine [19]. For each specific competency, a
observable skills or performance. This creates an infor- set of both learning and assessment method options are
mation burden for learners and the institution. It may listed, appropriately mapped to the pedagogical frame-
also lead towards ‘checkbox education’ and a focus on work. As can be seen in Table 1, some competencies
individual pieces of performance with the loss of the may lend themselves to a greater number of learning
more holistic, comprehensive competencies we desire in options than do others.

Table 1 Linking competencies at the abstract and contextualized levels with assessment and learning methods using
obstructed labor as an example
Competency Competency in context: Learning method options Possible assessment
domain [16] obstructed labor method
Effective Communication The learner explains different options for accelerating Structured practice using simulated Standardized patient
birth to the mother in a calm, clear manner. patients. Assigned reading on treatment exercise
options.
Basic Clinical Skills Using physical examination techniques, the learner Simulation/Mannequin practice. Physical Structured direct
identifies the presence of a nuchal cord as the exam textbook. Supervised clinical observation and
etiology behind obstructed labor. experiences. feedback.
Standardized patient
examination.
Using Science to Guide The learner identifies community-based resources to Self-guided search. Assigned reading. Written examination
Diagnosis, Management, assist in the prenatal management of women at risk
Therapeutics and Prevention for obstructed labor.
Moral reasoning and ethical The learner explains the most important competing Small group discussion of case Oral examination
judgment issues that weigh in the decision to perform life- scenarios.
saving maternal interventions that may place the
Programmed reading.
fetus at risk in obstructed labor.
Problem solving The learner appropriately identifies and refers high- Small group discussion with scripted Chart audit
risk cases of obstructed labor that require patient management problems.
subspecialty management Assigned problem set with feedback.
Professionalism and role The learner maintains confidentiality in the care of Lecture. Supervisor evaluation
recognition women with obstructed labor.
Self-directed review of confidentiality
policy.
Gruppen et al. Human Resources for Health 2012, 10:43 Page 5 of 7
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A system in which performance against preset expec- defined and assessment methods developed and applied.
tations determines progress through a learning program These standards may require technically complex proce-
challenges the notion of a ‘time-based’ curriculum and dures [24,25] to define the actual score or performance
may lead to the situation where ‘time and method are metric by which a learner would be considered.
the variables and achievement is the constant’ [20]. The
relationship of time and practice to skill development
has been well established [21]. However, it is also clear Implications for competency-based education in resource-
that different learners will require different amounts of poor settings
time to achieve certain standards of performance. The Resources for health are finite and often felt to be insuf-
logistics required to scale the implications of students ficient, regardless of the setting. Resource-poor countries
learning at different rates are substantial. Clustering of have a tendency to try to emulate resource-rich coun-
learners facilitates faculty and student convenience, as tries with regard to their educational standards and
well as efficient space allocation and resource expendi- desired health care outcomes. As a result, local educa-
tures. However, it also ignores the possibility that some tional standards are often driven by the desire to fit into
learners may require less time to achieve competence frameworks that are in place elsewhere. While many of
than thought, or that some may be able to ‘test out’ of a the domains of competency, such as professionalism and
given set of educational experiences if they have demon- communication, are universal, many of the more specific
strated the required level of performance at baseline. As competencies in resource-rich settings presume the
such, learning ‘efficiency’ takes on a vastly different presence of a particular health care system and an edu-
meaning when the time on task is individualized, flexible cation system in which those competencies can be nur-
and variable. tured and fully appreciated. This may not be the case in
Flexibility and individualized learning place considerable resource-poor countries. Furthermore, competence in
burden on information systems to track and document domains such as professionalism and communication,
learner progress through a CBE curriculum. It also requires like all competencies, is very sensitive to the context of
faculty members to attend to student progress and transi- the individual and their culture. The language or ap-
tions in ways not often required in traditional curricula. proach that is used to break bad news, elicit sensitive in-
formation, or motivate others to take care of themselves
Assessing learners for competence will vary widely with personal attributes and the culture.
Without evidence of the learner’s ability to fulfill a given While competencies are context-specific, there exist
competency, it is impossible to judge the success of ei- common approaches to CBE. First, as noted earlier, the
ther that individual or the educational program. The di- local health issues and priorities of a country should serve
versity of competencies defined for a given set of as the starting point. Second, there needs to be a discussion
learners also requires a diverse set of assessment meth- of what kinds of competencies are needed to address these
ods. The contextualized competencies in Table 1 illus- health care priorities. While these will often reflect the
trate how different competencies need to be assessed in major domains described earlier in this article, competen-
different ways but also how different methods may be cies will need to be very context-specific and take into ac-
appropriate for the same competency. count the availability of faculty and local resources. Third,
The need to match more complex assessment methods it should be clear which health professionals are expected
with more sophisticated competency outcomes is also to be able to achieve which competencies. Who should be
challenging. While a multiple-choice examination may competent at caesarean section? All graduating physicians?
be a reliable and accurate reflection of knowledge, it is Nurse midwives? Labor technicians? One of the conse-
an inappropriate measure of application and perform- quences of CBE is that skills that were once considered the
ance in real-world settings. Higher order assessments domain of only select professions could potentially be ‘task
would require direct observation, structured feedback on shifted’ to other professions if they are able to perform at
performance, or skills-based evaluations in simulated or the same level of competency. Finally, while the definition
real patients [22,23]. Without assessment, CBE becomes of competencies is necessary, it is insufficient unless the
little more than traditional education with a more clearly metrics of achievement are clearly defined – by what
defined set of goals and objectives. standard do we deem someone competent to be able to
In addition to assessment methods, CBE requires clearly do a caesarean section? These competencies should then
specified performance criteria or standards on these in turn drive the curricula and the modes of learning.
assessments that enable faculty to judge that the learner Resource-poor settings need health professionals who
has reached the minimal level of performance that quali- are not just clinically ‘competent’ but who can provide
fies as ‘competent’. It is important to recognize that stan- leadership to set expectations and transform health
dards can be set ONLY after the competencies have been within their country. These skills are particularly needed
Gruppen et al. Human Resources for Health 2012, 10:43 Page 6 of 7
[Link]

in resource-poor settings where health care systems have Competing interests

yet to be optimally shaped. A competency-based focus The author(s) declare that they have no competing interests.

on leadership, policy formation, management, and the

Authors' contributions
direction of interdisciplinary teams is essential for the LDG, RSM, and JCK collaborated equally in the discussions, literature review,
development of professionals in low-resource settings. conceptualization, and the drafting of the manuscript. All authors read and
Both resource-rich and -poor countries must recognize approved the final manuscript.

the need for faculty development in regard to planning Author details

and implementing CBE. CBE is challenging even for 1
Department of Medical Education, University of Michigan Medical School,
schools with adequate faculty numbers, but becomes even G1113 Towsley Center, 1500 E. Medical Center Drive, Ann Arbor, MI
48109-5201, USA. 2Department of Internal Medicine, University of Michigan
more so when faculty resources are inadequate. Because Medical School, 3110 Taubman Center, SPC 5368, 1500 E. Medical Center
CBE is so different from traditional educational models, Drive, Ann Arbor, MI 48109-5201, USA.
few faculty members readily adapt to CBE. This is an area
Received: 8 June 2012 Accepted: 25 October 2012
in which shared development and expertise would be Published: 16 November 2012
fruitful. Collaborations between countries will also aid
resource-rich countries to examine their assumptions and References
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doi:10.1186/1478-4491-10-43
Cite this article as: Gruppen et al.: The promise of competency-based
education in the health professions for improving global health. Human
Resources for Health 2012 10:43.

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