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In 2009-2010, the postgraduate residency training program at the Department of Family Medicine, Queen's University, wrestled with the practicalities of competency-based medical education (CBME) implementation when its accrediting body, the College of Family Physicians of Canada, introduced the competency-based Triple C curriculum.The authors used a stepwise approach to implement CMBE; the steps were to (1) identify objectives, (2) identify competencies, (3) map objectives and competencies to learning experiences and assessment processes, (4) plan learning experiences, (5) develop an assessment system, (6) collect and interpret data, (7) adjust individual residents' training programs, and (8) distribute decisions to stakeholders. The authors also note overarching processes, costs, and facil itating factors and processes or steps that would have been helpful for CBME implementation.Early outcomes are encouraging. Residents are being directly observed more often with increased documented feedback about performance based on explicit competency standards (24,000 data points for 150 residents from 2013 to 2015). These multiple observations are being collated in a way that is allowing the identification of patterns of performance, red flags, and competency development trajectory. Outliers are being identified earlier, resulting in earlier individualized modification of their residency training program.The authors will continue to provide and refine faculty development, are developing an entrustable professional activity field note app for handheld devices, and are undertaking research to explore what facilitates learners' competency development, what increases assessors' confidence in making competence decisions, and whether residents are better trained as a result of CBME implementation.

Assessing entrustable professional activities (EPAs), or carefully chosen units of work that define a profession and are entrusted to a resident to complete unsupervised once she or he has obtained adequate competence, is a novel and innovative approach to competency-based assessment (CBA). What is currently not well described in the literature is the application of EPAs within a CBA system. In this article, the authors describe the development of 35 EPAs for a Canadian family medicine residency program, including the work by an expert panel of family physician and medical education experts from four universities in three Canadian provinces to identify the relevant EPAs for family medicine in nine curriculum domains. The authors outline how they used these EPAs and the corresponding templates that describe competence at different levels of supervision to create electronic EPA field notes, which has allowed educators to use the EPAs as a formative tool to structure day-to-day assessment and feedback and a summative tool to ground competency declarations about residents. They then describe the system to compile, collate, and use the EPA field notes to make competency declarations and how this system aligns with van der Vleuten's utility index for assessment (valid, reliable, of educational value, acceptable, cost-effective). Early outcomes indicate that preceptors are using the EPA field notes more often than they used the generic field notes. EPAs enable educators to evaluate multiple objectives and important but unwieldy competencies by providing practical, manageable, measurable activities that can be used to assess competency development.