American Journal of Kidney Diseases

Assessing Achievement in Nephrology Training: Using Clinic Chart Audits to Quantitatively Screen Competency

Published:August 23, 2014DOI:


      Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.

      Study Design

      Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.

      Setting & Participants

      Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686 ± 408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.


      Proportion of chart audit and quality indicator deficiencies.


      Longitudinal deficiency and ITE performance.

      Measurements & Results

      Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4% ± 2.0% vs 17.3% ± 7.0%; P < 0.001) and declined between the first and second halves of the first year (22.2% ± 6.4% vs 12.3% ± 9.5%; P = 0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease–associated anemia recognition and management were fewer during the second year (P < 0.001). Yearly audit deficiencies ≥ 5% were associated with an ITE score less than the 25th percentile for second-year fellows (P = 0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P < 0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P = 0.6), suggesting that the decline was not due to auditor fatigue.


      Retrospective design and small trainee numbers.


      Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

      Index Words

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        • Nasca T.J.
        • Philibert I.
        • Brigham T.
        • Flynn T.C.
        The next GME accreditation system—rationale and benefits.
        N Engl J Med. 2012; 366: 1051-1056
      1. The Internal Medicine Subspecialty Milestones Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. February 2014. Accessed March 1, 2014.

        • ten Cate O.
        • Scheele F.
        Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?.
        Acad Med. 2007; 82: 542-547
        • Carracio C.
        • Burke A.E.
        Beyond competencies and milestones: adding meaning through context.
        J Grad Med Educ. 2010; 2: 419-422
        • Ten Cate O.
        Nuts and bolts of entrustable professional activities.
        J Grad Med Educ. 2013; 5: 157-158
        • Yuan C.M.
        • Nee R.
        • Abbott K.C.
        • Oliver III, J.D.
        Milestones for nephrology training programs: a modest proposal.
        Am J Kidney Dis. 2013; 62: 1034-1038
        • Abbott K.C.
        • Bohen E.M.
        • Welch P.G.
        • Yuan C.M.
        Analyzing process variation in chart review using a networked spreadsheet application in the Walter Reed Army Medical Center nephrology clinic.
        Mil Med. 2001; 166: 771-773
        • Lurie S.J.
        • Mooney C.J.
        • Lyness J.M.
        Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: a systematic review.
        Acad Med. 2009; 84: 301-309
      2. AAIM Connect. Building assessments for an EPA in three steps. Accessed August 14, 2014.

        • Paukert J.L.
        • Chumley-Jones H.S.
        • Littlefield J.H.
        Do peer chart audits improve residents' performance in providing preventive care?.
        Acad Med. 2003; 78: S39-S41
        • Babbott S.F.
        • Beasley B.W.
        • Hinchey K.T.
        • Blotzer J.W.
        • Holmboe E.S.
        The predictive validity of the Internal Medicine In-Training Examination.
        Am J Med. 2007; 120: 735-741
        • Rosner M.H.
        • Berns J.S.
        • Parker M.
        • et al.
        Development, implementation, and results of the ASN in-training examination for fellows.
        Clin J Am Soc Nephrol. 2010; 5: 328-334