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American Journal of Kidney Diseases

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

Published:August 23, 2014DOI:https://doi.org/10.1053/j.ajkd.2014.06.027

      Background

      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.

      Predictors

      Proportion of chart audit and quality indicator deficiencies.

      Outcomes

      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.

      Limitations

      Retrospective design and small trainee numbers.

      Conclusions

      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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