Brief Report

Developing a national clinical competency committee for family medicine training, South Africa

Louis S. Jenkins, Mergan Naidoo, Kefilwe Hlabyago, Dirk T. Hagemeister, Neetha Erumeda, Busisiwe Cawe, Tasleem Ras, Mulimisi Ramavhuya, Owen Eales

Received: 17 Jan. 2025; Accepted: 14 Mar. 2025; Published: 23 Apr. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Entrustable professional activities (EPAs) have been introduced into family medicine training programmes across South Africa (SA) as part of a competency-based medical education (CBME) framework. These EPAs provide a structured approach to assessing and developing the competencies required for independent practice in family medicine. Twenty-two EPAs, aligned with the scope of family medicine in SA, were identified and integrated into a national electronic portfolio of learning (ePOL), Scorion. This allows for continuous documentation, assessment, and feedback, supporting both registrars and supervisors in tracking progress. To ensure a robust assessment of competence and readiness for entrustment decisions, local and national clinical competency committees (CCCs) were established. Local CCCs operate within training institutions, comprising faculty teams that review registrar performance data from the ePOL to make entrustment decisions on specific EPAs. The national CCC, comprising of representatives from all nine family medicine departments in SA, provides oversight, ensures standardisation, and addresses inter-institutional variability in assessments.

Contribution: The implementation of EPAs and CCCs represents a significant advancement in family medicine education, fostering accountability, consistency, and transparency in assessment. Initial outcomes suggest improved alignment between training and workplace requirements, enhanced feedback quality, and better preparation for independent practice. Challenges remain, including ensuring faculty development, managing workloads, and fostering a culture of continuous quality improvement. Future steps include further refining the CCC framework, addressing implementation challenges and exploring the impact of these changes on registrar training and assessment.

Keywords: national; clinical competency committee; postgraduate; family medicine; training; assessment; South Africa.

Introduction

Clinical Competency Committees (CCCs) are decision-making entities that evaluate registrars’ workplace-based performance against speciality-specific milestones. In the United States of America, CCCs were introduced in 2013 as part of the Accreditation Council for Graduate Medical Education (ACGME)’s competency-based framework.¹ Clinical Competency Committees should consist of at least three faculty members directly involved in the training programme, with at least some of the members being familiar with the registrars.² The CCC should be diverse in terms of academic rank, gender, race, programme role, professional focus, and professional background.³ Other members may include an interprofessional colleague who works with registrars (e.g., nurse, social workers) or even a member of the public (to represent patients’ perspectives).⁴ The CCC should meet at least twice a year to review registrars’ progress by scrutinising multiple aggregated assessments from diverse perspectives of workplace-based clinical performance, to provide feedback to the training programme and registrars, to identify registrars in difficulty (which could be registrars struggling with personal, social, or professional issues), and to make recommendations regarding registrars’ progression and entrustability with patient care tasks.⁵

Besides making summative decisions about entrustment and registrar progress and associated feedback, CCCs need to formulate remediation interventions and tailored training opportunities for registrars who require them, evaluate programme effectiveness and identify weaknesses in the curriculum or programme of assessment, and provide feedback to those overseeing the assessment programme on the focus and quality of workplace-based assessments (WPBAs).⁶ Table 1 explains some of the pitfalls, misconceptions, and mitigating strategies for CCCs. The aim of this paper is to describe the process of creating a CCC for family medicine registrar training in SA.

Reflections on the national clinical competency committee process for family medicine in South Africa

South Africa has used WPBAs in many postgraduate clinical training programmes for some years.⁷ The discipline of family medicine recently embarked on an entrustable professional activity (EPA)-based curriculum, with 22 nationally agreed EPAs.⁸ The EPAs were agreed upon in an iterative national consensus process with all nine programmes in SA. The EPAs align with the national unit standards for family medicine training, which address the national health priorities in the country. The previous national portfolio of learning has been revised to capture WPBAs aggregated to various EPAs in the Scorion e-portfolio.⁹ This led to the establishment of local CCCs (at the academic institutions) and a national CCC. After reviewing best practices in the literature, many of the nine postgraduate family medicine specialist training programmes in the country started having local CCC meetings.^10,11 One of the functions of the local university CCCs is to evaluate their registrars’ portfolios of learning according to the multiple ‘low stakes’ entries of evidence and ad hoc entrustment decisions of workplace performance to enable a cumulative ‘high-stakes’ recommendation to proceed or not in their training. The local CCC also provides feedback to each registrar and the supervisors and to the training programme itself. This is an improvement towards reducing bias for or against a registrar, where previously, the head of department alone signed off on a registrar portfolio at the end of a training year.

The national CCC consists of nine members representing the nine training programmes. These members were opportunistically selected by each training programme, which nominated senior faculty who were actively involved in registrar training and WPBA. One of the functions of the national CCC is to review the portfolios of learning of final-year registrars who are applying to take the national exit exams, whether the candidates are eligible or not. The original College of Family Physicians regulations stipulated that a candidate needed three satisfactory portfolios of learning over three training years, the most recent of which should be within the last 3 years. More recently, these have been revised to stipulate that a candidate needs to have attained entrustability at level 4 (work safely under distant supervision) in most EPAs. The initial meeting in late 2023, during which 16 portfolios were evaluated, served to establish guidelines and work out the logistics of assessing registrars’ portfolios across the country. Subsequently, there were two CCC meetings in 2024. The meetings were 3 h–4 h long, held online via Zoom^©. The first CCC meeting in 2024 evaluated 15 registrar portfolios. The second CCC meeting evaluated 17 portfolios. The nine family medicine programme representatives on the CCC received access via a secure SharePoint^® folder in the case of paper portfolios which were uploaded as portable document format (PDF) files or received access to the e-portfolios via a secure code after the individual registrars gave consent for their portfolios to be viewed by the members of the CCC. Each CCC member evaluated 1–2 portfolios from a different programme, one week prior to the national online CCC meeting. The portfolios were evaluated according to a pre-determined template to ensure a fair and reasonably standardised review process (Table 2). During the online national CCC meeting a week or two later, every member presented their critical evaluation of the 1–2 portfolios they reviewed. After review of all the data points of evidence in the portfolio, including the registrar reflections, narrative feedback from the various supervisors, and feedback from the CCC member in the committee who knew the registrar personally, the CCC concluded with a high-level recommendation that either the registrar was ready and competent to proceed to the national exit exams or needed more evidence of workplace experience before readiness for the exams could be recommended. The main challenges included a time commitment from each committee member and the difficulty of agreeing as a CCC on a decision when an insufficient registrar portfolio was reviewed. This was made easier since the CCC members knew each other and had developed a level of trust among each other, with all agreeing on the need to maintain high standards for the profession and ensure competent specialists for the public.

Lessons learnt

The lessons learnt during the first three national CCC meetings are summarised in Table 3.

Recommendations and conclusion

This is a mind shift for the discipline of family medicine and in postgraduate health education in SA. The formal inclusion of WPBA and assessing registrar portfolios via CCCs at institutional and national levels are expected to impact positively on the quality of registrar training in the country. Practical recommendations include aligning the local CCC processes with the national CCC process; the national CCC representative of a training programme knowing the registrars being discussed at the CCC; training programmes being receptive to the feedback from the CCCs; and just getting on and starting organically with CCC meetings. Future steps include further refining the CCC framework, addressing feasibility challenges in implementation, and exploring the impact of these changes on patient care and health system outcomes in SA. Lessons learnt could be helpful in other disciplines in the country and in similar contexts in Africa.

Acknowledgements

The authors express their sincere thanks to the colleagues who participated in the implementation of the national CCC.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

L.S.J. was responsible for conceptualising the article. L.S.J., M.N., D.T.H., N.E., B.C., and K.H. provided inputs to subsequent drafts. L.S.J., M.N., D.T.H., N.E., B.C., K.H., T.R., M.R., and O.E. scrutinised and approved the final manuscript.

This article followed all ethical standards for research without direct contact with human or animal subjects.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors declare that all data that support this research article and findings are available in the article and its references.

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, or agency or that of the publisher. The authors are responsible for this article’s results, findings, and content.

References