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Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide., Competing Interests: JRF, JK, LSS, FB, VN, ST, JF, KH, RST were employees of the Royal College.JS, AA, AO, AKH, LC, SD, DR, WJC, RBC, TD, BT, LF, WG, ND, BW, RS, RA, DD, AB, MG, and EVM performed contract work for the Royal College., (Copyright: © 2024 The Author(s).)

In the past decade, the Canadian system of postgraduate medical education has been transformed with the implementation of a new approach to competency based medical education called Competence by Design. The Royal College of Physicians and Surgeons of Canada (Royal College) developed an approach to time-variable competency based medical education and adapted that design for medical, surgical, and diagnostic disciplines. New educational standards and entrustable professional activities consistent with this approach were co-created with 67 specialties and subspecialties, and implementation was scaled up across 17 universities and over 1000 postgraduate training programs. Partner engagement, systematic design of workshops to create discipline specific competency-based standards of education, and agile adaptation were all key ingredients for success. This paper describes the strategies applied by the Royal College, lessons learned regarding transformative change in the complex system of postgraduate medical education, and the current status of the Competence by Design initiative. The approach taken and lessons learned by the Royal College may be useful for other educators who are planning a transformation to CBME or any other major educational reform., Competing Interests: Individual authors received funding from the Royal College either as staff (JK, JS, JRF) or as consultants (AA, TD, AO)., (Copyright: © 2024 The Author(s).)

Competency based medical education is being adopted around the world. Accreditation plays a vital role as an enabler in the adoption and implementation of competency based medical education, but little has been published about how the design of an accreditation system facilitates this transformation. The Canadian postgraduate medical education environment has recently transitioned to an outcomes-based accreditation system in parallel with the adoption of competency based medical education. Using the Canadian example, we characterize four features of an accreditation system that can facilitate the implementation of competency based medical education: theoretical underpinning, quality focus, accreditation standards, and accreditation processes. Alignment of the underlying educational theories within the accreditation system and educational paradigm drives change in a consistent and desired direction. An accreditation system that prioritizes quality improvement over quality assurance promotes educational system development and progressive change. Accreditation standards that achieve the difficult balance of being sufficiently detailed yet flexible foster a high fidelity of implementation without stifling innovation. Finally, accreditation processes that recognize the change process, encourage program development, and are not overly punitive all enable the implementation of competency based medical education. We also discuss the ways in which accreditation can simultaneously hinder the implementation of this approach. As education bodies adopt competency based medical education, particular attention should be paid to the role that accreditation plays in successful implementation., Competing Interests: Some individual authors received funding form the Royal College either as staff (ST, JRF) or as consultants (TRD, BT)., (Copyright: © 2024 The Author(s).)