Chapter 4: Competencies, Certification, and Teamwork
Introduction
Emergency medicine emerged as a specialty to improve outcomes for patients with acute illnesses and injuries. Over the past 50 years, emergency care systems have evolved to provide timely access to quality care. This is the overarching context in which we consider the future of competencies, certification, and teamwork in emergency care.
The Relationship Between Competencies and Clinical Services Planning
The breadth, depth, and maintenance of competencies for team members to provide care can be relative to the category of an ED (see Chapter 3). But the care provided by all staff, including physicians, should not fall below a minimum standard, otherwise it cannot be called an emergency department anymore.
Before we elaborate, it is important to understand power and responsibility in healthcare before we can improve or change the system. Who is responsible for assuring EM competencies are met? Who is recognized as having the legitimacy to certify those competencies, and make changes under the current governance structures? In Canada, provincial governments and their ministries establish and regulate EDs. This includes the governance and implementation of standards, competencies, and certification. In the current era of competence-based education, knowledge and expertise is currently determined by someone’s initial education and the competencies they’ve acquired.
Emergency medicine competencies for physicians are defined and certified by national colleges, including the Certificate of Added Competence (CAC) for EM conferred by the College of Family Physicians; and the Royal College of Physicians’ EM and Pediatric Emergency Medicine (PEM) fellowships. These colleges additionally support and accredit both educational and physician maintenance of proficiency programs. Health authorities and hospitals operationalise ED standards and professional behaviour through the process of granting and renewing individual physician privileges. Provincial Colleges of Physicians and Surgeons are mandated to protect the public and hold individual physicians accountable to minimum competencies and professional standards. Finally, though not a certifying or accrediting body, CAEP advocates for physicians working in EDs across Canada, and for the patients/populations they serve.
EM:POWER, and its proposed emergency physician resource planning model (Chapter 6), supports the 2016 Collaborative Working Group (CWG) report and recommendations that showed a large and growing shortfall of emergency physicians working in Canada’s EDs. (2) Based on a national survey, Figure 1 below shows the shortfall estimates that were calculated before the impacts of COVID-19. The pandemic resulted in greater burnout, increased retirement rates, reduced clinical shift loads for many who remained, and the reduction or elimination of ED coverage from the comprehensive practices of many family physicians. The coverage gaps in rural and remote settings were under-represented in this data, as was the population growth, so the current and projected gaps are likely substantially larger than those presented here.
Figure 12. shows the estimated mix, demand, and supply of physicians providing ED coverage in Canada from a base year in 2016, and then projected to 2021 and 2026. At the time, the finding was that the FTE (Full Time Equivalent) shortfall would rise from approximately 500 to 1000 and to 1500 by 2026. (2) This data counts physician numbers not full-time equivalents (FTEs), so if two doctors are only working a half-time shift, they only make up one FTE. The data does not adequately capture the potential for more part-time emergency physicians post-pandemic.
Another key recommendation of the CWG report was for better alignment between the two main certification programs, with increased specific and meaningful collaboration needed between the CFPC and FRCP. Notably, the report did not recommend reducing the pathways to EM certification by eliminating one or merging the two programs together. The transition to competence-based education has allowed the two colleges to come together to clarify purpose, scope, and to work out how each can complement the other.
Through a systems lens there are benefits to having three pathways to EM certification in Canada (CFPC-EM, FRCP-EM, and FRCP-Peds EM): this makes the healthcare system more resilient though optionality. It also creates an element of safe redundancy and educational surge capacity in the EM training system. The three programs also offer a multitude of options for learners in terms of timing of entry, as well as intensity and duration of training, which additionally capitalizes on changing career plans.
Finally, the CFPC does certify that comprehensively-trained family physicians are qualified to work in small rural EDs without a certificate of added competence in EM. Instead, emergency competencies are attained during the Family Medicine residency. These are often supplemented by continuing medical education courses like Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), Point-of-Care Ultrasound (POCUS), and advanced airway management courses. Two other programs that increase the breadth and depth of EM competencies for family physicians who regularly work in an ED are the Supplementary Emergency Medicine Experience (SEME) program, developed at Mt Sinai in Toronto, (3) and the Nanaimo Emergency Education Program. (4) Both the Northern Ontario School of Medicine and Queen’s University School of Medicine also offer additional training for comprehensive rural generalists. Interestingly, one of the stated reasons for the previously proposed increase in the length (from two to three years) of the Family Medicine residency was to further supplement the growing body of knowledge, as well as the increasing number of competencies required for many aspects of a comprehensive family physician (FP) practice, including ED coverage. (5)
The Relationship Between Certification and Physician Resource Planning
Mathematical and modelling questions exist to plan future ED staffing both regionally and nationally. One question arises at a systems level when the goal is to provide optimal care and coverage for patients seeking care in Canada’s EDs: what is the ideal recommended mix/range of the variously certified emergency physicians, and comprehensively-trained family doctors with CFPC certification?
If we cannot differentiate practically, then we cannot count how many we have now and make intelligent recommendations about how many of each we need in the future to improve our system. Other questions include how do we optimize the scope of practice of other professionals? How do we improve our team approach to care? These are key considerations for a needs-based Health Human Resources model (see Chapter 6). Pragmatically, they are key considerations for system payors/planners and Post Graduate Medical Education Deans to consider when they appropriately adjust the number of residency positions required to meet the Canada’s future emergency care needs.
Forward-looking integrated health human resources (HHR) planning will focus on services planning at the system level AND optimizing teams at the site level, applying role clarity, team design, and collaborative practice. Certification (including practice eligibility routes) is essential at the system level for the future of EM care in Canada, but this does not minimize the importance of non-EM certified physicians who have contributed so much to the history and development of the emergency medicine field in the past. Many have been, and continue to be, key contributors in clinical practice, education, and leadership across the country.
EM:POWER endorses both the CAEP Definitions paper, (6) and the vision and mandate of the CAEP Rural, Remote, and Small Urban section, (7) both of which are relevant to these issues. These two documents are complementary rather than mutually exclusive as outlined below:
Emergency Medicine: is a field of medical practice (care of unexpected time-dependent illness and injury) defined by a unique body of knowledge. This means EM is not defined by the location of practice, but rather by a scope of competencies, as are other fields of medical practice. For instance, Family Medicine is also a field of medical practice defined by a unique body of knowledge. There is some overlap in competencies between these two fields of medical practice which makes the system more resilient.
Emergency Physician (when used as a noun): is a physician certified (or deemed practice-eligible by their respective colleges) in the practice of emergency medicine. Residency trained and certified FPs without CAC-EM certification in Canada also provide emergency care and may be particularly well-suited (but not limited) to practice in rural settings, as per the CFPC.
Emergency Department: taking the IFEM definition above one step further, the stratification and standards of Level 1,2,3,4 EDs are clarified in Chapter 3. At its core, an Emergency Department is structured and defined by its ability to provide acute care to all patients with unexpected and time-dependent illness and injury.
Canadians expect that an ED, by definition, can safely respond to the sickest patient that will arrive at its door, by ambulance, or by any other means. If it cannot, it should not be called an emergency department.
Certification in Emergency Medicine (either through the FRCP-EM, FRCP-Peds/EM or through the CFPC-CAC) strengthens the discipline of emergency medicine overall, and more importantly, improves the healthcare system’s pursuit of the Quintuple Aim. (8) CAEP/EM:POWER also supports the current situation that the CFPC has the jurisdiction to train and certify graduates to provide emergency care in rural and remote settings and recognizes that this is essential for the sustainability of the emergency care system in Canada.
Local and regional networks of emergency care must support physicians working in these locations through educational and competency maintenance opportunities (digital and experiential), shared/exchange workplace opportunities, and real-time peer-to-peer telemedicine connections as needed.
Provincial Emergency Care systems should be working towards requiring certified emergency physicians (or practice-eligible as defined by the respective colleges) to work in Level 1, 2, and 3 EDs. A comprehensively- trained family physician with emergency competencies is also certified by the CFPC to work in the ED and continues to play an essential role in staffing Level 4 emergency departments. Further discussion about developing and supporting this role, and the integration of all EDs into a single system with multiple access points are described in Chapter 6.
HHR Planning Must Follow Clinical Services Planning
Beyond physicians, providing effective emergency care at the bedside has always depended on interdisciplinary teams. Solutions to the current HHR gaps include training more emergency physicians, together with expansion of the team membership and evolution of the members’ scope of practice. Registered nurses, paramedics, social workers, discharge planning nurses, pharmacists, and many others can all play a vital role in the more-than-the-sum-of-its-parts ED unit. Specific emergency competencies for each should be clearly established, attained, certified (where appropriate) and maintained. All providers should work to the limits of their scope of practice.
When following good practice around adult learning and educational accreditation standards, scopes of practice can be specialized or expanded. An example of specialization is the emergence of geriatric emergency medicine (GEM) nurses to improve geriatric care in the ED. (9) An example of scope expansion is the use of paramedics within the ED who have been trained beyond their traditional scope of practice to suture, cast, splint, and assist with airway management, procedural sedation, and analgesia. (10)
Three questions should be asked with the addition of any new team member, or proposed expansion of a skillset in the ED, bearing in mind that the issue isn’t should we add a new member to the team; the question should be what unmet patient needs are there, and how do we best address them?
What unmet role/function on the team is being addressed?
How does this new/expanded skill contribute to improving patient outcomes?
What are the potential positive and negative unintended consequences?
Nurse practitioners (NPs) and physician assistants (PAs) are part of ED teams in some locations and fill different roles across the country. NPs are considered independent practitioners under most provincial legislation. In contrast, PAs are not independent practitioners, but rather are considered ‘physician extenders.’ In Canada, currently all NP programs are based on a 1–2-year primary care competencies curriculum following RN training. Some graduates receive additional disease-specific training after completing the NP program.
Currently, there are no NP programs in Canada designed specifically around emergency care skills and procedures. Most PAs are certified in some emergency care competencies. (Many were originally trained rigorously through the military although this is no longer our primary source). A more detailed description of the required skills, strengths/weaknesses, and potential roles in the ED for Canadian settings has been published by the Centre for Health Services and Policy Research at the University of British Columbia. (11)(12)
The evidence around the utility and benefits of NPs and PAs in the ED paints a mixed picture. An early systematic review suggested that the addition of NPs may result in the reduction of the wait times for low acuity patients, and in some cases, improved patient satisfaction. (13,14) However, a more recent three-year study in the US by the Federal Bureau of Economics comparing NPs to EPs practicing in the emergency department showed that the NPs ordered more tests, had worse outcomes, and incurred increased costs to the system overall. (15)(16) Clearly, the potential roles PAs or NPs could fill should be complementary to the ED’s team function—rather than in parallel or even as a replacement for an emergency physician. Optimizing ED care provided by NPs and PAs will require an intentional approach to roles, responsibilities, and team-building in site-specific contexts.
In a more rural setting, co-locating some primary care capacity provided by NPs may make sense if better access to primary care is unavailable elsewhere outside the ED, though again, the evidence is mixed on this. (17) On the other hand, busy urban EDs may benefit from the skills and procedures that a physician extender or PA could provide by maintaining the flow of CTAS 3,4 and 5 patients (where expanded scope RNs or paramedics can’t be trained to fill similar roles).
Regardless, different team members in different contexts can all bring value when the focus is on high-functioning teams in service of patient outcomes. Attaining, and maintaining individual and team competencies are essential to improve the future of emergency care in Canada. But effective teams are more than a sum of their competencies, or certifications; their performance depends on much more than that. Teams work best when they have a shared purpose, coordinated roles/contributions, and common core values.
Core Values
Emergency medicine values and principles drive behaviour in professional practice, leading to a sense of purpose and fulfillment. (18) Finding meaning in our work, otherwise known as being internally motivated, influences our actions more than external motivators, the proverbial sticks and carrots. (19) We are committed to the patients and populations we serve. Explicitly expressing, resolving, and refining these core values are important for developing our professional identity; doing so builds coherent and collaborative teams who work together effectively as we create the future of emergency care.
Unfortunately, a mismatch or incongruence of values can also be a source of moral injury and burnout. System leaders and policymakers must understand how their decisions (or non-decisions) indirectly impact patient care. Competencies define our education in emergency medicine, and professional identity development starts with core values (see Figure 2) that evolve with practice and experience.
Figure 11. Refined Emergency Medicine Value framework adapted from Purdy et al (18)
Two other concepts that are implicit in the values identified in Figure 13 are situational awareness and system savviness. These concepts are embodied in provider actions that address patient and family needs, balance a rational approach to resource stewardship, and help ED teams provide complicated and time-pressured clinical care—as well as transitions of care—to other services or hospitals.
Teams (and Teams of Teams)
Emergency care is a team sport, and emergency teams are inherently dynamic. No two shifts are the same. No two hours are the same. The team must act immediately in response to unscheduled and often unanticipated events; it must learn to read, react, respond, recover, and get ready again, together.
In his recent book “The Power of Teamwork: How we can all Work Better Together,” veteran emergency physician, Brian Goldman (20) speaks to the critical difference between a group and a team. Individuals with different skills and backgrounds can exist together in a group; but “to be a team, these individuals must be interdependent in terms of knowledge, abilities, and the materials they work with. And they must work together to achieve a shared goal.” (20) It is the shared goal, or shared purpose, and shared mental models that bring coherence and effectiveness to a team. (21,22)
Crisis Resource Management is a concept from aviation safety that has been modified for use in the healthcare setting and has been shown to significantly reduce error. (23) It is often taught to medical learners in simulation/resuscitation training, but the principles can be applied in broader contexts.
These principles include:
Knowing your environment
Knowing your goal
Knowing your role, shared workloads
Anticipate and share information, and
Have shared mental models, leadership and followership, and clear communication loops.
The Toyota Flow System (24) has three pillars: complex thinking, distributed governance, and team science. These pillars show that creating and nurturing teams is an essential part of any organization—and these lessons have relevance in emergency care. Some of these principles are like those found in crisis resource management, and include:
Goal/purpose identification
Training and learning together
Situational awareness, and
Human-centred design.
Human-centred design is a particularly important principle that stresses the importance of involving all stakeholders in the design of teams that are best able to improve value-based care in healthcare systems. In this context, patients, communities, providers, administrators, and payors should be part of the design process.
It is not just care in the ED; all healthcare is now (or should be) provided by multi-disciplinary teams. The future of emergency care will be improved in a Team of Teams environment. (25) The concept of organizing complex endeavours with a Team of Teams approach stems from the observation that rigid, top-down, command and control hierarchies are not a good fit for our increasingly turbulent and uncertain world. These old approaches lead to fragmentation and dis-integration, something that has been painfully obvious in healthcare.
Team adaptation and effectiveness must be valued more (or at least balanced with) efficiency. To that end, the principles of a Team of Teams approach include shared consciousness and empowered execution, following the idea that neurons that fire together, wire together. Shared consciousness in this context means there is trust amongst and between teams because of a shared purpose (value in healthcare), and radical transparency around information flows and resource allocation decisions. Once shared consciousness is achieved, decisive action with a sense of agency can be implemented, which means empowering front-line teams to do the right thing in service of the shared goal. This drives bottom-up innovation and system change.
Creating High Functioning Teams (Not Just Expanding Groups)
Team function within the emergency department can have a significant impact on provider wellness (or burnout), provider performance, patient flow, and ultimately patient outcomes. It is essential for achieving the Quintuple Aim. Emergency care team function is impacted by factors at various levels: system, organization, department, team, and individual. A recent response to the access block in some Canadian provinces has been to reactively alter care delivery models to include and/or expand the scope of other medical providers in the delivery of “emergency care,” often with politically-expedient timelines, rather than value-based considerations. (1) This might expand emergency department groups, but is it creating high-functioning emergency department teams? Every so-called innovation in care delivery models must be evaluated for its impact on team function and patient outcomes. This is key.
While the drive to maximize the scope of practice of medical providers can make intuitive sense in a resource-limited environment, it is critical to be intentional around our strategies. Appropriateness and effectiveness in the emergency department must be carefully considered. Nurses, NPs, paramedics, and physician assistants have inter-profession and intra-profession variations in clinical scope and practice independence. Emergency physicians have a breadth and depth of knowledge, training, skills, and system savviness, which makes them ideally suited to lead teams of emergency care providers. We must not equate independence (or lack thereof) with having the competencies to practice in the ED, or with being an ideal fit for team development. Rather, we need to consider the context (ED category, department size, remoteness index, resource deficiencies/metrics) and plan explicitly around whether additional members are simply enlarging the group or improving the team.
What is the problem we’re solving?
How does this improve the Quintuple Aim?
What are the alternatives?
What are the likely/potential unintended consequences?
Bottom line: emergency department function and quality of care is much more complex than access alone, and access without integration and teamwork can negatively impact performance and outcomes. Improving EDs with more and different providers needs to be intentional; it needs to be about expanding our team and not simply enlarging our group. (26,27) The implications of how optimizing the size and makeup of teams in the ED can impact HHR planning will be discussed in Chapter 6.
Community of Practice (CoP)
At a broader regional, provincial, and even national level, the concept of communities of practice is also important to the future of EM Canada. “A community of practice . . . is a group of people who share a common concern, a set of problems, or an interest in a topic and who come together to fulfill both individual and group goals.” (28) In other words, the CoP concept helps us to emphasize developing relationships in service of a shared purpose, (29) which is vital to improving emergency care in Canada.
This provides another mental model for breaking down silos and untangling turf wars. It keeps the eyes on the prize, which in this case is population outcomes, patient experience, provider wellness, equity, and cost-effectiveness.
In practical terms, a Community of Practice can be created with a larger, more academically-oriented ED, adopting a smaller sister site(s) with shared recruiting and scheduling. It can also manifest as mentoring relationships through hub-and-spoke related EDs, and/or practice support programs, regional interprofessional simulation programs, multi-disciplinary journal clubs, provincial emergency care clinical networks, and even national grand rounds.
Conclusion
Emergency Medicine is defined by a unique and growing body of knowledge which comes with a unique and growing spectrum of competencies. The future of Canada’s emergency care will be optimized by improving, strengthening and maintaining the competence-based education and ecosystem that serves our country well. The patients and populations we serve will also benefit from the intentional development of teams, and empowering communities of practice around shared goals.
Recommendations for Competencies, Certification and Teamwork
ECCNs should ensure that to work in an ED, attaining and maintaining individual and team emergency care competencies is required. The resources and opportunities necessary to meet this expectation should be funded and/or supported by the MoH/HA.
The CAEP 2020 vision statement should be updated, nuanced, and re-endorsed to reflect distinctions between Level 1-4 EDs in Canadian urban and rural centres. All emergency physicians entering practice in Level 1 and Level 2 EDs should be certified in emergency medicine. Coverage in Level 4 EDs can be provided by comprehensively-trained family physicians with the necessary EM competencies. Level 3 EDs should work towards coverage by certified emergency physicians over the next decade. Given the shortage of emergency physicians in Canada, concerted efforts to increase EM residency training positions and prepare practice-eligible certification candidates will be crucial in attaining this goal.
CAEP and emergency care leaders in nursing and paramedicine should advocate for the funding/support necessary for nurses and paramedics to attain and maintain emergency care competencies. They should also encourage all providers to work to their full scope of practice and enable expanded scopes where needed (e.g., geriatric critical care, etc.).
ECCNs should establish and support team-based care, creating complementary roles and responsibilities in the service of patient needs.
Team science should be used in the design and evaluation of team performance in the ED.
Mid-level providers such as NPs, PAs, Doctors of Pharmacy (Pharm Ds) etc. should attain/maintain emergency care competencies and be added to the ED staff when and where they complement the team approach to improving patient care.
Inter-disciplinary simulation should be used extensively in the training and maintenance of competence of ED teams. Simulation resources and programs should be funded and supported by ministries of health and health authorities.
Emergency physicians should provide a leadership role in a team approach to care in an ED.
A Community of Practice (muti-disciplinary, shared goal, common interests) approach to improving emergency care across silos, sectors, and systems should be intentionally developed and supported.
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