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									                                                Measurable Outcomes for
                                   Hospice and Palliative Medicine (HPM) Competencies
                                                      August 1, 2007
                                                                            Table of Contents

Preface .................................................................................................................................................................................. 2
HPM Work Group .................................................................................................................................................................. 4
Assessment Methods Used ................................................................................................................................................... 5
Patient and Family Care ........................................................................................................................................................ 6
Medical Knowledge ............................................................................................................................................................. 12
Practice-Based Learning and Improvement ........................................................................................................................ 31
Interpersonal and Communication Skills ............................................................................................................................. 34
Professionalism ................................................................................................................................................................... 44
Systems-Based Practice ..................................................................................................................................................... 47
Measurable Outcomes for HPM Competencies                                                                             Page 2


Preface
When developing outcome measures to assess competencies that a Hospice and Palliative Medicine (HPM) sub-
specialist must demonstrate, we made the assumption that a fellow would enter HPM training with a basic set of
competencies, allowing the fellow to focus on developing specialist-level HPM competencies. While we anticipate that
trainees from as many as ten different specialties, with ten different training experiences, may enter our training programs,
the competencies we present assume a basic foundation of knowledge, attitudes, and skills for all residents entering an
HPM training program.

Pre-Competencies
The following “pre-competencies” ought to represent the minimum basic skills necessary for entrance into an HPM
training program. Although HPM training programs, based on their resources and expertise, may make different decisions
about competency expectations for a trainee entering an HPM fellowship, we believe that the following “pre-
competencies” are essential in order to allow HPM training programs to focus on helping trainees develop the specialist-
level competencies that are the hallmark of a specialist in the field:
     Ability to carry out a comprehensive and accurate history and physical examination
     Ability to evaluate and treat common life-threatening medical illnesses seen in adults including but not limited to
       heart failure, COPD, renal insufficiency, cirrhosis, strokes, diabetes and common infectious diseases.
     Ability to develop a differential diagnosis for common symptoms such as dyspnea, pain, cognitive dysfunction and
       common lab abnormalities ;
     Understanding of fundamental knowledge (e.g., pathophysiology, pharmacology, natural history, complications)
       related to common life-threatening illnesses seen in adults
     Experience in the longitudinal, direct patient care of patients with a wide variety of cancer and non-cancer chronic
       diseases
     Basic familiarity with evidence-based medicine
     Ability to access and critically read the medical literature
     Basic ability to conduct open-ended, patient centered interviews using appropriate facilitating techniques
     Honesty, integrity, responsibility, reliability
     Basic ability to self-reflect
     Basic understanding of the health care system
     Ability to collaborate with others in patient care
Measurable Outcomes for HPM Competencies                                                                                                    Page 3


Competent vs. Expert
The measurable outcomes described in this document represent those for the minimally competent specialist palliative
care physician, not the expert. According to the Dreyfus model of skill acquisition1, “competence” falls midway between
the novice and expert physician.

Characteristics of competence include: being able to cope with an overwhelming number of rules, thinking ahead, seeing
the bigger picture, demonstrating organizing principles and systematic approaches that differ depending on the situation,
participating in active decision-making, and feeling a sense of personal responsibility.

The characteristics of an expert palliative care physician – being able to immediately and accurately assess a situation,
intuitively seeing how to deal with it; using rules and guidelines flexibly; analyzing new information and problems to arrive
at solutions; and being able to explain clinical reasoning and decision-making – develop only over time and with practice.

The measurable outcomes described in this document represent those for the minimally qualified specialist palliative care
physician, not the expert. A competent physician is capable of undertaking independent practice and continues to grow
towards proficiency and expertise.


Evaluation Tools
We intend that this set of measurable outcomes and suggested evaluation methods be used as a resource document
only. The level of detail is not practical for comprehensive use. However, it will provide fellowship directors with guidelines
for developing and improving new and existing education programs. This is a work in progress and the ultimate end
product will be a set of evaluation tools that will measure the ACGME competencies that are specific to HPM.




    1
     Dreyfus’ model of the five steps of skill acquisition includes the following: novice, advanced beginner, competent, proficient, expert. Based on
Dreyfus Hubert L, Dreyfus Stuart E, Mind over Machine, retrieved from the Internet Nov. 20, 2006, http://w3.msi.vxu.se/~per/CP-
web/PBDDSKIL.HTM
HPM Work Group
The following people contributed to this document:
Bob Arnold, M.D.                              Houston, TX 77030
Section of Palliative Care & Medical Ethics   lmorriso@bcm.tmc.edu                      Charles von Gunten, MD,PhD
University of Pittsburgh Medical School                                                 San Diego Hospice & Palliative Care
MUN, 9W, Pittsburgh, PA 15213-2582            Tomasz Okon, M.D.                         4311 Third Ave
412- 692-4888                                 Marshfield Clinic                         San Diego, CA 92103-1407
rabob@pitt.edu                                1000 North Oak Avenue                     619-278-6225
                                              Marshfield, WI 54449                      cvongunten@sdhospice.org
Andy Billings, M.D.                           715-389-4080
Massachusetts General Hospital Palliative     okon.tomasz@marshfieldclinic.org          David Weissman, MD
Care Service FND 600, 55 Fruit St.                                                      Medical College of Wisconsin
Boston, MA 02114                              Sandra Sanchez-Reilly, M.D.               9000 W. Wisconsin Ave
617-724-9197                                  South Texas Veterans Health Care System   Milwaukee WI 53226
jbillings@partners.org                        7400 Merton Minter                        414 805-4607
                                              San Antonio, TX 78229                     dweissma@mcw.edu
Susan Block, M.D.                             210-617-5237
Dana-Farber Cancer Institute and Brigham      Sandra.Sanchez-Reilly@med.va.gov          Dale Lupu, Ph.D.
and Women's Hospital, Boston, MA                                                        American Board of Hospice and Palliative
44 Binney Street                              Rodney Tucker, M.D.                       Medicine
Boston, MA 02115                              University of Alabama at Birmingham       9200 Daleview Ct
617- 632-6179                                 Center for Palliative Care                Silver Spring, MD 20901
sblock@partners.org                           CH19 219U                                 301-439-8001
                                                     rd
                                              1530 3 Ave., South                        dlupu@abhpm.org
Nathan Goldstein                              Birmingham, AL 35294-2041
Mount Sinai School of Medicine                rtucker@aging.uab.edu                     Judy Opatik Scott, M.A.
Hertzberg Palliative Care Institute                                                     American Board of Hospice & Palliative
One Gustave L. Levy Place, Box 1070           James Tulsky, MD                          Medicine
New York, NY 10029                            Center for Palliative Care                9200 Daleview Ct
212-241-1446                                  Duke University Medical Center, Hock      Silver Spring, MD 20901
nathan.goldstein@mssm.edu                     Plaza                                     301-439-8001
                                              2424 Erwin Road, Box 1105                 opatik1@aol.com
Laura Morrison, MD                            Durham, NC 27705
Baylor College of Medicine Faculty Center     919/668-2362
1709 Dryden, Suite 850                        jtulsky@duke.edu
Assessment Methods Used
 1.   Direct observation by attending
 2.   Global rating scale
 3.   Self-assessment
 4.   Attendance log
 5.   360 evaluation
 6.   Chart-stimulated recall examination
 7.   Checklist evaluation (e.g. communication skills exercise)
 8.   Objective structured clinical examination (OSCE)
 9.   Standardized Patient (SP)
10.   Mini-CEX
11.   Case log
12.   Patient survey
13.   Family survey
14.   Consultant survey
15.   Peer survey
16.   Learner survey
17.   Portfolio
18.   Chart/record review
19.   Multiple choice questions (MCQ)
20.   Standardized oral exam
21.   Writing assignment
Measurable Outcomes for HPM Competencies                                                                                                 Page 6



 Patient and Family Care
                                                                                                                               Assessment
 Competency                            Sub-competency                                        Sample Behavior
                                                                                                                               Method
 1.1 Gathers comprehensive and         1.1.1. Obtains a comprehensive medical history                                          SP
 accurate information from all         and physical exam, including:                                                           Direct
 pertinent sources, including           Patient understanding of illness and prognosis                                        observation by
 patient, family members, health        Goals of care/advance care planning/proxy                                             attending
 care proxies, other health care          decision-making                                                                      Patient and
 providers, interdisciplinary team      Detailed symptom history (including use of                                            family survey
 members and medical records              validated scales)                                                                    360 Evaluation
                                        Psychosocial and coping history including loss
                                          history
                                        Spiritual history
                                        Functional assessment
                                        Quality of life assessment
                                        Depression evaluation (including stressors and
                                          areas of major concern)
                                        Pharmacologic history including substance
                                          dependency or abuse
                                        Detailed neurological exam, including mental
                                          status exam
                                       1.1.2 Performs diagnostic workup; reviews primary     Formulates a plan of care         Direct
                                       source information and evaluation; determines         based on available information    observation by
                                       prognosis and palliative course                       and prognosis                     attending
                                                                                                                               MCQ
                                       1.1.4 Utilizes information technology; accesses on-   Operates electronic information   Direct
                                       line evidence-based medicine resources; uses          resources in a familiar manner    observation by
                                       electronic repositories of information, and medical                                     attending
                                       records
 1.2 Synthesizes and applies           1.2.1 Develops a prioritized differential diagnosis                                     Direct
 information in the clinical setting   and problem list                                                                        observation by
                                                                                                                               attending
                                                                                                                               Chart/record
                                                                                                                               review
                                       1.2.2 Develops recommendations based on patient       Integrates patient’s and/or       360 Evaluation
                                       and family values                                     family’s values into written      Family survey
                                                                                             goals of care and treatment
Measurable Outcomes for HPM Competencies                                                                                               Page 7


 Patient and Family Care
                                                                                                                              Assessment
 Competency                           Sub-competency                                        Sample Behavior
                                                                                                                              Method
                                                                                            plan

                                      1.2.3 Routinely obtains additional clinical           Collects information from other   360 Evaluation
                                      information (from other physicians, nurses,           clinicians when needed
                                      pharmacists, social workers, case managers,
                                      chaplains, respiratory therapists) when appropriate

 1.3 Demonstrates use of the                                                                                                  360 Evaluation
 interdisciplinary approach to                                                                                                Chart/record
 develop a care plan that                                                                                                     review
 optimizes patient and family
 goals and reduces suffering
 1.4 Assesses and                                                                           Identifies and communicates       Direct
 communicates prognosis                                                                     prognosis accurately              observation by
                                                                                                                              attending
                                                                                                                              360 Evaluation
                                                                                                                              Checklist
                                                                                                                              evaluation
                                                                                                                              Family survey
 1.5 Assesses and manages                                                                                                     MCQ
 patients with the full spectrum of                                                                                           360 Evaluation
 advanced, progressive, life-                                                                                                 OSCE
 threatening conditions, including
 common cancers, common non-
 cancer diagnoses, chronic
 diseases, and emergencies
 1.6 Manages physical                 1.6.1 Assesses pain and non-pain symptoms                                               MCQ
 symptoms, psychological issues,                                                                                              360 Evaluation
 social stressors, and spiritual
 aspects of the patient and family
                                      1.6.2 Uses opioid and non-opioid pharmacologic                                          MCQ
                                      options                                                                                 chart/record
                                                                                                                              review
                                                                                                                              360 Evaluation
                                      1.6.3 Uses non-pharmacologic symptom                                                    MCQ
                                      interventions                                                                           chart/record
Measurable Outcomes for HPM Competencies                                                                                                      Page 8


 Patient and Family Care
                                                                                                                                     Assessment
 Competency                           Sub-competency                                               Sample Behavior
                                                                                                                                     Method
                                                                                                                                     review
                                                                                                                                     360 Evaluation
                                      1.6.4 Manages neuropsychiatric disorders                                                       MCQ
                                                                                                                                     chart/record
                                                                                                                                     review
                                                                                                                                     360 Evaluation
                                      1.6.5 Manages physical symptoms and                                                            MCQ
                                      psychosocial and spiritual distress in the patient and                                         chart/record
                                      family                                                                                         review
                                                                                                                                     360 Evaluation
                                      1.6.6 Re-assesses symptoms frequently, and                                                     360 Evaluation
                                      makes therapeutic adjustments as needed
 1.7 Coordinates, orchestrates,                                                                    Facilitates withdrawal of LST’s   360 Evaluation
 and facilitates key events in                                                                     according to recognized
 patient care, such as family                                                                      standards
 meetings, consultation around
 goals of care, advance directive
 completion, conflict resolution,
 withdrawal of life-sustaining
 therapies, and palliative
 sedation, involving other team
 members as appropriate
 1.8 Provides care to patients        1.8.1 Performs palliative care assessment and                                                  360 Evaluation
 and families that reflects unique    management for the home visit, nursing home visit,
 characteristics of different         inpatient hospice unit visit, outpatient clinic visit, and
 settings along the palliative care   hospital patient visit
 spectrum
                                      1.8.2 Delivers timely and accurate information and                                             360 Evaluation
                                      addresses barriers to patient and family access to                                             pt/family
                                      palliative care in multiple settings                                                           surveys
                                      1.8.3 Works with families in an interdisciplinary                                              360 Evaluation
                                      manner to formulate discharge plans for patients                                               pt/family
                                      and families                                                                                   surveys
 1.9 Bases care on patient’s past     1.9.1 Demonstrates a patient-family centered                 Produces a patient and family-    360 Evaluation
 history and patient and family       approach to care                                             centered plan of care             family survey
 preferences and goals of care,
Measurable Outcomes for HPM Competencies                                                                                              Page 9


 Patient and Family Care
                                                                                                                            Assessment
 Competency                           Sub-competency                                       Sample Behavior
                                                                                                                            Method
 prognostic information, evidence,
 clinical experience and judgment
                                      1.9.2 Makes recommendations to consulting            Formulates adequate palliative   Direct
                                      physician(s) as appropriate                          care recommendations; follows    observation by
                                                                                           appropriate consult etiquette    attending
                                                                                                                            Consultant
                                                                                                                            survey
 1.10 Demonstrates the ability to                                                                                           360 Evaluation
 respond to suffering through                                                                                               pt/family survey
 addressing sources of medical
 and psychosocial/spiritual
 distress, bearing with the
 patient’s and family’s suffering
 and distress, and remaining a
 presence, as desired by the
 patient and family
 1.11 Demonstrates care that                                                               Recognizes and respects          360 Evaluation
 shows respectful attention to                                                             patient’s and family’s           pt/family survey
 age/developmental stage,                                                                  uniqueness
 gender, sexual orientation,
 culture, religion/spirituality, as
 well as family interactions and
 disability
 1.12 Seeks to maximize               1.12.1 Evaluates functional status over time         Uses appropriate tools to        360 Evaluation
 patients’ level of function, and                                                          measure functional status        chart/record
 quality of life for patients and                                                                                           review
 families
                                      1.12.2 Evaluates quality of life over time           Documents quality of life in     360 Evaluation
                                                                                           medical chart                    chart/record
                                                                                                                            review
                                      1.12.3 Provides expertise in maximizing patient’s    Refers to appropriate services   360 Evaluation
                                      level of function and quality of life                                                 chart/record
                                                                                                                            review
                                      1.12.4 Seeks to preserve opportunities for                                            360 Evaluation
                                      individual and family life in the context of life-                                    Pt/family
                                      threatening illness                                                                   surveys
Measurable Outcomes for HPM Competencies                                                                                                   Page 10


 Patient and Family Care
                                                                                                                                  Assessment
 Competency                         Sub-competency                                            Sample Behavior
                                                                                                                                  Method
                                    1.12.5 Recognizes the potential value to patients         Identifies and facilitates          360 Evaluation
                                    and their family members of completing personal           opportunities to resolve
                                    affairs/unfinished business                               unfinished issues
                                    1.12.6 Effectively manages physical symptoms and                                              360 Evaluation
                                    psychosocial and spiritual distress in the patient and                                        MCQ
                                    family                                                                                        chart/record
                                                                                                                                  review
 1.13 Provides patient and family   1.13.1 Educates families in maintaining and                                                   360 Evaluation
 education                          improving level of function to maximize quality of life
                                    1.13.2 Explains palliative care services,                                                     360 Evaluation;
                                    recommendations and latest developments to                                                    pt/family survey
                                    patients and families
                                    1.13.3 Educates patient and family about disease                                              360 Evaluation
                                    trajectory and how and when to access palliation in
                                    future
 1.14 Recognizes signs and          1.14.1 Effectively prepares family, other health care     Adequately interprets signs of      360 Evaluation;
 symptoms of impending death        professionals, and caregivers for the patient’s death     impending death for other           pt/family survey;
 and cares for the imminently                                                                 clinicians and family members       SP
 dying patient and their family
 members
                                    1.14.2 Provides assessment and symptom                    Identifies transition to actively   360 Evaluation
                                    management for the imminently dying patient               dying and changes                   MCQ
                                                                                              management accordingly
 1.15 Provides treatment to the     1.15.1 Provides support to family members at the          Demonstrates compassion,            Observation by
 bereaved                           time of death and immediately after                       expresses condolences,              attending
                                                                                              explores family questions, and      physician
                                                                                              provides information as             Family survey
                                                                                              desired by the family               360 Evaluation
                                    1.15.2 Involves interdisciplinary team members in
                                    treating the bereaved
                                    1.15.3 Refers family members to bereavement               Knows available community           MCQ
                                    programs                                                  resources                           360 Evaluation
 1.16 Refers patients and family    1.16.1 Recognizes the need for collaboration with                                             Direct
 members to other health care       clinicians providing disease-modifying treatment                                              observation by
 professionals to assess, treat                                                                                                   attending
 and manage patient and family                                                                                                    Self-
Measurable Outcomes for HPM Competencies                                                                                           Page 11


 Patient and Family Care
                                                                                                                           Assessment
 Competency                           Sub-competency                                         Sample Behavior
                                                                                                                           Method
 care issues outside the scope of                                                                                          assessment
 palliative care practice and                                                                                              Consultant
 collaborates effectively with them                                                                                        survey
                                      1.16.2 Collaborates with and makes referrals to                                      Direct
                                      pediatricians with expertise relevant to the care of                                 observation by
                                      children with advanced, progressive, and life-                                       attending;
                                      threatening illness                                                                  Consultant
                                                                                                                           survey
                                      1.16.3 Accesses specialized pediatric and geriatric                                  Direct
                                      palliative care resources appropriately                                              observation by
                                                                                                                           attending
                                      1.16.4 Collaborates with other mental health           Integrates mental health      Direct
                                      clinicians to meet the needs of patients with major    clinicians’ recommendations   observation by
                                      mental health issues                                   into patients’ plan of care   attending;
                                                                                                                           Consultant
                                                                                                                           survey
   Measurable Outcomes for HPM Competencies                                                                  Page 12



Medical Knowledge
                                                                                                           Assessment
Competency                                       Sub-competency   Sample Behavior
                                                                                                           Method
2.1 Describes the scope and practice of
hospice and palliative medicine, including:

 Domains of hospice and palliative care                          Recalls professional background of
 History of hospice and palliative medicine                      Cicely Saunders, the name of her         MCQ
                                                                  hospice program, and the year it
                                                                  was established

                                                                  Identifies year of establishment of      Standardized
                                                                  Hospice Medicare Benefit, its major      oral examination
                                                                  features, and its significance in the    MCQ
                                                                  history of hospice in the U.S.

 Settings where hospice and palliative                           Demonstrates appropriate                 360 Evaluation
  care are provided                                               preparation for home visit

 Elements of patient assessment and                              Prepares appropriate discharge plan      360 Evaluation
  management across different hospice and                         for complex inpatients, carries out or   Chart/record
  palliative care settings, including home                        assures all related chores, and          review
  visit, nursing home visit, inpatient hospice                    assures good follow-up                   OSCE
  unit visit, outpatient clinic visit, and in                                                              Peer survey
  hospital patient visit.                                         Assesses compliance in the
                                                                  ambulatory setting and uses home         360 Evaluation
 The Medicare/Medicaid Hospice Benefit,                          services to promote and further          Chart/record
  including essential elements of the                             assess compliance.                       review
  program, eligibility, and key regulations                                                                Peer survey
  for all levels of hospice care                                  Describes essential elements and
                                                                  eligibility criteria for hospice         Direct
                                                                                                           observation by
 Barriers faced by patients and families in                                                               attending
  accessing hospice and palliative care                           Correctly evaluates patients for their   Peer survey
  services                                                        hospice eligibility and                  OSCE
                                                                  appropriateness for a variety of
                                                                  hospice levels of care                   Direct
                                                                                                           observation by
   Measurable Outcomes for HPM Competencies                                                                                          Page 13


Medical Knowledge
                                                                                                                                   Assessment
Competency                              Sub-competency                                    Sample Behavior
                                                                                                                                   Method
                                                                                          In evaluating patients and families      attending
                                                                                          for hospice, identifies psychological,   Peer survey
                                                                                          social, economic, and other barriers     360 Evaluation
                                                                                          to accessing hospice                     OSCE
2.2 Recognizes the role of the          2.2.1 Describes the role of the palliative care   Identifies the roles performed by a      Standardized
interdisciplinary team in hospice and   physician in the interdisciplinary team           physician on a particular team and       oral examination
palliative care                                                                           evaluates this in terms of the           Direct
                                                                                          potential range of roles that            observation by
                                                                                          physicians can play                      attending
                                                                                                                                   Peer survey
                                                                                                                                   360 Evaluation
                                        2.2.2 Identifies the various members of the       Describes the actual role of various     Standardized
                                        interdisciplinary team and their roles and        clinicians on a team and evaluates       oral examination
                                        responsibilities                                  their behaviors in terms of the
                                                                                          potential roles they can play

                                                                                          Identifies behaviors that facilitate
                                                                                          and hinder team function
                                                                                                                                   Standardized
                                                                                                                                   oral examination
                                                                                                                                   Direct
                                                                                                                                   observation by
                                                                                                                                   attending
                                                                                                                                   Peer survey
                                                                                                                                   360 Evaluation

                                        2.2.3 Recognizes how and when to collaborate      Demonstrates appropriate referral to     Direct
                                        with other allied health professionals, such as   allied health professionals in           observation by
                                        nutritionists, physical therapists, respiratory   formulating and carrying out a care      attending
                                        therapists, occupational therapists, speech       plan.                                    Peer survey
                                        therapists, and case managers                                                              360 Evaluation
                                        2.2.4 Describes concepts of team process and      Describes team processes evident         Standardized
                                        recognizes psychosocial and organizational        in a team meeting                        oral examination
                                        elements that promote or hinder successful                                                 Writing
                                        interdisciplinary team function                                                            assignment
                                                                                          Recognizes psychosocial and
   Measurable Outcomes for HPM Competencies                                                                                       Page 14


Medical Knowledge
                                                                                                                                Assessment
Competency                          Sub-competency                                     Sample Behavior
                                                                                                                                Method
                                                                                       organizational elements that             Standardized
                                                                                       promote or hinder successful             oral examination
                                                                                       interdisciplinary team function in a     Writing
                                                                                       clinical setting, and then constructs    assignment
                                                                                       a plan to facilitate more facilitating
                                                                                       behaviors

                                                                                       Demonstrates appropriate behaviors       Direct
                                                                                       and facilitating of team process in      observation by
                                                                                       team meetings and informal               attending
                                                                                       contacts                                 Peer survey
                                                                                                                                360 Evaluation
2.3 Describes how to assess and     2.3.1 Identifies what elements of the patient’s    In evaluating patients, identifies key   Chart/record
communicate prognosis               history and physical examination are critical to   elements (history, physical              review
                                    formulating prognosis for a given patient          examination, and laboratory) that        Standardized
                                                                                       are useful in prognostication.           oral examination
                                                                                                                                OSCE
                                                                                                                                SP
                                                                                                                                Writing
                                                                                                                                assignment
                                    2.3.2 Describes common chronic illnesses with      For cancer, heart failure, dementia,     MCQ
                                    prognostic factors, expected natural course and    and anoxic or traumatic brain injury,    Standardized
                                    trajectories, common treatments, and               describes the key prognostic factors     oral examination
                                    complications                                      for severe disability or death and       Direct
                                                                                       formulates a prognosis                   observation by
                                                                                                                                attending
                                                                                       For common cancers at typically          OSCE
                                                                                       incurable stages, describes the
                                                                                       mean survival for treated and
                                                                                       untreated disease                        MCQ
                                                                                                                                Standardized
                                                                                       Describes major modalities of            oral examination
                                                                                       treatment for metastatic cancer,
                                                                                       congestive heart failure, chronic
                                                                                       obstructive lung disease, ALS, and
                                                                                       dementias, and is able to apply this     MCQ
   Measurable Outcomes for HPM Competencies                                                                                               Page 15


Medical Knowledge
                                                                                                                                        Assessment
Competency                                   Sub-competency                                    Sample Behavior
                                                                                                                                        Method
                                                                                               knowledge to outline care options for    Standardized
                                                                                               specific clinical cases                  oral examination

                                                                                               Recognizes common side effects of
                                                                                               chemotherapy agents and
                                                                                               biologicals, and is able to describe
                                                                                               these to patients and family
                                                                                               members

                                                                                               Describes key clinical features and      Direct
                                                                                               is able to recognize major and           observation by
                                                                                               urgent cancer complications, such        attending
                                                                                               as cord compression, superior vena       Peer survey
                                                                                               cava syndrome, hypercalcemia,            Standardized
                                                                                               hyponatremia                             oral examination

                                                                                                                                        Direct
                                                                                                                                        observation by
                                                                                                                                        attending
                                                                                                                                        Peer survey
                                                                                                                                        SP
                                                                                                                                        OSCE
                                                                                                                                        MCQ
                                             2.3.3 Describes effective strategies to           Uses clinical data to construct a        Direct
                                             communicate prognostic information to patients,   prognosis, and then communicates         observation by
                                             families and health care providers                this prognosis to a patient              attending
                                                                                                                                        SP
2.4 Recognizes the presentation and          2.4.1 Identifies common diagnostic and            In a variety of clinical situations in   Direct
management of common cancers, including      treatment methods in the initial evaluation and   which metastatic disease is              observation by
their epidemiology, evaluation, prognosis,   ongoing management of cancer                      suspected, describes typical             attending
treatment, patterns of advanced or                                                             diagnostic efforts to confirm the
metastatic disease, emergencies,                                                               diagnosis.
complications, associated symptoms, and
symptomatic treatments                                                                         In a variety of clinical situations in
                                                                                               which metastatic disease is              Direct
                                                                                               demonstrated, suggests appropriate       observation by
  Measurable Outcomes for HPM Competencies                                                                                 Page 16


Medical Knowledge
                                                                                                                         Assessment
Competency                         Sub-competency                                  Sample Behavior
                                                                                                                         Method
                                                                                   treatment options.                    attending
                                   2.4.2 Identifies common elements in             For common cancers at various         MCQ
                                   prognostication for solid tumors and            stages, distinguishes potentially     Standardized
                                   hematological malignancies at various stages,   curable from incurable disease, and   oral examination
                                   including the natural history of untreated      describes the prognosis for treated   Direct
                                   cancers                                         and untreated disease                 observation by
                                                                                                                         attending
                                                                                   Uses prognostic information
                                                                                   appropriately in discussing
                                                                                   diagnostic and treatment options      Direct
                                                                                   with patients and families.           observation by
                                                                                                                         attending
                                                                                                                         Peer survey
                                   2.4.3 Describes patterns of advanced disease,   Demonstrates familiarity with the     MCQ
                                   associated symptoms, and symptomatic            common patterns of metastatic         Standardized
                                   treatments for common cancers                   disease and associated symptoms       oral examination
                                                                                   for advanced ovarian cancer           Direct
                                                                                                                         observation by
                                                                                                                         attending

                                                                                   Demonstrates familiarity with
                                                                                   common patterns of spread of
                                                                                   common metastatic cancers, such       MCQ
                                                                                   as colonic carcinoma                  Standardized
                                                                                                                         oral examination
                                                                                                                         Direct
                                                                                   For common symptoms of advanced       observation by
                                                                                   cancer, formulates a differential     attending
                                                                                   diagnosis of the etiology and of
                                                                                   appropriate diagnostic efforts to     MCQ
                                                                                   delineate the etiology.               Standardized
                                                                                                                         oral examination
                                                                                                                         Direct
                                                                                   For common presenting symptoms        observation by
                                                                                   of advanced cancer (e.g, prostate     attending
                                                                                   cancer) describes symptomatic
   Measurable Outcomes for HPM Competencies                                                                                              Page 17


Medical Knowledge
                                                                                                                                       Assessment
Competency                                    Sub-competency                                    Sample Behavior
                                                                                                                                       Method
                                                                                                treatment
                                                                                                                                       Standardized
                                                                                                                                       oral examination
                                                                                                                                       Direct
                                                                                                                                       observation by
                                                                                                                                       attending
                                              2.4.4 Describes the presentation and              For a patient with metastatic breast   Standardized
                                              management of common complications of             cancer and new onset of severe         oral examination
                                              malignancy, i.e. hypercalcemia and brain          back pain, demonstrates an
                                              metastases, and emergencies, i.e. seizures and    awareness of the possibility of        Direct
                                              hemorrhage                                        epidural cord compression, it's        observation by
                                                                                                diagnosis, and early treatment         attending

                                                                                                Advises a patient with a cancer
                                                                                                metastatic to the brain, as well as
                                                                                                the family, about the emergency
                                                                                                management of seizures
2.5 Recognizes the presentation and           2.5.1 Identifies markers of advanced disease in   In analyzing the presenting clinical   MCQ
management of common non-cancer life-         common non-cancer life-threatening conditions,    data for patients with a variety of    Standardized
threatening conditions, including their       such as congestive heart failure, chronic         non-cancer life-threatening            oral examination
epidemiology, evaluation, prognosis,          obstructive pulmonary disease, and dementia       conditions, formulates a prognosis     Direct
treatment, patterns of disease progression,                                                     and eligibility for hospice            observation by
complications, emergencies, associated                                                                                                 attending
symptoms, and symptomatic treatments
                                              2.5.2 Describes patterns of advanced disease,     Identifies common symptoms of          Standardized
                                              associated symptoms, (i.e. dyspnea for            advanced gastric cancer                oral examination
                                              congestive heart failure and dysphagia for        and describes symptomatic              Direct
                                              dementia), and symptomatic treatments for         treatment.                             observation by
                                              common non-cancer life-threatening conditions                                            attending

                                                                                                Provides a comprehensive               Direct
                                                                                                evaluation for the symptoms            observation by
                                                                                                associated with hypercalcemia and      attending
                                                                                                prescribes appropriate treatment       OSCE
                                              2.5.3 Describes the presentation and              Provides a comprehensive               Standardized
                                              management of common complications of non-        evaluation of advanced chronic lung    oral examination
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Medical Knowledge
                                                                                                                                          Assessment
Competency                                  Sub-competency                                       Sample Behavior
                                                                                                                                          Method
                                            cancer life-threatening conditions, i.e.             disease, and prescribes or suggests      Direct
                                            pulmonary edema and psychosis, and                   appropriate management, including        observation by
                                            emergencies, i.e. myocardial infarction for          preparation for dealing with likely      attending
                                            coronary artery disease and stroke for               signs of deterioration or the need for
                                            cerebrovascular disease                              emergency care




2.6 Explains principles of assessing pain   2.6.1 Describes the concept of “total pain”          Provides a comprehensive analysis        Direct
and other common non-pain symptoms                                                               of patients with pain and identifies     observation by
                                                                                                 the physical, psychosocial, and          attending
                                                                                                 spiritual components of distress         Chart/record
                                                                                                                                          review
                                            2.6.2 Explains the relevant basic science,           Evaluates patients with pain and         Direct
                                            pathophysiology, associated symptoms and             other non-pain symptoms, and             observation by
                                            signs, and diagnostic options useful in              differentiates among possible            attending
                                            differentiating among different etiologies of pain   etiologies.                              OSCE
                                            and non-pain symptoms                                                                         MCQ

                                                                                                 Describes common features of pain
                                                                                                 and non-pain symptoms that               Direct
                                                                                                 suggest particular etiologies, and       observation by
                                                                                                 distinguishes and identifies useful      attending
                                                                                                 diagnostic options to clarify the        OSCE
                                                                                                 etiology                                 MCQ
                                                                                                                                          Standardized
                                                                                                 Describes the basic science and          oral examination
                                                                                                 pathophysiology of common pain
                                                                                                 and non-pain symptoms                    Direct
                                                                                                                                          observation by
                                                                                                                                          attending
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Medical Knowledge
                                                                                                                                              Assessment
Competency                                     Sub-competency                                        Sample Behavior
                                                                                                                                              Method

                                                                                                                                              OSCE
                                                                                                                                              MCQ
                                                                                                                                              Standardized
                                                                                                                                              oral examination
                                               2.6.3 Describes a thorough assessment and             In evaluating patients, demonstrates     Direct
                                               functional status of pain and other symptoms,         an ability to assess and                 observation by
                                               including the use of appropriate diagnostic           appropriately manage pain and            attending
                                               methods and symptom measurement tools                 other symptoms                           Standardized
                                                                                                                                              oral examination
                                               2.6.4 Names common patient, family, health            In evaluating patients, identifies and   Direct
                                               care professional, and health care system             addresses common barriers to             observation by
                                               barriers to the effective treatment of symptoms       effective treatment, such as fears of    attending
                                                                                                     addiction and tolerance, difficulties    Standardized
                                                                                                     with adhering to complicated             oral examination
                                                                                                     medication schedules, discomfort
                                                                                                     with intimate bodily contact or
                                                                                                     exposure, and inability to manage
                                                                                                     such complex skills as dressing
                                                                                                     changes, inserting rectal
                                                                                                     suppositories, or administrating IV
                                                                                                     fluids
2.7 Describes the use of opioids in pain and   2.7.1 Lists the indications, clinical                 Demonstrates an ability to correctly     Direct
non-pain symptom management                    pharmacology, alternate routes, equianalgesic         prescribe opioids for pain and non-      observation by
                                               conversions, appropriate titration, toxicities, and   pain symptom management in a             attending
                                               management of common side effects for opioids         variety of settings, including choice    Standardized
                                                                                                     of route, dosage, intervals, steps in    oral examination
                                                                                                     titration, and prevention and            MCQ
                                                                                                     management of side effects and
                                                                                                     toxicity



                                               2.7.2 Describes appropriate opioid prescribing,       For a patient with poorly controlled     Direct
                                               monitoring of treatment outcomes, and toxicity        pain on acetaminophen, chooses           observation by
                                               management in chronic, urgent and emergency           the appropriate additional pain          attending
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Medical Knowledge
                                                                                                                               Assessment
Competency                         Sub-competency                                    Sample Behavior
                                                                                                                               Method
                                   pain conditions.                                  medication and dosage, reflecting         Standardized
                                                                                     an awareness of the etiology of the       oral examination
                                                                                     pain, it's severity, risks of toxicity,   MCQ
                                                                                     and appropriate monitoring and            SP
                                                                                     follow-up

                                                                                     For a patient on chronic oral
                                                                                     methadone for abdominal and back
                                                                                     pain associated with metastatic
                                                                                     pancreatic cancer who now is
                                                                                     unable to take pills because of
                                                                                     severe nausea and vomiting,
                                                                                     prescribes an appropriate regimen
                                                                                     of morphine or hydromorphone,
                                                                                     administered via patient controlled
                                                                                     analgesia
                                   2.7.3 Describes appropriate opioid prescribing    For a patient on a complex                Direct
                                   in different clinical care settings: home,        analgesic regimen and being               observation by
                                   residential hospice, hospital, long-term care     discharged to a nursing home from a       attending
                                   facility                                          hospital, prescribes an appropriate       Standardized
                                                                                     analgesic regimen that is suitable for    oral examination
                                                                                     this new setting                          MCQ
                                                                                                                               SP
                                                                                     In choosing an opioid regimen for a
                                                                                     patient in hospice, prescribes
                                                                                     medications in a manner that
                                                                                     demonstrates awareness of such
                                                                                     issues as cost, convenience,
                                                                                     availability, and compliance


                                   2.7.4 Describes the concepts of addiction,        For a patient in the recovery from        Direct
                                   pseudoaddiction, dependence and tolerance,        opioid abuse and now with pain from       observation by
                                   and describes their significance in pain          widely metastatic bony metastasis,        attending
                                   management, as well as approaches to              counsels the patient about the risks      Standardized
                                   managing pain in patients with current or prior   of the dependence and tolerance,          oral examination
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Medical Knowledge
                                                                                                                                        Assessment
Competency                                   Sub-competency                                    Sample Behavior
                                                                                                                                        Method
                                             substance abuse                                   the importance of good analgesia         SP
                                                                                               and a regimen that allows for careful
                                                                                               monitoring while minimizing the risk
                                                                                               of addiction
                                             2.7.5 Explains the legal and regulatory issues    Writes opioid prescriptions that         Direct
                                             surrounding opioid prescribing                    reflect an awareness of pertinent        observation by
                                                                                               legal and regulatory issues,             attending
                                                                                               including the amount prescribed,         Standardized
                                                                                               managing increases in dosage             oral examination
                                                                                               between prescriptions, and the need      MCQ
                                                                                               for written prescriptions for refills    SP
2.8 Describes the use of non-opioid          2.8.1 Identifies the indications, clinical        Recognizes neuropathic pain and          Direct
analgesics, adjuvant analgesics, and other   pharmacology, alternate routes, appropriate       correctly prescribes anticonvulsants     observation by
pharmacologic approaches to the              titration, toxicities, and management of common   or antidepressants                       attending
management of both pain and non-pain         side effects for: acetaminophen, aspirin,                                                  Standardized
symptoms                                     NSAIDs, corticosteroids, anticonvulsants, anti-   Correctly describes the use of non-      oral examination
                                             depressants, and local anesthetics used in the    opioid analgesics, their common          MCQ
                                             treatment of pain and non-pain symptoms.          toxicities, contraindications, and how   SP
                                                                                               they are prescribed

                                                                                               In prescribing corticosteroids at low
                                                                                               doses for pain, identifies additional
                                                                                               beneficial and harmful effects
2.9 Describes pharmacologic approaches to    2.9.1 Describes use of common agents used to      Describes a clinical approach to         Direct
the management of common non-pain            treat dyspnea, nausea, vomiting, diarrhea,        managing nausea and vomiting             observation by
symptoms                                     constipation, anxiety, depression, fatigue,       refractory to common agents,             attending
                                             pruritus, confusion, agitation, and other         including the utility of various         Standardized
                                             common problems in palliative care practice       diagnostic efforts                       oral examination
                                                                                                                                        MCQ
                                                                                               In evaluating patients with delirium,    SP
                                                                                               provides a comprehensive
                                                                                               differential diagnosis based on
                                                                                               history, physical examination, and
                                                                                               laboratory tests, and correctly
                                                                                               prescribes treatments aimed at the
                                                                                               etiology of the delirium or at the
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Medical Knowledge
                                                                                                                                    Assessment
Competency                          Sub-competency                                         Sample Behavior
                                                                                                                                    Method
                                                                                           symptom, including both
                                                                                           pharmacological and
                                                                                           nonpharmacological treatments

                                                                                           Correctly diagnosis and prescribes
                                                                                           treatment for small bowel
                                                                                           obstruction, including surgical
                                                                                           approaches, pharmacological
                                                                                           approaches, and counseling of the
                                                                                           patient and family

                                                                                           In evaluating a lung cancer patient
                                                                                           with new onset dyspnea, describes
                                                                                           a differential diagnosis, evaluation
                                                                                           plan, and first-line treatments for
                                                                                           various etiologies

                                    2.9.2 Identifies the indications, clinical             Prescribes a satisfactory bowel          Direct
                                    pharmacology, alternate routes, appropriate            regimen whenever prescribing             observation by
                                    titration, toxicities, and management of common        opioids                                  attending
                                    side effects for: opioids, anxiolytics, antiemetics,                                            Standardized
                                    laxatives, psychostimulants, corticosteroids,          Prescribes benzodiazepines with an       oral examination
                                    antidepressants, antihistamines, neuroleptics,         awareness of their half- lives,          MCQ
                                    sedatives and other common agents used in              appropriate titration, and common        SP
                                    palliative care practice                               toxicities

                                                                                           Appropriately suggests neuroleptics
                                                                                           for delirium and agitation, and is
                                                                                           able to provide a rationale for use of
                                                                                           particular agents
2.10 Describes the use of non-      2.10.1 Identifies indications, toxicities, and         In describing the diagnosis and          Direct
pharmacologic approaches to the     appropriate referral for interventional pain           treatment of pancreatic cancer,          observation by
management of pain and non-pain     management procedures, as well as surgical             explains the role of celiac plexus       attending
symptoms                            procedures commonly used for pain and non-             block, complications, and usual          Standardized
                                    pain symptom management                                outcomes                                 oral examination
                                                                                                                                    MCQ
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Medical Knowledge
                                                                                                                                    Assessment
Competency                                 Sub-competency                                   Sample Behavior
                                                                                                                                    Method
                                                                                                                                    SP
                                           2.10.2 Identifies indications, toxicities,       Suggests the use of hypo-               Direct
                                           management of common side effects, and           fractionated radiation therapy for      observation by
                                           appropriate referral for radiation therapy       selected patients with metastatic       attending
                                                                                            bone cancer                             Standardized
                                                                                                                                    oral examination
                                                                                                                                    MCQ
                                                                                                                                    SP
                                           2.10.3 Identifies indications, toxicities, and   For appropriately selected patients,    Direct
                                           appropriate referral for commonly used           explains and suggests relaxation        observation by
                                           complementary and alternative therapies, i.e.    exercises, and makes appropriate        attending
                                           acupuncture, aromatherapy, guided imagery        referrals                               Standardized
                                                                                                                                    oral examination
                                                                                                                                    MCQ
                                                                                                                                    SP
                                           2.10.4 Explains the role of allied health        For patients with ALS at various        Direct
                                           professions in pain and non-pain symptom         stages of progression, is familiar      observation by
                                           management, such as speech, physical,            with and able to prescribe              attending
                                           respiratory, and occupational therapy            appropriate use of speech, physical,    Standardized
                                                                                            respiratory, and occupational           oral examination
                                                                                            therapy                                 MCQ
                                                                                                                                    SP
2.11 Describes the etiology,               2.11.1 Recognizes how to evaluate, and treat     Describes an organized, step-wise       MCQ
pathophysiology, diagnosis, and            common neuropsychiatric disorders                approach to evaluation and              Standardized
management of common neuropsychiatric                                                       treatment of common                     oral examination
disorders encountered in palliative care                                                    neuropsychiatric disorders
practice, such as depression, delirium,
seizures, and brain injury
                                           2.11.2 Describes how to refer appropriately to   Identifies triggers for referral to a   MCQ
                                           neurological and mental health professionals     neurologist or mental health            Direct
                                                                                            professional                            observation by
                                                                                                                                    attending
                                                                                                                                    Standardized
                                                                                                                                    oral examination
                                           2.11.3 Describes the indications,                Discusses the main indications and      MCQ
                                           contraindications, pharmacology, appropriate     contraindications, basic                Direct
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Medical Knowledge
                                                                                                                                            Assessment
Competency                                      Sub-competency                                    Sample Behavior
                                                                                                                                            Method
                                                prescribing practice, and side-effects of         pharmacology, appropriate                 observation by
                                                common psychiatric medications                    prescribing practice, and main side       attending
                                                                                                  effects of SSRIs, tricyclic               Standardized
                                                                                                  antidepressants, anticonvulsants,         oral examination
                                                                                                  benzodiazepenes, antipsychotics,
                                                                                                  barbiturates
                                                2.11.4 Recognizes the diagnostic criteria and     Lists the diagnostic criteria for brain   MCQ
                                                management issues of brain death, persistent      death and persistent vegetative           Standardized
                                                vegetative state, and minimally conscious state   state,                                    oral examination

                                                                                                  Describes common management
                                                                                                  issues around brain death and             MCQ
                                                                                                  persistent vegetative state               Standardized
                                                                                                                                            oral examination
                                                                                                                                            Mini-CEX
2.12 Recognizes common psychological            2.12.1 Recognizes psychological distress          Identifies the presence of common         MCQ
stressors and disorders experienced by                                                            psychological stressors                   Standardized
patients and families facing life-threatening                                                                                               oral examination
conditions, and describes appropriate                                                             Assesses for common physical and
clinical assessment and management.                                                               behavioral signs of psychological
                                                                                                  distress                                  MCQ
                                                                                                                                            Standardized
                                                                                                                                            oral examination
                                                                                                                                            OSCE/SP
                                                                                                                                            Mini-CEX
                                                                                                                                            360 Evaluation
                                                2.12.2 Describes concepts of coping styles,       Lists and defines coping styles and       MCQ
                                                psychological defenses, and developmental         psychological defenses                    Standardized
                                                stages relevant to the evaluation and                                                       oral examination
                                                management of psychological distress              Identifies relevant coping styles and
                                                                                                  psychological defense mechanisms
                                                                                                                                            Standardized
                                                                                                                                            oral examination
                                                                                                                                            Mini-CEX
                                                                                                                                            OSCE/SP
                                                2.12.3 Describes how to provide basic             Lists basic concepts of supportive        MCQ
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Medical Knowledge
                                                                                                                                            Assessment
Competency                                    Sub-competency                                        Sample Behavior
                                                                                                                                            Method
                                              supportive counseling and to strengthen coping        counseling and strategies to            Standardized
                                              skills                                                strengthen coping skills                oral examination
                                              2.12.4 Recognizes the needs of minor children         Routinely evaluates issues and          360 Evaluation
                                              when an adult parent or close relative is             needs of minor children involved in     OSCE/SP
                                              seriously ill or dying, and provides appropriate      cases                                   Mini-CEX
                                              basic counseling or referral
                                                                                                    Demonstrates effective basic            360 Evaluation
                                                                                                    counseling and appropriate referral     OSCE/SP
                                                                                                    for minor children                      Mini-CEX
                                              2.12.5 Recognizes the needs of parents and            Routinely evaluates needs of            360 Evaluation
                                              siblings of children who are seriously ill or dying   siblings and parents when children      OSCE/SP
                                              and provides appropriate basic counseling or          are seriously ill                       Mini-CEX
                                              referral
                                                                                                    Demonstrates effective basic
                                                                                                    counseling and appropriate referral     360 Evaluation
                                                                                                    for siblings and parents                OSCE/SP
                                                                                                                                            Mini-CEX
May delete or combine with 2.11.2 later on    2.12.6 Explains appropriate utilization of            Identifies common triggers for          MCQ
                                              consultation with specialists in psychosocial         specialist consultation in the          Standardized
                                              assessment and management                             psychosocial domain                     oral examination
                                                                                                                                            Mini-CEX
2.13 Recognizes common social problems        2.13.1 Able to assess, counsel, support, and          Identifies signs of caregiver burden    MCQ
experienced by patients and families facing   make appropriate referrals to alleviate the                                                   Standardized
life-threatening conditions and describes     burden of caregiving                                  Explains strategies to relieve          oral examination
appropriate clinical assessment and                                                                 caregiver burden                        Mini-CEX
management                                                                                                                                  OSCE/SP
                                                                                                    Routinely assesses for level of
                                                                                                    caregiver burden                        360 Evaluation
                                                                                                                                            Mini-CEX
                                                                                                    Refers appropriately to colleagues to
                                                                                                    address caregiver burden                360 Evaluation
                                                                                                                                            Peer survey
                                              2.13.2 Able to assess, provide support, and           Routinely assesses for distress         360 Evaluation
                                              make appropriate referral around fiscal issues,       around financial insurance, and legal   Mini-CEX
                                              insurance coverage, and legal concerns                concerns
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Medical Knowledge
                                                                                                                                             Assessment
Competency                                     Sub-competency                                      Sample Behavior
                                                                                                                                             Method
                                                                                                   Refers appropriately to colleagues to     360 Evaluation
                                                                                                   address financial, insurance and          Peer survey
                                                                                                   legal concerns
2.14 Recognizes common experiences of          2.14.1 Describes the role of hope, despair,         Defines hope, despair, meaning and        360 Evaluation
distress around spiritual, religious, and      meaning, and transcendence in the context of        transcendence in a practical sense        Peer survey
existential issues for patients and families   severe and chronic illness                          that promotes understanding for           Direct
facing life-threatening conditions, and                                                            patients, families, and staff in this     observation by
describes elements of appropriate clinical                                                         setting                                   attending
assessment and management                                                                                                                    Standardized
                                                                                                                                             oral examination
                                               2.14.2 Describes how to perform a basic             Explains an organized approach to         Standardized
                                               spiritual/existential/religious evaluation          covering basic elements of a              oral examination
                                                                                                   spiritual/existential/religious history   MCQ
                                               2.14.3 Describes how to provide basic spiritual     Defines basic principles of spiritual     MCQ
                                               counseling                                          counseling and common scenarios           Standardized
                                                                                                   where counseling could be of benefit      oral examination
                                               2.14.4 Identifies the indications for referral to   Lists indications for referral to         MCQ
                                               chaplaincy or other spiritual counselors and        chaplaincy or other spiritual             Standardized
                                               resources                                           resources                                 oral examination
                                               2.14.5 Knows the developmental processes,           Describes common tasks of life            MCQ
                                               tasks, and variations of life completion and life   closure for dying patients                Standardized
                                               closure                                                                                       oral examination
                                               2.14.6 Describes processes for facilitating         Names strategies to facilitate growth     MCQ
                                               growth and development in the context of            and development for a patient with        Standardized
                                               advanced illness                                    advanced illness                          oral examination
                                                                                                                                             Mini-CEX
                                                                                                                                             OSCE/SP
2.15 Able to recognize, evaluate, and          2.15.1 Recognizes major contributions from          Assesses patient and family cultural      Standardized
support diverse cultural values and customs    non-medical disciplines, such as sociology,         values and customs in regard to           oral examination
with regard to information sharing, decision   anthropology, and health psychology, in             information sharing, decision-            MCQ
making, expression and treatment of            understanding and managing the patient’s and        making, expression and treatment of       Peer survey
physical and emotional distress, and           family’s experience of serious and life-            physical and emotional distress, and
preferences for sites of care and death.       threatening illness                                 preferences for sites of care and
                                                                                                   death

                                                                                                   Demonstrates respect for and effort
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Medical Knowledge
                                                                                                                                           Assessment
Competency                                      Sub-competency                                     Sample Behavior
                                                                                                                                           Method
                                                                                                   to honor diverse cultural values and
                                                                                                   customs                                 Chart/record
                                                                                                                                           review
                                                                                                                                           360 degree
2.16 Recognizes the components of               2.16.1 Identifies common symptoms, signs,          Describes stages of dying, including    Standardized
management for the syndrome of imminent         complications and variations in the normal dying   common symptoms, signs, and             oral examination
death                                           process and their management                       complications, as well as relevant      MCQ
                                                                                                   management strategies

                                                2.16.2 Describes strategies to communicate         Identifies approaches for               Standardized
                                                with patient and family about the dying process    communicating with a patient and        oral examination
                                                and to provide support                             family about the dying process          MCQ
                                                                                                                                           Mini-CEX
                                                                                                   Describes strategies for
                                                                                                   demonstrating support to a patient      Standardized
                                                                                                   and family during the dying process     oral examination
                                                                                                                                           MCQ
                                                                                                                                           Mini-CEX
2.17 Recognizes the elements of                 2.17.1 Describes appropriate and sensitive         Explains a step-wise process for        Standardized
appropriate care of the patient and family at   pronouncement of death                             death pronouncement, including          oral examination
the time of death and immediately thereafter                                                       personal preparation, patient           MCQ
                                                                                                   assessment, family notification, and    Mini-CEX
                                                                                                   documentation


                                                                                                                                           Standardized
                                                                                                                                           oral examination
                                                                                                                                           MCQ
                                                                                                                                           Mini-CEX
                                                2.17.2 Identifies the standard procedural          Describes post-death care, including    Standardized
                                                components and psychosocial elements of post-      family notification of death, autopsy   oral examination
                                                death care                                         option, organ donation option,          MCQ
                                                                                                   funeral arrangements, routine care      Direct
                                                                                                   of the body, and death certificate      observation by
                                                                                                   completion                              attending
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Medical Knowledge
                                                                                                                                                Assessment
Competency                                          Sub-competency                                    Sample Behavior
                                                                                                                                                Method
                                                    2.17.3 Recognizes the potential importance        Routinely elicits and facilitates post-   360 Evaluation
                                                    and existence of post-death rituals and how to    death rituals of importance to            Peer survey
                                                    facilitate them                                   patients and families                     Chart/record
                                                                                                                                                review
2.18 Describes the basic science,                   2.18.1 Demonstrates knowledge of normal grief     Defines normal grief                      MCQ
epidemiology, clinical features, natural            and elements of bereavement follow-up,                                                      Standardized
course, stages, and management options for          including assessment, treatment, and referral                                               oral examination
normal and pathologic grief                         options for bereaved family members
                                                                                                      Lists elements of bereavement             MCQ
                                                                                                      assessment                                Standardized
                                                                                                                                                oral examination

                                                                                                      Identify approaches to bereavement        MCQ
                                                                                                      treatment                                 Standardized
                                                                                                                                                oral examination

                                                                                                      Explain local referral options for        MCQ
                                                                                                      bereavement counseling                    Standardized
                                                                                                                                                oral examination
                                                    2.18.2 Recognizes the risk factors, diagnostic    Discuss risk factors, diagnostic          MCQ
                                                    features, epidemiology, and management of         features, and epidemiology of             Standardized
                                                    depression and complicated grief                  complicated grief and depression          oral examination
                                                                                                      associated with bereavement

                                                                                                      Identify management strategies for
                                                                                                      complicated grief and depression
                                                                                                      associated with bereavement               MCQ
                                                                                                                                                Standardized
                                                                                                                                                oral examination
                                                    2.18.3. Appreciates risk of suicide in the                                                  Direct
                                                    bereaved and carries out initial assessment for                                             observation by
                                                    suicide risk                                                                                attending
                                                                                                                                                MCQ
2.19 Describes common issues in the                 2.19.1 Describes the epidemiology of pediatric    Names common causes of death for          MCQ
palliative care management of pediatric and         life-threatening conditions                       infants, children, and adolescents        Standardized
geriatric patients and their families that differ                                                     and the age ranges for these              oral examination
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Medical Knowledge
                                                                                                                                        Assessment
Competency                                     Sub-competency                                  Sample Behavior
                                                                                                                                        Method
from caring for adult patients, in regard to                                                   categories
physiology, vulnerabilities, and
developmental stages                                                                           Discusses the difficulty of
                                                                                               prognostication in the setting of rare   Standardized
                                                                                               syndromes and other congenital           oral examination
                                                                                               abnormalities in childhood and its
                                                                                               relevance to clinical care
                                               2.19.2 Appreciates developmental perspectives   Explains common age- specific            MCQ
                                               on illness, grief, and loss                     perspectives for patients and family     Standardized
                                                                                               members, as applied to illness,          oral examination
                                                                                               loss, and grief                          360 Evaluation
                                                                                                                                        Mini-CEX
                                               2.19.3 Describes pharmacologic principles       Explains weight-based dosing             MCQ
                                               applicable to the management of symptoms in     approach for medications in              Standardized
                                               infants, children, and adolescents              pediatric patients.                      oral examination

                                                                                               Recognizes the emphasis on
                                                                                               preventing and managing                  MCQ
                                                                                               procedure-related pain in pediatrics     Standardized
                                                                                                                                        oral examination
                                                                                               Names physiologic characteristics of
                                                                                               neonates that may affect opioid
                                                                                               pharmacology                             MCQ
                                                                                                                                        Standardized
                                                                                                                                        oral examination
2.20 Describes ethical and legal issues in     2.20.1 Discusses ethical principles and         Explains common ethical principles       Standardized
palliative and end-of-life care and their      frameworks for addressing clinical issues       and their application in palliative      oral examination
clinical management                                                                            medicine                                 MCQ

                                                                                               Applies ethical principles to given
                                                                                               ethical dilemma                          Standardized
                                                                                                                                        oral examination
                                                                                                                                        Mini-CEX
                                                                                                                                        OSCE/SP
                                                                                                                                        Writing
                                                                                                                                        assignment
  Measurable Outcomes for HPM Competencies                                                                                      Page 30


Medical Knowledge
                                                                                                                              Assessment
Competency                         Sub-competency                                    Sample Behavior
                                                                                                                              Method
                                   2.20.2 Describes federal, state, and local laws   Discusses federal, state, and local      Standardized
                                   and practices that impact on palliative care      laws regarding such issues as            oral examination
                                   practice                                          advance directives, controlled           MCQ
                                                                                     substance regulation, management         Mini-CEX
                                                                                     of resuscitation status, limits of       Direct
                                                                                     doctor-patient relationship, decision-   observation by
                                                                                     making capacity and consent, and         attending
                                                                                     management of life-sustaining            360 Evaluation
                                                                                     therapy
                                   2.20.3 Consults clinical ethicist appropriately   Explains local procedure for ethics      Direct
                                                                                     consultation                             observation by
                                                                                                                              attending
                                                                                     Identifies appropriate scenarios for
                                                                                     ethics involvement                       MCQ
                                                                                                                              Standardized
                                                                                                                              oral examination
                                                                                                                              Direct
                                                                                                                              observation by
                                                                                                                              attending
                                                                                                                              Mini-CEX
                                   2.20.4 Describes professional and institutional   Explains professional and                Standardized
                                   ethical policies relevant to palliative care      institutional ethical policies           oral examination
                                   practice                                          commonly applied to palliative care      MCQ
                                                                                     practice, such as limiting life-         Mini-CEX
                                                                                     sustaining therapies, use of advance     Direct
                                                                                     directives, decision-making capacity     observation by
                                                                                                                              attending
                                                                                                                              360 Evaluation
  Measurable Outcomes for HPM Competencies                                                                                                 Page 31



Practice-Based Learning and Improvement
                                                                                                                                       Assessment
Competency                                Sub-competency                                     Sample Behavior
                                                                                                                                       Method
3.1 Maintains safe and competent          3.1.1 Demonstrates an ability to self-reflect on   Self assess and critique personal         360 Evaluation
practice, including self-evaluation and   personal learning deficiencies and develop a       learning deficiencies.                    Portfolio
continuous learning                       plan for improvement                               Choose a plan of remediation.
                                          3.1.2 Demonstrates knowledge of and                Construct a plan for life-long learning   360 Evaluation
                                          commitment to continuing professional              – staying up to date, obtaining CME,      Portfolio
                                          development and life-long learning                 goal oriented professional
                                                                                             development.
                                                                                             Participates in program and
                                                                                             institutional continuing medical
                                                                                             education offerings
                                          3.1.3 Demonstrates knowledge of the roles          Applies knowledge of trainee/mentor       Global rating
                                          and responsibilities of the trainee/mentor         role in daily activities. – looks to      scale
                                                                                             mentor for appropriate guidance,          Portfolio - log of
                                                                                             follows through on agreed tasks,          activities with
                                                                                             open to assuming mentor role in           mentor
                                                                                             interactions with trainees
                                          3.1.4 Demonstrates the ability to reflect on       Categorize personal learning styles in    Chart/record
                                          his/her personal learning style and use            development of self-learning plan.        review
                                          different opportunities for learning                                                         Portfolio

                                          3.1.5 Demonstrates the ability to actively seek    Interpret feedback to improve patient     Checklist
                                          and utilize feedback                               care and collegial relationships.
                                                                                             Routinely seeks feedback.
                                                                                             Discusses current areas for personal
                                                                                             improvement.
                                          3.1.6 Demonstrates the ability to develop an       Combine feedback and self-                360 Evaluation
                                          effective learning relationship with members of    assessment into a plan for effectively    Checklist
                                          the faculty and other professionals                working with colleagues and peers
3.2 Accesses, analyzes and applies the    3.2.1 Demonstrates knowledge of, and               Differentiates the quality of research    Chart/record
evidence base to clinical practice in     recognizes limitations of, evidence-based          in palliative care for patient care       review
palliative care                           medicine in palliative care                        applications.                             MCQ
                                                                                             Able to analyze the evidence-base         Standardized
                                                                                             for a particular clinical question with   oral exam
                                                                                             discussion of limitations                 Checklist
                                          3.2.2 Actively seeks to apply the best             Uses best medical research to solve       Chart/record
  Measurable Outcomes for HPM Competencies                                                                                         Page 32


Practice-Based Learning and Improvement
                                                                                                                               Assessment
Competency                         Sub-competency                                     Sample Behavior
                                                                                                                               Method
                                   available evidence to patient care to facilitate   patient-care problems.                   review
                                   safe, up-to-date clinical practice, and                                                     MCQ
                                   encourages others to do so                         Facilitates environment of application   Standardized
                                                                                      of best evidence as member of            oral exam
                                                                                      clinical team                            Checklist
                                                                                                                               Peer survey
                                                                                                                               360 Evaluation
3.3 Develops competencies as an    3.3.1 Recognizes the importance of                 Employs a needs assessment               Portfolio
educator                           assessing learning needs in initiating a           process in educational planning.
                                   teaching encounter
                                   3.3.2 Reflects on benefits and drawbacks of        Appraises audience learning needs        Portfolio
                                   alternative approaches to teaching, and the        and learning objectives in the choice
                                   role of different teaching techniques to           of teaching techniques.
                                   address knowledge, attitudes, and skills
                                                                                      Identifies range of potential teaching
                                                                                      strategies and explains their
                                                                                      application to teaching knowledge,
                                                                                      skills and attitudes

                                                                                      Discusses benefits and drawbacks of
                                                                                      particular teaching strategies in a
                                                                                      given circumstance

                                                                                      Participates in teaching continuing
                                                                                      medical education offerings to other
                                                                                      disciplines
                                   3.3.3 Shows respect towards other learners         Demonstrates respect and empathy         360 Evaluation
                                                                                      for learners                             Learner survey
                                   3.3.4 Describes the importance of defining         Explains why developing learning         Portfolio
                                   learning goals and objectives as a basis for       objectives are essential in
                                   developing educational sessions                    educational program development.

                                                                                      Describes key components for writing
                                                                                      an effective learning objective
                                   3.3.5 Demonstrates the ability to supervise        Evaluates clinical trainees using        Learner survey
                                   clinical trainees (e.g., medical students,         objective metrics.                       Checklist
  Measurable Outcomes for HPM Competencies                                                                                                 Page 33


Practice-Based Learning and Improvement
                                                                                                                                       Assessment
Competency                                  Sub-competency                                    Sample Behavior
                                                                                                                                       Method
                                            residents, and other health care professionals)                                            Direct
                                            and give constructive feedback                    Critiques clinical trainees in a         observation by
                                                                                              professional manner acknowledging        attending
                                                                                              positives and areas for improvement.     Peer survey


3.4 Demonstrates knowledge of the           3.4.1 Recognizes and values the importance        Explains key ethical issues in           Portfolio
process and opportunities for research in   of addressing ethical issues in palliative care   palliative care research.
palliative care                             research
                                            3.4.2 Is realistic about the benefits and         Recognizes the value of palliative       Portfolio
                                            challenges of palliative care research and        care research.
                                            supports research as appropriate to the
                                            setting
                                            3.4.3 Recognizes and values the use of data       Describes how palliative care            Portfolio
                                            to demonstrate clinical, utilization, and         financial data can be used to plan for   MCQ
                                            financial outcomes of palliative care             different clinical service delivery      Standardized
                                                                                              models.                                  oral exam
3.5 Describes common approaches to          3.5.1 Demonstrates an openness and                Uses clinical data to develop clinical   Portfolio
quality and safety assurance                willingness to evaluate and participate in        practice improvement projects in
                                            practice and service improvement                  palliative care.

                                                                                              Describes a model for approaching
                                                                                              healthcare improvement and can
                                                                                              apply to clinical problem, i.e. PDSA
                                                                                              Cycle or Model for Improvement
                                            3.5.2 Demonstrates knowledge of palliative        Identifies key clinical, financial and   Portfolio
                                            care’s clinical, financial, and quality-of-care   quality of life measurement tools.       MCQ
                                            outcome measures                                                                           Standardized
                                                                                                                                       oral exam
                                            3.5.3 Demonstrates awareness of and               Uses patient safety standards in daily   Checklist
                                            adherence to patient safety standards             clinical practice.                       360 Evaluation
                                                                                                                                       Portfolio
                                                                                              Identifies potential patient safety
                                                                                              issues in any given clinical scenario
  Measurable Outcomes for HPM Competencies                                                                                             Page 34




Interpersonal and Communication Skills
                                                                                                                                   Assessment
Competency                             Sub-competency                                     Sample Behavior
                                                                                                                                   Method
4.1 Initiates informed relationship-   4.1.1 Assesses patient/family wishes               Inquires about how much information      Direct
centered dialogues about care          regarding the amount of information they wish      the person wants at the initial visit    observation by
                                       to receive and the extent of their participation                                            attending
                                       in clinical decision-making                        Asks if the patient wants to be          SP
                                                                                          involved in decision making when         Family survey
                                                                                          discussing goals of care                 360 Evaluation


                                       4.1.2 Determines, in collaboration with            Inquires if there are other people who   Direct
                                       patient/family, the appropriate participants in    should be present when giving bad        observation by
                                       discussions concerning a patient’s care            news                                     attending
                                                                                                                                   SP
                                                                                                                                   Family feedback
                                                                                                                                   360 Evaluation
                                       4.1.3 Assesses patient’s and family                Can justify a determination of           Direct
                                       members’ decision-making capacity, and             decision making capacity                 observation by
                                       other strengths and limitations of                                                          attending
                                       understanding and communication                    Can discuss different criteria and       SP
                                                                                          their advantages and disadvantages       Family survey
                                                                                          for determining decision making          360 Evaluation
                                                                                          capacity
                                       4.1.4 Enlists legal surrogates to speak on         Can describe the relevant law            Direct
                                       behalf of a patient when making decisions for      regarding surrogacy                      observation by
                                       a patient without decision-making capacity                                                  attending
                                                                                                                                   SP
                                                                                          Can describe the moral justifications    Family survey
                                                                                          for choosing a surrogate                 360 Evaluation

                                                                                          Asks the surrogate about what the
                                                                                          patient would have wanted when
                                                                                          discussing goals of therapy
                                       4.1.5 Recognizes differences between               Can describe differences in pediatric    MCQ
                                       relationship-centered dialogues in adult and       and adult communication about            Direct
                                       pediatric palliative care                          palliative care topics                   observation by
  Measurable Outcomes for HPM Competencies                                                                                                  Page 35


Interpersonal and Communication Skills
                                                                                                                                        Assessment
Competency                                 Sub-competency                                        Sample Behavior
                                                                                                                                        Method
                                                                                                                                        attending
                                                                                                                                        Checklist
4.2 Demonstrates empathy                   4.2.1 Uses empathic and facilitating verbal           Demonstrates empathic and              Direct
                                           behaviors such as: naming, affirmation,               facilitating verbal behaviors when     observation by
                                           normalization, reflection, silence, listening,        giving bad news                        attending
                                           self-disclosure, and humor in an effective and                                               SP
                                           appropriate manner                                    Demonstrates these behaviors in        Family survey
                                                                                                 response to empathic opportunities     360 Evaluation
                                           4.2.2 Employs empathic and facilitating non-          Same as above                          Direct
                                           verbal behaviors such as: touch, eye contact,                                                observation by
                                           open posture, and eye-level approach in an                                                   attending
                                           effective and appropriate manner                                                             SP
                                                                                                                                        Family survey
                                                                                                                                        360 Evaluation
4.3. Demonstrates ability to effectively   4.3.1 Expresses awareness of own emotional            Can reflect on one’s emotions when     Checklist
recognize and respond to own emotions      state before, during, and after patient and           talking to patient or families in
                                           family encounters                                     discussions

                                           4.3.2 Reflects on own emotions after patient                                                 Checklist
                                           and family encounter or related event
                                           4.3.3 Effectively processes own emotions in           Based on self report feels able to     Direct
                                           clinical setting in order to focus on the needs       tolerate strong patient emotions       observation by
                                           of the patient and family                                                                    attending
                                                                                                                                        SP
                                                                                                                                        Family survey
                                                                                                                                        360 Evaluation
                                           4.3.4 Responds to requests to participate in          Can reflect on his/her ability to      Direct
                                           spiritual or religious activities and rituals, in a   respond genuinely when asked to        observation by
                                           manner that preserves respect for both the            participate in spiritual/religious     attending
                                           patient and family, as well as one’s own              activities.                            SP
                                           integrity and personal and professional                                                      Family survey
                                           boundaries                                            Is felt by a SP to show respect when   360 Evaluation
                                                                                                 asked to participate in
                                                                                                 religious/spiritual rituals
                                           4.3.5 Self-corrects communication miscues                                                    Direct
                                                                                                                                        observation by
  Measurable Outcomes for HPM Competencies                                                                                                  Page 36


Interpersonal and Communication Skills
                                                                                                                                       Assessment
Competency                                    Sub-competency                                    Sample Behavior
                                                                                                                                       Method
                                                                                                                                       attending
                                                                                                                                       SP
                                                                                                                                       Family survey
                                                                                                                                       360 Evaluation
4.4. Demonstrates the ability to educate      4.4.1 Demonstrates self-awareness and             Can identify the differences and       SP
patients/families about the medical, social   ability to recognize differences between the      tensions between one’s own beliefs     360 Evaluation
and psychological issues associated with      clinician’s own and the patient and family’s      and the families regarding what
life-limiting illness                         values, attitudes, assumptions, hopes and         constitutes “good death”
                                              fears related to illness, dying, and grief
                                              4.4.2 Recognizes the importance of serving                                               Checklist
                                              as an educator for patient/family                                                        360 Evaluation
                                              4.4.3 Identifies patients/families’ gaps in       Asks patient/families if they have     SP
                                              knowledge                                         questions                              Family survey
                                                                                                                                       360 Evaluation
                                              4.4.4 Communicates knowledge to                   Avoids jargon in conversations with    SP
                                              patients/families based on the patient/family’s   families/patients                      Family survey
                                              level of understanding                                                                   360 Evaluation
                                              4.4.5 Educates patients/families about life       Asks patients about their desire for   SP
                                              completion tasks such as completion of            life completion tasks                  Family survey
                                              practical affairs and relationships,                                                     360 Evaluation
                                              achievement of a satisfactory sense of life
                                              completion and closure
                                              4.4.6 Recognizes the importance of                Recognizes the importance of           SP
                                              ambivalence when making decisions about he        patient/family ambivalence             Family survey
                                              goals of care and uses appropriate strategies                                            360 Evaluation
                                              to address it                                     Can describe strategies for dealing
                                                                                                with ambivalent families/patient

                                                                                                Can use a strategy for dealing with
                                                                                                ambivalent families/patients

                                              4.4.7 Identifies patients/families who may        Asks appropriately for a translator    SP
                                              benefit from a language translation service or                                           Family survey
                                              interpreter                                       Can describe difficulties associated   360 Evaluation
                                                                                                with using a translator
                                              4.4.8 Educates surrogates about their role as     Prepares legal surrogate to focus on   SP
  Measurable Outcomes for HPM Competencies                                                                                                 Page 37


Interpersonal and Communication Skills
                                                                                                                                       Assessment
Competency                                      Sub-competency                                  Sample Behavior
                                                                                                                                       Method
                                                medical decision-makers                         what patient would want in the given   Family survey
                                                                                                situation and to express those         360 Evaluation
                                                                                                wishes, separate from wishes of any
                                                                                                other person involved
4.5 Uses age, gender, and culturally-           4.5.1 Routinely assesses patients/families to   Ask if there are any religious or      SP
appropriate concepts and language when          identify individuals who might benefit from     spiritual traditions the team should   Family survey
communicating with families and patients        age, gender, and culturally-appropriate         know about when talking to families    360 Evaluation
                                                interventions or support
                                                4.5.2 Shows sensitivity to developmental        Discusses issues at developmental      SP
                                                stages and processes in approaching             level appropriate to the individual,   Family survey
                                                patients/families                               and demonstrates ability to adjust     360 Evaluation
                                                                                                explanation/discussion based on
                                                                                                developmental stage
                                                4.5.3 Appreciates the need to adjust                                                   SP
                                                communication strategies based on cultural                                             Family survey
                                                beliefs                                                                                360 Evaluation
4.6 Demonstrates the above skills in the                                                        Displays comfort and effective         Direct
following paradigmatic situations with                                                          communication skills in routinely      observation by
patients or families and documents an                                                           addressing these situations            attending
informative, sensitive note in the medical                                                                                             Checklist
record:                                                                                         Documents the conversation in the      Chart/record
    A. Giving bad news                                                                          medical record                         review
    B. Discussing transitions in goals of                                                                                              OSCE/SP
        care from a curative and/or life                                                                                               Mini-CEX
        prolonging focus to palliative care                                                                                            Writing
    C. Dealing with family members who                                                                                                 assignment
        want to protect the patient from                                                                                               SP
        distressing information                                                                                                        Family survey
    D. Discussing patient wishes for                                                                                                   360 evaluation
        inappropriate or “futile” care at the
        end of life                                                                                                                    SP
    E. Addressing patient/family emotional                                                                                             Family survey
        distress about talking about death                                                                                             360 Evaluation
        and dying and end-of-life issues                                                                                               Direct
    F. Introducing option of palliative care                                                                                           observation by
        consultation                                                                                                                   attending
  Measurable Outcomes for HPM Competencies                                                                                          Page 38


Interpersonal and Communication Skills
                                                                                                                                Assessment
Competency                                   Sub-competency                              Sample Behavior
                                                                                                                                Method
  G. Discussing goals of care including                                                                                         Checklist
     advance care planning and                                                                                                  Chart /record
     resuscitation status                                                                                                       review
  H. Discussing appropriate care                                                                                                OSCE/SP
     settings                                                                                                                   Mini-CEX
  I. Discussing the end-of-life care                                                                                            Writing
     needs of a dying child with parents                                                                                        assignment
  J. Discussing the needs of minor
     children of dying adults
  K. Withholding or withdrawing of any
     life-sustaining therapy
  L. Continuing life-sustaining therapy
     with focus on palliation
  M. Discussing enrollment into hospice
  N. Dealing with requests for physician
     aid in dying
  O. Discussing palliative sedation
  P. Discussing artificial hydration and
     nutrition
  Q. Discussing severe spiritual or
     existential suffering
  R. Referring to tasks of life review,
     completion of personal affairs,
     including relationships and
     sexuality, and social and spiritual
     aspects of life completion and
     closure
  S. Saying good-bye to patients or
     families
  T. Pronouncing death in presence of
     patient’s family
  U. Writing condolence notes and
     making bereavement calls

4.7. Organizes and leads or co-facilitates   4.7.1 Identifies when a family meeting is   Appropriately initiates arrangements   Direct
a family meeting                             needed                                      for family meetings                    observation by
  Measurable Outcomes for HPM Competencies                                                                                                   Page 39


Interpersonal and Communication Skills
                                                                                                                                         Assessment
Competency                                    Sub-competency                                     Sample Behavior
                                                                                                                                         Method
                                                                                                                                         attending
                                                                                                                                         Mini-CEX
                                                                                                                                         Peer survey
                                                                                                                                         SP
                                                                                                                                         Family survey
                                                                                                                                         360 Evaluation
                                              4.7.2 Identifies appropriate goals for a family    Able to define goals for a given        Direct
                                              meeting                                            family meeting                          observation by
                                                                                                                                         attending
                                                                                                                                         Mini-CEX
                                                                                                                                         Peer survey
                                                                                                                                         SP
                                                                                                                                         Family survey
                                                                                                                                         360 Evaluation
                                              4.7.3 Demonstrates a step-wise approach in         Employs an organized approach in        Mini-CEX
                                              leading a family meeting                           leading a family meeting                OSCE/SP
                                                                                                                                         Peer survey
                                                                                                                                         360 Evaluation
                                                                                                                                         Family survey
                                              4.7.4 Demonstrates techniques for mediating        Employs and identifies specific         Mini-CEX
                                              intra-family or family-health care team conflict   strategies for mediating family-        OSCE/SP
                                                                                                 healthcare professional conflicts       Direct
                                                                                                                                         observation by
                                                                                                                                         attending
                                                                                                                                         360 Evaluation
                                                                                                                                         Family survey
                                              4.7.5 Documents the course and outcome of          Records important process and           Chart/record
                                              a family meeting in the medical record             outcome points from a family meeting    review
                                                                                                 in the medical record                   Peer survey
4.8 Collaborates effectively with others as   4.8.1 Facilitates efficient team meetings          Displays ability to define and follow   Peer survey
member or leader of IDT                                                                          agenda as physician leader to           360 Evaluation
                                                                                                 achieve efficient team meetings         Direct
                                                                                                                                         observation by
                                                                                                 Demonstrates strategy for redirecting   attending
                                                                                                 team meeting when the discussion is
                                                                                                 tangential                              Peer survey
  Measurable Outcomes for HPM Competencies                                                                                               Page 40


Interpersonal and Communication Skills
                                                                                                                                     Assessment
Competency                                  Sub-competency                                   Sample Behavior
                                                                                                                                     Method
                                                                                                                                     360 Evaluation
                                                                                                                                     Direct
                                                                                                                                     observation by
                                                                                                                                     attending
                                            4.8.2 Accepts and solicits insights from         Demonstrates openness to input from     Peer survey
                                            Interdisciplinary Team (IDT) members             IDT members regarding a patient’s       360 Evaluation
                                            regarding patient and family needs in evolving   plan                                    Direct
                                            the patient’s plan of care                                                               observation by
                                                                                             Appropriately requests input from IDT   attending
                                                                                             members regarding patient’s plan of
                                                                                             care
                                                                                                                                     Peer survey
                                                                                                                                     360 Evaluation
                                                                                                                                     Direct
                                                                                                                                     observation by
                                                                                                                                     attending
                                            4.8.3 Manages and recognizes the need for        Identifies and employs effective        Peer survey
                                            conflict resolution in IDT meetings              strategies for conflict resolution in   360 Evaluation
                                                                                             IDT meetings                            Direct
                                                                                                                                     observation by
                                                                                                                                     attending
                                                                                                                                     Writing
                                                                                                                                     assignment
                                            4.8.4 Provides constructive feedback to IDT      Demonstrates an effective strategy      360 Evaluation
                                            members                                          for delivering feedback in IDT          Direct
                                                                                                                                     observation by
                                                                                                                                     attending
                                                                                                                                     360 Evaluation
                                                                                                                                     Direct
                                                                                                                                     observation by
                                                                                                                                     attending
                                            4.8.5 Accepts feedback from IDT members          Responds to feedback from IDT           360 Evaluation
                                                                                             members in a, respectful manner         Direct
                                                                                                                                     observation by
                                                                                                                                     attending
4.9 Develops effective relationships with   4.9.1 Provides a concise verbal history and      Can make a concise patient              Direct
  Measurable Outcomes for HPM Competencies                                                                                                   Page 41


Interpersonal and Communication Skills
                                                                                                                                         Assessment
Competency                                     Sub-competency                                  Sample Behavior
                                                                                                                                         Method
referring physicians, consultant physicians,   physical exam presentation for a new            presentation                              observation by
and other health care providers                palliative care patient                                                                   attending
                                                                                                                                         Peer survey
                                                                                                                                         360 Evaluation
                                                                                                                                         Mini-CEX
                                               4.9.2 Summarizes the active palliative care     Provides an informative summary of        Direct
                                               issues and treatment recommendations for a      active patient issues and                 observation by
                                               known patient in signing out to or updating a   interventions to facilitate transfer of   attending
                                               colleague                                       care                                      Peer survey
                                                                                                                                         360 Evaluation
                                                                                                                                         Mini-CEX
                                               4.9.3 Communicates with referring and                                                     Direct
                                               consultant clinicians about the care                                                      observation by
                                               plan/recommendations for the patient and        Appropriately initiates communication     attending
                                               family                                          with other clinicians about care plans    Peer survey
                                                                                               for a patient and family                  360 Evaluation

                                                                                               Employs effective communication
                                                                                               strategies when discussing care           Direct
                                                                                               plans with other clinicians               observation by
                                                                                                                                         attending
                                                                                                                                         Peer survey
                                                                                                                                         360 Evaluation


                                                                                                                                         Direct
                                                                                                                                         observation by
                                                                                                                                         attending
                                                                                                                                         Peer survey
                                                                                                                                         360 Evaluation
                                               4.9.4 Communicates with health care             Appropriately anticipates                 Direct
                                               providers when there is disagreement about      disagreement about treatment plans        observation by
                                               treatment plans                                                                           attending
                                                                                               Effectively negotiates differences in     Peer survey
                                                                                               opinion regarding treatment plans         360 Evaluation
 Measurable Outcomes for HPM Competencies                                                                                    Page 42


Interpersonal and Communication Skills
                                                                                                                         Assessment
Competency                        Sub-competency                              Sample Behavior
                                                                                                                         Method

                                                                                                                         Direct
                                                                                                                         observation by
                                                                                                                         attending
                                                                                                                         Peer survey
                                                                                                                         360 Evaluation
                                                                                                                         Checklist
                                  4.9.5 Works toward consensus building                                                  Direct
                                  about treatment plans and goals of care                                                observation by
                                                                              Maintains a positive focus on the          attending
                                                                              needs of patient and family when           Peer survey
                                                                              there are disagreements                    360 Evaluation

                                                                                                                         Direct
                                                                                                                         observation by
                                                                                                                         attending
                                                                                                                         Peer survey
                                                                                                                         360 Evaluation
                                  4.9.6 Supports and empowers colleagues to   Encourages relevant physicians and         Direct
                                  lead and participate in family meetings     staff to participate in a family meeting   observation by
                                                                                                                         attending
                                                                              Advocates for pre-meetings with            Peer survey
                                                                              clinician participants prior to family     360 Evaluation
                                                                              meetings when appropriate
                                                                                                                         Direct
                                                                              Demonstrates flexibility in role during    observation by
                                                                              family meetings, including ability to      attending
                                                                              lead or support                            Peer survey
                                                                                                                         360 Evaluation

                                                                              Counsels clinician colleagues in           Direct
                                                                              effective leadership of family             observation by
                                                                              meetings when the opportunity arises       attending
                                                                                                                         Peer survey
                                                                                                                         360 Evaluation
  Measurable Outcomes for HPM Competencies                                                                                                 Page 43


Interpersonal and Communication Skills
                                                                                                                                       Assessment
Competency                              Sub-competency                                    Sample Behavior
                                                                                                                                       Method
                                                                                                                                       Direct
                                                                                                                                       observation by
                                                                                                                                       attending
                                                                                                                                       Peer survey
                                                                                                                                       360 Evaluation
                                        4.9.7 Elicits concerns from and provides          Routinely assesses staff in a given          Direct
                                        emotional support and education to staff          case for needed emotional support            observation by
                                        around difficult decisions and care scenarios     and provides when needed                     attending
                                                                                                                                       Peer survey
                                                                                                                                       360 Evaluation
4.10 Maintains comprehensive, timely,   4.10.1 Documents legible notes in the             Enters legible notes in the medical          Chart/record
and legible medical records             medical record in a timeframe consistent with     record in an appropriate timeframe           review
                                        individual program and institutional                                                           Peer survey
                                        requirements and regulatory agencies                                                           360 Evaluation
                                        4.10.2 Adapts medical record documentation        Communicates relevant medical                Chart/record
                                        in different settings (hospice, hospital, home)   record information in a format or            review
                                                                                          protocol appropriate to each palliative      Peer survey
                                                                                          care setting                                 360 Evaluation
                                        4.10.3 Addresses the major domains of             Attends to all relevant domains of           Chart/record
                                        palliative care, (as per the National             palliative care in the initial history and   review
                                        Consensus Project) as appropriate, in the         physical exam                                Peer survey
                                        initial history and physical exam                                                              Mini-CEX
                                        4.10.4 Consistently includes all relevant         Attends to all relevant domains of           Chart/record
                                        domains of palliative care (as per the National   palliative care in progress notes            review
                                        Consensus Project) in progress notes and                                                       Peer survey
                                        follow-up documentation                                                                        Mini-CEX
                                        4.10.5 Documents death pronouncement in           Completes documentation of death             Chart/record
                                        the medical record and completes death            pronouncement in the medical                 review
                                        certificate in a correct and timely               record, in a timely manner                   Peer survey

                                                                                          Correctly completes death certificate
                                                                                          in a timely manner
                                                                                                                                       Chart/record
                                                                                                                                       review
   Measurable Outcomes for HPM Competencies                                                                                                   Page 44



Professionalism
                                                                                                                                           Assessment
Competency                                     Sub-competency                                   Sample Behavior
                                                                                                                                           Method
5.1 Achieves appropriate balance between       5.1.1 Recognizes the signs of fatigue,           Identifies personal vulnerabilities that   Writing assignment
needs of patients/family/team, while           burnout, and personal distress and makes         may lead to burnout                        MCQ
balancing one’s own need for self-care         adjustments to deal with it                      Describes signs of burnout using
                                                                                                personal examples
                                               5.1.2 Describes effective strategies for self-   The trainee will describe personal         Writing
                                               care, including balance, emotional support,      activities that support a sense of         assignment
                                               and dealing with burn-out and personal loss      personal balance
                                               5.1.3 Contributes to team wellness               Exhibits caring behaviors toward other     360 Evaluation
                                                                                                team members
                                               5.1.4 Explains how to set appropriate            Colleagues will report that the trainee    360 Evaluation
                                               boundaries with colleagues and with patients     demonstrates appropriate attention to
                                               and families                                     professional boundaries
5.2 Recognizes own role and the role of the    5.2.1 Assesses personal behavior and             The trainee receives feedback without      360 Evaluation
system in disclosure and prevention of         accepts responsibility for errors when           defensiveness                              Chart stimulated
medical error                                  appropriate                                                                                 recall
                                                                                                                                           examination
                                                                                                                                           Writing
                                                                                                                                           assignment
                                               5.2.2 Discloses medical errors in accord with                                               360 Evaluation
                                               institutional policies and professional ethics
5.3 Demonstrates accountability to patients,                                                    Trainee shows commitment to own            Attendance log,
society, and the profession; and a                                                              professional growth through reading,       360 Evaluation
commitment to excellence                                                                        attendance at educational programs
                                                                                                and other appropriate activities, and
                                                                                                brings new understandings back to the
                                                                                                team.
5.4 Describes role of hospice medical                                                                                                      MCQ
director in terms of quality of care,
compliance, and communication with other
professionals
5.5 Fulfills professional commitments          5.5.1 Responds in a timely manner to                                                        360 Evaluation
                                               requests from patients and families for
                                               medical information
                                               5.5.2 Responds to requests for help from                                                    360 Evaluation
                                               colleagues
   Measurable Outcomes for HPM Competencies                                                                                   Page 45


Professionalism
                                                                                                                           Assessment
Competency                                        Sub-competency                                         Sample Behavior
                                                                                                                           Method
                                                  5.5.3 Demonstrates accountability for                                    360 Evaluation
                                                  personal actions and plans
                                                  5.5.4 Fulfills professional responsibilities and                         360 Evaluation
                                                  works effectively as a team member
                                                  5.5.5 Addresses concerns about quality of                                360 Evaluation
                                                  care and impaired performance among
                                                  colleagues
                                                  5.5.6 Treats co-workers with respect, dignity,                           360 Evaluation
                                                  and compassion
5.6 Demonstrates knowledge of ethics and                                                                                   360 Evaluation
law that should guide care of patients,                                                                                    MCQ
including special considerations around
these issues in pediatric, adult, and geriatric
palliative care, including:
 Foregoing life-sustaining treatment
 Confidentiality
 Truth-telling
 Decision-making for children and
  adolescents, and older patients with
  dementia
 Limits of surrogate decision-making
 Decision-making capacity
 Conflicts of interest
 Use of artificial hydration and nutrition
 Requests for aid in dying
 Research ethics
 Nurse-physician collaboration
 Principle of double effect
Organ donation
5.7 Demonstrates respect and compassion           5.7.1 Demonstrates willingness and ability to                            360 Evaluation
towards all patients and their families, as       identify own assumptions, individual and                                 Patient/Family
well as towards other clinicians                  cultural values, hopes and fears related to                              survey
                                                  life-limiting illness and injury, disability, dying,
                                                  death and grief
                                                  5.7.2 Displays sensitivity to issues                                     Patient/Family
   Measurable Outcomes for HPM Competencies                                                                              Page 46


Professionalism
                                                                                                                      Assessment
Competency                                     Sub-competency                                       Sample Behavior
                                                                                                                      Method
                                               surrounding age, ethnicity, sexual orientation,                        surveys
                                               culture, spirituality and religion, and disability
                                               5.7.3 Effectively communicates the mission                             360 Evaluation
                                               of palliative care to hospital administrators,
                                               clinicians, and community at large
5.8 Demonstrates the capacity to reflect on                                                                           Writing
personal attitudes, values, strengths,                                                                                assignment
vulnerabilities, and personal experiences to
optimize personal wellness and capacity to
meet the needs of patients and families.
    Measurable Outcomes for HPM Competencies                                                                                                  Page 47




Systems-Based Practice
                                                                                                                                          Assessment
Competency                                     Sub-competency                                  Sample Behavior
                                                                                                                                          Method
6.1 Demonstrates care that is cost-effective   6.1.1 Recognizes relative costs of              Arranges common medications in             MCQ
and represents best practices                  medications and other                           order of relative cost
                                               therapeutics/interventions
                                               6.1.2 Implements best evidence based            Demonstrates ability to develop plan       Chart/record
                                               practices for common palliative medicine        of care consistent with evidence base      review
                                               clinical scenarios across settings
                                                                                                                                          Direct observation
                                                                                                                                          by attending
                                               6.1.3 Explains the rationale for the use of     Differentiates between meds on             MCQ
                                               medication formularies                          formulary and not, explains reason         Standardized oral
                                                                                               why choices were made                      exam
                                               6.1.4 Identifies similarities and differences   Defines reimbursement practices for        MCQ
                                               between reimbursements for palliative           various settings where palliative
                                               medicine, hospice, hospital, home health,       medicine is practiced
                                               and long term care
                                                                                               Explains reimbursement principles to
                                                                                               patients and their families                Direct observation
                                                                                                                                          by attending
                                                                                                                                          Family survey
                                               6.1.5 Describes basic concepts and patterns     Outlines key differences between           MCQ
                                               of physician billing, coding and                physician billing practices in different   Standardized oral
                                               reimbursement across settings                   settings of care                           exam
6.2 Evaluates and implements systems           6.2.1 Reviews pertinent clinical or             Systematically evaluates current           PIM
improvement based on clinical practice or      patient/family satisfaction data about          practice and designs ways to improve       Chart/record
patient and family satisfaction data, in       personal, team, or institutional practice       weaknesses within practice                 review
personal practice, team practice, and within   patterns.
institutional settings
6.3 Integrates knowledge of health care        6.3.1 Describes policies and procedures of      Lists elements of care at commonly         MCE
system in developing plan of care              pertinent health care systems                   encountered systems of care within
                                                                                               institutional environment
                                               6.3.2 Describes philosophy, admissions          Summarizes possibilities of care and       Standardized pral
                                               criteria, range of services, and structure of   strengths/weaknesses of commonly           exam
                                               hospice care                                    encountered systems of care within
                                                                                               institutional environment
    Measurable Outcomes for HPM Competencies                                                                                                    Page 48


Systems-Based Practice
                                                                                                                                            Assessment
Competency                                       Sub-competency                                     Sample Behavior
                                                                                                                                            Method

                                                                                                    Correctly describes basics of hospice
                                                                                                    as option for care                      Direct observation
                                                                                                                                            by attending
                                                                                                                                            Checklist
                                                 6.3.3 Recognizes resources and barriers            Explains barriers to care for certain   Global rating
                                                 relevant to the care of specialized                populations and demonstrates ability    scale
                                                 populations in hospice and palliative              to provide resources/support            Checklist
                                                 medicine, and has basic knowledge of how to
                                                 mobilize appropriate support for these
                                                 populations (e.g. pediatric patients, HIV
                                                 patients, etc.)
6.4 Demonstrates knowledge of the various        6.4.1 Describes differences in admission           Distinguishes between services          Global rating
settings and related structures for              criteria for various settings such as hospitals,   provided at each locus of care and      scale
organizing, regulating, and financing care for   palliative care units, skilled-nursing and         determines which site of care is most   Checklist
patients at the end of life                      assisted-living facilities, acute/sub-acute        applicable for each patient
                                                 rehab facilities, and long-term acute care                                                 Chart record
                                                 settings as well as traditional home hospice                                               review
6.5 Collaborates effectively with all elements   6.5.1 Effectively utilizes members of                                                      360 Evaluation
of the palliative care continuum, including      interdisciplinary team to create smooth and
hospitals, palliative care units, nursing        efficient transitions across health care                                                   Chart/record
homes, home and inpatient hospice, and           settings for patients and families                                                         review
other community resources
                                                 6.5.2 Communicates with care                       Demonstrates ability to work in         Peer survey
                                                 managers/appropriate staff across sites to         interdisciplinary team to create        Consultant survey
                                                 enable seamless transitions between settings       effective care plans and optimize
                                                                                                    transitions between settings            360 Evaluation
                                                 6.5.3 Communicates with clinicians at time of      Communicates with clinicians at other   Peer survey
                                                 care transitions to clarify and coordinate care    settings at time of transition to       Consultant survey
                                                 plan across settings                               preserve medical plan
6.6 Advocates for quality patient and family     6.6.1 Communicates and supports patient            Arranges family meetings relating to    Patient/family
care and assists patients and families in        and family decision-making about discharge         discharge and runs them effectively     surveys
dealing with system complexities                 planning – including settings of care, service     and smoothly
                                                 options, and reimbursement/payer systems                                                   Direct observation
                                                                                                                                            by attending
    Measurable Outcomes for HPM Competencies                                                                                                    Page 49


Systems-Based Practice
                                                                                                                                            Assessment
Competency                                     Sub-competency                                   Sample Behavior
                                                                                                                                            Method
                                               6.6.2 Coordinates and facilitates dialogue       Demonstrates ability to determine           Patient/family
                                               between patients/families and service            which services are appropriate and          surveys
                                               provider representatives (e.g. hospice liaison   then facilitates (and participates in, as
                                               nurses, nursing home administrators; and         appropriate) meetings with family and       360 Evaluation
                                               inter-hospital departments including but not     representatives of service provider.
                                               limited to ICU, intermediate care, emergency
                                               department)
6.7 Partners with health care managers and     6.7.1 Describes hospital and palliative care     Discusses local or national quality         Direct observation
health care providers to assess, coordinate,   program continuous quality improvement           improvement projects and suggests           by attending
and improve patient safety and health care,    programs and their goals and processes           ways that care can continue to be           MCQ
and understands how these activities can                                                        improved                                    Standardized oral
affect system performance                                                                                                                   exam


                                               6.7.2 Demonstrates ability to work with          Identifies problems with system             360 Evaluation
                                               managers of varying disciplines to improve       factors that affect patient safety and
                                               patient safety and system-based factors that     need improvement.                           Direct observation
                                               affect care delivery                                                                         by attending

								
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