Entrustable Professional Activities

EPA 7: Management of cardiac conditions from fetal to adolescence, including end-of-life care

EPA 7

Management of cardiac conditions from fetal to adolescence, including end-of-life care

Manage and coordinate the longitudinal care of patients with complex cardiac conditions, including end-of-life

This activity requires the ability to:

  • develop management plans in consultation with patients, their families or carers
  • facilitate patients’, families’ or carers’ self-management and self-monitoring
  • demonstrate problem-solving skills to manage chronic conditions, complications, disabilities, and comorbidities
  • liaise with other health professionals and team members to ensure continuity of care
  • engage with the broader health policy context, and responsibly use public resources
  • manage end-of-life care plans

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify and address current clinical concerns as well as longer-term clinical objectives, as appropriate to patients’ context
  • contribute to managing the care of patients from fetal through to adolescence
  • create accurate and appropriately prioritised problem lists in clinical notes, or as part of ambulatory care reviews
  • provide documentation on patients' presentations, management and progress, including key points of diagnosis and decision making
  • ensure that patients, families or carers contribute to their need assessments and care planning
  • monitor treatment outcomes, effectiveness, and adverse events
  • review goals of care and treatment plans with patients, family or carers if significant changes in patients’ conditions or circumstances occur
  • recognise and manage the terminal phase in a timely way

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • assess patients’ knowledge, beliefs, concerns, and daily behaviours related to their chronic condition/disability and its management
  • contribute to medical record entries on histories, examinations, and management plans in an accurate and sufficient manner as a member of multidisciplinary teams

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • encourage patients’ access to self-monitoring devices and assistive technologies
  • communicate with multidisciplinary team members, and involve patients in that dialogue
  • help patients navigate the healthcare system by collaborating with other services, such as community health centres and consumer organisations, to improve access to care
  • link patients to specific community-based health programs and group education programs
  • identify opportunities to discuss end-of-life care, aligning it with patients’, families’ and carers’ values and preferences
  • identify appropriate timing of palliative care involvement

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • work in partnership with patients, and motivate them to comply with agreed care plans
  • wherever practical, meet patients’ specific language and communication needs
  • facilitate appropriate use of interpreter services and translated materials
  • discuss appropriate support and bereavement care with family or carers

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • maintain up-to-date certification using innovative models of chronic disease care (e.g. telehealth and digitally integrated support services)
  • participate in quality improvement processes impacting on patients’ ability to undertake normal activities of daily living
  • practice health care that maximises patient safety
  • adopt a systematic approach to the review and improvement of professional practice in the outpatient clinic setting
  • identify aspects of service provision that may be a risk to patients’ safety
  • ensure patients are informed about fees and charges
  • review all deaths to determine the safety and quality of patients’ end-of-life care and how it could be improved

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • participate in continuous quality improvement processes and clinical audits on chronic disease management
  • identify activities that may improve patients’ quality of life
  • address issues if patients’ safety may be compromised
  • employ a systematic approach to improving the quality and safety of health care
  • participate in organisational quality and safety activities, including clinical incident reviews
  • collect and review data on the safety and effectiveness of end-of-life care delivery

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • contribute to the development of clinical pathways for chronic diseases management based on current clinical guidelines
  • educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
  • evaluate own professional practice
  • demonstrate learning behaviour and skills in educating junior colleagues
  • contribute to the generation of knowledge
  • maintain professional continuing education standards relevant to the profession
  • recognise feelings of moral distress and burnout in self and colleagues

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use clinical practice guidelines for chronic diseases management
  • recognise the limits of personal expertise, and involve other professionals as needed to contribute to patients’ care
  • use information technology appropriately as a resource for modern medical practice
  • encourage junior colleagues to participate in multidisciplinary case reviews, mortality and morbidity meetings and adverse event reviews

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • prepare reviews of literature on patients’ encounters to present at journal club meetings
  • search for and critically appraise the evidence to resolve clinical areas of uncertainty
  • obtain informed consent or other valid authority before involving patients in research
  • inform patients about their rights, the purpose of the research, the procedures to be undergone, and the potential risks and benefits of participation before obtaining consent

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • search literature using Problem/ Intervention/Comparison/ Outcome (PICO) format
  • recognise appropriate use of review articles
  • refer to evidence-based clinical guidelines
  • consult current research on investigations

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • apply knowledge of the cultural needs of the community serving and how to shape service to those people
  • mitigate the influence of own culture and beliefs on interactions with patients and decision making
  • adapt practice to improve patient engagement and healthcare outcomes

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • provide culturally safe chronic disease management
  • acknowledge the social, economic, cultural, and behavioural factors influencing health, both at individual and population levels

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • share information about patients’ health care, consistent with privacy laws and professional guidelines about confidentiality
  • use consent processes for the release and exchange of health information
  • identify and respect the boundaries that define professional and therapeutic relationships
  • respect the roles and expertise of other health professionals
  • comply with the legal requirements of preparing and managing documentation
  • demonstrate awareness of financial and other conflicts of interest
  • recognise the complexity of ethical issues related to human life and death, when considering the allocation of scarce resources

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • share information between relevant service providers
  • acknowledge and respect the contribution of health professionals involved in patients’ care
  • understand the responsibility to protect and advance the health and wellbeing of individuals and communities
  • maintain the confidentiality of documentation, and store clinical notes appropriately
  • ensure that the use of social media is consistent with ethical and legal obligations
  • respond appropriately to patients’, family, carers’ or colleagues’ distress or concerns

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • implement stepped care pathways in the management of chronic diseases and disabilities
  • recognise patients’ needs in terms of both internal resources and external support on a long-term care journey
  • integrate prevention, early detection, health maintenance, and chronic condition management, where relevant, into clinical practice
  • work to achieve optimal and cost effective patient care that allows maximum benefit from available resources

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise personal limitations, and seek help in an appropriate way when required
  • understand the appropriate use of human resources, diagnostic interventions, therapeutic modalities, and health care facilities

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use a multidisciplinary approach across services to manage patients with chronic diseases and disabilities
  • develop collaborative relationships with patients, families or carers, and a range of health professionals
  • coordinate whole-person care through involvement in all stages of the patients’ care journey
  • prepare for and conduct clinical encounters in an organised and efficient manner
  • work effectively as a member of multidisciplinary teams or other professional groups
  • ensure all important discussions with colleagues, multidisciplinary team members, and patients are appropriately documented
  • review discharge summaries, notes, and other communications written by junior colleagues
  • support colleagues who raise concerns about patient safety

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • participate in multidisciplinary team care for patients with chronic diseases and disabilities, including organisational and community care, on a continuing basis appropriate to patient context
  • attend relevant clinical meetings regularly

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • assess alternative models of health care delivery to patients with chronic diseases and disabilities
  • participate in initiatives for chronic diseases management to reduce hospital admissions and improve patients’ quality of life
  • help patients access initiatives and services for patients with chronic diseases and disabilities
  • demonstrate capacity to engage in the surveillance and monitoring of the health status of populations in the outpatient setting
  • maintain good relationships with health agencies and services
  • apply the principles of efficient and equitable allocation of resources to meet individual, community, and national health needs
  • consider location and urgency of care/treatment to ensure it is provided as close as possible to home, and that travel to and within the networked services only occurs when essential, ensuring timely care access and the best possible outcomes

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate awareness of initiatives and services available for patients with chronic diseases and disabilities, and knowledge of how to access them
  • identify common population health screening and prevention approaches