Table 1
Implementation Matrix for Equity with Van Melle et al.’s 2019 Core Components of CBE.
| LEVEL/CORE COMPONENT | 1. OUTCOMES & COMPETENCIES DEFINED | 2. SEQUENCED PROGRESSION OF COMPETENCE | 3. TAILORED LEARNING EXPERIENCES | 4. COMPETENCY-FOCUSED INSTRUCTION & ASSESSMENT | 5. PROGRAMMATIC ASSESSMENT APPROACH |
|---|---|---|---|---|---|
| MACRO (Global, regional, institutional) | National and institutional policy [68] & standards [69]: embedding equity explicitly into accreditation and regulatory frameworks; integrating equity criteria; patient/care partner/community representation and co-creation https://canmedsproject.ca/en/consultations. CBHPE standards and frameworks: co-creation with diverse voices [65]; avoiding assumptions based on contexts, including geography and resource level; collaboratively building contextualized frameworks. | Context-specific (e.g., size of program, level of resources, discipline) recommendations or best practices: for the sequencing of progression Funding & access to opportunities: removing SES-related structural barriers; scholarships, bursaries, and loans for financially unstable learners to provide equitable opportunities during training (core and elective); Pathway programs for individuals with one or more structurally excluded identities starting as early as 4 years old [70, 71, 72]. We argue that these pathway programs bring needed diversity into the health learner and workforce and potentially set them up for success even before they start, and facilitate smooth progression | Program structure: training opportunities aligned with social accountability mandates; training sites serving structurally excluded communities (including and not limited to patients/care partners from or experiencing rural/remote regions, immigration, refugeeism, long-term care, unhoused, or justice-involved) aka service learning with direct engagement with community and reciprocal partnerships [73, 74]. | Context-specific (e.g., size of program, level of resources, discipline) recommendations or best practices for equity-informed instruction and assessment [72], which are then adapted to the local environment. Curricular requirements: National program accreditation bodies ensure representation and equity standards as part of their common program requirements and program accreditation standards when reviewing program curricula and evaluation elements | Accreditation of programs: accrediting bodies provide guidelines for equity audits of assessment systems within programs and ensure national accreditation standards. These standards, ranging from certification eligibility to program accreditation, include co-produced elements focused on equity in determining program accreditation and learner progression to unsupervised practice. |
| MESO (Program/educational institution) | Curricular design: integrating equity across competencies and EPAs [75]; structurally excluded identities as one of many dimensions for case complexity; aligning patient cases with the population served [76]. | Admissions: fair access; pathway programs (see above); addressing structural, historic, and current-day barriers. | Institutional support (cross-cutting): the well-being of learners, faculty, and staff; implementation of the Ottawa, Edmonton, Okanagan, and Limerick Charters (https://www.healthpromotingcampuses.org/charters) (well-being, social justice, and planetary health) for health-promoting campuses [77]; inclusive orientation and onboarding [78]. | Faculty development: mitigating bias in teaching and assessment [72, 79, 80]. Assessment practices: equity-informed assessment [72]; coaching mindset; meaningful feedback; development of professional relationships to foster trust and psychological safety in the learning and work environment; structured improvement opportunities; multisource feedback; coaches outside the assessor pool; forward feeding within the CQI culture. | Program evaluation: equity-informed continuous quality improvement (CQI); multisource data; evaluating representativeness of clinical cases/experiences to communities served; mitigating bias at individual, team, and program/institutional levels (through education, ongoing dialogue, equity-informed policy review and creation, etc.) Institutional governance: shared decision-making; learner or patient/care partner/community representation in competence and other curriculum committees. |
| MICRO (Classroom, clinical, interpersonal) | Coproduction: Outcome competencies are co-created with a diverse representation of learners, faculty, and staff to reflect the local context. | Individualized learning: Learners progress at their own rate, with clear evidence that standards are applied equitably and that there are no differences between groups (broadly defined) in rate of progression, which is audited regularly. | Clinical learning: clinical experiences/rotations in underserved communities; genuine reciprocity with community partners; exposure to diverse contexts reflective of communities served [73, 75]. | Teacher–learner interaction [72]: inclusive pedagogy; relationship-building, acknowledging lived experience; individualized accommodations. Learning environment: safe, welcoming spaces; addressing microaggressions (racism, gender, disability, neurodiversity, just to name a few) [72]: equity-informed reporting mechanisms; restorative justice approaches to navigating conflict and reporting processes [81, 82]. | Individual assessment: recognizing diverse ways of demonstrating competence; context-aware WBAs [72, 83]. Mentoring & support: mentorship and peer support for underrepresented learners and faculty; tailored support based on individual needs [75, 84]. |