Figure 1
Process for Developing the Competency-Based Health Professions Education (CBHPE) Outcomes Theory of Change.
This figure outlines the process for developing the CBHPE Outcomes Theory of Change. First, evidence was gathered through literature searches, and a small group drafted the Theory of Change. Then, the large group edited and deliberated drafts, alongside ICBHPE member-checking. After these iterative cycles were completed and consensus achieved, the CBHPE Outcomes Theory of Change was finalized.
Table 1
Definitions of the Elements of the Program Theory Used in the CBHPE Outcomes Theory of Change.
| ELEMENT OF PROGRAM THEORY | DEFINITION |
|---|---|
| Core Component [3] | Five foundational building blocks of contemporary Competency-Based Education (CBHPE), as described by Van Melle [3] which serves as the anchor for design and implementation (e.g., sequenced progression, programmatic assessment). |
| Implementation Strategies [3, 22, 25, 33, 45, 49, 50, 57, 58, 59, 60] | Specific actions, interventions, or structural changes that transform the curriculum using the core components (e.g., coaching systems, milestone mapping, feedback mechanisms) |
| Drivers of Change [4, 5, 61] | The underlying educational, organizational, or societal problems that the implementation strategy is trying to resolve (e.g., time-based progression, variability in learner readiness, inequitable assessment practices). |
| Theory of Change [45, 46, 52] (Assumptions & Mechanisms) | The rationale and assumptions about how and why these activities will lead to desired outcomes (e.g., deliberate practice improves skill acquisition; personalized feedback enhances motivation). This includes:
|
| Theoretical & Conceptual Foundations [62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80] | The underlying learning science theories, conceptual frameworks, and implementation models that explain or support how the core component is intended to function in practice. These include both learner-centered theories (e.g., motivation, cognition, development) and systems-level implementation frameworks that support coherence, sustainability, and change (e.g., implementation science frameworks, change management models). |
| Key Stakeholder Actions/Behavior Changes [81, 82] | Observable changes in behaviors, roles, or responsibilities of involved stakeholders (learners, faculty, administrators, clinical educators) necessary to sustain implementation (e.g., learners seeking feedback, faculty acting as coaches). |
| Implementation Outputs (Early Signals) [3, 15, 26, 27, 33, 45, 49, 50, 52, 53, 57, 69, 83] | Implementation outputs are early, observable products and signals of CBHPE implementation quality and progress. They reflect whether core components, structures, processes, and supports have been put in place and are functioning as intended, including stakeholder engagement and behavior enactment. Outputs indicate implementation fidelity and readiness for impact, and are operationalized using indicators/metrics, specific, measurable variables used to assess these early signals (e.g., adoption, fidelity, feasibility, uptake, participation). Implementation outputs are distinct from outcomes and do not represent educational, practice, or societal change. |
| Outcomes Over Time (Proximal, Intermediate, Distal) [3, 15, 26, 27, 33, 45, 49, 50, 52, 53, 57, 69, 83] | Outcomes are changes attributable to CBHPE implementation that emerge beyond early implementation signals. Outcomes are staged as proximal, intermediate, and distal/impact and align with the Hall timeline (in training → transition to practice → in practice).
|
| Barriers/Enablers [49, 50, 51, 57, 84, 85, 86, 87, 88, 89, 90, 91] | Factors that obstruct or facilitate change, often at the individual, cultural, or system level (e.g., resistance to change, faculty development resources, policy incentives). |
| Equity Considerations [31, 92, 93] | Attention to how CBE structures may promote or hinder inclusion, equity, and access for diverse learners and populations (e.g., addressing bias in assessment, ensuring fair advancement opportunities). |
| Indicators/Metrics [49, 50, 85] | Specific, measurable variables that can be applied across the full engine, including contextual modifiers, stakeholder behaviors, implementation inputs/outputs, and outcome tiers, using defined indicators/metrics (specific, measurable variables) to quantify implementation quality, mechanisms, and impacts across educational, professional, and societal levels |
Figure 2
Competency-Based Health Professions Education (CBHPE) Outcomes Engine and the Theory of Change.
This figure presents the CBHPE Outcomes Engine, a theory-driven model describing how competency-based health professions education (CBHPE) translates a need for change (societal, educational, and organizational) into measurable implementation signals and outcomes over time. The model emphasizes that outcomes are not assumed; they emerge when stakeholder behaviors activate the mechanisms specified in the theory of change within a given implementation context.
At the center, the theory of change represents the key assumptions and causal mechanisms linking behavior change to outcomes. The theory of change is positioned centrally to indicate that aligned behaviors, enacted by direct stakeholders, provide a framework of how the five core components of CBHPE (outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment) produce outcomes. However, these outcomes must be cultivated through rigorous planning, implementation, and examination of outcomes. Direct stakeholders (e.g., learners, faculty, administrators, and clinical educators/workplace educators) are those whose actions and behaviors are intentionally targeted by, and integrated into, CBHPE design and implementation, and who constitute the primary levers through which CBHPE functions.
Contextual modifiers surrounding the core components represent system conditions that shape whether and how effectively CBHPE mechanisms are activated and sustained. These include enablers and barriers, equity considerations, and implementation/quality improvement strategies. Contextual modifiers influence stakeholder behaviors (e.g., feasibility, engagement, decision processes) and moderate the strength and consistency of implementation, thereby shaping the interpretability of outcomes.
To the right, implementation outputs (early signals) reflect immediate, observable indicators that CBHPE has been initiated and is being delivered with sufficient quality to make downstream outcomes interpretable. In this model, early signals include: adoption, fidelity, feasibility, penetration, reach, acceptability, appropriateness, and sustainability [53].
These implementation outputs are operationalized using indicators/metrics, specific, measurable variables used to quantify early signals (e.g., evaluation completion rates, observation counts, inter-rater calibration results, time-to-feedback, coverage across sites, resource utilization). These outputs are distinct from outcomes over time, which represent effects that emerge as CBHPE matures. Outcomes are staged over time as proximal (in training), intermediate (transition to practice), and distal/impact (in practice) outcomes, aligning the outcome tiers with the Hall taxonomy timeline (training → transition to practice → practice). This sequencing aligns with CBME outcomes literature in which early implementation outputs establish interpretability and precede longer-term outcomes [3, 33, 45, 52].
The stakeholder band distinguishes between direct and indirect stakeholders. Indirect stakeholders (e.g., interprofessional teams and patients/public [54]) are influenced by and may influence CBHPE through system-level interactions and downstream effects, but their behaviors are not necessarily the primary targets specified in the CBHPE intervention. Together, the model provides a coherent framework for understanding how behavior-driven implementation of CBHPE, shaped by contextual modifiers, generates early implementation signals and progressively meaningful outcomes across educational, professional, and societal levels.
Finally, the Indicators/Metrics band denotes that measurement can be applied across the full engine, including contextual modifiers, stakeholder behaviors, implementation outputs, and outcome tiers, using defined indicators/metrics (specific, measurable variables) to quantify implementation quality, mechanisms, and impacts across educational, professional, and societal levels.
