Major healthcare reform, including limits on work hours for health professionals and the involvement of multiple individuals, teams and settings have made handovers a common and frequent aspect of patient care. Research has shown that errors commonly occur during handovers, and can result in patient harm.1 ,2 As a result, healthcare systems, at the behest of regulatory agencies, must now ensure that handover processes are safe and reliable. Similarly, medical education programmes and credentialing bodies are required to monitor clinician competence with respect to handovers.

Developing valid measures of clinician competence is a major challenge. The handover requires the application and integration of clinical and communication skills, and an understanding of the systems of care, which must come together in one, time-limited and highly constrained activity.3 ,4 Acquiring the ability to perform this activity well is, because of its complexity, not a simple linear process and requires years to perfect. A trainee cannot be asked to study it from a book, or practice in a course, with the expectation of a satisfactory score on a skills assessment. The quality of handing over patient information and responsibility is highly provider and context-dependent and case-specific. Because many doctors do it on a daily basis, it must be learned in training and the competence to do this should be assessed. Well trained physicians should be trusted to provide adequate information in handovers, and recipient doctors and other healthcare professionals must understand, accept and appropriately apply this information to guarantee optimal care.

Policy makers and educators have called for added training of healthcare professionals to improve their skills and competence for conducting handovers. The European HANDOVER Project encompassed several initiatives to improve the education and training of healthcare professionals in this important area of patient safety and continuity of care.5–7 While the need for added training in handovers is gaining wider acceptance, assessment of the effects of education on the ability to provide safe and effective handovers has lagged behind. Regular in-training assessment methods in medical education do not focus on circumscribed activities as units of evaluation. Rather, competency-frameworks, such as the Canadian CanMEDS model or the US ACGME model focus on the myriad component skills, knowledge and attitudes necessary to perform the duties of a physician, with assessment of knowledge still being the most common method. Yet the core clinical activities of a physician are holistic in nature, that is, represent the simultaneous application and integration of many competencies, in a dynamic and fluid context. As a framework for assessment, it is questionable whether the deconstructed approach of assessing separate competencies can justify decisions to entrust a trainee, or for that matter, any clinician with the responsibility to carry out clinical activities.8

To link competency-frameworks to actual practice for the purpose of training and assessment, the concept of ‘Entrustable Professional Activities’ (EPAs) was designed.9 ,10 EPAs are units of professional practice, defined as tasks or responsibilities to be entrusted to a trainee once sufficient specific competence is reached to allow for unsupervised practice. EPAs are independently executable within a time frame and observable and measurable in their process and outcome, and, therefore, suitable for entrustment decisions. Typically, EPAs can be scheduled and allocated to individuals. It is also clear that entrustment decisions are highly contextual and vary, among other attributes, by time of day, adjacent personnel, geographic location of the supervisor relative to the trainee, and other team and systems factors.11 As a sign of progressive independence of the trainee, the level of mastery of an EPA is reflected by five stages of decreasing supervision10 ,12: (1) no task execution, (2) task execution under direct supervision on site, (3) task execution with supervision quickly available on call, (4) unsupervised practice and (5) supervision may be provided to juniors. Level 4 reflects formal entrustment. ‘Unsupervised’ does not exclude supervision at a distance, which must be present throughout residency, but checking can be done post hoc or virtually.13 The ultimate aim of the application of EPAs is not to result in ‘independent practice’ in any literal sense, as healthcare is becoming increasingly interdependent, and collaboration is the standard rather that the exception. Rather ‘independent practice’ refers to when clinicians have demonstrated the ability and judgment to take full, proactive responsibility for their role, based on a genuine professional contribution to the healthcare team, and therefore no longer require supervision by a teacher or proctor to certify the quality or safety of their work.

The full description of an EPA can be structured in eight paragraphs with an intended length of not more than two pages. In this contribution we have attempted to provide a full description of the patient handover as an EPA. As EPAs primarily have an educational purpose, that is to facilitate competency-based medical education, the physician is called ‘trainee’. However, this framework is equally relevant to any kind of process of certification or credentialing and could also be applied to non-physician handover training.⇓