Implementing entrustable professional activities: Practical lessons and legal considerations from an international interview study

PURPOSE: Entrustable professional activities (EPAs) provide a framework for supervising and assessing readiness for independent practice in postgraduate medical education. Their implementation has raised concerns about legal liability. This study explored practical and legal implications of EPA implementation across international contexts.

METHODS: Fifteen participants from various specialties and 12 countries across six continents, all involved in EPA implementation, participated in qualitative semi-structured interviews. Interviews focused on accountability, competence assessment, and legal considerations. Thematic analysis was conducted.

RESULTS: Five themes were identified: (1) Shifting accountability: EPAs shift accountability to trainees as competence increases, though supervision remains essential; (2) Sharing responsibilities: EPAs support role clarity and shared responsibility, with autonomy varying by setting; (3) Ascertaining competence: EPAs offer a transparent framework for competence assessment; (4) (Mis-)conceptions of legal consequences: legal concerns were largely unfounded as supervisors were still viewed as legally accountable; and (5) Context matters: implementation is shaped by institutional, regulatory, and cultural contexts, requiring local adaptation.

CONCLUSIONS: Participants perceived EPAs as strengthening educational accountability and competence assessment without altering legal responsibilities. Successful implementation depends on alignment with local context, emphasizing their role as flexible educational tools rather than legal instruments. Continued research should examine their long-term legal and institutional impact in postgraduate training.