The study, published in Global Surgical Education, the Journal of the Association for Surgical Education, examined a program struggling with low adoption of the System for Improving and Measuring Procedural Learning, known as SIMPL. The smartphone-based platform was designed to let faculty deliver rapid, structured workplace-based assessments of residents using entrustable professional activities, or EPAs, which describe the discrete tasks a surgeon must be able to perform without supervision. The American Board of Surgery now requires EPA-based assessment for general surgery residency, typically delivered through SIMPL, but programs nationwide have reported inconsistent engagement that undermines the reliability of the resulting data.

Researchers at Sidney Kimmel Medical College at Thomas Jefferson University and Jefferson Einstein Philadelphia Hospital, led by Jandie Posner and Ramsey M. Dallal, approached the problem not as an education question but as an organizational change problem. They turned to ADKAR, a change-management model developed by Jeff Hiatt that breaks successful change into five sequential elements: awareness of the need for change, desire to participate, knowledge of how to change, ability to implement new skills, and reinforcement to sustain the change. Rather than simply asking faculty and residents to use the platform more, the team first diagnosed why they had stopped.

The diagnostic phase took the form of a faculty survey completed by 66 surgeons, whose responses were mapped onto the five ADKAR domains to identify where the implementation was failing. The findings informed a multicomponent intervention delivered between August and December 2024. It included re-education sessions for both faculty and residents on the purpose and mechanics of EPA assessments, a monthly leaderboard that gamified participation by ranking assessment activity, and formal recognition of high performers. The bundle was designed to act on multiple ADKAR domains simultaneously, raising awareness of the national mandate, cultivating desire through competition and recognition, restoring knowledge through refresher training, and building reinforcement into the program’s monthly rhythm.

To measure the effect, the investigators compared matched calendar quarters before and after the intervention: January through March 2024 served as the baseline, and January through March 2025 as the post-intervention period. The analysis included 48 resident-periods representing 31 unique residents, with 24 residents in each period. Because assessment counts are skewed count data, the team used count-data regression adjusted for postgraduate year and resident type, a statistical approach that accounts for the fact that senior residents and categorical residents might naturally accumulate more assessments than junior or preliminary residents. The model also accounted for residents who were present in both periods, allowing a within-person comparison.

The results were striking. Total EPA assessments rose from 36 to 100 across the two periods. Adjusted for training level and resident type, residents completed approximately 2.6 times as many assessments after the intervention, with an incidence-rate ratio of 2.58 and a 95 percent confidence interval of 1.17 to 5.73, reaching statistical significance at p equals 0.019. The confidence interval spans a range from a modest to a large effect, a nuance the authors acknowledged rather than smoothed over. Resident participation rates doubled, climbing from 37.5 percent to 75 percent, also statistically significant. Assessment activity expanded across all phases of surgical care, indicating that the gains were not confined to a single rotation or service line.

The statistical model revealed an additional pattern: activity varied significantly by training level, peaking among mid-level residents, but did not differ between categorical and preliminary residents. This distributional detail matters for program directors, because it suggests that mid-level trainees, who are often entrusted with greater operative autonomy, may be the natural center of gravity for workplace-based assessment, while interventions may need tailoring to activate junior and senior cohorts differently.

The authors were notably candid about the limits of their success. Decomposing the increase, they estimated that roughly 40 percent of the program-level gain reflected resident cohort turnover rather than behavior change among existing faculty and residents, as new interns arrived in a climate of heightened engagement. When the analysis isolated residents present in both periods, the within-resident change was not statistically significant, and a concurrent national trend toward increased EPA use may have contributed to the observed rise. The study was a single-center before-after design reported according to SQUIRE 2.0 quality-improvement standards, without a concurrent control group, so these uncontrolled results warrant caution. The team also emphasized that the study measured only EPA utilization, not the quality of feedback, resident learning, or actual competency outcomes, leaving open the question of whether more assessments translate into better surgeons.

Those caveats, however, do not erase the study’s practical value. The authors frame the intervention as a reproducible bundle: diagnose barriers systematically, map them to a recognized change framework, deliver targeted re-education, and embed reinforcement through gamification and recognition. The gamification element builds on a growing literature showing that leaderboards and competition can increase engagement in health professions education, while the ADKAR mapping gives other programs a vocabulary for figuring out which stage of change their own implementation is stuck at. A program whose faculty are unaware of the EPA mandate needs a different fix than one whose faculty know the mandate but lack the desire to comply, and the ADKAR lens makes that distinction actionable.

The work also extends a lineage of re-implementation studies. A prior BMC Surgery report from a different program, published under the pointed title When the First Try Fails, documented a similar recovery effort, and earlier multi-institutional trials had established SIMPL’s feasibility for real-time intraoperative assessment. What the new study adds is a theoretically grounded, low-cost template that programs facing low EPA engagement can adapt without new technology or funding. The research received no specific grant funding, the institutional review board deemed it exempt, and the authors report no conflicts of interest. As EPA-based assessment becomes a fixed feature of surgical training, the study’s central message resonates beyond surgery: implementing an assessment platform is a change-management exercise, and treating it as one may be the difference between a tool that collects dust and one that transforms how surgical competence is measured.

Subject of Research: ADKAR-guided re-implementation of the SIMPL EPA assessment platform in a general surgery residency program

Article Title: When implementing SIMPL is not so simple: an ADKAR-guided re-implementation and engagement strategy in a general surgery residency

Article References: Posner, J., Kardan, R., Godbole, M., Lei, J., Moran, B., & Dallal, R. M. (2026). When implementing SIMPL is not so simple: an ADKAR-guided re-implementation and engagement strategy in a general surgery residency. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 160. https://doi.org/10.1007/s44186-026-00569-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00569-5

Keywords: entrustable professional activities, SIMPL, ADKAR, change management, surgical education, general surgery residency, resident assessment, faculty engagement, gamification, quality improvement, workplace-based assessment, competency-based education