1. Reflections of 20 years of Public Health at AUA: Parallels Between Quality Assurance in Healthcare and Accreditation in Public Health Education
Michael E. Thompson, MS, DrPH
Associate Professor of Public Health Sciences
Coordinator, Graduate Public Health Programs
The University of North Carolina at Charlotte
with thanks to Haroutune Armenian and Vahe Kazandjian (part 1) and
Kim Hekimian, Bob & Jackie McPherson, and Varduhi Petrosyan (part 2)

2. Preface My first trip to Armenia was at this time of year in 1995
My 2nd trip outside US (other a pleasure trip to Portugal)
Arrived on Armenian Airlines (via Amsterdam)
Power and water generally were limited to 1 hour, twice per day (except places like AUA)
Few products in markets
Difficult times; proud, positive people
I learned the reality of March being the ‘crazy month’

3. Preface
Launch of the Graduate Certificate in Public Heath (what is now the first year of the MPH curriculum)
Met with many high ranking MOH officials
Learned about AUA and Armenia
Co-delivered first course in Public Health Problem Solving*
The start of the academic program was not the start of AUA’s public health activities, however.
* Until 2012, I was the only person to lead that course at AUA

4. Preface
That history started earlier, with 1994 marking the first tangible institutional commitments to public health in Armenia
…but we’ll get to all that in a few minutes.

5. Outline Defining Public Health
Perspectives on Quality and Accreditation
The AUA Experience
Planning
CHSR
Recommendations & Future Directions
Q & A; Sharing
Closing Thoughts 5

6. What is public health? C.E.A. Winslow (1923) [Yale Epidemiologist]
Public health is the science and the art of
preventing disease,
prolonging life, and
organized community efforts for the
sanitation of the environment
the control of communicable diseases,
the education of the individual in personal hygiene
the organization of medical and nursing services for the early diagnosis & preventive treatment of disease, and
the development of the social machinery
to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity. 6

7. What is public health?
Rene Dubos (1968) [ecological environmentalist ... ‘Think globally, act locally’]
Social organization and ways of life that promote & support the survival of the group
Dan Beauchamp (1976) [health policy & ethics, UNC Chapel Hill, among other places]
Means to achieve social justice & protect all human life
Avi Ellencweig & Ruthellen Yoshpe (1984)
Protection of the community against the hazards engendered by group life 7

8. How is public health different from clinical medicine?
“Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.”
C. Everett Koop, M.D.
Former U.S. Surgeon General

9. How do we assure the quality of our programs?
Peer Review
Accreditation 9

10. Accreditation and Quality
Accreditation has evolved over time as both the culture of quality improvement and the tools and resources to monitor and assess quality have advanced
In medicine, the Donabedian Hospital Quality Assurance model was one of the first to be embraced (underpins Joint Commission [formerly JCAHO] standards):
Structure  Process  Outcome 10

11. Accreditation and Quality
Structure  Process  Outcome
Initial hospital quality efforts focused on structures
number of beds
staffing ratios
etc.
{these elements were was easy to objectively measure, but were not firmly linked to quality} 11

12. Accreditation and Quality
Structure  Process  Outcome
Subsequent efforts emphasized processes
job descriptions
protocols
policies and procedures
Etc
while still reviewing structure
{this approach is similar to the ISO 9001 process in business practices, where a consistent, thoughtful process results in a quality product… “write what you do, do what you write.”} 12

13. Accreditation and Quality
Structure  Process  Outcome
Recent efforts emphasize outcomes
survival
cost
adverse events
etc.
while retaining elements of structure and process assessment (now rationally linked to the outcomes) 13

14. Accreditation and Quality
Structure  Process  Outcome
Outcome assessment allows for comparison of alternate pathways/ processes for achieving the same goal
surgical vs. pharmacological
in-patient vs. outpatient
Beware that outcome driven criteria do not result in
perverse incentives or unintended consequences
financial rewards replacing moral and ethically-based decision-making 14

15. a US-based comic strip that satirizes the workplace
Dilbert
a US-based comic strip that satirizes the workplace 15

16. 16

17. Accreditation and Quality
Parallel developments have occurred in educational effectiveness assessment as well
Assessment of educational programs is no longer solely or primarily based on factors such as the number of faculty or the square meters of classroom space or the number of volumes present in a library
But rather on the availability of the requisite structural and process resources to achieve the program’s specific mission (desired outcomes). 17

18. Accreditation and Quality
Granted some minimal set expectations remain, but emphasis is on providing a coherent, justified argument relating the resources to the desired outcome and demonstrating that the outcome was achieved and is sustainable
Emphasis is on an organizational culture of continuous quality improvement (a ‘learning institution’) and assessment of student outcomes (e.g., professional practice oriented capstone assessments, certification rates, employment rates) 18

19. Accreditation and Quality
In the United States educational system, accreditation is a voluntary quality-improvement activity
De facto mandatory
Government loans, educational support
Employer, agency recognition of degrees
Access to training and research program funds
Accreditation occurs at two level
Institutional (colleges, universities)
Professional (specialized programs, schools)
Regional (e.g., WASC, SACS, Middle States)
National 19

20. Accreditation and Quality
Professional (specialized programs, schools)
Typically ‘sponsored’ by one academic and one professional stakeholder
LCME - Liaison Committee on Medical Education
Accredits US & Canadian MD degrees
Sponsored by Association of American Medical Colleges and the American Medical Association.
CEPH - Council on Education for Public Health
Accredits Schools and Programs of Public Health
Sponsored by the Association of Schools and Programs of Public Health and the American Public Health Association
These accrediting bodies are themselves accredited by the US Department of Education 20

21. Accreditation and Quality
Accreditation in Public Health…the improvement of health through the assurance of professional personnel who are able to identify, prevent and solve community health problems. … objectives are:
1) to promote quality in public health education through a continuing process of self-evaluation by the schools and programs that seek accreditation;
2) to assure the public that institutions offering graduate instruction in public health have been evaluated and judged to meet standards essential for the conduct of such educational programs; and
3) to encourage - through periodic review, consultation, research, publications, and other means - improvements in the quality of education for public health.
-Council on Education for Public Health (US) 21

22. CEPH (
In the US, the Council on Education for Public Health is responsible for Accreditation (Schools or Programs)
Criteria (abridged):
Mission
CQI and Planning processes
Organizational setting
Governance structure
Resources 22

23. CEPH (www.ceph.org) Criteria (abridged, continued):
Appropriate Curricular Content (MPH)
Core (defined competencies)
Practicum
Capstone (thesis/project)
Technical (credits, policies, number of faculty, assessment)
Research
Service
Workforce Development
Faculty/Staff/Student 23

24. ASPHER (www.aspher.org)
In Europe, the Association of Schools of Public Health in the European Region (ASPHER) provides external consultations (“PEER” assessments)
Collegial as opposed to evaluative
Seen as first step in a planned formal accreditation process (based on US CEPH)
named the European Agency for Public Health Education Accreditation (
‘parented’ by ASPHER and European Public Health Association (EUPHA)
Challenge disparate national processes 24

25. ASPHER PEER (Public Health European Education Review) Criteria:
Mission
External Environment
Internal Organizational Environment
Teaching Staff
Students and Graduates
Training Programs
Teaching/Learning Facilities
Research
Institutional Quality Management System 25

26. My Experience… CEPH ASPHER/PEER Regional
Supported 2 Johns Hopkins re-accreditations (School)
Advised American University of Beirut in their planning for initial accreditation (Program)
Planned and led UNC Charlotte’s initial accreditation (Program) and successful expansion and reaccreditation
Trained as a CEPH Site Visitor
ASPHER/PEER
Planned and led American University of Armenia’s PEER review
Served as a PEER Site Visitor
Regional
Assisted in planning and leading American University of Armenia’s initial WASC accreditation
Supported Middle States (Hopkins) and SACS (UNC Charlotte) 26

27. Implications for Academic Program Development …
Need driven/mission relevant
Competency-based
Organized around a guiding paradigm/rationale for curriculum (conceptual roadmap)
Taught using strategies consistent with learning objectives
Knowledge/skills/behavior
Assessed by methods consistent with desired competencies (course/semester)
Validated by measurable program impacts
outcomes assessed by students, employers, graduates – employment rate, satisfaction, etc… ultimately health indicators 27

28. So, how did these principles play out at AUA?

29. Public Health at AUA
AUA, launched the same day Armenia declared its independence, was founded with the commitment to complement rather than compete with existing programs in Armenia
Consequently, the first programs were in business and industrial & earthquake engineering, intended to facilitate Armenia’s transition to a market economy and replace resources lost due to the 1988 earthquake… plus intensive English/academic preparation programming.
Political Science was added next.
Public Health and Law followed

30. Public Health at AUA
The university had contemplated founding a medical school
A needs assessment by Dr. Krikor Soghikian documented that
Armenia’s medical system was sufficient
The pressing need was for training the existing workforce in modern public health.
Thus planning shifted to an MPH Program.

31. Public Health at AUA
Dr. Haroutune Armenian, of Johns Hopkins, was asked to head the planning efforts.
Dr. Armenian’s appointment was the first of a non-University of California (system) affiliated leader.
In 1994, a series of curriculum planning workshops were held, primarily including prominent Diasporan public health faculty and others connected to Armenia.
This group included Avedis Donabedian
As the curriculum plan coalesced, I was involved to assist Dr. Armenian with the planning efforts.

32. First faculty planning meeting (Baltimore, 1994)
First faculty planning meeting (Baltimore, 1994). From second left: Ara Tekian, George Piligian, Kim Hekimian, Haroutune Armenian – all remain active in the program to this day.

33. Faculty dinner following final 1994 planning meeting
Faculty dinner following final 1994 planning meeting. Haroutune Armenian (far right), Avedis Donabedian to his right; center right Krikor Soghikian.

34. Public Health at AUA The curriculum was
Designed to meet US accreditation standards
Content
Competency model
Application
Adapted to meet the needs/constraints of Armenia
Oriented toward methods and critical thinking
Dynamic environment
Self-learn content
Utilized intensive modular approach
Increase involvement of senior US faculty
Facilitate concurrent employment
Alternate year admission facilitated workplace absorption

35. Public Health at AUA Formal affiliation signed with Johns Hopkins
In parallel, Hopkins graduate student Kim Hekimian was living in Armenia, learning the language and identifying health-sector project opportunities that might also serve as the basis for her dissertation.
Kim’s interest in health communication and maternal child health issues combined with UNICEF priorities for the region coalesced around a ‘Baby Friendly Hospital’ /breastfeeding promotion initiative.

36. AUA President Mihran Agbabian (left) visits Baltimore to sign MOU with Johns Hopkins (Spring 1994)

37. Public Health at AUA
In , this project became the first funded public health activity at AUA and launched what is now know as CHSR – the Center for Health Services Research and Development
CHSR built upon the centers linked to AUA’s other programs (ERC, CBRD)
Centers serve a vital link between academia, practice, and community service/development
This BFHI launched the first series of successful collaborations
The success of AUA’s public health training programs was inextricably linked to CHSR’s success

39. Public Health at AUA
Concurrent with implementing this project, Kim also laid the groundwork for the public health program
identifying potential students
contributing practical considerations and local imperatives to the curriculum planning process
In Fall 1994, prospective students enrolled in AUA’s intensive English Program
In March 1995, the certificate program launched
Annual faculty planning & evaluation meetings commenced (US)

40. Michael Thompson(center) with the first certificate cohort (March 1995)

41. Julie Gazmararian and Kim Hekimian (seated) with first certificate cohort (1995)

42. Public Health at AUA CHSR’s mission
The research staff within the CHSR offers expertise to support the existing health infrastructure and the development of quality health services in public and private healthcare sectors. The guiding principles of the center are to:
Provide supervised field training in research and program development for students enrolled in the AUA Master of Public Health Program
Serve as a venue for linkages among the Ministry of Health, humanitarian organizations, and other institutions and agencies
Respond to request for technical assistance from local Armenian ministries and research institutes and from international organizations interested in the implementation and evaluation of health programs within the country
Support programmatic development of health services in conjunction with the Armenian ministries within the Regions

43. Public Health at AUA 1996 1997-98 A second certificate cohort ran
CHSR activities continued under Kim’s oversight
Annual faculty meetings continued
The program expanded to full MPH degree with students from the certificate program cohorts returning
CHSR activities continue under the leadership of Bob & Jackie McPherson
Most students graduate having been involved in at least one CHSR project
Fall 1997: 1st MPH graduates

44. Jackie & Bob McPherson (center) with graduates of the first MPH cohort (1997)

45. Faculty Meeting, November 1997 (Baltimore)

46. Public Health at AUA
1999
On site leadership shifts to Sosig Salvador
Endowment for Garo Meghrigian Eye Institute for Preventive Ophthalmology (GMEIPO) established
2000
On site leadership transfers to Michael Thompson
CHSR benefits from the generosity of Mr. Ed Avedisian in the form of the Zvart Avedkdian Onanian endowment that honors his sister, a nurse.
These funds allow CHSR to hire ‘permanent’ staff
And support master’s capstone projects

47. Public Health at AUA 2000 (continued) 2001-2005
Small project with AI2K leads directly contributes to national immunization strategy for Hepatitis B
Hospital Quality Assurance Project with Nork Marash Medical Center begins (spearheaded by Bob McPherson with Anahit Demirchyan)
CHSR plays major role in evaluation of Hopkins PCS/USAID Green Path Campaign
AUA graduates have assumed key leadership roles in IGO/NGOs
Center activities continue to expand
More ‘permanent’ staff are hired.,
Most students serve as temporary CHSR staff

48. Public Health at AUA 2001-2005 (continued)
AUA takes on larger roles in projects, becoming a key partner in many proposals
ASTP2
HAP/NK
Staff (permanent and temporary) total over 60 at one point
AUA establishes first US NIH registered IRB
Staff are presenting works at international conferences and publishing in peer-reviewed journals
OSI funds students from Moldova to complete AUA MPH program.

49. Public Health at AUA 2001-2005 (continued) AUACHSR.com goes live
MPH program joins ASPHER; undergoes ASPHER PEER visit
Non-credit on-line training programs are offered
Epidemiology
Research Ethics
Malaria
AUA leads OSI funded civic activism initiative that develops support for non-smoking efforts; resulting coalition contributed to Armenia being among the initial FCTC signatories
AUA hosts 2005 ASPHER conference

50. Public Health at AUA
2006 On-site leadership transfers to Varduhi Petrosyan
2006-Present (CHSR)
Major projects continue; Increased integration with EU partners; deepening partnerships with MoH, IGOs
Primary Health Care Reform Project (USAID/ )
Evaluation of the Child Health State Certificate and Obstetric Care State Certificate Programs (requested by MOH; supported by USAID)
Evaluation of Public Health Services (requested by MOH; supported by WHO)
AUA asserts leadership in Tobacco Control area
First Conference on “Tobacco or Health” in Armenia
First Randomized trial - Epidemiology and Intervention Research for Tobacco Control in Armenia” ( ) with Johns Hopkins

51. Public Health at AUA 2006–Present (CHSR, continued)
Post-Earthquake Psychopathological Investigation
CHSR asserts leadership in TB Control area
First research grants from MOH for Tuberculosis operational research
First TB assessment in 2008 with ICRC
Household Infection Control for Tuberculosis (Armenian Medical Fund)
Randomized trial (pilot): Innovative Approach in TB Care in Armenia (Grand Challenges Canada)
CHSR focuses on environmental Health
International Scientific Symposium on Environmental and Occupational Health
Global Inventory Project for Toxic Waste Sites in Armenia and Pilot Community Education Project

53. Public Health at AUA 2006 –Present (MPH) To date: 186 MPH Graduates
Quality validated
Two Self-Studies and external MPH Program Reviews
“The content and quality are comparable to the top tier of MPH degrees at universities in the United States. ” External Reviewer 2013
Graduates continue to enter western doctoral programs and excel (approximately 10%)
Graduates enter employment and excel, domestically and internationally (near full employment)

54. Graduates of the cohort with faculty Varduhi Petrosyan, Tsovinar Harutyunyan, Dana Walrath, and Byron Crape (2013)

55. Public Health at AUA 2006 –Present (MPH) Program expands
First students from India, Iran, Lebanon and other countries
MPH/MBA, first formal dual degree at AUA in 2012 (currently suspended)*
Every year admission started in 2013
Outreach builds
Public Health Seminar Series expands
Approximately 50 events such as this since 2008
Bi-annual CHS Newsletter (now SPH Newsletter) since 2009
Health content delivered to new AUA undergraduates
*Technically Tatul Hakopian, MPH (‘97) was AUA’s first dual MPH/MBA degree graduate. He previously had earned an MBA and was granted permission to earn a second masters. He did not benefit, however, from the reduced credit load of an articulated dual degree.

56. After the Annual Faculty Workshop (Boston 2013): Varduhi Petrosyan, Dana Walrath,
Ed Bunker, Robert Bagramian, Kim Hekimian, Michael Thompson, Bruce Boghosian, Haorutune Armenian, George Piligian, Adam Atherly, and Lusine Poghosyan

57. Public Health at AUA
Overall impact and recognition of the School of Public Health*
Many funded projects resulting in
Approximately 114 project reports
Over 30 educational materials addressing a variety of health topics
53 publications in internationally ranked peer-reviewed journals
Roughly 25% resulting from MPH Thesis projects
Over 90 published abstracts
Over 132 international conference presentations
*Renamed School of Public Health from College of Health Sciences as part of 2012 AUA restructuring.

58. My recommended priorities for the next 20 years …
Plan for evolution into an accreditable program/school of public health
Assess need for
Graduate Certificate or short course for working professionals that can serve as a gateway to degree programs
Expansion of graduate tracks; degree offerings
Undergraduate programs in health sciences
Strengthening/influencing the pipeline of undergraduate programs
Assess need for related professional programs 58

59. Key Points for AUA … Faculty & leadership are critical
Identify priorities
Keep things moving
Focus on what’s important (mission focused/need driven)
Target recruitment and professional development to meet the needs of implementing these programs
Generate/secure needed resources (stakeholder support, internal & external)
Link with critical resources 59

60. Key Points for AUA … Programs continue to respond to documented needs
Adhere to international standards and perspectives while responding to needs and constraints of Armenia and the region
Serve as a role model and resource for the development of public health programs in the region. 60

61. Key Points for SPH … Take time to reflect on successes…
CHSR
MPH Program
Graduates
And the principles that guided this success…
Modelling western standards in business practices
Commitment to transparency, fairness, and quality
Ethical practice
Aligning teaching with practice
Treating students as mentees and future colleagues
Developing potential and rewarding initiative and entrepreneurism 61

62. Questions/comments…
I especially invite our alumni in the audience to briefly share their thoughts/experiences on the value of CHSR to their education and professional development

63. And a few closing thoughts
The following is a poem that I wrote during my first visit in 1995

64. Dawn Comes to Yerevan
As the morning sun rises from the east, The gray that wakens man and beast Slowly lightens over sleeping Yerevan.
The sun crests Aragat's shoulder and takes a timid peek At sister Ararat, who, in return, proffers a snow-white cheek, All the while smiling gently down upon the morning flower, Yerevan.
Far below, the people rise, from their slumber they are drawn, Lest the hour grow too late to catch the new day's dawn, And see the sun brightly christen another day in joyful Yerevan.
Nestled in the valley between two inspiring peaks, The people's warmth, their hope and character, bespeaks An enduring faith that daily overcomes the challenge Yerevan.
And radiantly the sun into this peaceful valley comes Restoring light and hope to everyone; And thus, as always, dawn does come to the city Yerevan.
(27 March 95)