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Reflections of 20 years of Public Health at AUA: Parallels Between Quality Assurance in Healthcare and Accreditation in Public Health Education Michael.

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Presentation on theme: "Reflections of 20 years of Public Health at AUA: Parallels Between Quality Assurance in Healthcare and Accreditation in Public Health Education Michael."— Presentation transcript:

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 My first trip to Armenia was at this time of year in 1995 My 2 nd 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 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 AUAs public health activities, however. * Until 2012, I was the only person to lead that course at AUA

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

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

6 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 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 8 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. 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 Peer Review Accreditation 9

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

16 16

17 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 programs specific mission (desired outcomes). 17

18 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 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) Institutional (colleges, universities) Regional (e.g., WASC, SACS, Middle States) National 19

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

27 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


29 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 Armenias 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 The university had contemplated founding a medical school A needs assessment by Dr. Krikor Soghikian documented that Armenias 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 Dr. Haroutune Armenian, of Johns Hopkins, was asked to head the planning efforts. Dr. Armenians 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). 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. Haroutune Armenian (far right), Avedis Donabedian to his right; center right Krikor Soghikian.

34 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 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. Kims 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 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 AUAs 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 AUAs public health training programs was inextricably linked to CHSRs success


39 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 AUAs 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 CHSRs 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 1996 A second certificate cohort ran CHSR activities continued under Kims 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: 1 st MPH graduates

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

45 Faculty Meeting, November 1997 (Baltimore)

46 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 masters capstone projects

47 2000 (continued) 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 (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 (continued) 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 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 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 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 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 AUAs 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 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 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 Faculty & leadership are critical Identify priorities Keep things moving Focus on whats 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 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 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 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 The following is a poem that I wrote during my first visit in 1995

64 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)


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