Reflections of 20 years of Public Health at AUA: Parallels Between

Quality Assurance in Healthcare and

Accreditation in Public Health EducationMichael E. Thompson, MS, DrPHAssociate Professor of Public Health SciencesCoordinator, Graduate Public Health ProgramsThe University of North Carolina at Charlotte

with thanks to Haroutune Armenian and Vahe Kazandjian (part 1) andKim Hekimian, Bob & Jackie McPherson, and Varduhi Petrosyan (part 2)

PrefaceMy 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 marketsDifficult times; proud, positive peopleI learned the reality of March being the ‘crazy month’

PrefaceLaunch of the Graduate Certificate in Public Heath (what is now the first year of the MPH curriculum)

Met with many high ranking MOH officialsLearned about AUA and ArmeniaCo-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

PrefaceThat 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.

OutlineDefining Public HealthPerspectives on Quality and Accreditation The AUA Experience

PlanningCHSR

Recommendations & Future DirectionsQ & A; SharingClosing Thoughts

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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 environmentthe control of communicable diseases, the education of the individual in personal hygienethe 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.

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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

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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

How do we assure the quality of our programs?

Peer ReviewAccreditation

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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 advancedIn medicine, the Donabedian Hospital Quality Assurance model was one of the first to be embraced (underpins Joint Commission [formerly JCAHO] standards):

Structure Process Outcome

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Accreditation and Quality

Structure Process Outcome

Initial hospital quality efforts focused on structures

number of bedsstaffing ratiosetc.

{these elements were was easy to objectively measure, but were not firmly linked to quality}

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Accreditation and QualityStructure Process Outcome

Subsequent efforts emphasized processesjob descriptionsprotocolspolicies and proceduresEtc

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.”}

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Accreditation and Quality

Structure Process Outcome

Recent efforts emphasize outcomes survivalcostadverse eventsetc.

while retaining elements of structure and process assessment (now rationally linked to the outcomes)

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Accreditation and QualityStructure Process Outcome

Outcome assessment allows for comparison of alternate pathways/ processes for achieving the same goal

surgical vs. pharmacologicalin-patient vs. outpatient

Beware that outcome driven criteria do not result in

perverse incentives or unintended consequencesfinancial rewards replacing moral and ethically-based decision-making

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Dilberta US-based comic strip that satirizes the workplace

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Accreditation and QualityParallel 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).

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Accreditation and QualityGranted 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)

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Accreditation and QualityIn the United States educational system, accreditation is a voluntary quality-improvement activity

De facto mandatoryGovernment loans, educational supportEmployer, agency recognition of degreesAccess to training and research program funds

Accreditation occurs at two levelInstitutional (colleges, universities)Professional (specialized programs, schools)

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

Accreditation and QualityProfessional (specialized programs, schools)

Typically ‘sponsored’ by one academic and one professional stakeholder

LCME - Liaison Committee on Medical Education Accredits US & Canadian MD degreesSponsored by Association of American Medical Colleges and the American Medical Association.

CEPH - Council on Education for Public HealthAccredits Schools and Programs of Public HealthSponsored 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

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Accreditation and QualityAccreditation 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

CEPH (www.ceph.org)In the US, the Council on Education for Public Health is responsible for Accreditation (Schools or Programs)Criteria (abridged):

MissionCQI and Planning processesOrganizational settingGovernance structureResources

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CEPH (www.ceph.org)Criteria (abridged, continued):

Appropriate Curricular Content (MPH)Core (defined competencies)PracticumCapstone (thesis/project)Technical (credits, policies, number of faculty, assessment)

ResearchServiceWorkforce DevelopmentFaculty/Staff/Student

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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 evaluativeSeen as first step in a planned formal accreditation process (based on US CEPH)

named the European Agency for Public Health Education Accreditation (www.aphea.net) ‘parented’ by ASPHER and European Public Health Association (EUPHA)Challenge disparate national processes

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ASPHERPEER (Public Health European Education Review) Criteria:

MissionExternal EnvironmentInternal Organizational EnvironmentTeaching StaffStudents and GraduatesTraining ProgramsTeaching/Learning FacilitiesResearchInstitutional Quality Management System

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My Experience…CEPH

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 reaccreditationTrained as a CEPH Site Visitor

ASPHER/PEERPlanned and led American University of Armenia’s PEER reviewServed as a PEER Site Visitor

RegionalAssisted in planning and leading American University of Armenia’s initial WASC accreditationSupported Middle States (Hopkins) and SACS (UNC Charlotte)

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Implications for Academic Program Development …

Need driven/mission relevantCompetency-basedOrganized around a guiding paradigm/rationale for curriculum (conceptual roadmap)Taught using strategies consistent with learning objectives

Knowledge/skills/behaviorAssessed 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

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So, how did these principles play out at AUA?

Public Health at AUAAUA, 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

Public Health at AUA

The university had contemplated founding a medical schoolA 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.

Public Health at AUADr. 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 DonabedianAs the curriculum plan coalesced, I was involved to assist Dr. Armenian with the planning efforts.

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.

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

Public Health at AUAThe curriculum was

Designed to meet US accreditation standardsContentCompetency modelApplication

Adapted to meet the needs/constraints of Armenia Oriented toward methods and critical thinking

Dynamic environmentSelf-learn content

Utilized intensive modular approachIncrease involvement of senior US facultyFacilitate concurrent employment

Alternate year admission facilitated workplace absorption

Public Health at AUAFormal affiliation signed with Johns HopkinsIn 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.

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

Public Health at AUAIn 1993-94, 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/developmentThis BFHI launched the first series of successful collaborationsThe success of AUA’s public health training programs was inextricably linked to CHSR’s success

Public Health at AUAConcurrent 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 launchedAnnual faculty planning & evaluation meetings commenced (US)

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

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

Public Health at AUACHSR’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 ProgramServe as a venue for linkages among the Ministry of Health, humanitarian organizations, and other institutions and agenciesRespond 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 countrySupport programmatic development of health services in conjunction with the Armenian ministries within the Regions

Public Health at AUA1996

A second certificate cohort ranCHSR activities continued under Kim’s oversightAnnual faculty meetings continued

1997-98The program expanded to full MPH degree with students from the certificate program cohorts returningCHSR activities continue under the leadership of Bob & Jackie McPhersonMost students graduate having been involved in at least one CHSR projectFall 1997: 1st MPH graduates

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

Faculty Meeting, November 1997 (Baltimore)

Public Health at AUA1999

On site leadership shifts to Sosig SalvadorEndowment for Garo Meghrigian Eye Institute for Preventive Ophthalmology (GMEIPO) established

2000On site leadership transfers to Michael ThompsonCHSR 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’ staffAnd support master’s capstone projects

Public Health at AUA2000 (continued)

Small project with AI2K leads directly contributes to national immunization strategy for Hepatitis BHospital 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 CampaignAUA graduates have assumed key leadership roles in IGO/NGOs

2001-2005Center activities continue to expand

More ‘permanent’ staff are hired., Most students serve as temporary CHSR staff

Public Health at AUA2001-2005 (continued)

AUA takes on larger roles in projects, becoming a key partner in many proposals

ASTP2HAP/NK

Staff (permanent and temporary) total over 60 at one pointAUA establishes first US NIH registered IRBStaff are presenting works at international conferences and publishing in peer-reviewed journalsOSI funds students from Moldova to complete AUA MPH program.

Public Health at AUA2001-2005 (continued)

AUACHSR.com goes liveMPH program joins ASPHER; undergoes ASPHER PEER visitNon-credit on-line training programs are offered

EpidemiologyResearch EthicsMalaria

AUA leads OSI funded civic activism initiative that develops support for non-smoking efforts; resulting coalition contributed to Armenia being among the initial FCTC signatoriesAUA hosts 2005 ASPHER conference

Public Health at AUA2006 On-site leadership transfers to Varduhi Petrosyan2006-Present (CHSR)

Major projects continue; Increased integration with EU partners; deepening partnerships with MoH, IGOs

Primary Health Care Reform Project (USAID/2005-2010)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 areaFirst Conference on “Tobacco or Health” in ArmeniaFirst Randomized trial - Epidemiology and Intervention Research for Tobacco Control in Armenia” (2008-2011) with Johns Hopkins

Public Health at AUA2006–Present (CHSR, continued)

Post-Earthquake Psychopathological InvestigationCHSR asserts leadership in TB Control area

First research grants from MOH for Tuberculosis operational researchFirst TB assessment in 2008 with ICRCHousehold Infection Control for Tuberculosis (Armenian Medical Fund)Randomized trial (pilot): Innovative Approach in TB Care in Armenia (Grand Challenges Canada)

CHSR focuses on environmental HealthInternational Scientific Symposium on Environmental and Occupational HealthGlobal Inventory Project for Toxic Waste Sites in Armenia and Pilot Community Education Project

Public Health at AUA2006 –Present (MPH)

To date: 186 MPH GraduatesQuality 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 2013Graduates continue to enter western doctoral programs and excel (approximately 10%)Graduates enter employment and excel, domestically and internationally (near full employment)http://sph.aua.am/mph-1997/

Graduates of the 2012-13 cohort with faculty Varduhi Petrosyan, Tsovinar Harutyunyan, Dana Walrath, and Byron Crape (2013)

Public Health at AUA2006 –Present (MPH)

Program expandsFirst students from India, Iran, Lebanon and other countriesMPH/MBA, first formal dual degree at AUA in 2012 (currently suspended)*Every year admission started in 2013

Outreach buildsPublic Health Seminar Series expands

Approximately 50 events such as this since 2008Bi-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.

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

Public Health at AUAOverall impact and recognition of the School of Public Health*

Many funded projects resulting inApproximately 114 project reportsOver 30 educational materials addressing a variety of health topics

53 publications in internationally ranked peer-reviewed journals

Roughly 25% resulting from MPH Thesis projectsOver 90 published abstractsOver 132 international conference presentations

*Renamed School of Public Health from College of Health Sciences as part of 2012 AUA restructuring.

My recommended priorities for the next 20 years …

Plan for evolution into an accreditable program/school of public healthAssess need for

Graduate Certificate or short course for working professionals that can serve as a gateway to degree programsExpansion of graduate tracks; degree offeringsUndergraduate programs in health sciencesStrengthening/influencing the pipeline of undergraduate programsAssess need for related professional programs

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Key Points for AUA …Faculty & leadership are critical

Identify prioritiesKeep things movingFocus on what’s important (mission focused/need driven)Target recruitment and professional development to meet the needs of implementing these programsGenerate/secure needed resources (stakeholder support, internal & external)

Link with critical resources

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Key Points for AUA …Programs continue to respond to documented needsAdhere 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.

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Key Points for SPH …Take time to reflect on successes…

CHSRMPH ProgramGraduates

And the principles that guided this success…Modelling western standards in business practicesCommitment to transparency, fairness, and qualityEthical practiceAligning teaching with practiceTreating students as mentees and future colleaguesDeveloping potential and rewarding initiative and entrepreneurism

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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

And a few closing thoughts

The following is a poem that I wrote during my first visit in 1995

Dawn Comes to Yerevan As the morning sun rises from the east,The gray that wakens man and beastSlowly lightens over sleeping Yerevan. The sun crests Aragat's shoulder and takes a timid peekAt 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, bespeaksAn enduring faith that daily overcomes the challenge Yerevan. And radiantly the sun into this peaceful valley comesRestoring light and hope to everyone;And thus, as always, dawn does come to the city Yerevan. (27 March 95)