Michael E. Thompson, MS, DrPH Associate Professor of Public Health Sciences

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 VaheKazandjian (part 1) and Kim Hekimian, Bob & Jackie McPherson, and VarduhiPetrosyan (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 • AviEllencweig & RuthellenYoshpe (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. 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) • Institutional (colleges, universities) • 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 (www.ceph.org) • 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 (www.aphea.net) • ‘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 • 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. KrikorSoghikian 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 AvedisDonabedian • 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: AraTekian, 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), AvedisDonabedian to his right; center right KrikorSoghikian.

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 MihranAgbabian (left) visits Baltimore to sign MOU with Johns Hopkins (Spring 1994)

37. Public Health at AUA • In 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/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 • A second certificate cohort ran • CHSR activities continued under Kim’s oversight • Annual faculty meetings continued • 1997-98 • 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 GaroMeghrigian 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 ZvartAvedkdianOnanian 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) • Small project with AI2K leads directly contributes to national immunization strategy for Hepatitis B • Hospital Quality Assurance Project with NorkMarash Medical Center begins (spearheaded by Bob McPherson with AnahitDemirchyan) • CHSR plays major role in evaluation of Hopkins PCS/USAID Green Path Campaign • AUA graduates have assumed key leadership roles in IGO/NGOs • 2001-2005 • 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 VarduhiPetrosyan • 2006-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 area • First Conference on “Tobacco or Health” in Armenia • First Randomized trial - Epidemiology and Intervention Research for Tobacco Control in Armenia” (2008-2011) with Johns Hopkins