An Accreditation Perspective on the Future of Professional Public Health Preparation 1

Transcription

1 An Accreditation Perspective on the Future of Professional Public Health Preparation 1 Patricia P. Evans Executive Director Council on Education for Public Health Washington, DC Thank you for the opportunity to share my perspectives about education for public health careers with the IOM Committee on Educating Public Health Professionals for the 21 st Century. I am honored to be asked to provide comments from the vantagepoint of the accrediting body for public health. The Council on Education for Public Health is recognized by the US Department of Education as the official accrediting agency for schools of public health, graduate community health education programs, and graduate community health/preventive medicine programs. These educational entities have some organizational and programmatic differences, but they all offer the Master of Public Health (MPH) degree and share a common mission to prepare competent practitioners dedicated to enhancing health in human populations, through organized community effort. 2 Accreditation is widely used in the United States in many arenas, but especially in higher education where it is the premiere form of self-regulation and the primary means by which academia and the professions promote quality control. Specialized or professional accreditation is a voluntary process that evaluates educational programs that prepare for entry into a profession. All accreditation, whether focusing on universities in their entirety or on schools and programs that prepare for entry into a profession, share common features: a) agreed-upon criteria or standards that serve as the basis for evaluation; b) an analytical self-study; c) an on-site visit by external peer evaluators; and d) publication of the results. Accreditation publicly attests that a program meets generally accepted educational standards in that field of practice. Some of you are familiar with accreditation in general and with public health accreditation specifically, but for others I would like to describe the Council as a prelude for the observations to follow. The Council on Education for Public Health was established as a separate and independent nonprofit corporation in 1974 by the American Public Health Association and the Association of Schools of Public Health, which continue to serve as our 2 corporate members. The American Public Health Association initiated the formal accreditation of schools of public health 1 Presented to the Institute of Medicine Committee on Educating Public Health Professionals for the 21 st Century, March 13, 2002, Irvine, California 2 Definition adopted by Council on Education for Public Health, in 1945, initially recognizing 10 schools of public health. At that time, all of the accreditation evaluation visits were done annually by C.E.A. Winslow, who shaped much of the early thinking about public health education and also about APHA s role in accreditation. By the mid-1970s, there was wide recognition in the higher education community that the credibility of accreditation decisions which increasingly were being used for a variety of public purposes, such as GI educational benefits, federal capitation and traineeship grants, job qualifications, and in some fields licensure or certification of graduates depended on the ability of the accrediting agency to make independent decisions, uncompromised by political considerations. APHA and ASPH joined forces to plan a new organizational model for accreditation that would assure independence and constitute a partnership between academia and practice. The result was the Council on Education for Public Health. APHA transferred the responsibility for accreditation of schools of public health to CEPH in 1974 and a few years later transferred the responsibility for graduate community health education programs. There continue to be important relationships with our 2 corporate members, not the least of which is that they appoint or concur in the appointment of the 10 individuals who constitute the governing board of CEPH. I want to acknowledge that one of your committee members, Pat Wahl, dean of the School of Public Health and Community Medicine at the University of Washington, is a current member of the CEPH board. Our governing board a) manages the business of the corporation, b) adopts policies and procedures by which it carries out accreditation, c) adopts the criteria against which schools and programs are evaluated and d) makes accreditation decisions about individual schools and programs. These decisions are not subject to review and approval by any other body, although our procedures and processes assure many opportunities to solicit input from various constituents. I would like to spend a moment discussing the Council s responsibility for adopting the criteria that constitute the basis for an accreditation evaluation. The criteria are the rules. The criteria are the sole basis for conferring accreditation status. If a school or program meets the criteria, we must accredit. If a school or program does not meet the criteria, we cannot accredit. It is as simple as that. Thus, the criteria take on enormous importance and, in fact, have the potential to significantly influence the direction, structure and content of professional preparation programs. The criteria become a vehicle through which the profession institutionalizes desired changes. If the criteria specify required curricular content, then all schools and programs that want to be accredited have to cover that content. If the criteria require a practice experience, as ours do, then all schools and programs that want to be accredited have to include a planned and evaluated internship, field placement, or practicum. Schools and programs have considerable flexibility in how they do these things, but they must do them if they expect to be accredited.

2 Adopting the criteria is a responsibly that is not taken lightly. Changes in the criteria tend to occur only when there is consensus in the field, both in the field of practice and within the academic community. While consensus is not a prerequisite to amending the criteria, the extent to which the criteria are broadly accepted within the community will determine their success in defining what public health education should be. Part of the challenge to the CEPH governing body is to garner opinions from multiple constituents, assess implications for the field of public health, anticipate the possible impact on schools and programs, and to mediate potentially conflicting positions. This is why the criteria revision process has always been lengthy, arduous, and sometimes contentious. The Council recently announced a major review of the criteria and invited suggestions for revisions; comments will be welcome through May 15. After that, the Council will review the suggestions, agree in principle to selected revisions, develop specific language to modify the criteria, circulate the proposed language to constituents for review and comment, and finally adopt the new language. I mention this review because I hope that the report of this committee and the report of the IOM Committee on Assuring the Health of the Public in the 21 st Century will become available in the near future, in time to be a part of CEPH s deliberations about the criteria. Alternatively or in addition, I hope that this committee or you as individual committee members will send recommendations to us directly. These do not have to be fully-formed proposals for specific language; they may be framed as general ideas about what the future of public health practice should look like and how schools and programs should be preparing students to meet the challenges of the future. The suggestions do have to reach us by May 15. I would note that the 1988 IOM Future of Public Health 3 report had a very significant impact on the last major revision of the CEPH criteria. Changes in the criteria or changes in emphasis that were highly congruent with the 1988 recommendations related to: establishing and maintaining linkages with state and local public health agencies; encouraging public health practice perspectives among school of public health faculty; requiring learning opportunities across the broad scope of public health practice; incorporating a practice component in all professional degree curricula; valuing applied research relevant to real public health problems; and supporting short courses and continuing education to upgrade the skills of the workforce. 3 Institute of Medicine s Committee for the Study of the Future of Public Health, The Future of Public Health, 1988, National Academy Press, Washington, DC. With that as an introduction, I would like to share my observations regarding the academic public health landscape, noting how formal public health preparation has changed over the years and what we might expect in the next decade or so. These are my personal observations and not the position of the Council on Education for Public Health. You should know, however, that I never stray very far from what I believe to be an accurate representation of CEPH policy. These observations, particularly where I offer opinions, are sometimes outside CEPH s current frame of reference and I thus take personal responsibility for them. I have an unusual vantagepoint, in that I have been the executive director of the Council for more than 20 years and during that time I have personally visited every accredited school and program except for 2 recently accredited programs. This includes consultation visits, onsite evaluation visits, and in most cases multiple visits over long spans of time. The count includes 74 of the 76 CEPHaccredited schools and programs. In addition, I have provided consultation and personally visited 28 schools and programs that are not yet accredited. The vantagepoint of an accreditor is an unusually candid one. An accreditor is not limited by what a school or program wants to put forth to the public or other constituents. An accreditor may ask to see anything. In fact, the federal legislation governing privacy of student records specifically exempts accrediting agencies; yes, we may even examine individual student files. We don t usually do this, but I think our ability to do so points out the unusual access to information that accrues to accrediting bodies. We have an ability to see a school or program as few others ever see it. As a consequence, we accept an obligation to honor the trust placed in us. So, what has the recent past wrought? Does professional preparation of public health workers look much different than it did 30 years ago when CEPH was established, or 60 years ago when APHA initiated the formal accreditation of schools of public health? Here are my observations: 1. The most notable difference in the public health professional preparation landscape is the sheer number of institutions of higher education offering graduate training in public health. There were 10 schools of public health when APHA initiated accreditation in the mid-1940s and 18 accredited schools when CEPH was established in the mid-1970s. Today there are 31 accredited schools of public health, 14 graduate community health education programs, and 31 graduate community health/preventive medicine programs. The 76 schools and programs represent more than a 400% increase since CEPH became the accrediting agency. The most dramatic growth over the past 30 years occurred in programs outside schools of public health. This is not at all unexpected, given that universities can assemble the resources needed to support a program much more easily than the resources needed to provide the comprehensive offerings in a school of public health. A program, for example, may offer only 2

3 a generalist MPH or 1 or 2 areas of specialization, whereas a school of public health must offer a full range of public health concentrations, plus doctoral programs. I believe that programs, which typically start small but often grow quite large, are the spawning ground for new schools of public health. Already we have had a number of accredited programs make the transition to accredited schools of public health and I expect more to do so in the near future. Of the 8 newest schools of public health, 5 were first accredited as programs. But the growth we have seen in the past pales in comparison to the growth that appears to be on the immediate horizon. We went from 10 to 18 schools of public health in about 30 years during APHA s tenure as the accrediting body, then from 18 to 76 institutions in the subsequent 30 years under CEPH. We are likely to more than double again in the next 10 years. In addition to the 76 accredited schools and programs, there are another 11 institutions in formal applicant status with CEPH, ie, they have initiated the accreditation process and will be evaluated within 2 years but they do not yet appear on our published list. In addition to those, there are at least another 70 institutions on what I call our early warning list. I try to track programs and schools that are under development, in early operational stages, and considering accreditation. The list grows longer every year, even as many drop off this list and go on the accredited list. I will share this list with the committee but I caution that, except for those in applicant status, this is a very unofficial list. I want to point out that this list predates 9/11. I fully expect to see a surge of interest in new MPH programs but they won t show up on my early warning list for a while yet. 2. At one time schools of public health were located exclusively in the large research universities; in fact, an early criterion for accreditation as a school of public health was that the institution be a member of the Association of American Universities, then and now a prestigious association of the most prolific research institutions in higher education. The nature of the institutions offering graduate public health training has broadened considerably. The broadening of the base of institutions supporting public health training often in institutions whose dominant traditional role has been teaching rather than research has some important implications regarding the nature of these programs. Elizabeth Fee, a noted historian and author of A History of Education in Public Health: Health That Mocks the Doctors Rules, 4 reported that a debate about whether there should be a few elite institutes of hygiene or many state schools preparing frontline public health workers characterized the early deliberations about the development of public health training capacity in this nation. This debate has been 4 Elizabeth Fee and Roy M Acheson, A History of Education in Public Health: Health That Mocks the Doctors Rules, Oxford Press, laid to rest; there will be many programs in many types of universities. 3. There is an ever widening set of professions and disciplines that are hospitable to public health, as evidenced by the settings where public health training programs are emerging. Judging by these settings and by the cross-school participation that almost always characterizes new schools and programs, interdisciplinary communication and cooperation is alive and well. Medical schools are the most likely organizational base from which an MPH program may evolve; this was true even of the earliest schools of public health. Other likely sites include education; health, physical education, recreation and dance; public administration and policy; allied health; human ecology; pharmacy; and health and human services. Of the 31 accredited community health/preventive medicine programs, 20 are in medical schools. Of the applicant and emerging schools and programs, approximately 30 to 35 are in medical schools. Of the nation s 125 accredited medical schools, close to 40% have operational MPH programs or are in some stage of developing a graduate public health degree program. There is also considerable recent interest in MPH programs on the part of osteopathic medical schools, whose orientation toward primary care proves to be a good fit with public health. 4. Another new wrinkle in the professional preparation landscape and one that really pushes the envelope is the development of collaborative schools and programs. These are schools or programs operated as a single unit but sponsored by more than one institution of higher education. I am not talking about universities that make use of joint faculty appointments or collaborate on research or service projects or facilitate cross-university registrations. I am talking about a single, integrated MPH program that draws resources from multiple institutions and functions under a single administrative or governance structure. They often serve a large geographic area, usually an entire state. They frequently involve 2 or 3 public universities in a single state system. This collaboration, it seems to me, is often driven by higher level mandates such as those of state legislatures or board of regents or higher education coordinating councils primarily interested in avoiding duplication of resources. Most of these thus far have been programs, but we recently accredited the first school of public health with a collaborative organizational structure. That is the University of Medicine and Dentistry of New Jersey, jointly sponsored with Rutgers University, and the New Jersey Institute of Technology. While it is challenging to get any new school or program up and running, it is infinitely more difficult to do so when 2, 3 or more institutions are involved. 5. The broadening of the disciplinary base of public health is reflected in new and emerging specializations, as well. I note the quite rapid development of public health specializations in areas such as human genetics, clinical investigations, and infomatics. And 3

4 joint degrees, although they account for a relatively small number of graduates, are growing more common all the time. The MD/MPH in particular is a highly attractive combination and, I believe, often drives the interest of medical schools in developing an MPH. 6. At the same time that public health is expanding to embrace new areas of specialization, there are centrifugal forces at work that cause public health to pull away from the basic public health foundations. The result is a constant tension about what the basic public health foundation is or should be. For accreditation, this translates to controversy about the public health core, or the body of knowledge that should be transmitted to all public health professionals, regardless of their areas of specialization. As practice changes, it is reasonable to expect that the core knowledge, or the applications of that knowledge, will change as well. The basic public health sciences have remained incredibly stable for many years, yet always challenged by those centrifugal forces. 7. For well over 20 years CEPH has pressed accredited schools and programs to identify competency-based learning objectives and to assess student achievement against those objectives. As higher education and the accrediting community move toward assessment of outcomes, as opposed to inputs, the need for the precise identification of expected competencies takes on added importance. It is very exciting today to see public health organizations broadly and actively engaged in defining expected competencies for public health practice. The future challenge for schools and programs will be to translate those competencies to curricula and for CEPH to translate agreed-upon competencies into curricular requirements. 8. There is an enormous demand for nontraditional, technology-based modes of delivering education preferably for academic credit and formal credentials and all kinds of organizations are rushing to fill that void, some of them reputable and some of them not so reputable. Schools of public health, which have taken a leadership role in distance education, will find they have plenty of competition and not just from programs but from a whole new set of actors outside the traditional education community. 9. There is growing demand and interest in baccalaureate preparation in public health and in many specializations within public health, such as environmental health and health education. Yet, those of us in the academic public health community have long cherished the MPH as the entry degree and we are very uncertain about how to respond to bachelor s degrees in public health. In fact, the 1988 IOM report on the The Future of Public Health expressed this very ambivalence when it noted, The committee did not conclude whether undergraduate degrees in public health are useful. 5 The debate about the level of preparation appropriate for professional public health training is a very old one, never fully resolved. The baccalaureate phenomenon is occurring, for the most part, outside schools of public health. Historically a few schools of public health have offered undergraduate degrees, but these have been modest. In recent years a number of schools have embraced an undergraduate component, driven, I believe, by 2 factors: a) there is significantly greater valuing of undergraduate education in the major research universities than there was 20 years ago and b) more and more universities are implementing responsibilitycentered budgeting, which assigns specific worth to credit hour production, among other productivity indicators. Thus large undergraduate enrollments with their high student/faculty ratios allows a school to support graduate programs that require much lower student/faculty ratios. A factor that we have not considered but should, relates to staffing patterns in state and local public health agencies. State and local health departments hire far more bachelors-trained staff than they do master-prepared professionals. While this may relate in part to the supply of applicants with MPHs, it also has a relationship to the economics of the departments. They can hire a BS graduate for less. It is time that we as a field examine this phenomenon much more closely than we have in the past and help shape higher education s response to needs in the workforce. 10. The student market is shifting in dramatic ways. When schools of public health were first established, most students were physicians, nurses and engineers. Even 25 years ago, the student market was composed largely of individuals with prior professional degrees who came back for an MPH at mid-career. The wide availability of federal public health traineeships at that time reinforced this practice since public health work experience was an eligibility requirement. Today, the applicant market increasingly includes a large proportion of students right out of baccalaureate programs, who have little or no public health work experience. That is both good and bad. It is bad in the sense that some MPH curricula particularly those that are only 1-year in duration don t provide the breadth and depth needed to serve this student population well. This shift has significance for curriculum planning within individual institutions, and it challenges the field about the nature of professional preparation in general. The shift in the student market is good because it reflects the apparent growing popularity of public health as a career option. The fact that young people are drawn to public health as an early career choice bodes well for our future. 5 Institute of Medicine s Committee for the Study of the Future of Public Health, The Future of Public Health, 1988, National Academy Press, Washington, DC, p

5 These issues are not new by any means; they are just the modern version of what I call our abiding ambivalences. The development of the public health profession in the early part of the last century was part of a deliberate plan and strategy, not a haphazard, incremental set of events. It was characterized by debates about what the profession should be and how its practitioners should be trained. In her book on the history of education for public health, Elizabeth Fee reported 6 on a 1914 conference in the offices of the General Education Board of the Rockefeller Foundation, describing it as a critical event in shaping the future structure of the public health profession. This meeting, which involved public health leaders and Rockefeller Foundation representatives, set about defining the necessary knowledge base for public health practice and designing the educational system needed to train a new profession. Two participants, William Wickliffe Rose and William Henry Welch, would expand on these ideas in what would become the major reference for the design of schools of public health, the Welch-Rose report of It is of interest to note that the issues that concerned the participants at the 1914 conference are many of the same issues that we debate today in terms of professional preparation of the public health workforce: Debate about the relationship of public health to other disciplines and professions, especially to medicine. A focus on bacteriology and biological research versus a concern for broad social, economic and environmental conditions that affect health. Debate about advanced education for leaders or basic training for frontline public health workers. Debate about whether there should be a few elite national institutes of hygiene or many state schools of public health to train workers in practical methods. Debate about graduate education vs. undergraduate education vs. short, continuing education offerings. A focus on research and research methods versus practical skills needed to carry out programs. Debate about the relative importance that public health training should place on education of the public. Thank you for allowing me to share these observations. These are exciting times for public health, and I am privileged in a small way to be able to contribute to its bright future. 6 Elizabeth Fee and Roy M Acheson, A History of Education in Public Health: Health That Mocks the Doctors Rules, Oxford Press, Patricia P. Evans Executive Director Council on Education for Public Health 800 Eye Street, NW, Suite 202 Washington, DC Phone: (202) FAX: (202) patevans@ceph.org 5