4

Engaging New Partners in Accreditation

THE ROLE OF PATIENTS, FAMILIES, COMMUNITIES, AND POPULATIONS IN HEALTH PROFESSIONAL EDUCATION ACCREDITATION

Jo Ann Regan with the Council on Social Work Education led off the session on engaging new partners by focusing on the role of patients in accreditation. To explore the issue, she interviewed Christine MacDonell from the Commission on Accreditation of Rehabilitation Facilities on her involvement with persons, families, communities, and populations in health professions accreditation. Regan set the stage for the interview by describing how the session was formed. She referred the audience to proceedings from a 2014 Josiah Macy Jr. Foundation conference that recommended convening a summit of major education accreditors and professional certification bodies with education leaders, clinicians, patients, families, and communities to produce a framework and a position statement that reflects a commitment and action plan for incorporating partnerships with patients, families, and communities into accreditation, certification, or maintenance of certification (Fulmer and Gaines, 2014). To operationalize such an action plan, accreditors would have to think differently about their site visit teams. Accreditors tend to do the same thing, she said. Then, speaking from personal experience, Regan described her own education site visit teams that, like others, typically include practitioners and have less focus on public members. Even as social workers, her profession has not incorporated their eventual clients and constituents into their accreditation, and she sees that as a problem.

A Person-Centered Approach to Accreditation

Regan then introduced MacDonell from the practice side of accreditation, and described the basic structure of the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is an international organization that accredits more than 50,000 programs and services from multiple health professions at 23,000 locations. They serve more than 8 million persons of all ages annually through 6,800 CARF-accredited service providers (CARF International, 2016a). The mission of CARF is to promote quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of persons served. As the managing director of the Medical Rehabilitation and International Aging Services/Medical Rehabilitation accreditation areas, MacDonell added that CARF was first established in 1966 because consumers were looking for reliable rehabilitation services; while there was an ample supply of providers, there were no baseline quality measures on which to distinguish one from another. CARF was started by individuals

in the community and has remained heavily influenced by the people who are served by the organization. This includes a variety of different health and human services accredited by CARF as well as persons served. Persons served are the primary consumers of services, and include clients, participants, residents, patients, and inmates, since CARF also works within the correctional system. Persons served can also be interpreted as those persons willing, able, and legally authorized to make decisions on behalf of the primary consumer.

Views of persons served are incorporated into all aspects of the CARF governance structure. For example, CARF is a not-for-profit organization and wanted to identify their moral owners.¹ CARF asked the question, who can we not fail to protect? While a controversial question, it led to a healthy debate about CARF’s responsibility in protecting the person who pays for the survey versus the person who actually receives the rehabilitative services. In the end they agreed that the person served is the one CARF cannot fail to protect through its accreditation process. This decision encouraged CARF to develop standards that were and continue to be person centered. For their accreditation process, CARF also includes personnel and other stakeholders. MacDonell speculated that stakeholders in education might include other professions at the university, university-affiliated community organizations and clinicians, and possibly the university’s board of trustees. Using the CARF process of inclusion, she asked the audience, how do you get input from your self-identified stakeholders that go beyond just collecting the data?

In response to her own question, MacDonell emphasized her desire to know how data is used. If used well, data can either confirm that current practice is satisfactory or it can provide information that something different must happen. These changes might include performance improvement, strategic planning, reassessing the organization’s resources, or conducting financial planning. At CARF, they are not satisfied with paper results, but rather want demonstrations of how groups are actively listening to their stakeholders and how such findings are taken forward. This includes looking at trends to assess how best to use the information received.

MacDonell described the three tasks of an accreditation survey. There is one-on-one, confidential interviewing; there is direct observation; and there is written documentation following the survey. While each element is important for developing a framework, what is most critical for her is how the information is embedded into day-to-day practice. When asked whether CARF focuses more on performance improvement than quality assurance, MacDonell responded definitively that it is the former. They do

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¹ As a private, not-for-profit, CARF does not have shareholders, so moral owners are individuals that make up CARF’s equivalent to shareholders in for-profit companies.

not employ a punitive system, but a consultative process. The survey should be a collaborative learning process. In addition, they have different tiers of accreditation awards; the highest is 3 years of accreditation, followed by an award of 1-year accreditation, and finally nonaccreditation. Provisional accreditation is yet another category that occurs when a program receives two sequential, 1-year awards. The program is then put on notice that if they do not obtain the 3-year award within 1 year, they will be become nonaccredited. MacDonell added that CARF employees are there to offer assistance to organizations on improving quality and standards toward a 3-year award.

Competencies for Health Professional Students

In preparing for her presentation, MacDonell asked some CARF stakeholders what issues they would like her to share with the health professional educators in the audience that could be imparted to their students. Her stakeholders identified two key areas that health professional educators might want to consider as they develop individual competencies.

Active Listening

The first is to train students to actively listen so they actually hear the person being served rather than rely on a questionnaire to tell the person’s story. After listening to a person’s story, they suggested students use their professional expertise to consider how to incorporate the unique situation of that person into a meaningful, individualized care plan that will move the person closer to his or her self-identified result. Such an outcome might be to resume a life role, or in the case of a child, to get back into school. Whatever the goal of the person is, they said, it is the job of the health professional to work with that person to get them closer to achieving that goal.

Learning from Persons Served

The second area involves a tension between time efficiency for conducting a health evaluation and a person’s satisfaction with being heard during their visit. MacDonell acknowledged the reality that within the field of health and human services there is not a lot of time to listen to long stories; trying to find the right balance is a struggle. Her stakeholders summarized their thoughts by expressing a desire for health professional graduates to enter the workforce ready to learn from those they serve to make sure their competencies continuously increase. To make her point, MacDonell described a typical rehabilitation setting where the client-driven outcome is not based on the intervention of one individual health provider but the

culmination of the interdisciplinary team working together toward the same outcome. New hires would be open to learning effective interdisciplinary communication and collaboration and how they fit within a team-based, outcomes-driven health system.

Maintaining a Focus on Persons Served

MacDonell then went on to describe some practices CARF has found successful in connecting with their persons served. One came from a realization that parents of children in their rehabilitation programs are more open with other parents than with trained surveyors, so CARF now trains parents as surveyors. Another draws from the United Kingdom in partnership with the Care Quality Commission—the independent regulator of health and adult social care in England.² There, CARF relies on an adult liaison who has gone though the program and trained to interview the person in rehabilitation as well as his or her support network of family and caregivers. A third example involves the Patient-Centered Outcomes Research Institute (PCORI), a U.S. independent, nonprofit, nongovernmental organization set up to improve patient care and outcomes through patient-centered comparative clinical effectiveness research.³ By using those enrolled in a study for peer-to-peer education, a person with a spinal cord injury or an adolescent may be better positioned to educate than the therapist. MacDonell emphasized the importance of letting go of ego in order to learn from those who have gone through the services.

Incorporating Input from Persons Served

Going back to her opening remarks of developing a patient-centered education framework for accreditation, Regan asked MacDonell if she could elaborate on how to get input from the persons served within the areas of quality and accountability. MacDonell responded by describing a CARF initiative promoted by their second chief executive officer. It involved developing an instrument that could provide a higher level of quality and accountability to all their stakeholders. The tool they created, called uSPEQ (pronounced you speak),⁴ focuses on both the consumer experience and the employee climate. Data for each of these areas are drawn from surveys that are self-administered, voluntarily, and anonymous (CARF International,

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² For more information about the Care Quality Commission, see www.cqc.org.uk/content/about-us (accessed September 21, 2016).

³ For more information about the Patient-Centered Outcomes Research Institute (PCORI), see www.pcori.org/about-us/what-we-do (accessed September 21, 2016).

⁴ For more information about uSPEQ, see www.uspeq.org (accessed September 21, 2016).

2016b). Looking at the consumer experience tool, MacDonell explained that it can be used in a variety of settings to provide insight into client perceptions about the service they are receiving within key areas including informed choice, respect, dignity, participation, input, and satisfaction. MacDonell then described how such a survey might be used to assess the acceptability of technology and the digital literacy of a client population before employing the latest rehabilitation technology.

Regan directed the next question to the audience. She asked the participants to reflect on the philosophy presented by MacDonell and to consider whether and how the organization they work at incorporates the person or persons served into their assessment and evaluation measures. She took three comments from the audience. The first strongly endorsed the use of the word person and the need to change the medical lexicon to reflect the thinking behind using it to describe those served by health providers. The second from David Benton at the National Council of State Boards of Nursing (NCSBN) expanded the term to persons served. He emphasized that for NCSBN, the standard process is to survey students, educators, employers, and board members, and they often attend events hosted by those groups where they can gain access to these various stakeholders. MacDonell followed up with a question about whether the information gained is shared with the accreditor and used to improve curricula or other aspects of the educational process? The answer from Benton was yes. As the overarching body that supports the state regulatory authorities, NCSBN uses the data obtained to structure the content of the examination processes that students have to pass before they can get a license; it is a very direct and open process that allows NCSBN to determine where emphasis on particular aspects of its education is needed. This, said Benton, translates into change.

The third comment involved the practice side and the example of a local Virginia hospital that takes patient input very seriously—although it was also pointed out that things can go public within this sector. MacDonell used this comment as an opportunity to discuss “transparency.” CARF standards require that facilities share information about their actual performance with the person served, with personnel, and with stakeholders. The measurements include effectiveness, efficiency, access, and satisfaction as viewed by the person served as well as a stakeholder group.

Opportunities and Challenges to Providing a PersonCentered Philosophy

In the final minutes of the session, Regan asked MacDonell to consider opportunities and challenges associated with providing a person-centered philosophy. She emphasized the value of a strong survey process and collaborative partnerships for enhancing the life of the individual who is being served through accredited programs. The process she encouraged obtains

feedback about the accrediting organization itself and their methods for obtaining input as well as feedback from the surveyors on the health program and on their teammates. Such a collaborative approach is not without challenges. MacDonell expressed concern and desire that people understand why accrediting organizations exist, which is to protect the person served in the program. She also admitted that at times, egos of such highly accomplished professionals can get in the way of taking a collaborative approach and being open to more participatory methods for getting feedback on their program and their organization’s performance. Another challenge is instilling passion and interest in demonstrating a lasting difference to individuals receiving their services that is confirmed through information gathering and data collection. Regan asked MacDonell to summarize her suggestions for a potential multiprofession accreditation framework containing a person-centered philosophy. Her response was to make sure people are prepared to really listen to the person served, make a difference in their lives, and be able to have the skills to do this throughout the accreditation process or survey. In her parting message to the audience, MacDonell asked, “How are you preparing the incoming workforce to work efficiently and productivity while demonstrating that they can listen?”

INNOVATIVE MODELS OF ACCREDITATION: VETERINARY MEDICINE AND ONE HEALTH ACCREDITATION ACROSS NATIONS AND SECTORS

Deborah Kochevar of Tufts University Cummings School of Veterinary Medicine and the Association of American Veterinary Medical Colleges (AAVMC) moderated a panel focusing on One Health accreditation. The One Health Initiative is a movement to forge coequal collaborations among human health professionals, ecologists, and veterinarians to, among other purposes, monitor and control public health threats.⁵

Kochevar believes that accreditation can stimulate innovative models and proposed that One Health accreditation can be part of this. She defined One Health as the collaborative effort of multiple disciplines working locally, nationally, and globally to obtain optimal health for people, animals, and the environment. Kochevar noted that the U.S. Agency for International Development has supported the concept that what is needed is a new breed of health professional students who no longer consider their profession as strictly defined in one sector but rather necessarily across several sectors.

There were three presenters on the panel. Panelists provided insights drawn from their experiences, harmonizing accreditation standards and

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⁵ For more information about the One Health Initiative, see http://www.onehealthinitiative.com (accessed September 21, 2016).

operations across multiple continents, countries, and accreditors. Beth Sabin, Associate Director for International and Diversity Initiatives at the American Veterinary Medical Association (AVMA), is involved with the International Accreditors Working Group, which is a group that comprises representatives from national and regional veterinary medical accrediting bodies across several continents. Stuart Reid is the principal of the Royal Veterinary College in London. He has led AVMA-accredited international schools, is a leader in veterinary medicine, and has worked internationally in both the private and public sector. William Bazeyo is professor of occupational medicine at Makerere University College of Health Sciences School of Public Health, where he also serves as dean. He convenes, coordinates, and creates innovative programs, and is the principal investigator for One Health Central and Eastern Africa.

Veterinary Medicine: Council on Education, International Accreditors Working Group, and the World Organization for Animal Health Working Group on Veterinary Education

Beth Sabin, American Veterinary Medical Association

During her presentation, Beth Sabin explained the evolution of the AVMA Council on Education accreditation standards. She described the international efforts of the council over the last couple of decades, including the work of the International Accreditors Working Group. She also described the efforts of the World Organization for Animal Health (OIE) in veterinary medicine and One Health.

AVMA Council on Education

The AVMA Council on Education⁶ is the accrediting body for veterinary medical education in the United States and Canada. The U.S. Department of Education has recognized it since the 1950s. The council is an independent accrediting body recognized by the Council on Higher Education Accreditation, and is a member of the Association of Specialized and Professional Accreditors. The purview of the council is on the first professional degree program (doctor of veterinary medicine, or DVM, in the United States; in other countries, the equivalent to the first professional degree). It does not look at postgraduate education or continuing education. It functions in cooperation with the Canadian Veterinary Medical As-

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⁶ For more information about the Council on Education accreditation process, see www.avma.org/professionaldevelopment/education/accreditation/colleges/pages/default.aspx (accessed September 21, 2016).

sociation and the AAVMC. The U.S. Department of Education, U.S. state boards, and five veterinary schools in Canada use Council on Education accreditation as a means for identifying individuals eligible for licensure. There are 11 standards, and one of the standards is on outcomes assessment (see Box 4-1). In the past, said Sabin, most Council on Education members were appointed by the professional association. Currently, the AAVMC appoints the academic, decision-making body of the council.

Sabin then described the development of the Council on Education outcomes assessment standard. Prior to 2002, outcomes assessment was part of the larger curriculum standard and did not have its own separate standard. At that time, there was no requirement for a feedback loop from outcomes assessment to program improvement. The Council on Education added outcomes assessment for many reasons. First, the U.S. Department of Education required it, wanting more accountability. Second, said Sabin, society was changing in part because of increasing tuition; therefore, parents and students wanted measurable accountability. Finally, outcomes assessment is a great way to help innovative educators try different delivery methods for curriculum and assess students on learning both basic sciences and clinical sciences.

The Council on Education gathered stakeholders together (the public, members of the profession, the academicians) and spent about 2 years working toward the development of a standard. The next 5 to 10 years were spent in constant review and revision of the effectiveness of the outcomes assessment standard. In 2007, the Council on Education added nine clinical competencies to its outcomes assessment. Sabin stated that many colleges are creating innovative ways of measuring outcomes, both with clinical competencies as well as more of the basic science competencies. Many of the outcomes assessments tie into the curriculum standard.

The competencies, said Sabin, fit into the One Health portfolio. One of the clinical competencies added to outcomes assessment, for example, is an understanding of health promotion and biosecurity, prevention, and control of disease including zoonosis and principles of food safety. That competency can be related to the curriculum standard, which states that the curriculum shall provide instruction in the principle of epidemiology, zoonosis, food safety, the interrelationship of animals and the environment, and the contribution of the veterinarian to the overall public and to professional health care teams.

While outcomes assessment was being developed and while the standards were being reviewed, the Council on Education was also becoming more involved in international education and international accreditation. Sabin stated that the Council on Education has offered accreditation to established international schools on a voluntary basis since the 1970s; Utrecht University Faculty of Veterinary Medicine in the Netherlands, for example, has been accredited since 1973 by the Council on Education. Currently, 14 schools outside the United States and Canada are accredited by the Council on Education.

The International Accreditors Working Group

In the late 1990s, the Council on Education and the Royal College of Veterinary Surgeons in the United Kingdom began to hold regular meetings. In the early 2000s, the Australasian Veterinary Boards Council, the accrediting body in Australia and New Zealand, the European Association of Establishments for Veterinary Education, and the South African Veterinary Council began to come to these meetings as well. The groups met to learn about each other’s processes, to see their similarities, and to identify common challenges and opportunities. In 2007, the International Accreditors Working Group (IAWG) was formed to carry on the work of these informal meetings and to develop a way to do joint accreditation site visits at veterinary schools that were being accredited by the Council on Education, the Royal College of Veterinary Surgeons, and the Australasian Veterinary Boards Council (AVMA, 2013).

The first combined site visit was at Massey University in March 2007, in which a team from the Council on Education and a team from the Australasian Veterinary Boards Council did a site visit at the same time, side by side. The teams worked separately to prepare their reports of evaluation and remained independent decision makers. The IAWG thought this might work for a joint site visit, and recommended a protocol for joint site visits in fall of 2007. They suggested that the first one occur at Murdock University in Australia, and it was conducted in 2009 (AVMA, 2009). Subsequent IAWG meetings recommended the now established protocol for Council on Education, Australasian Veterinary Boards Council, and Royal College of Veterinary Surgeons joint site visits at schools accredited by one or more of these accreditors.⁷ To summarize, Sabin explained that these joint site visits include a single, combined site team with co-leaders, onsite training. A single self-study and a single reported evaluation is developed. There are combined standards, though accrediting entities remain independent decision makers.

World Organization for Animal Health (OIE) Veterinary Education Initiative

Sabin briefly described the OIE ad hoc Group on Veterinary Education,⁸ which was formed in response to a recommendation adopted at the first OIE Global Conference on Veterinary Education. The OIE is interested in delivery of national veterinary services and public veterinary medicine, similar to the U.S. Department of Agriculture. To do this, the OIE wants to build the educational infrastructure.

Sabin’s Key Messages

Based on her experience and understanding of veterinary medicine and accreditation, Sabin presented her three key points. First, the ability to work effectively across national and regional borders requires time, trust, relationships, understanding, respect for other’s professions, an awareness of societal and professional needs, and sufficient resources to address challenges and create opportunities. Second, entry-level competencies may vary across regions, but common ground can be found—perhaps more easily across countries and regions with similar societal and professional needs

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⁷ The International Accreditors Working Group recommends protocols for joint site visits and is not a decision-making body.

⁸ For more information on the OIE ad hoc Group on Veterinary Education, visit www.oie.int/en/support-to-oie-members/veterinary-education/ad-hoc-group-on-veterinary-education (accessed September 21, 2016).

and resources. Third, she believes that One Health might be a key area to finding initial common ground.

Creating the One Health Professional: Lessons from a Multilingual, Multicultural Setting

Stuart Reid, Royal Veterinary College, London

The One Health concept, said Stuart Reid, has been in existence for some time, but it is not evident how to accredit the new One Health professional in the current environment. Because of the diversity of One Health and its global scope, One Health brings forth the challenges of environment, context, and language. Given this diversity, Reid considered how accreditors function within that environment even on a basic level, such as accreditation of the veterinary medical degree and its specializations.

Reid explained the European context and the challenge that Europe faces. First, there are many different countries, currencies, and languages in Europe. There are different licensing requirements, societies and cultures, industries, and professions. In each of the European countries, the veterinary profession is addressing a pet population, a food animal population, or a society.

One Health: A Day1 Skill

Reid considers One Health as a day-1 skill; in other words, it is a skill that veterinarians should be able to use immediately upon graduation. In Europe, the accreditation system includes the European Association of the Establishments for Veterinary Education and the Federation of Veterinarian in Europe, which both look at the 110 undergraduate veterinary schools across the continent of Europe. These schools produce roughly 10,000 graduates, all of whom are taught in different languages. They use a model with a common language for accreditation at the European level (English), and a common set of standards similar to those mentioned by Sabin during her description of the IAWG. There is a rubric or template that every school completes for the evaluation. There is no common licensing exam across the continent, however; the standards focus on bringing together the processes by which all countries meet in a coherent way, and it does not focus on any final assessment. The model is also a visitation scheme for accreditation, functioning as a process with interim measurements. In addition, the model allows for diversity and variation of practice, understanding that some issues apply only to certain countries. Because this is used at the undergraduate veterinarian level, Reid wondered how health

would improve with these models being used within a DVM program or at an undergraduate program of medicine or environmental health.

One Health: A Specialty

Reid also considers One Health a specialty. For this topic, Reid presented the example of the European Board of Veterinary Specialization, which looks at the individual boards and colleges within Europe to accredit the specialist. As an accreditation scheme in Europe, it faces the same challenges that the undergraduate DVM model faced: language differences, diversity of disciplines, and several different colleges. The model that is used is a core postgraduate curriculum for each of the colleges functioning across the continent. There are several routes to credentials, but there is one single exam per college that is a capstone event for every college. These colleges are not visited in this case because the exams are somewhat virtual and approved by documentation.

Lessons Learned

Reid drew lessons learned for the One Health professional from these examples he presented. First, One Health needs to be both a day-1 skill and a specialty skill, he said. Second, he noted that the two different models are important; one model is built into professional education accreditation, and the second model is built into specialty and career progression. If there is no career progression and no career framework, then there will not be a meaningful accreditation system for a One Health professional since effectively there will be no profession in existence, he said. Finally, Reid believes there must be a single language used for an accreditation system. A challenge, said Reid, is going to be how the accreditation system moves from multidisciplinary into interdisciplinary through to transdisciplinary.

Reid closed his presentation by reminding the participants that One Health is not new. He quoted text from the Glasgow Tuberculosis Trial of 1889:

If accreditation bodies from the two branches of medical practice are brought together, he said, the answers may be found.

One Health Accreditation

William Bazeyo, Makerere School of Public Health, Uganda

William Bazeyo also emphasized that One Health is not a new term. He congratulated the veterinarians on their work to integrate One Health into their practice. Bazeyo quoted 19th-century Germany physician Rudolph Virchow, who said “Between animal and human medicine there is no dividing line, nor should there be. The object is different, but the experience obtained constitutes the basis of all medicine.” Bazeyo believes that professions, especially medicine, still exist in siloes that must be broken. The One Health approach, he said, is integrated and is beneficial to multiple health professionals. The challenges faced by One Health can be overcome through collaboration among multiple professionals.

One Health Central and Eastern Africa

One Health Central and Eastern Africa (OHCEA) has an integrated approach for promoting One Health, and in many countries OHCEA is looking at breaking the siloes that exist. Professions involved in One Health include veterinary medicine, human health, environmental health, and wildlife health. OHCEA has also included business schools and social scientists.

OHCEA is preparing future public health leaders with a common vision. It was formed in 2010 and was composed of 14 universities (7 public health schools and 7 veterinary schools) located in 6 countries (the Democratic Republic of the Congo, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda) and recently added 2 more countries (Cameroon and Senegal). The countries are at different levels of development, speak different languages, and have different policies. They partner with the University of Minnesota and Tufts University. OHCEA collaborates with governments through One Health country coordination committees. The South East Asia One Health University Network is working toward a similar goal, and it is currently composed of 14 faculties of veterinary medicine, medicine, public health, and nursing from 10 universities in Indonesia, Malaysia, Thailand, and Vietnam.

Bazeyo explained that to break down the siloes that exist, OHCEA has worked through regional and country networks to support member universities. OHCEA aims to participate with government, academia, and other key partners in defining what is needed to create a One Health workforce. Engaging all stakeholders, especially the public, is important to Bazeyo; if they are not brought in, he said, accreditation is not serving the people it was mandated to serve. Another goal of OHCEA is to strengthen graduate and undergraduate preparation of future health workers to meet

a country’s need for a well-trained workforce. OHCEA aims to strengthen governments’ provision of in-service preparation and improve the current One Health workforce, as well as help strengthen regional and national university networks to promote their sustainability.

OHCEA has worked with countries to revise their curricula and examine how the curricula could be standardized. The One Health model was added to the curriculum of OHCEA countries, and the next step is to bring governments and accreditation bodies together to discuss this and begin to understand the importance of a standard One Health curriculum across the countries. OHCEA is also exploring opportunities for multidisciplinary accreditation, as certain professions are already being trained together beginning at the undergraduate level.

Requisites for Accreditation

Bazeyo then listed requisites for accreditation. Common training principles, he said, are helpful if a university’s faculty is lacking someone with a particular specialty or skill. In this case, OHCEA uses its database to find an expert from other countries, University of Minnesota, or Tufts University who can go to the university and teach the specialty or skills.

Bazeyo echoed other presenters’ call for agreed skills and competencies. He also emphasized the need for recognition by fellow disciplines, and seeing all professions as equal. In addition, accreditation must be recognized by policy makers, employers, and governments, said Bazeyo; this ensures that students will have jobs once they graduate. Professional standardization and a clear career path, as Reid mentioned, are other important requisites. Finally, cross-border recognition is needed for leadership communication.

Opportunities and Challenges for Accreditation

One Health accreditation faces many challenges. History, professional protection, and a tendency toward pride and secrecy could impede the growth of One Health accreditation. In addition, government policies regarding the training and recognition of accreditation bodies vary by country. Universities and institutions have different policies on curricula and teaching methods. Employers also vary in accepting the standards. There are international requirements and demands, and the level of development in each country and what is achievable varies.

However, there are also many opportunities in One Health accreditation. Bazeyo lauded veterinarians and medics for their extensive knowledge and understanding of disease processes and epidemiology. These health professionals also have experience diagnosing and managing diseases in large populations, both across Europe and across Africa. There have been

successes in eliminating and preventing infectious diseases. In addition, both professions have access to local and national regulatory systems.

For moving the One Health accreditation standard forward, Bazeyo envisions developing centers of excellence for education and training in specific areas. Enhanced collaboration among colleges and schools of veterinary medicine, human medicine, public health, and allied health sciences might lead them to embrace agreed-upon standards for recognition and accreditation. He believes medical, veterinary, and allied health sciences curricula should be expanded to include more emphasis on One Health issues, without developing entirely new curricula. Lastly, Bazeyo believes all health professionals should be sensitized to embrace the One Health approach.

Discussion

Kochevar asked each presenter to describe one of the main difficulties with undertaking national accreditation or One Health accreditation. Reid described the challenge of mutual recognition. Using the word harmonization, he said, can be helpful in this situation. He reminded the group that harmonization means groups can “sing the same song but play different parts that sound good together.” Reid suggested starting with the harmonization element, and then moving toward mutual recognition of standards. Sabin agreed with Reid, and stated that this process takes time. People need to work together and understand where every group is coming from, to learn the similarities and differences between each group, and to respect each group, she said.

Bazeyo also agreed with Sabin and Reid. The main difficulty that he has seen is protection; governments want to protect their own people and standards, he said. In addition, protection within the universities is an issue because universities want to be different from each other and also want to attract different applicants. Breaking the barriers, he said, is difficult when professionals want to protect themselves, do their own research, and only work with individuals of their profession. Sabin agreed with Bazeyo about the culture of protectionism that persists within professions. An additional challenge that feeds into this culture are the different levels of desire for globalization or understanding of globalization. The idea of looking outside one’s borders as a tool for growth often conflicts with a country’s desire to close its borders and protect its own, she said.

Environmental Health

Malcolm Cox raised the issue of environmental health, which is part of the One Health movement, as a critical potential facilitator for promoting

forward movement in the climate change discussion. He asked the presenters to what extent they have used One Health in trying to bring people and countries together around this issue. Bazeyo responded to Cox, sharing that environmental health brings together the different disciplines. When promoting One Health curriculum, he said, OHCEA has encouraged universities to develop environmental health training programs. Reid expanded on this topic by describing the Food and Agriculture Organization of the United Nations paradigm within the One Health concept, which includes three levels: the technical level, the societal and behavioral level, and the intergovernmental or legislative level. At each of these levels, one must consider the host, the agent, and the environment. Bringing these three levels together, he said, is ultimately what delivers a One Health answer. One example of where these three levels have been brought together is the human papilloma virus vaccination for teenage girls.

One Health in the Educational Curriculum

Kochevar asked the panelists how to move from discussing an idea of One Health to actually incorporating One Health in a functional way into the educational curriculum to then examine the outcomes. Specifically, she asked Bazeyo about the mapping and the gap analysis that OHCEA conducted, and how OHCEA began to address this topic on a practical level. Bazeyo responded that the process of incorporating One Health into the curriculum was not easy. He then explained the long process, saying that first, the deans and advisors of the universities gathered together to discuss what was already being taught in their universities. Then, schools were nominated and also applied to be part of their network. Specialists examined the curricula and revised them, and included the skills and competencies that OHCEA leaders wanted in the curricula. The revised curricula and list of desired skills and competencies were given to the deans to take to their universities so the faculty and schools could discuss and eventually accept them. Bazeyo emphasized that everything OHCEA puts forward must be acceptable by the faculty, the universities, the individual countries, and the regulatory bodies. It is a long process that is not yet complete, he said. However, OHCEA encourages members to use any curricula that are completed and ready to use in the university setting. Finally, OHCEA developed short courses, training programs, and continuing education programs for those already practicing in the field.

Sabin discussed the outcomes assessment that the Council on Education implemented. There has been a significant amount of dialogue between the schools and the accreditors. The Association of American Veterinary Medical Colleges (AAVMC), for example, has schools in North American and around the world coming together to discuss what it means to measure

outcomes and how it can be done. Initially, she said, there was resistance to outcomes assessment, but now groups are beginning to see how outcomes assessment can actually drive innovation. She called for a better understanding of what the veterinary profession desires to see in their graduates, and how measurement can help to achieve that goal. Reid raised the idea of embedding the outcomes assessment in a feedback loop so outcomes can then affect positive change in the education and program. He noted that there is misunderstanding on what exactly the term outcomes assessment means, in addition to a lack of understanding on what One Health means. Because of this, he said that it is premature to develop a complete set of outcomes assessment for the One Health professional because it has different meanings in different contexts. This, he said, is the challenge of accreditation.

David Benton, National Council of State Boards of Nursing, asked Reid if he had considered using the knowledge and skills framework that was introduced to the health service as a bridge to have some of this further discussion (Department of Health, 2004). When it was discussed in the 1990s, said Benton, it enabled anyone working in the health service to be within a single common competency framework. This involved a core set of competencies that every practitioner, no matter the profession, had to possess, in addition to subject specific competencies. Reid responded that the Royal College of Veterinary Surgeons is in the process of modernizing and is looking at new models to improve its regulation. It is striving to look at the allied professions rather than paraprofessionals. It has added veterinary nursing to its portfolio, and it has the ability to regulate other professions should it wish. There is an opportunity, said Reid, for the framework Benton mentioned to become much more relevant than it is currently.

Building the One Health Movement

Eric Holmboe from the Accreditation Council for Graduate Medical Education commented that One Health fits naturally with the Triple Aim, where the health of the populations is a primary driver. He reflected on the effects of environmental changes, the current Zika virus epidemic, and the tragedy of the Ebola virus epidemic, and how these and many other current issues are directly related to the health and wellness of populations. Holmboe then asked presenters what recommendations they had for the human health professions to better engage with the One Health initiative.

Bazeyo suggested collaboration and cultivating a desire to address the issues and to be involved. He shared an example of when the Ebola virus was in West Africa. Because of Uganda’s experience with the Ebola virus and success in containing it, they sent a multidisciplinary team with social scientists, environmental health experts, medics, and veterinarians to West Africa. He suggested that the various professions come together with a com-

mon vision and use what is available to each of them. Reid also responded to Holmboe’s question, suggesting that health professionals first tackle the “low hanging fruit.” In his mind, the low hanging fruit on the One Health agenda is antimicrobial resistance. It involves environmentalists, technologists, medics, veterinarians, pharmacists, other health professionals, and more. While there are other important diseases to also be addressed, defining specific projects that are truly multinational and transdisciplinary is where he thought progress could be made.

Kochevar suggested that a new breed of student is needed—one who identifies across specialties. One Health student-led clubs are opportunities to involve students and pique their interest in One Health. She has seen students embrace the One Health initiative through their time participating with these clubs. Irene Naigaga, project manager with OHCEA, shared that every country in the OHCEA network has a One Health student club that is multidisciplinary, constituted of veterinary, medical, animal culture, and engineering students. Every year, they develop a work plan that OHCEA funds. Their activities range from sensitization in schools, community outreach, going to slaughterhouses, and even talking on the radio about One Health. Despite the silos that exist in the professions and in the faculty, the students have embraced the One Health, multidisciplinary work whole heartedly. Adding to Naigaga’s comments, Bazeyo shared that OHCEA has also engaged students in outbreak investigations. They are trained in surveillance, outbreak investigations, and how to manage communities. He concurred, however, that the faculty is not typically interested in this work.

Many of the veterinary schools in the United States, said Sabin, are colocated with medical schools or other health professional schools. In these instances, they can incorporate problem-based learning and case scenarios that are One Health related. For example, rabies is currently on the rise in the United States, and Sabin sees it as a true One Health issue. Bringing students from various professions together to examine real studies and address the challenges that are identified can be a learning opportunity in One Health. Sabin sees this happening in many universities. She also suggested that perhaps this work is easier with younger students because they are not set in their ways, as are some of the more veteran professionals. Relationship building, she said, is very important for the One Health agenda to succeed.

Susan Scrimshaw of The Sage Colleges raised the issue of policy and the importance of students and health professionals being engaged in policy. Sometimes, policy makers may make it difficult for critical preventative work to be done. She asked, how do we include the ability to convince policy makers that these are critical issues? Ultimately, said Scrimshaw, the decisions of policy makers affect the outcomes that One Health and accreditation is trying to reach.

Bazeyo agreed that while policy makers can sometimes cause difficulty, they are critical partners in this work. OHCEA has formed country coordinating committees, which are groups formed with nominations from each country’s government. Forming these groups required some sensitization. The groups discuss One Health, and then take the topic to the regional body, the East African community, and the African Union. The reason it has worked, said Bazeyo, is because they were successful in convincing ministers and other bodies that One Health is important. They have then asked OHCEA to also talk to the policy makers at the regional level about One Health, and it is now on the agenda for East Africa and West Africa. The reason policy makers resist, said Bazeyo, is because they think One Health has implications with financing. At OHCEA, they tell policy makers that the finances remain the same; however, by accepting and embracing One Health, there is a chance that the expenditures and budgets will be reduced.

Sabin noted the AVMA fellowships and externships that are available for veterinarians and students. The student externship is 1 month in Washington, DC, learning about policy, lobbying, and the workings of the federal government. The veterinarian fellowship is 1 year working in a congressional office on various issues, oftentimes related to animal or public health. This program, she said, has grown a cadre of veterinarians who understand policy. One of the veterinary schools with AVMA has a public and corporate track, which focuses on public policy. These types of programs, she said, will help the profession be better prepared to positively affect policy. Also in response to Scrimshaw’s question, Reid called for more diversity of gender and age in policy; he said that unless there is greater diversity at all of the levels of decision making, policy will not be engaged in the way that is desired and needed.

Kochevar concluded the discussion by expressing hope that the workshop participants will now think about One Health and interprofessional education, as well as the pros and cons of globalization and accreditation.

REFERENCES

CARF International. 2016b. About uSPEQ. www.carf.org/About/uSPEQ (accessed September 21, 2016).

Department of Health. 2004. The NHS knowledge and skills framework (NHS KSF) and the development review process. Department of Health. http://www.libraryservices.nhs.uk/document_uploads/KSF/NHS_KSF_Document.pdf (accessed September 29, 2016).

Fulmer, T., and M. Gaines. 2014. Partnering with patients, families, and communities to link interprofessional education. Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in April 2014. New York: Josiah Macy Jr. Foundation.

Schwabe, C. W. 1978. Cattle, priests, and progress in medicine. Minneapolis: University of Minnesota Press.

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