Creating a problem based, competency based and community oriented education

Abstract: This article describes the development of a new curriculum for health services administrators in Cracow in Poland from the fall of 1991 through the spring of 1993. The guiding principles behind the curriculum development were community-oriented and problem and competency based education. The author coined the term competency-based education during his tenure at Johns Hopkins University where he championed new developments in postgraduate public health education while there. The article describes the modus operandi of the developmental work leading to a highly successful program where nearly half of the student body was hired out of the program halfway through it due to their demonstrated value in the local institutions where they were doing their practicums. Such students were offered part-time completion of the program, which nearly all participated in.

Keywords: Public health education, health services administration education, problem based learning, competency based learning, community oriented education

Background:

Contact with Jagellonian University, which at the time was considering supporting development of a new school of public health, was made between Project Hope and a principle of the Jagellonian University during a visit to Cracow in early spring of 1991. At the time, the author was working in the US government Department of Health and Human Services to plan the development of a one-stop shopping technique in healthcare for the disadvantaged population of Southeast Washington DC. The author was called by a professor at the University of North Carolina Chapel Hill in order to ascertain whether he was interested in being the resident faculty advisor for Project Hope. The background for the contact was the professor’s experience with the author during the CDC/HRSA Public health faculty agency forum which later led to a disruptive upheaval in the manner in which public health candidates were educated in the USA. This development had as its motivating impetus the Institute of Medicine’s 1988 report The Future of Public Health [1]. It was during this time that the author coined the term competency-based education as a means of rooting education in the community, broadly speaking, in order to maximize the utility of the educational process vis-à-vis its relevance for local and/or regional administration and development.

The contact led to the planning of a three-day workshop in Millwood, Va, September 1991during which the overall plan for the school would be discussed and the role of Project HOPE’s involvement was put in place. The result of the conference was a general developmental model. The assumptions of the model were:

1.         that the level of expertise needed to implement a quality curriculum was insufficient in Poland,

2.         that foreign faculty were needed at all levels of planning, curriculum and syllabus development, faculty development and program evaluation, and

3.         that the need for continuing education for practising administrators was at least as acute as the need for graduate education to prepare a new generation of health services administrators.

In areas where foreign faculty involvement was deemed necessary, a counterpart arrangement was to be devised between the responsible Polish faculty member and the foreign faculty. A series of teams would thus be established. Each team would plan and implement a program for development in a specific technical area. Initially this was to include:

• development of course objectives and an overview of the course materials in the selected field,
• development of a short continuing education module to be run by the visiting consultant team in Cracow,
• development of the complete syllabus of the corresponding course and the details of course implementation while serving as visiting faculty in Cracow; and
• development of the role of and plan for the use of the provided expertise in the planning, implementation and management of a health care management project

The relationships between foreign faculty and their Polish counterparts were envisaged as long term. Foreign faculty would serve as mentors in the development of quality coursework in the short run and a self-sustaining faculty in the long run. The latter was to be accomplished through variations on the general theme of medium-term visits to foreign universities by Polish faculty, practising managers or doctoral students as visiting faculty or special fellows in highly specialized courses. In addition to developing such specialized, advanced courses, the cooperative model was to be useful in the development of course evaluation and redesign. The resident faculty advisor was to facilitate and prepare the background in order to make this model as successful as possible as well as to fill in the gaps through workshop activities and participation in the school's general development. More specifically, the resident advisor was to act as a shadow director of the school.

The only piece of this program which was implemented was the provision of the advisor. This was provided in the absence of any program support in terms of e.g. computer, communications support or secretarial assistance, all of which was generously provided by the school. There was a severe lack of support for the program in terms of feedback and coordination with other HOPE activities in the region. Communication with headquarters was extremely problematical until the program in August, 1992 was put under the administrative arm of the regional office in Bratislava. Since then, communication has improved considerably.

The role of the advisor as a representative of HOPE relative to the school was extremely difficult. As the newness of the advisor role wore off and no further input from HOPE faculty evolved, certain elements of the faculty came to view the advisory role as adversarial and unhelpful. Although this faction of the faculty was marginalized and the main development very positive, this aspect of the advisory role could probably have been avoided if a little more support were provided from HOPE. Further complicating this problem, there was a lack of clear decision making in Millwood (the residence of HOPE) concerning program development and more importantly, a lack of long term commitment to the program as formulated in Millwood in September, 1991. The program was to be the basis for the cooperation which was to evolve. These trends led to a deterioration of the expectations on the part of the school as regards HOPE which unfortunately has been generalized to a significant part of the health care establishment in the Cracow area. If there is a lesson to be drawn from this, it may be that there should be more support for fewer programs.

The provision of the advisor was on the other hand an action which in itself had significant and positive influence on the development of the school. One has only to assess the development of the school’s director over the 18 months that the advisory role existed to ascertain that the provision of the advisor has had a significant impact. In the main, the development has taken the school’s director through several levels of sophistication concerning program development, curriculum development, program assessment and administrative capability. The director’s large capacity for creating contacts and developing ideas metamorphosed into a much more focused set of activities with clear success criteria and mechanisms in place to assess progress. The director internalized the concepts of strategic planning and situation analysis, and this was in and of itself probably the most significant single factor ensuring the survival of the school as an institution in changing and challenging political environment.

It is difficult to assess the role of the HOPE effort in the development of the school over the 18 months that the advisory role lasted. It is tempting, however, to draw a parallel to the school of public health in Bratislava, which in temporal terms and point of departure had a similar background in institutional development. During the 18 months in question, the school in Bratislava maintained status quo, but did not expand its activities and did not appear to command a desirable level of respect from its client base. The Cracow school, on the other hand, expanded its staff from approximately 15 to 45 full time equivalents, developed two new certificate programs in health promotion and pharmacy inspection, created several major consulting, community, and research projects and last but not least completely revamped the main program for health services administrators so that it maintained a good level of compatibility with state of the art in the field. A fully problem based, competency based and community-oriented program was devised, mainly by the author based on his experience with the superiority of this approach in bringing about the problem solving and improvement strategies among students [2, 3, 4, 5]. The coursework was rooted in actual problems that hospital and/or health clinic administrators were facing and creating solutions required development of the competencies needed to solve the problem. Thus competency based. The choosing of the problem facing the institutional leaders gave the community orientation. Students of the program were very active in collaborating with hospitals and other health institutions in devised practicum programs, and many were prematurely hired out of the program because the directors thought so highly of the skills they had acquired at the school. All of this happened despite severe budgetary restraints and hostility from certain elements in the Ministry of Health (MoH). The latter was due to the traditional provincialism and “post-communism” era in Poland which predicated a significant personally belligerent behavior between various high-level professionals in the ministry.

There certainly were large differences between the situation in Bratislava and in Cracow, and teasing apart the causes and effects of the marked difference in achievement was hardly possible. On the other hand, there every reason to believe that the efforts which HOPE made possible through the provision of the advisor have played a significant role in the success at the time of the Cracow school. Last but not least, the author wishes to express his personal appreciation of the opportunity he was provided to impact the situation in Cracow in what he viewed as a positive and sustainable fashion. In the following, the author will attempt to provide an overview of the developments at Cracow SPH over its first 18 months.

1.1.1. Budget from MoH

In the beginning of the school's history, the budgetary situation in Poland was chaotic. The funds available during the spring of 1991 were acutely needed by state institutions which were floundering in a state of budgetary transience which to a large extent continued through 1992. No budget was adopted before June of 1992, when the Suchocka  government came to power. The budget that was finally approved was lower than running costs for most state institutions, which includes all hospitals and university schools in Poland. In spite of this situation, the director of health education and science department, MoH was able in 1991 to squeeze some 6 billion zloty (approx. USD 600,000) as seed money to start the school. Most of this money was allotted as developmental funds, which was to say that it was specified for use in building renovation, office and lecture room equipment, library development and a special budgetary category for the school's computer lab. The latter with its 12 PCs in a network and internet connection was quite unique in a university setting in Poland at the time. The smaller portion, or approximately 1.5 billion zloty (USD 150000) was for staff wages and running costs. This was the amount which was used as the basis for the school budget in 1992. Because of various loopholes in accounting laws, it was possible to set aside a certain amount of money for school development. The school was thus able to meet its running costs commitments as well as expand its staff to an acceptable level (45 FTEs).

Faculty development was singularly lacking in the finances of the school. The funding which was to have been developed for the HOPE project did not materialize, and there was not sufficient attention given to development of alternative financing sources for the school. The resident faculty advisor was instructed not to pursue this, as it was deemed to potentially conflict with other HOPE fundraising interests. The school should be pursuing funds on its own accord in a fashion similar to US schools, but there has not been any possibility to hire a development officer for the school, as a competitive wage for such a person is not within the financial reach of the school. The school was also supported by the French-Polish Foundation (financed came from the French Government) and Ecole National Sante Public from Rennes (ENSP).

Applications for financial support

World Bank

The World Bank had been working on a loan for the development of 3 pilot health care consortia in Poland in 3 regions in the north of Poland (published in Health Policy Journal, 1993 or 1994). Throughout the existence of the school, there was much talk between various parties connected with these consortia as well as within the World Bank regarding the role that the school might play in the education of the personnel necessary to grant these projects the needed intellectual infrastructure. Much energy was devoted to this effort from the school. The most time-consuming aspect of this work was the attempt to get a clear picture from the Polish MoH concerning the application and review process for getting funds from the USD 125 million loan for such things as personnel development and teacher training. Clarity was not reached on these issues. There was a significant hostility toward the school from certain elements in the MoH, and unfortunately, until that time, those elements had the long end of the straw in the World Bank context. One interesting detail in this story is that the MoH officials recognized the school as a center for health promotion, but not for health care management. It has not been possible for the school to convince the MoH officials even with much hard evidence that the main focus is health care management.

1.2.3. TEMPUS

TEMPUS was an EU fund which was targeted towards the development of projects between EU universities and Eastern and Central European universities as funding for "Teaching the Teachers". Hogeschool von Amsterdam (HvA) was very active in seeking and executing various TEMPUS projects, and HvA had very good relations with the school. This led to a series of visits from HvA to the school with the single purpose of finding areas of interest in which HvA could develop in partnership with ENSP projects for funding from TEMPUS. Representing HOPE was in this regard a very difficult task, since HvA's main area of interest is health care management, and HOPE's explicit policy concerning the school was that HOPE wanted to be the controlling partner in the health care management area. In the absence of funding coming on-line for the programmed activities, this policy backfired. In the end, a TEMPUS contract was awarded which created good steps in cementing the school’s position.

1.2.4. Polish/French Foundation

The school had very strong contacts with Foundation  Polish/French (FFP), which also had strong relations with the SPH and the Sucha Beskidzka local health authority and hospital. FFP had an agreement with ENSP and French MoH regarding the use of Sucha as a laboratory for development of health insurance, management improvements, health information systems development and epidemiological studies. The school functioned as a consulting body in this connection. FFP had via this avenue provided the school with grants for study travel to and from France, library materials, and the development of a program for pharmacy inspectors at the school. In March, 1993, FFP placed a young French national with a marketing and finance background who served 16 months working with the school. FFP has an interesting arrangement with the ministry of defence which allows them to utilize conscientious objectors for this type of arrangement. The advantage for FFP is low cost. The ministry of defence was thus able to offer exciting options for a few highly qualified individuals who could be placed in other countries.

1.2.5. Private Loans

This area was explored as a source of funding for students at the school. The idea came about towards the end of 1991, at which time the MoH had an amount of money available which they wanted to give to the school, but could not find an appropriate route for doing so which would be acceptable under existing legal constraints. A usable strategy appeared to be a student loan program. Under the MBA enterprise corps, based in Chapel Hill, NC,  recent graduates were active in Cracow, and it happened that one of them  was dissatisfied with his assignment at the Cracow Steel Mill (Nowa Huta). It was arranged for him to come to the school and work out a loan program. The basic concept was that the money from the ministry, which amounted to USD 170,000, would be used as seed money for a loan program which would cover students' living expenses during their first year of study. During the second year of study, the students were expected to arrange work-study arrangements, and after the end of the two-year program, the students would pay back the loans as a percentage of their income. The basic concept was one of collective payback which had been propounded in the U.S. several times but never implemented. The advantage of collective payback by percentage of income is that there is less need for graduates to land high paying jobs. Given the low pay for public hospital and health services administrators and managers in Poland in the foreseeable future, this was a very important issue. The model would have provided between 7 and 9 years of funding with the available money.

All through the development of the program, it did not become clear what financial assumptions the ministry of health was willing to make in future as it was a pilot cohort only. Thus, the critical numbers such as payback percentage and running time for the loans were not clear when the program leader left the school in August, 1992. This resulted in the Poles finishing the concept. They have opted for a more standard mode of individual payback and individual contacts have been signed. The money has been freed and about half of the new student body has opted for taking the loans. It appeared to the author that the program was doomed to failure as a standard loan program, since the payback levels attainable with the wages which were available simply could not finance a year of living expenses during which there was no wage income. The Polish students were also not used to thinking about education as an investment, which made marketing of the program difficult. Meanwhile, the ministry of education debated making some form of loan program universal for university education. In conclusion, the issue of student support is a critical one in the recruitment of quality candidates. and the school was fighting an uphill battle.

1.2.6. Public Health Foundation

The public health foundation (PHF) was funded by Medical Academy and Jagiellonian University and conceived as a conduit for raising capital for the school. PHF was designed to be capable of generating income on a number of fronts. At the time, only one activity was generated, which was a high-tech concept to produce print-ready graphics and books in public health area. This operation was close to making enough money to cover its operating expenses but did not generate any income. There was no obvious reason for this to change over a short time. One of the areas which the PHF was to concentrate on was conference contracting. So far, two such have occurred. PHF could become a very useful tool for the school, but there needs to be a development officer who knows what he/she is doing. Such a person would necessarily have extensive western experience.

1.3. Capital

After the establishment of the school, there was not any significant change in capital. The school was originally well funded for building renovation, office furniture and equipment and appointment of the lecture hall and group work rooms, even to the extent that visiting faculty from other Polish institutions expressed a thinly veiled jealousy over the standard. Although the school was well equipped within its framework of approx. 50 students total, there was little room for expansion within the building and no funds available for new buildings. In light of the enormous unmet demand for this type of training in Poland and the region, this situation was one which demanded serious attention and resources.

1.3.1. Library

One of the great difficulties in starting the school was the lack of relevant literature at the school in the field of health services management. Donations from various organizations, including HOPE, were of limited usefulness in that the titles tended to be marginally relevant and either obsolete, e.g. as in the case of software books, or texts of marginal quality.  Fortunately, the MoH recognized the need for developing the library resource and committed significant funds to the effort. As a result, the school had a decent selection of texts and journals. The main remaining problem was the lack of back issues of journals from which literature lists could be built for courses, etc. The school pursued a strategy to get microfilm back issues copied from existing stocks and the acquisition of microfilm reader/copiers. Furthermore, the establishment of Medline and Medlars, the precursors of Pubmed from the US based National Institutes of Medicine, were online at the time and extremely useful.

There was some activity concerning publishing of teaching materials, among other things a very useful compendium of relevant laws and regulations in the management of health care. Plans to expand this publishing activity were hampered by lack of funds and qualified personnel. In general, the lack of relevant teaching materials in the health care management field was a very serious obstacle in giving students the breadth of perspectives they needed to develop workable strategies for the administrative problems in health care. This was a high priority area for development and is relatively cheap. Budgets for translation can be competitively priced at approximately USD 8.00 per page of typical textbook or article text. Printing was relatively cheap in Poland and good quality.

2. Legal status

The legal status of the school was somewhat of a Pandora’s box, in that many of the constructed budgets and administrative arrangements were sources of contention and resistance within the MoH. For example, the status of the school as a postgraduate educational center is one for which there was no existing legal framework. Although the school was small compared to the medical academies, it figured on the MoH budget as an individual line. The status until this finally was approved in November, 1992 was as a temporary institute under the Cracow Medical Academy. The problems with the institute status were that the Medical Academy had ultimate budgetary responsibility and therefore a strong interest in keeping things regular. Because of the nature of this field in Poland, i.e. one in which no qualified professorial level staff existed, the institute status was administratively challenging. The status at the time was perhaps somewhat tenuous, since there was no insulation layer of administration between the MoH and the school, meaning that the whole project could have been discontinued with the stroke of a pen. This was unlikely in the political situation at the time, but it was difficult to project whether the political climate would persist or for how long. The school remained a joint project between the Cracow Medical Academy and the Jagiellonian University. At the same time Medical Academy was coming from MoH and JU budget from Ministry of Higer Education.

3. Personnel

There were many additions and changes during the course of the 18 months of my tenure there. The most striking was the change of directors. The first director was chosen on the basis of his academic qualifications and ties to the main source of faculty available in management training, i.e. his alma mater, the Cracow Economic Academy. The shortsightedness of this choice was lost on the Economic Academy, although it had carried out management and economics training for the last 75 years, but had yet to prove itself as an institution capable of training competent managers for the current political and economic situation in general and certainly not in the health care system. Until the advent of the school, the academy had no ties to the health sector and had not done any training of health sector managers. The first director drew almost exclusively on his contacts at the Economic Academy for faculty appointments, and by the time the first cohorts of students entered the school, the only part of the program not controlled by Economic Academy staff was health promotion, pharmacy inspectors cell and IT centre/digital data . When Dr. Skarbek thus had arranged the program, it consisted, with the exception of health promotion and IT cources, of a series of courses which had run in the Economic Academy for the last generation. Student dissatisfaction was high, course load was very light, and the level of competencies being reached relative to what was needed was totally unacceptable.

An important party to this problem complex was a professor from the Economic Academy who is well qualified by Polish standards but disastrously ill equipped in terms of leading a health care management program for a situation in flux. The first director was a protegé this professor, and the first director followed the professor’s guidance to a fault. At one point, it looked very much as though the professor had plans for taking over the school by coup, so to speak, but that was nipped in the bud. The professor was very much an old guard type, and his involvement in the projects that the author had observed limited the usefulness of the result and made the work so academic as to be more or less non-understandable. The phenomenon is well known in Eastern Europe - I would like to term the syndrome controlophilia. The type is an individual addicted to control for control's sake with little or no deeper appreciation of the motivational, consensus-building, empowerment and strategic planning aspects of the managerial process. During the winter of 1991/1992, the author spent a considerable amount of energy trying to limit the professor's influence on the program, which the author viewed as very destructive. The result was that the professor was effectively marginalized.

The situation between two directors came to a head in February/March of 1992 after a series of short workshops and seminars which the author had planned and run, showing the glaring deficiencies of the program in terms of competencies reached. These led to the beginning of the plan for the curriculum which was then put in place, described below. This led to a series of confrontations between which ended with a change of directors. The author attempted to keep as neutral a line as he could in this process, but the author also made it clear that he did not think that the school could survive without change. The process lasted, one might say, from the beginning of the school until the actual change took effect in August, 1992. The new director had been convinced all along that he was the right person for the job, but had himself been convinced especially by powers in Jagiellonian University that his lacking academic qualifications would make his leadership ineffective in the academic setting.

At any rate, the new director took over the reigns in August, 1992. The change in management style was quite dramatic, but not unfailingly positive. In terms of managing the school, the situation was fairly well controlled on the curriculum front, moderately under control but not developing satisfactorily on the research front, very poorly under control from an administrative point of view and disastrous in terms of documentation. Although finances were well accounted for, the economic incentives in the school were not clear. It was not clear who relates to whom and what the function of the secretariat was, and communication was undeveloped. The result was that anyone and everyone was constantly tugging at the director’s elbow, trying to get piddling details and large decisions taken care of at the same time. The director was refractive to the author’s efforts to help him understand how to tackle this problem. The author used every possible opportunity to bring this to the director’s attention, to the extent that the director became so tired of hearing about it that he had either to start listening or turn off completely. In the end, he listened. As in any setting, criticism is not easily absorbed. Common comments were "You do not understand Polish conditions," or "These people are better than normal - you should see how it works at the other places (in Poland)." Standard practices are not in place for e.g. telephone messages or speedy mail handling, and there is a lack of understanding of why such things are important.

In terms of documentation, the school had no catalogue, and had only recently produced its first brochure and logo, did not have an internal information service (e.g. a school newspaper) and with a few minor exceptions, the only material which was published from the school about the school was what the author had written. Some of this has been translated to Polish for publication in the health care management weekly. It must be mentioned in this context that the health promotion unit was very productive and innovative in its own area.

The lack of program documentation was not a serious problem in the Polish context, as other institutions in the field did not produce such documentation, either. However, it prohibited the school from making an international impression and made it very unlikely for the school to be competitive in any form of international grant procedure save those specifically designed to aid such institutions. Furthermore, the situation in Poland was rapidly changing, and it was likely that surviving institutions would have to get used to western standards of institutional documentation. My efforts to get this issue under control have been hampered; 1. by the lack of time for the director to take primary responsibility for this activity and 2. the lack of competitive wages the school can offer a capable individual (Poles with professional training and excellent English language skills easily command three times what the school can offered). My suggested solution was to add an assistant to the resident advisor position and let the documentation issue play a strong role in the selection of the individual. The assistant would have as one of his/her main responsibilities to train a counterpart.

In the author’s view, the optimal way to improve the director’s capacity in these areas would be to put him through a good management program, e.g. MHS or MPH. The director needed to be motivated to do this, as his family situation was not conducive in this regard. Given that the first director continued as deputy director, he would need this training as well.

The faculty developed a much broader scope than at the beginning of the school, with additions from the Jagiellonian University Institutes of Economics and Psychology and the Medical Academy. The Medical Academy institute, which dealt with social medicine, was being disbanded and the school was taking over its functions and the course for medical students. The same was likely to happen with the medical epidemiology group. The medical informatics group was formed by faculties coming from Technical University (AGH) and medical school. There have also been additions from outside Cracow, notably one recent graduate of a French pharmacy inspector program in ENSP, Rennes. The school had at the time a sufficient reputation to attract quality faculty, which was predicated by its ability to continue to attract funds in spite of the general tendency for other institutes to lose funds.

There were numerous attempts to get regular meetings going between faculty, but that remained an elusive goal. Faculty did not meet often by U.S. standards, and the spectrum of committees which one would find at any U.S. institution of this type did not exist, i.e. admissions, evaluation, academic, search committees, etc. Although the director understood the need to have such a system institutionalized as a consensus building and time management tool, he did not put enough energy into it to make it work. At the time, the number of faculty had been small enough to keep it under control with meetings in the halls, etc. The situation was getting critical, however, and neither the director or his 2^nd in command understood its gravity. There was not a likely solution to this problem without outside input. The next real test of this came in connection with the production of the next year's curriculum in time to print a catalogue which was timely for use in candidate recruitment.

Besides the author, there had been two other foreigners active at the school. A student from a combined MHS/MPH program was at the school during the summer of 1992 as a practicum student. She was very helpful in the curriculum development work in which she effectively functioned as the author’s assistant. She was working with Polish counterparts whose main responsibility was facilitating case study development. This arrangement changed after a short time when one of the faculty went to Holland for further training in problem based education, thus highlighting one of the critical problems in school staffing. When one of the younger staff got up to speed on an issue, they tended to find contacts which made it possible for them to enter advanced training in the west. Thus, the school lost this faculty resource and had already lost the developmental leader of the health promotion unit who moved to Leiden University.

A Fullbright Scholar from the University of South Carolina arrived at the school in September, 1992 and was involved in continuing education efforts in the area of cost accounting and health system informatics. He also acted as a consultant in connection with various aspects of the Sucha Beskidska projects and was the nominal temporary head of the accounting and public finance group at the school. He also became active in various organizational projects among U.S. hospital administrators, and his experience in that area was utilized in developing parallel activities in Cracow. He was active in creating contacts with the then nascent group of hospital administrators in Poland.

3.1. Faculty development

As per above, there were significant plans for faculty development at the school with HOPE mediated funding. Although these plans did not develop, there was at least one point to be taken from the experience here which was not taken into account in the original plans. The majority of the faculty at the school were married and settled, and few of them would be interested in pursuing a graduate degree in public health, even if they were offered full funding to do so. It was clear that it would be quite difficult to find faculty willing to undertake even modest plans for continuing education efforts under e.g. special student status for a month at a time. Students, on the other hand, presented less of a problem in this regard. Efforts to raise funds for these training modules needed to take this into account or risk program failure.

There were a number of activities in the faculty development area, most notably in the area of pedagogical training and consensus building. There were a series of developmental seminars, but the time we had available from faculty was chronically insufficient to break old habits. There was face value commitment to a more active role for students in the curriculum, but the methods needed to make it work were far from firmly cemented. Nevertheless, there was more activity in the educational area, and the faculty were accepting more and more commitment of time to discussion and development of course syllabi. The author believes that this was a function of a certain degree of excitement about the program.

The author’s efforts at developing faculty group research meetings and faculty wide literature discussion meetings did not take root. There was no tradition for that in Poland. Faculty valued their free time very highly, not the least reason for which was that they needed free time in order to make more money to live on. As a result, any activity which was not viewed as absolutely necessary in terms of fulfilling wage requirements was not prioritized. This was complicated by the fact that insufficient numbers of the faculty read English well enough to make this effort practicable. There have been some publications on the part of the faculty in Polish language journals, but none at the time in international, peer reviewed journals.

4. Students

4.1. Admissions/registration

The first and second cohort of candidates at the school were attracted by general advertising in the media. That is to say, there was no reputation to draw on and no network of graduates to recommend students, etc. The first advertisements were to the effect that anyone with a master’s degree in any field was eligible for study. The first group was very disparate and numbered about 50. It became clear very early on that approx. 1/3 of the cohort were not interested in the field or were unqualified for managerial positions for various reasons, the most common of which was a lacking basic knowledge of the health care system. There was a good deal of attrition over the academic year, and there were approx. 25-30 students left. They were with different degrees: MD, nursing, biology, mathematics, economics, engineering, etc.

In spite of the author’s repeated admonitions, there was still no clear-cut application and admissions procedure nor any official admissions committee. An ad hoc committee was formed to review applications in the summer of 1991. Nonetheless, the quality of the student body from 1991/92 improved dramatically with the entrance of the student body for 1992/93. On the other hand, there was still a large gap between the envisaged target group of mid-career health system managers and the current students. Although the school had attracted several mid-career students, the majority of the students were recent graduates of other programs most of whom chose the program because they thought it would enhance their possibilities of getting work in their fields. The battle for quality candidates was much more uphill than in the US, and any dramatic changes it this situation was not likely in the near future for two good reasons. The first is the support problem described above, i.e. no mid-career individual can afford to pull a year out of the calendar. The second is tied to the first, i.e. that there were no financial incentives which would justify an investment in such an education in terms of higher pay in more superior jobs. This situation is acknowledged by the ministry of health, but as of that time, competitive wage levels for positions had been limited by the ministry itself.

5. Courses/curriculum

The curriculum for the first year students was, as described above, a hodge podge of various courses with little direct relevance to the current health care system problem complex, with the exception of the health promotion course. The author instigated two main activities designed to attack this issue from a developmental perspective. The first was a strategic planning process which started in November, 1991 and continued until the beginning of the management crisis This conflict effectively slowed most activities going on at the school to the extent that the author was apprehensive that a complete dissolution might take place. Most of the work carried out in the preparations and meetings had at least left a lasting impression on the new director to the extent that he then expounded the strategic planning process as the only way to give a new institution the necessary consensus for a clear identity and sense of purpose.

Despite the leadership vacuum, curriculum development went on apace. In the absence of activity on this front from the first and second directors, the author’s input to this process became the mainstay of the activity, and the curriculum was basically as I proposed. The first attempt at curriculum for 1991/92 was basically as described above, a series of courses from the Economic Academy repertoire. Coursework was limited to afternoons, as students needed to spend their mornings earning money to live on. The program was designed to continue as such over two years, ending with a master’s thesis. The second year of the program never got planned in any detail, however. This is due to the process described above in which it became clear in the spring of 1992 that the curriculum would undergo extensive changes.

The activity which gave the coup de grace to the old curriculum was a problem based course which came about because the author convinced directors that something drastic needed to happen if we were move in the right direction in bringing about relevant management competencies among our students. With short notice, the curriculum was altered so that more than half of the remaining curriculum was devoted to a problem solving course in which students were teamed with hospital directors to identify priority problems which needed attention. The course was beset with a number of problems predicated by the fact that none of the Poles had experience with the small group teaching method. The author’s activity in the classroom context was effectively excluded because of the language problem. With constant coaching of directors , however, the course succeeded at least to the extent that the school was able to give the students a clear picture of the problems they would be facing when assuming management responsibilities. This opened many minds and turned off a few others, in that we lost several students apparently did not think the problems thus presented were what they wanted to work with. The course also succeeded, in spite of many beginner problems, to convince a critical mass of the faculty that the method was a needed addition to the more traditional lecture and seminar activities.

The basic concept of the course was to have a problem identified by a hospital director, research the problem through library activities, site visits and meetings with implicated stakeholders and write up of a decision memo as the main basis for student assessment. See figure 1 for the ideology behind this work. Students worked in groups of from three to seven and presented their memos in groups of two or three. The presentation groups were asked to identify each their own sub-facet of the problem in order to facilitate individual student assessment. Approx. half of the students did well in this exercise and slightly less than half very poorly. The latter were told that they would have to redo their memos for handing in after the summer break.

Figure 1

This course became the main experience base for the planning of a series of problem solving courses or case studies which became the backbone of the new curriculum. The most important conclusion derived from the experience of the first year of the school was that the course load would have to be expanded if there was any hope of producing competent graduates. This led to the development of a full-time curriculum which was made possible by the development of the loan program described above. The basic concept of the program was as illustrated below:

The configuration was problem solving courses in the mornings followed by a 3 hour break in which the students were expected to find literature, carry out meetings, etc. and take their lunch break. In the afternoons, basic skills courses are run. The idea with the basic skills courses, which cover areas such as basic accounting, statistical methodology, population dynamics, behavioral management psychology, etc., was to coordinate the highest possible degree of concordance with the material being covered and the knowledge needed to solve the problems in the problem-solving courses. This strategy was only moderately successful, since some of the basic skills faculty were not involved in problem solving courses and not all of the basic skills areas were appropriately covered in case studies. The summarized result of this structural problem was that the grand design of the program was less clear than desirable with the resultant difficulties in documenting and consensus building.

Curriculum planning was slow and laborious, planned several weeks in advance rather than a semester or a year in advance. This was one of the reasons for the lacking catalogue mentioned above. The author was not optimistic that a standard catalogue would be ready for the 1993/94 academic year, but with continued pressure, this could have worked out for the 1994/95 academic year.

The curriculum consisted of both mandatory courses and electives in a four-quarter system. The first three quarters consisted mainly of mandatory courses and the fourth quarter allowed about half time in electives, for a total of 2 or 3 electives. It was not possible to expand this in the face of stiff competition from older faculty who were generally opposed to the concept. The second year, however, was almost entirely devoted to elective activities. This was designed to be an arrangement with a selected institution from which the students would be receiving wages for their work as what probably in most cases would have been a form of resident management consultant. Problems with doable solutions under a one-year time frame would have been defined in collaboration between the institutional leaders, school faculty and the students. The students would spend approximately one week per month in residence at the school and the rest of their time at the institution. The end product would be the production of a thesis which took one of three basic configurations:

o          1-3 English language articles publishable in peer reviewed journals concerning projects done at institutions, evaluation based on acceptance for publication;

o          report of project(s) completion which after publication were teaching materials for the field, evaluation based on adaptability of material for coursework and comprehensiveness of the literature review;

o          a fully developed project protocol intended for use in fund-raising/budgeting, evaluation based on completeness and operationalization level of plans.

5.1. Short courses

The various programs targeting the development of health services management education in Eastern Europe had concentrated primarily in the provision of continuing education (CE) courses for practising managers. This had been driven by the logic that the current managers were not able to cope with their roles and therefore must take first priority for training. The downside of this focus was first that the staying power of CE effects among practising managers was low because of high turnover rates in the field, and second that the lack of qualified managers in the systems was by logical inference highly correlated to the lack of specific training in the field. The focus of the school has primarily been to get the career program going rather than focus on CE. It remained to be seen whether the critical indicator of this strategy, i.e. the success of the graduates as managers, would endorse it or damn it. At any rate, the school concentrated most of its resources on the planning and implementation of the fulltime program. There had been much pressure on the school to develop CE activities, and the director overcame earlier constraints.. CE activities started in earnest in the beginning of 1993.

Accounting in the Polish health care system was undergoing fundamental changes, and there was a huge need for training accounting personnel to handle the new rules. The school offered a series of short courses tailored to that issue. Short courses were also offered on statistical methodology, financial and cost accounting, computing and specialized management courses, e.g. time management, meeting leadership, etc. Finally, it turned into part-time two year program for working health care managers, one year program for pharmacy inspectors and one year program in health promotion.

6. Research and Consulting

The need for health services research in Eastern Europe was acute. There was no decent data available concerning the effectiveness of programs, the quality of hospital services, satisfaction of patients, flow of finances in the system and a host of other questions. The lack of this information was such that it was virtually impossible to give a clear idea of system function and the assessment of whether decisions were relative to any defined optimum. The situation was predicated by a glaringly unmet demand in the available funding for health services research. On the other hand, MoH usually said that there was money available for any reasonable project. This was to a large extent also the way that most of the current research and consulting projects had been funded, i.e. the individual with the idea talks to MoH and the project gets funded. Besides the obvious potential for misuse of this method, there have been extreme delays in getting project money into school accounts. Monies allocated to projects for the full calendar year 1992 under the national research fund have thus been made available in the beginning of December, 1992 for use before the end of 1992. This situation appeared to be mainly correlated to the lack of qualified middle level personnel at MoH, the improvement of which was not a priority for anyone at the ministry level.

Meetings on the Sucha Beskidska hospital projects led to an increased understanding of what needed to be done, but the concrete implementation of useful work remained to get moving. It slowly but surely got rolling on surveys and data compilation work designed to complete some of the information which was at the time available for analysis. The author was, however, very sceptical of the possibilities for meaningful results from the Sucha  Beskidska project, and it was therefore not prioritized.

The MoH was somewhat impatient with regard to seeing results from its investment of time and channelling of funds to the school. They seemed to be of the opinion that the school had had enough time to produce useful results. The author told them that one year is nothing in this context, and that they needed to be prepared to wait two or three years  before anything really useful was developed.

7. Hospital projects, etc.

The management information system (MIS) project had received financial support from the MoH, and it should have been possible to reach some concrete results in that area in short order. The journal systems, accounting systems and facility management systems were all paper based at the time, with a gargantuan paper filing system. There was still a huge gap between the level of understanding which exists among the active staff and the level needed. The author put together a plan for upgrading this which could be useful in a proposal for funding in this area. With regard to other sources of support, the project drew attention from various sources, the most concrete of which was a Danish consortium interested in using the Cracow project as a pilot for running a non-profit organization and marketing know-how in the health care management area. The Danish group was represented by the author in Cracow.

Further devleopments:

Graduates of the school were expected to be active change agents within hospital and health services administration in Poland. The school participated actively in the development of modern management methods and staff in close collaboration with health care delivery institutions in Cracow and in Poland. Education of the students provided a simultaneous learning laboratory for the students, managers and school faculty.

From the time of the resident advisor, the school developed management and research programs in the fields of pharmacy inspection (started in academic year 1992/93), health behaviour and promotion (came on line for the academic year 1993/94, and environmental health (came on line for the academic year 1994/95). Short courses in epidemiology and statistics were being offered. The long range target of the school was to become a full fledged teaching and research institution to serve as a model for similar institutions in Eastern and Central Europe.

The research and consulting profile of the school was also under development with major projects coming on line. The most important are:

-           a cross-sectional analysis of current trends and synthesis of improvement strategies/guidelines in hospital management;

-           a project aimed at generating a MIS/HIS proposal for the region of Cracow and seek funds for its development,

-           the development and assessment of a health promotion program to reduce the number of poisonous mushroom intoxications in Poland,

-           the establishment of further documentation of cost centers and especially a more flexible reporting system in hospital services,

-           work related stress in intensive care wards and ways to combat it, and

-           the creation of a new professional organization for general practitioners and a set of practice functions to be used in general practitioner development projects supported by PHARE (the EU program).

A. Education

At the end of 1993, the projection was that the school would cement the commitment of the faculty to the student centered, problem solving and community oriented educational paradigm from which the project drew its developmental strategy. The current curriculum model would remain intact, but there would be numerous additions and changes. My impression was that this would follow the path of more numerous electives and greater student autonomy.

The gaps in faculty expertise and the external support systems for faculty, student, curriculum and school infrastructure development were well documented, and a long-term plan of action for developing a high-quality resolution of these issues was prepared by the author. Significant advances in these areas were achieved through intensive study, workshop and exchange programs, and faculty infrastructure issues were resolved at least preliminarily. The role of the school in developing national and regional responses to pressing policy and management issues became clarified. The progress of the students in the first two years of study was assessed. A plan for a self-containing support system for students comprised of stipends, loans and work/study was developed and at least partially implemented.

B. Consulting/Research

Cost accounting in the current budgetary situation: Two major projects were underway. One was being conducted based on a preliminary study at the Cracow Polish/American Children's Hospital which documented the need for further information about fiscal movements in the hospital (e.g. in one day surgery system) in order to plan necessary changes in light of the new health institutions law and rising prices under falling revenues. A new accounting system was put in place, and its results were evaluated, funded by the Polish MoH. The second ran under the FFP funded Sucha Beskidska project. The strategy at the time was to attempt to modify a French system operational in a series of hospitals in the Lorraine region for use in the Sucha health system.

Cross-sectional analysis of current trends and synthesis of improvement strategies/guidelines in hospital management: The project described current management structures, including incentive systems, operations management, cost systems and information flow in Polish hospital settings, and was projected to produce improvement strategies and/or guidelines in the management sphere towards the end of the three year contract. Significant problems with communications between the hospital leadership and the active academics were worked out, and this was an important side effect. Funded by the Polish MoH.

Mushroom poisoning prevention campaign: This project was a health promotion initiative testing methods of interventions and researching their effectiveness. Also included in this project was the development of multi-media health promotion models. Funded by the Polish MoH.

Anti-smoking campaign, with first Polish video clips, with Miss Poland and Miss World, supported by MoH and published by Polish TV

General Practice models for Poland: This project was designed to implement a model program for general practice, a professional organization for general practice and an educational model for primary care. The project had ties to the school of public health although it at the time officially resided within the Medical Academy. Funded by EU PHARE funds via the Polish MoH.

Development of a regional health and management information system with the Cracow Voivod: This system was in the planning stages, with the minimum data set defined. The cost center concept for the system was the patient. By the end of 1993, the project would have been operational at the development and educational level, and the main body of resources needed were put in place. 

The school has since these first two years (1991-1993) developed into a full-fledged school of Public Health and as a member ASHPER has healthy relationships with like-minded institutions in Europe as well as in North America. The educational program has reverted to the mean, according to one professor from the school that the author spoke to some time ago. That is to say that the problem based, competency-based and community-oriented focus has quit being the top priority. It is clear to the author, that in order to maintain a high level of a problem based, competency-based and community-oriented focus, one must have a long-term commitment from a strong proponent of these concepts. The research focus of the school has developed richly, although the pedagogical focus of the early years has fallen by the wayside. Addressing these issues was the main focus of the CDC/HRSA faculty agency forum [6]. The final report from this activity led to the establishment of the Washington D.C. Public Health Foundation and the Council on Linkages in Public Health Practice, among many other remarkable initiatives that have as their main focus to better the health of target populations. There is no better way to achieve this than through a problem based, competency-based and community-oriented educational program.

References:

1. Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press
2. Bogdah N, Bloomfield J, Birch P, Ricketss W. Problem based learning: a review. Br J Hosp Med (Lond). 2017 Nov 2;78(11):C167-C170
3. Lee GB, Chiu AM Assessment and feedback methods in competency-based medical education. Ann Allergy Asthma Immunol. 2022 Mar;128(3):256-262.
4. Koh GC, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ. 2008 Jan 1;178(1):34-41.
5. Ali A. Community-oriented medical education and clinical training: comparison by medical students in hospitals. J Coll Physicians Surg Pak. 2012 Oct;22(10):622-6.
6. Sorensen A, Bialek R. The CDC/HRSA Public Health Faculty Agency Forum: Final Report, USF press, 1993