MD3150E Epidemiology,

Biostatistics and Public Health

Lecture 1

Ekaterine Cherkezishvili, MD, MPH

March 12, 2021
University of Georgia
• Education
A little about me
▫ MD from Tbilisi State Medical University
(Georgia)

▫ MPH from Kent State University, Ohio, US

• 6 year of clinical practice and 17 years of

public health experience  mostly in health
education, quality of health services,
monitoring and evaluation, continuous
professional development,
• Past and Current positions
• Teaching experience: development and
implementation of CPD courses in QI, Chronic
Care, Behavioral change, 6th semester at UG
Office Hours and Contact information

• Email: eka.cherkezishvili@ug.edu.ge (Best way

to reach me)
• MS Team chats, and discussion boards
• Mobile: 514443113
• FB : https://www.facebook.com/echerkezishvili
• Office hours:
▫ Friday 19:00-21:00
▫ Saturday 9:00-11-00
Syllabus Review
 Mandatory Textbook

https://www.cdc.gov/csels/dsepd/ss1978/index.html
Recommended Textbook
Teaching Style/Approach
• Less lecturing, more questions than answers
• A lot of class discussion and interaction
• Real-world and relevant examples and context
• Try to get you to think intelligently about the
issues

▫ Course and activities are designed to stimulate

thought and excitement, but also not “easy”
▫ Writing must be carefully drafted and error-free
 Think about what you write before you write it
▫ You are responsible for turning in all work when
it’s due.
Grading Components (tentative)

Point Breakdown
• Weekly Assignments/ quizzes 39 points
• Presentation 9 points
• Final Paper 12 points
• Final Exam 40 points
• TOTAL 100 points
 a ct i ve es
e A N D c t ivi ti
te nd anc s i o n s /a
a to r y at s d i sc us
Mand n i n c las
ti ci p a tio
par

Active Participation
 g y o u for
ch pre parin
n t s ea g an d
3 poi f or l ea rn i n
n e d
Desig
e e x a m.
th

Weekly assignments/ quizes

 12+9
poin
You
r rev ts
iew
and
diss
ectio
n of
a few
peer
revie
w ar
ticle
Final paper & presentation s
 12

Final Paper
• Individual PICO(T) project: Merge the evidence
from different types of studies to create
recommendations for patient care and clinical
practice

▫ Week 2: 1st draft of the background

▫ Week 4: Define you Clinical(Public Health,
Managerial) Question 
▫ Week 10: Methods and Literature Review Matrix
▫ Week 14: Final Paper 
 13

Academic integrity
 14

Academic integrity

https://libguides.library.kent.edu/tutorials 
 15
APA style is required for all essays/papers

• https://www.theclassroom.com/use-apa-formatting-college-writing-7221546.html

APA Resources
• https://libguides.library.kent.edu/apa/basics
• http://www.lib.usm.edu/help/tutorials/apa_tutoria
l/apa_intro/

• http://www.citationmachine.net/apa/cite-a-book
 40 p
oint
Com s
preh
Mul e
tiple nsive
c h oi
ce, T
/F a
n d ga
p s( s
h or t
a n sw
Final Exam ers)
 17

https://www.youtube.com/watch?v=-dmJSLNgjxo
 18

https://www.youtube.com/watch?v=AGm1Vrcuu6U
 19

Let’s agree on what we are talking about

“I Hate Definitions”
Benjamin Disraeli (British Prime Minister XIX century)
 20

Science & Research

Science is the search for truth, that is the

effort to understand the world: it involves
the rejection of bias, of dogma, of
revelation, but not the rejection of morality.

Linus Pauling

https://www.brainyquote.com/quotes/linus_pauling_539791
 21

Health
Health is a state of complete physical,
mental and social well-being and not
merely the absence of disease or infirmity.
Preamble to the Constitution of WHO as adopted by the
International Health Conference, New York, 19 June -
22 July 1946;

Health is the ability to adapt and manage physical,

mental and social challenges throughout life..
Huber, Machteld; Knottnerus, J. André; Green, Lawrence; Horst,
Henriëtte van der; Jadad, Alejandro R.; Kromhout, Daan;
Leonard, Brian; Lorig, Kate; Loureiro, Maria Isabel (2011-07-26).
"How should we define health?". BMJ. 343: d4163.
doi:10.1136/bmj.d4163. ISSN 0959-8138. PMID 21791490.
 22

All organized
measures to prevent
disease, promote
health, and prolong
life among the
population as a
whole.

http://www.wspha.org/
(WHO,2015)
 23

Core Public Health Disciplines

 24

We accomplished a lot…

http://www.cdc.gov/about/history/tengpha.htm
 25

But not enough to fulfill its mission

“Public health is a vital function that is in trouble… Public health in the United States
has been taken for granted, many public health issues have become inappropriately
politicized, and public health responsibilities have become so fragmented that
deliberate action is often difficult if not impossible...

The committee intends not to prescribe one best way of rescuing public health, but to
admonish the readers to get involved in their own communities in order to address
present dangers, now and for the sake of future generations”.
(IOM, 1988)
 26

But not enough to fulfill its mission

 27

But not enough to fulfill its mission

 28

Why Can we Step on the Moon and can’t solve

Basic Public Health Problems

http://www.think-in-colour.com.au/gallery/graphic-recording/wicked-problems_colour/
 29

WHO Health System Building Blocks

System Common
Characteristics
Self- Constantly Tightly
organizing changing linked

Governed
History
by Not-linear
dependent
feedback

Counter- Resistant
intuitive to change

http://apps.who.int/iris/handle/10665/44204
 30

Errors in Medicine

Estimated 44,000 Americans die

each year as a result of medical
errors.
More people die in a given year as a result
of medical errors than from motor vehicle
accidents (43,458), breast cancer (42,297),
or AIDS (16,516)

https://www.ncbi.nlm.nih.gov/books/NBK225182/pdf/Bookshelf_NBK225182.pdf 
 31

Historical example

• The great Russian poet Aleksandr Pushkin

(1799-1837) died 46 hours after being
wounded by a pistol shot in a duel. The
bullet penetrated the right pelvic bone,
continued through the lower abdomen, and
crushed the right part of the sacral bone. 
• Treatment:
▫ Application of ice on the wound
▫ Application of leeches (hirudotherapy)
▫ Narcotics for pain

https://shurigin.livejournal.com/789919.html
 32

McGlynn et al. NEJM 2003. “The quality of health care

delivered to adults in the U.S.”

• 439 indicators of clinical quality of care

• 30 acute and chronic conditions, plus prevention
• Medical records for 6712 patients
• Participants received 54.9% of scientifically
indicated care (Acute: 53.5%; Chronic: 56.1%;
Preventive: 54.9%)
• Conclusion: The “defect rate” in the technical
quality of American health care is approximately
45% © Institute for Healthcare Improvement
 33

Heath Care System

Between the health care we have and

the care we could have lies not just a
gap, but a chasm.

The current care systems cannot do the

job. Trying harder will not work.
Changing systems of care will.
(IOM, 2001)

http://toppun.com/Cool_Free_Stuff/Free_for_All/Free-Public-Health-Stuff/Free-Public-Health-Wallpapers/Free-Publi
c-Health-Computer-Desktop-Wallpaper-Health-Care-System-Unhealthy-1024.gif
 34

Aims for Quality Health Care System

 Safety
 Effectiveness
 Patient Centeredness
 Timeliness
 Efficiency
 Equity

Institute of Medicine, USA

What is the problem?

“The reality is straightforward. The power of existing

interventions is not matched by the power of health
systems to deliver them to those in greatest need, in a
comprehensive way, and at an adequate scale.”
—Margaret
Chan
Director General
World Health Organization

https://www.who.int/healthsystems/strate
gy/everybodys_business.pdf
35
Fundamental Concept of Improvement

“Every system is perfectly designed to achieve the

results it achieves. To receive new result you
need to change the system”

Paul Batalden,
Healthcare Improvement Institute
Boston, USA

36
 37

Lucy from Chocolate factory

https://www.youtube.com/watch?v=NkQ58I53mjk
 38

Red Bead Game

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/QI-
Games-The-Red-Bead-Experiment.aspx

Or https://www.youtube.com/watch?v=oMb_UKYHvto&feature=emb_logo (if you

Quality Improvement is not Quality Assurance

Quality Assurance Quality Improvement

Motivation Measuring compliance Continuously improving
with standards processes to meet
standards
Means Inspection Prevention
Attitude Required, defensive Chosen, proactive
Focus Outliers: “bad apples” Processes
Individuals Systems
Scope Medical provider Patient care
Responsibility Few All
The Framework for Health Care Quality
Improvement
 Evolution of a Group to a Team
Performing
cces s Concerns:success

t o su Are we learning?
Path How can we be
Norming most
Concerns:openness effective? What
What do you think? actions
Storming How can I help you? should we take?
Concerns:control How can I find out Relationships:
Forming open
What role should I more?
Concerns: Inclusion communication
play? Relationship:
Why am I here? support
Why is he/she taking Trust ideas/feelings
Do I want in? Consensus
charge? understanding
Will we be Activities:
Relationships: support
successful? learning
Conflict, emotional Activities:
Relationship: making decisions
argumentative Adopt rules
guarded supporting others
Activities: communication
basic information taking actions
confrontation gathering data
low trust
control conflicts confronting issues
Activities:
attempting to set giving feedback
introductions
rules
orientations
hidden agendas Institute for Healthcare Improvement
 Model for Improvement
What are we trying to accomplish?

How we will know that a change is an improvement?

What changes can we make that will result in improvement?

Plan

Key: Prediction!
Act Do

Study
Measures for Improvement
• Improvement is not equals
only indicators and their
results. At the same time
without measurement we will
never know if the change
lead to improvement
• In QI we need data for
learning and not to assign
the blame
 44

Donabedian Model
 Model for Improvement: Key Questions

Plan
Objective: what is change is tested?
Questions and predictions (Why?)
Plan to carry out the cycle (who, what, where, when)
Plan for data collection

Act Do
Are we ready to make a new test Carry out the plan
or change? Document problems and unexpected
Planning for next cycle? observations
Begin analysis of the data

Study
Complete the analysis of the data
Compare data to predictions and summarize learning
Complete the analysis of the data
 Building Knowledge with PDSA Tests

Breakthrough
Results

Wide scale
tests of change
Test under
new condition
Follow up test
Theories
And Best
Practices Very small scale
 Principles of Improvement

1. Understanding work in terms of processes and

systems
2. Team work
3. Focusing on patient needs
4. Testing and measuring changes
 48

Niger: AMTSL Compliance and PPH

Reduction
Thank you
Employee
Engagement
(…or lack thereof)