Not enough guidelines? CA offers some more
Rule-making sessions produce more than paper
With California’s recent announcement that it would publish its own set of TB guidelines has come a surprisingly positive by-product: Instead of cranking out yet another pile of rules for harried TB controllers to read, the state’s rule-making sessions have served to build consensus and generate buy-in, TB experts in the state say.
As TB control gets increasingly complicated, guidelines get more layered and nuanced. As one way to head off divisiveness or, maybe even worse, indifference, rule-making bodies seem to be opting for more democracy and less dictatorship.
Take the national preventive therapy guidelines now being crafted by the Centers for Disease Control and Prevention (CDC) in Atlanta and the American Thoracic Society (ATS) in New York City. Rule makers knew ahead of time the guidelines would have to cover some controversial and complicated ground. So they decided to invite more people than usual to be part of the process and then let the resulting squabbles continue longer than normal.
"In the end, of course, it does come down a fiat from high," notes David Cohn, MD, associate director of Denver Public Health and one of the chief attendants to the fractious birthing process of the new preventive therapy guidelines. "But there has never been a CDC or ATS statement that’s had so much input from so many people at so many different levels. You know going in that you’re not going to be able to please all of the people all of the time. But it’s like pay now, or you pay later."
In California, the need to get all the TB control players together and talking was definitely a driving force, say some of the players.
"This was about building a consensus among the TB control community," says Jayne Ash, RN, director of the California Tuberculosis Control lers’ Association (CTCA). "It’s about getting people from across the entire spectrum to sit down in one room and hash things out. When you think about it, that’s quite an accomplishment." The state TB guidelines were co-written by the state department of health and the CTCA, with the second organization taking the lead, Ash says.
Sure, democracy can be messy. But another point in favor of bringing everyone into the room is that it gets people thinking and listening, says Selma Abinader, MEd, director of strategic planning for the state TB control division. "It’s been years since some jurisdictions have done any TB treatment," she points out. "In other jurisdictions, we’re grappling with massive TB-related issues."
The fact that TB control in the state is decentralized provides extra-powerful incentive for building consensus, says Ash. "We can’t simply register edicts from on high like some state TB divisions do," she says. "We have to get people from state and local jurisdictions to sit down together and agree."
The state’s size and complexity also make getting consensus and buy-in very important. "The size of this state makes it unique. So does the scope of situations in which TB control is practiced," says Abinader. "There’s Los Angeles, as big as some states all by itself, with multiple regions within one county, and at the other end of the spectrum, there are tiny, rural counties where they have no dedicated TB staff at all."
Getting all the players together may reflect on their roles, too, says Abinader. "It’s a great way to get folks from correctional institutions, refugee health, and the private sector all to the table, where it becomes clear what they do and what everyone else does."
Screening guidelines revised
The guidelines grew out of a summit intended to draft a five-year state strategic plan for TB control. CTCA has assumed leadership for developing the state guidelines and has formed working groups, one of which is revising screening guidelines. "It’s an ongoing process," says Ash.
The next guideline-crunching session should tackle the issue of elimination, Abinader says. When the strategic plan was developed in 1994, "we decided not to say anything about a target date, just to beef up the infrastructure," she says. As a kick-off, two conferences are planned — one this fall and a second in the spring — on elimination-related issues.
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