External reviews open doors to big changes
Warning: Not for the faint-hearted, fans warn
Wisconsin got one — and for the first time, the TB control program got itself a TB nurse, a part-time TB physician consultant, and a terrific new system for delivering medications, says Tanya Oemig, director of the state TB control program.
Virginia got one last year. Since then, the state TB program has been busy pushing through a series of "profound changes in the way we’re structured,"enthuses Ram Koppaka, MD, the state TB program’s public health adviser.
Mississippi got one, and presto! There was universal DOT across the land! OK, that’s an exaggeration — but not by much, says state TB division director Mike Holcombe, MPH, MPPA.
Nearly every state TB control program that has commissioned an external program review agrees the process has potentially big rewards. But external reviews are not for wimps and weaklings, fans of the process caution. For one thing, your report card may conclude that your program has got it all wrong.
Plus, getting a review approved and carried out is just the start, says Virginia’s Koppaka; the heavy lifting comes when it’s time to plug in all those recommendations.
Despite the hazards and the hard work, Koppaka, Holcombe, and Oemig all agree that the reviews afford leverage required to pull off big-scale transformations.
"Many times over the past year, we’ve said, The program reviewers said to do this,’" Koppaka says. "It’s helped us get a lot of stuff pushed through that otherwise we probably wouldn’t have been able to do at all."
The team that carried out Virginia’s review included Holcombe; Carol Pozsik, RN, MPH, director of South Carolina’s Division of TB Control in Columbia; Phil Hopewell, MD, associate dean of San Francisco General Hospital and professor of medicine at the University of California, San Francisco; Brenda Ashkar, RN, MSN, PHN, former nursing director for Los Angeles County TB Control; and Sue Etkind, RN, director of the Massachusetts Division of TB Control in Boston.
Masterminding the whole process was Russ Hansen, the genial TB health educator and TB advocate for the Virginia chapter of the American Lung Association.
The cumulative impact of so much expertise in one place is considerable, Hansen says. "When Phil Hopewell, this internationally known TB expert, walks into the health commissioner’s office, people definitely sit up and take notice," he says.
Hansen, it turns out, acts as front man for lots of the reviews, and the Virginia team members are much sought after as reviewers. Though Hansen’s job description says nothing about organizing reviews, he’s been doing it since he retired six years ago from the Division of TB Elimination (DTBE) at the Centers for Disease Control and Prevention in Atlanta.
Hansen says team members are drawn from an informal slate of 10 or so people who have become known as those willing to do the reviews. The ones who are available usually fill the slots, he adds.
Once upon a time, reviews were largely carried out by the DTBE, says Hansen. That changed in the early 1990s when the TB resurgence hit; suddenly, the CDC’s TB experts had their hands full. Hansen made it known that he was willing to fill the gap. Because he had several decades of experience with TB program operations under his belt by the time he retired six years ago, he was a logical choice for people to call.
Drivers who know lay of the land
The review process begins with about six weeks’ worth of advance preparation, Hansen says. Next, the team of reviewers flies in and begins an intensive week’s worth of work on-site. Once on the ground, teams like having someone from the program provide chauffeur services — both for the opportunity to find out more about the program and to avoid getting lost.
Reviewers use "Essential Components of a TB Control Program," the venerable and thoroughly objective 1994 CDC document, as their measuring stick.
After the site visit, two more weeks are devoted to writing up findings and recommendations. The cost for the entire process runs from $10,000 to $20,000, which covers travel expenses, meals, and modest honoraria for team members. "No one’s going to pay for their retirement with these kinds of fees," stresses Hansen.
Reasons for requesting a review are varied. In both Wisconsin and Virginia, TB programs were poised at transitional moments, with both Oemig and Koppaka wanting to start their jobs with a fresh slate of ideas. "Sometimes we get so busy shuffling paper, we can’t see the forest for the trees," says Holcombe.
In other instances, TB program leaders have a specific agenda they’re trying to push, or an issue they want examined more closely, says Hansen. "They could have some issue related to nursing, or clinics, or outreach; or maybe a program is considering going more to private providers." At such times, it helps to have someone from outside make the recommendations, he adds.
Holcombe agrees. "Having an outside expert come in and say the same thing you’ve been saying for years carries a lot of weight," he says. "And you have this document you can hold up in a budget or a legislative conference. It’s not just you, a lowly employee; it’s some high-powered expert. People definitely respond to that."
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