POTENTIAL SOLUTIONS TO COMMON QUALITY GAPS IN VOLUNTARY MEDICAL MALE CIRCUMCISION PROGRAMS

Transcription

1 health Department: Health REPUBLIC OF SOUTH AFRICA POTENTIAL SOLUTIONS TO COMMON QUALITY GAPS IN VOLUNTARY MEDICAL MALE CIRCUMCISION PROGRAMS A local guide explains the steps that have been taken to raise awareness about HIV in Soweto outside Johannesburg, South Africa 2010 Marisa Hast, Courtesy of Photoshare This document comprises recommendations from the Unites States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project for addressing challenges that are commonly experienced during the implementation of voluntary medical male circumcision (VMMC) programs. The quality gaps described and the associated recommendations are based on the experiences of ASSIST technical advisory staff working with service delivery sites on the improvement of VMMC service quality in South Africa. April 2017 This publication was prepared by University Research Co., LLC (URC) for review by USAID. The work described was conducted under the USAID ASSIST Project, which is made possible by the generous support of the American people through USAID. DISCLAIMER The contents of this publication are the sole responsibility of URC and do not necessarily reflect the views of USAID or the United States Government.

2 Potential to Common Quality Gaps in VMMC Programs Introduction Medical male circumcision (MMC) is an effective intervention for signifi cantly reducing the risk of female-to-male sexual transmission of HIV 1. Since 2007, the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) have recommended MMC as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision 2. In 2009, the WHO published standards for MMC service delivery, as well as tools for assessing MMC service quality 3. Continuous Quality Improvement Providing VMMC services that consistently comply with the standards defi ned by the WHO requires robust quality assurance and quality improvement at all levels. The USAID ASSIST Project works in more than 20 countries globally on building the capacity of service delivery organizations to improve the effectiveness, effi ciency, client-centeredness, safety, accessibility and equity of health and family services. The project applies and instils modern improvement methods to advance, strengthen and sustain quality healthcare and other services for vulnerable populations 4. ASSIST directly supports healthcare sites and implementing partners to integrate continuous quality improvement (CQI) into VMMC programs in six countries in Eastern and Southern Africa, namely Malawi, Mozambique, Namibia, South Africa, Tanzania and Uganda. Continuous quality improvement (CQI) is an ongoing process for assessing performance and working towards improving the quality of services to address a client s needs in an effective, responsive and respectful manner. Since May 2014, ASSIST has been focusing on providing CQI technical assistance to strengthen the capacity of implementing partners funded by Centers for Disease Control and Prevention (CDC) and US President s Emergency Plan for AIDS Relief (PEPFAR) to deliver high quality VMMC services in more than 120 sites across all nine provinces of South Africa. Signifi cant progress has been achieved and is substantiated by improvement in performance indicators, such as leadership and planning; management systems; monitoring and evaluation (M&E); registration and group education; individual counseling and testing; infrastructure, supplies, equipment and environment; surgical procedure; and infection prevention. VMMC Quality Gaps This publication presents potential solutions to the following quality gaps that are commonly encountered in VMMC programs: 1. Adverse events 2. Low client follow-up rates 3. Inconsistent observation of infection prevention and control 4. Inadequate demand generation 5. Lack of integration with other health programs 6. Inconsistent messaging to clients 7. Insuffi cient leadership involvement in quality improvement 1 Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, Available online at: 2 WHO Fact Sheet: Voluntary medical male circumcision for HIV prevention Available online at: sheet/en/ 3 Male Circumcision Services Quality Assessment Toolkit ISBN Available online at: qa_toolkit/en/ 4 2

3 1. ADVERSE EVENTS Potential to Common Quality Gaps in VMMC Programs Adverse events related to male circumcision are defined as any injury, harm or undesired outcomes occurring during or following male circumcision that would not have occurred if the client had not been circumcised 5. Adverse events are classifi ed into mild, moderate and severe and can occur as a result of multiple factors during surgery or device placement (e.g. anesthetic-related problems or penis disfi gurement) or after the procedure or placement of the device (e.g. wound infection or injury during device removal). VMMC sites are required to monitor, document and report adverse events. Rapid scale-up of VMMC has resulted in concerns regarding the management of adverse events, especially in resource limited settings and during peak circumcision seasons (in South Africa, the winter months generally show highest demand for VMMC, because of the belief that circumcision wounds heal faster in cold weather). When short-staffed facilities face large influxes of VMMC clients, attention to detail with reference to client safety might be compromised. Inconsistencies in identifying, recording, monitoring, handling and reporting of adverse events have been documented as areas requiring improvement across sites offering VMMC services in South Africa. and potential solutions to reduce VMMC adverse events: Minimal pre-procedure physical examination and client history taking Familiarize staff with all policies and procedures, including preprocedure requirements and documentation (e.g. vital signs, medical history) Inadequate post-operative monitoring Observe and follow vital signs of each client for at least 30 minutes after procedure Inconsistent post-operative counseling on wound care and abstinence Clients lack knowledge on adverse events and VMMC follow-up Insufficient training and/or clinical experience Lack of capacity to identify and manage adverse events Insufficient infection prevention and control measures Use job aids to ensure that key messages related to signs of complications, post-operative wound care, abstinence, compliance to folow-up, and emergency care are consistently covered Provide clients with written information related to wound care and possible signs of adverse events Validate qualifi cations and confirm that health workers have relevant background and experience Provide in-service training on adverse event identifi cation, classifi cation and management Ensure that site has trained staff and is equipped to attend to emergencies at all times Provide in-service training and refresher courses Educate staff and clients on post-surgical care and infection prevention Poor surveillance and documentation of adverse events Ensure availability and consistent use of standard registers for thoroughly documenting client particulars and data related to follow-up and adverse events Proper management of adverse events plays a crucial role in the successful implementation of VMMC. Policies, guidelines and quality standards provide direction to VMMC program implementers on improving and sustaining service quality and minimizing the occurrence of adverse events. Successful implementation of guidelines not only impacts positively on quality and safety, but also contributes to client satisfaction that in turn can lead to mobilization of more clients for VMMC and general public health services. 5 Adverse Event Action Guide for Voluntary Medical Male Circumcision by Surgery or Device - Second Edition, Available online at: www. malecircumcision.org/sites/default/fi les/document_library/adverse-event-action-guide-2nd-edition-14jul2016.pdf 3

4 2. LOW CLIENT FOLLOW-UP RATES Potential to Common Quality Gaps in VMMC Programs VMMC clients are advised to return to VMMC sites (or healthcare facilities) for follow-up visits to track progress on wound healing and to identify and manage possible adverse events. In addition, follow-up visits provide the opportunity to reinforce HIV prevention and risk reduction messages. Facilities offering VMMC services should develop and maintain mechanisms for recording, tracking and encouraging all clients circumcised to return for follow-up. Many countries recommend three VMMC follow up visits: at 48 hours, at seven days and at six weeks relative to surgery 6. VMMC sites are expected to record and continuously analyze client follow-up data. This can support the identifi cation of service gaps and improvement of the safety and quality of VMMC services. In VMMC programs in South Africa, CQI assessments have identifi ed disparities between the number of clients circumcised and the number of clients returning for follow-up visits, due to various reasons. The table below lists some common challenges and potential solutions to address poor client follow-up. and potential solutions to improve VMMC client follow-up: Difficult to track clients due to poor records/lack of data to report on follow-up Lack of communication between service delivery sites - in cases where clients are referred for follow-up Insufficient and/or inconsistent messaging to clients regarding the importance of follow-up Clients forget/are reluctant to present for follow-up Clients face challenges related to distance, transport and costs incurred to travel to a facility to access follow-up services Clients cannot get to VMMC facilities during hours of operation (usually regular business hours) Implement standard operating procedures (SOPs) and registers for thoroughly documenting client data, including contact details, contact details of next of kin, and client follow-up dates Foster collaboration and participation with referral sites to ensure: systematic data sharing active follow-up strategies effective coordination of campaigns/outreach events regular quality review meetings Provide clients with information related to wound care and followup in: client s home language if possible the presence of parents/guardians/partners the form of written appointment cards that clearly list dates Provide clients with written appointment cards that clearly list return dates Make phone calls or send WhatsApp/text messages to remind clients Incorporate reminders related to the importance of follow-up into demand creation messages, so that previous VMMC clients are prompted for follow-up through ongoing VMMC campaigns Send roaming/mobile teams to do follow-up at specific venues (especially after campaigns) Provide client transport where feasible Keep sites open for extended hours to accommodate follow-up at times that might better suit full-time employees Because of the direct impact of VMMC client follow-up on the reduction of adverse events, good follow-up rates and accurate records are vital for effi cient and high quality VMMC programs. 6 PEPFAR Guide to Monitoring & Reporting Voluntary Medical Male Circumcision (VMMC) Indicators version 1,2013.Available online at: malecircumcision.org/sites/default/fi les/document_library/pepfar_guide_to_monitoring_and_reporting_vmmc_indicators_main.pdf 4

5 Potential to Common Quality Gaps in VMMC Programs 3. INCONSISTENT OBSERVATION OF INFECTION PREVENTION AND CONTROL Infection prevention and control (IPC) measures are a combination of interventions and activities, ranging from hand hygiene, aseptic technique, waste management, rational antibiotic use, cleaning and the use of chemical cleaning agents, pest and rodent control, food handling, linen handling and management, isolation, surveillance, risk management, the use of personal protective equipment, immunization programs and personal hygiene 7. To ensure a safe environment for patients and staff, it is the responsibility of healthcare facility management to adopt and consistently implement IPC policies and measures. Findings from continuous quality improvement assessments conducted in South Africa indicate that VMMC facilities often fi nd it diffi cult to consistently comply with IPC guidelines, ranging from poor handwashing to the absence of personal protective equipment, thus compromising the safety of patients and staff and impacting negatively on the quality of services offered. and potential solutions to improve IPC: Lack of documented IPC guidelines Lack of knowledge and capacity to manage consistent implementation of IPC Insufficient and/or inconsistent messaging to clients regarding infection prevention Inconsistent supply of cleaning agents and protective equipment Inadequate use of disinfectants during cleaning Poor scrubbing techniques Lack of handwashing between procedures Inconsistent use of personal protective equipment Poor waste disposal procedures Institutionalize policies and implement standard operating procedures (SOPs) for IPC Familiarize staff with IPC guidance Provide ongoing/in-service training for staff on IPC Encourage site to form committees to mentor staff and oversee IPC processes Ensure that site is adequately staffed to implement IPC at all times Ensure availability of IPC job-aids and education materials for client counseling Supply VMMC clients with verbal as well as written instructions regarding wound care and personal hygiene Ensure effective communication with providers Clearly identify roles, responsibilities and timelines for placing orders/submitting requests for supplies Continuously reiterate importance of IPC during team meetings and informal interaction Ensure availability and visibility of IPC guidelines and job-aids Set timelines and assign responsibilities to implement improvement plans Conduct routine inspections to monitor IPC interventions and activities IPC is vital for the successful implementation of healthcare programs, including VMMC. Policies, guidelines and quality standards provide direction to VMMC program implementers on reducing risk and managing infections. 7 South Africa National Department of Health: Infection Prevention and Control Policy & Strategy, Available online at 5

6 Potential to Common Quality Gaps in VMMC Programs 4. INADEQUATE DEMAND GENERATION Demand generation for VMMC includes various approaches aimed at motivating strategically important target groups to present for VMMC. VMMC demand generation efforts may be hampered by the fact that men are less likely than women to seek healthcare as well as various cultural and religious signifi cance and sensitivity around circumcision. Platforms employed for VMMC demand generation include television, radio, print media, community mobilization, school-based advocacy, road shows and household campaigns. To ensure that supply is aligned with demand, collaboration between service delivery and demand generation is critical. When demand for services is not properly matched with supply, it can lead to long waiting times for clients or clients being turned away. This can impact negatively on client experience and deter clients from referring their peers for circumcision. With country-wide scale-up of VMMC in South Africa, demand generation remains pivotal for aligning demand with investment in service delivery. and potential solutions to improve demand generation: Lack of coordination between service delivery and outreach/mobilization Failure of targeting women (sexual partners/mothers) as key infl uencers Seasonality - perception that circumcision wounds heal faster during winter Access to services, due to economic and structural barriers Lack in standardization of mobilizer training Low mobilizer morale because of poor compensation and lack of recognition Lack of site usage data and analysis of site capacity that should be used to inform site operations Disconnect between HIV counseling and testing (HCT) sites and VMMC sites Lack of age-specific communication and waiting areas Establish and sustain good relationships and frequent communication with the relevant demand generation partners Engage women as influencers Promote messages linked to benefits of VMMC for female sexual partners Include images of both women and men on educational and demand-creation materials Run VMMC demand generation campaigns year-round Promote testimonials from off-season clients on healing Train practitioners to counteract bias related to seasonality Arrange transport for clients to site Offer mobile services that take VMMC to where the target groups are, e.g. tertiary education institutions, work places, etc. Extend VMMC service hours on certain days of the week to accommodate full-time workers Ensure complete and consistent messages through standardizing mobilizer training and job aids Fairly compensate mobilizers Offer routine supervision and performance management to mobilizers Involve mobilizers in strategic planning to reach targets Strengthen monitoring and use of data to inform demand generation activities Exhort HCT sites as referral points for HIV negative men into VMMC services Separate waiting areas and group education by age group, so that men are grouped into sessions with their peers Understand and address age-specific barriers and motivators In order to scale up and sustain VMMC, a comprehensive service delivery package designed to address quality, volume and effi ciency is essential. 6

7 Potential to Common Quality Gaps in VMMC Programs 5. LACK OF INTEGRATION WITH OTHER HEALTH PROGRAMS Integrated care holds remarkable potential to reduce cost and improve healthcare accessibility, quality and effi ciency. Linkages and referral of men for VMMC from other programs allows the circumcision program to leverage inward referral, or pull factors and ensure the provision of comprehensive services, including health screening. Building relationships with HIV treatment programs offered at facility-level provides opportunities for HIV testing and treatment programs to ensure active referral of men or push factors, as well as integration with ongoing health programs. Even though VMMC forms part of the South African National Strategic Plan for HIV, TB and STIs , VMMC services have not been consistently integrated into general primary healthcare. VMMC is often viewed as a separate service provided by non-profi t partners and functioning in parallel with the Department of Health. This hampers a client-centered approach, effective referrals and continuous client care. and potential solutions to advance the integration of services: Lack of integrated healthcare strategy Confusion related to roles in provision of services, accountability and ownership Pre-existing divisions in management, infrastructure and financing Develop an integration framework with support from various stakeholders Governmental leadership can guide the implementation of an integrated care model Familiarize staff with integrated care model Provide ongoing/in-service training for staff on service integration Form committees to mentor staff and oversee integration processes Emphasize a client-centered approach Establish leadership coalitions Allocate funding for service integration Share data and client records in uniform and coordinated way to enable access across the continuum of care Integration of VMMC with other healthcare programs can streamline services and improve client-centeredness and overall service quality. It also supports improved health outcomes through potential of early diagnosis and efficient access to diverse health services regardless of point of entry into the health system. 7

8 Potential to Common Quality Gaps in VMMC Programs 6. INCONSISTENT MESSAGING TO CLIENTS VMMC services offer a unique opportunity to engage adolescent and adult males in high-quality HIV prevention communication and services, and to share key messages with males who otherwise might not interact with the health system 8. Consistent communication and counseling throughout VMMC services is critical for capitalizing on this opportunity. Clients seeking VMMC services should be well informed regarding basic HIV facts (e.g. modes of transmission, risk reduction, VMMC partial protection), health benefi ts of VMMC, VMMC procedure (different VMMC options, e.g. surgical, device and associated benefi ts and risks), post-operative care (importance of abstinence after VMMC, healing period, signs of complications, emergency measures, compliance with follow-up, instructions on wound care and hygiene) and condom demonstration. It is important for facilities offering VMMC services to standardize information and education on HIV and VMMC during group education and individual counseling sessions. Boys below the age of sexual maturation should be grouped separately from sexually mature adolescents and men. It is recommended that group education be followed by individual counseling sessions to allow clients to ask questions. and potential solutions to improve in-service communication: Varied VMMC and HIV messages presented to clients across VMMC sites and different counselors/mobilizers (even at same site) Materials not available and/or counselors not fluent in client s mother tongue Non-HIV VMMC benefits, such as hygiene, are often missing from materials these benefi ts can be strong motivators for VMMC Provide VMMC staff (including mobilizers, counselors, clinical teams) with training, guidance and tools covering the scope and delivery of information related to relevant topics Equip staff with core set of HIV and VMMC information and associated job aids, e.g. checklists of topics to cover during demand generation, group education, counseling and client follow-up When feasible, ensure that messages are translated to local languages Have interpreter available during counseling sessions Provide information to clients in presence of parents/ guardians/partners Develop materials to cover the following comprehensively: VMMC benefi ts and limitations Potential VMMC risks Post-procedure care Follow-up HIV facts Sexual risk reduction and condom use Consistent messaging related to VMMC benefits, limitations and post-procedure care, as well as HIV prevention are vital for client safety and creating demand for services. 8 PEPFAR Voluntary Medical Male Circumcision In-service Communication Best Practices Guide Health Communication Capacity Collaborative. Available online at: 8

9 Potential to Common Quality Gaps in VMMC Programs 7. INSUFFICIENT LEADERSHIP INVOLVEMENT IN QUALITY IMPROVEMENT It has been noted that facility staff respond more positively to quality improvement efforts when senior managers are informed, dedicated and committed. Leading by example, senior managers can build trust with staff and create a corporate culture for improved and consistent service quality. In addition to senior management, the hospital board/clinic committee can play an important role in adopting continuous quality improvement by allocating fi nancial resources and linking quality services with the facility s strategic objectives. and potential solutions to improve leadership involvement: Insufficient knowledge of, involvement in, and support for quality assurance and quality improvement Inadequate involvement of facility leadership in day-to-day operations and quality of services Lack of ownership and accountability Lack of mechanisms and processes to plan and prioritize tasks Arrange quality assurance and quality improvement sensitization/trainings for facility managers and board members Brief facility management and board on quality improvement and its return on investment, i.e. improved patient outcomes and staff fulfi lment Engage facility management in all quality improvement activities, including assessments Share assessment fi ndings with leadership and inspire buy-in through involving them in action planning to address gaps/ needs Ensure continuous communication with facility leadership regarding quality improvement efforts Conduct regular meetings between VMMC program staff and management Foster a culture for quality improvement by linking it to the facility s mission and strategic objectives Include VMMC service quality as standing agenda item for hospital board/clinic committee meetings Support the development of operational plans, and budgets where applicable, for service delivery, staffi ng, commodities, quality improvement, community involvement and M&E Document plans and adopt tools for prioritizing tasks and monitoring impact Management buy-in and involvement is vital for the sustainability and institutionalization of quality improvement in VMMC services. 9

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