AIDS 2016 SATELLITE SESSION

Transcription

1 AIDS 2016 SATELLITE SESSION Voluntary Medical Male Circumcision Quality Assurance and Quality Improvement: Lessons Learned from East and Southern Africa July 21, :30pm 8:30pm SAST Co-chaired by Dr. Yogan Pillay and Dr. Emmanuel Njeuhmeli 1

2 Welcome CO-CHAIRS Dr. Yogan Pillay Deputy Director General National Department of Health, Republic of South Africa Dr. Emmanuel Njeuhmeli Senior Biomedical Prevention Advisor USAID Office of HIV/AIDS 2

3 Welcome and Opening Remarks PRESENTATIONS Applying External Quality Assessment and Continuous Quality Improvement to VMMC Addressing Key Quality Gaps in VMMC: Strategies and Results Improving Efficiency through Site Utilization/Capacity Assessments Q & A on Presentations SHORT FILM A Finer Cut: South Africa s Journey to Improve Quality in VMMC PANEL DISCUSSION Scaling Up and Sustaining Quality VMMC Programs: Lessons and Implications for Other Programs Q & A for Panelists Closing Remarks Dr. Yogan Pillay, NDOH, South Africa Dr. Donna Jacobs, URC, Southern Africa Dr. John Byabagambi, URC, Uganda Dr. James Ndirangu, URC, Southern Africa Moderated by Dr. Yogan Pillay Introduced by Dr. Isaac Choge, USAID, South Africa Moderated by Dr. Emmanuel Njeuhmeli, USAID Panelists: Dr. Alex Opio, MOH, Uganda Mr. Isaac Ngomane, Mpumalanga Provincial DOH, South Africa Dr. Shephard Maphisa, Dr. Maphisa & Partners, South Africa Dr. Wendell Isaacs, TB/HIV Care Association, South Africa Moderated by Dr. Emmanuel Njeuhmeli, USAID Dr. Yogan Pillay, NDOH, South Africa

4 Applying External Quality Assessment (EQA) and Continuous Quality Improvement (CQI) to VMMC Dr. Donna Jacobs Regional Director for Southern Africa USAID ASSIST Project, University Research Co., LLC (URC) 4

5 What is quality? Interpersonal relations Effectiveness Technical performance Knowledge Safety Choice Reliability QUALITY Comfort Physical infrastructure Consistency Continuity Access to services Efficiency Commitment Doing the right thing, right, the first time. Doing it better the next time, within the available resources, and to the satisfaction of the community. - ODI Consulting 5

6 Quality assurance vs. quality improvement CQI QUALITY ASSURANCE Full cycle of activities and systems for maintaining the quality of patient care. Generally associated with the monitoring of compliance with standards. ACT STUDY PLAN DO EQA SIMS QUALITY IMPROVEMENT The combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development 6

7 Purpose of QA and QI support to VMMC programs Describe existing VMMC delivery services or practices Use the findings to determine sites eligible for the various types of intervention (intense, light, annual support) Guide the development and support the implementation of appropriate quality improvement actions Build the capacity of managers and staff to continuously improve VMMC service quality Improve quality of services, patient safety and outcomes 7

8 External quality assessment (EQA) tools for VMMC A. SOPs, guidelines, policies B. Facilities, supplies and equipment C. Clinic record review D. Emergency management E. Adequacy of staffing F. Surgical equipment and procedures G. Communication to clients H. PrePex procedures I. Site utilization / Site efficiency (public health impact and efficiency) 8

9 Examples of VMMC EQA dashboards Swaziland (4 sites) Zimbabwe (5 sites) Tool Description Achievement Score Tool Description Overall Tool A SOPs, Guidelines, Policies & Job Aids 100.0% Tool A SOPs, Guidelines, Policies & Job Aids 97.3% Tool B Facility, Supplies & Equipment 88.2% Tool C Client Record Review 94.1% Tool D Emergencies Management 90.5% Tool E Adequacy of Staff 100.0% Tool F Surgical Equipment & Procedure 94.8% Tool G Communication to clients 76.6% Tool H PrePex Procedure N/A Overall achievement 92.0% Tool B Facility, Supplies & Equipment 89.2% Tool C Client Record Review 98.2% Tool D Emergencies Management 85.0% Tool E Adequacy of Staff 93.5% Tool F Surgical Equipment & Procedure 89.5% Tool G Communication to clients 85.2% Tool H PrePex Procedure 92.8% Overall achievement 91.3% *Performance Score : = >85%+: (Good); 70%- 85% (Fair); <70% (Poor) 9

10 VMMC EQA app Real-time collection and analysis of data Multiple inputs simultaneously off line and online capabilities Faster feedback to facilities for action planning Generation of various reports (EQA dashboard / Site utilization analysis) Faster generation of facility-level and country-level reports (3 weeks vs. 12 months) Generation of stand-alone SIMS reports for facilities that have been assessed 10

11 Continuous quality improvement (CQI) in VMMC service delivery Rapid testing of changes to improve care at the point of service delivery and ongoing measurement to assess performance Model for Improvement What are we trying to accomplish? How will we know that change is improvement? What changes can we make that will result in improvement? CQI led by site staff, often with coaching support from MOH and IP ACT PLAN Addresses all points of VMMC continuum of care to ensure high-quality care that is effective, responsive, and respectful STUDY DO Adapted from Associates in Process Improvement,

12 CQI approach applied to VMMC Comparison of performance against standards National policy, guidelines and standards WHO guidelines, adapted to local context Across 7 (8) program areas and 56 (60) standards Leadership and planning (South Africa) Management systems Supplies, equipment and environment (infrastructure) Registration, group education and IEC Individual counseling and HIV testing for VMMC clients Male circumcision surgical procedure Monitoring and evaluation Infection prevention & waste management 12

13 Steps in the VMMC CQI process Stakeholder engagement, select sites and identify coaches Local adaptation of tools and training for assessors Baseline assessment Sites form improvement teams CQI training, analysis of baseline findings, and development of action plans Sites test changes to improve quality and monitor indicators to evaluate effect of changes tested Sites re-assessed quarterly CQI coaching (monthly, quarterly or annually) and sharing of learning across sites 13

14 VMMC CQI dashboard used for baseline and re-assessments No. Quality Standards Areas Score LEGEND 1 Leadership and Planning Management systems Monitoring and Evaluation Registration, group education and IEC Individual counselling and HIV testing Infrastructure, supplies, equipment and environment Male circumcision surgical procedure Infection prevention 65.6 Average

15 Dashboard results in Uganda: 30 sites supported by 10 implementing partners Baseline (Feb-Mar 2013) Jan 2014 Feb 2015 Health unit Manageme nt systems Supplies, equipment & environme nt Baseline Feb-May 2013 Registratio n group education and IEC Individual counseling & HIV testing Male circumcisi on surgical procedure Monitoring & evaluation Infection prevention Manageme nt systems Supplies, equipment & environme nt Registratio n group education and IEC Individual counseling & HIV testing Male circumcisi on surgical procedure Monitoring & evaluation Infection prevention Manageme nt systems Supplies, equipment & environme nt Jan-14 Registratio n group education and IEC Feb-15 Individual counseling & HIV testing Male circumcisi on surgical procedure Monitoring & evaluation Infection prevention Improving the quality of voluntary medical male circumcision through use of the continuous quality improvement approach: A pilot in 30 PEPFAR-supported sites in Uganda 15

16 South Africa VMMC CQI dashboards (baseline, 1 st, 2 nd, 3 rd reassessments aggregate; 70 sites) Jun-Dec 2014 Jan-Sep 2015 Oct 2015-Mar

17 Malawi: Baseline vs. follow-on assessment at nine VMMC sites Baseline Assessment (May & June 2015) Follow-on assessment (2 nd ) October 2015 Management Systems Supplies, equipment & environment Registration, group education & IEC Individual counseling & HIV testing Male Circumcision surgical procedure Monitoring & Evaluation Infection Prevention Management systems Supplies, equipment & environment Registration, group education & IEC Individual counseling & HIV Testing Male circumcision Surgical procedure Monitoring & Evaluation Infection prevention Site Baseline Assessment (May & June 2015) Follow-on assessment (2 nd ) February NA Not assessed USAID Applying Science <50% to Strengthen 50-80% >80% and Improve Systems

18 Tanzania: VMMC dashboard, 10 sites in Njombe Region 18

19 Value-added of CQI in VMMC programs Quality initiatives are critical components of the newly released National MMC guidelines & operational plan (Uganda, South Africa, Tanzania) CQI complements QA and provides the engine to address areas of deficient performance & raise awareness Critical to good programmatic and clinical outcomes: Ensure patient safety Improve infection control Reduce adverse events Empowers frontline health workers to assume control over quality and outcomes; encourages innovation and accountability 19

20 CQI guidance products and tools Case studies of CQI efforts of individual sites Excel CQI dashboard tool CQI web-based VMMC CQI toolkit in development Resource page on the USAID ASSIST website with current tools: 20

21 Addressing Key Quality Gaps in VMMC: Strategies and Results Dr. John Byabagambi Senior Improvement Advisor USAID ASSIST Project, University Research Co., LLC (URC) 21

22 Government of Uganda commitment to VMMC safety and quality 22

23 Gaps identified in inter-agency External Quality Assessments (EQAs) in 2012 Most sites lacked guidelines, SOPs, job aids Staff performed procedure without formal VMMC training Sites were not recording VMMC services, adverse events and follow-up visits Clinical records, consent forms, adverse event forms difficult to locate at many sites Many sites had forms that did not contain all necessary data fields for required reporting and good clinical care; too many versions in use Incorrect informed consent process for minors General anesthesia (ketamine/diazepam) used for some routine VMMC clients Some sites not using weight-based local anesthesia dosing 23

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27 PEPFAR recommendations Immediate attention to sites that were in violation of PEPFAR policy regarding: Use of general anesthesia Preparedness for emergency management Urgently instituted continuous quality improvement (CQI) in the program USAID ASSIST requested to provide technical assistance Support Ministry of Health (MoH) with setting up national systems to improve quality of VMMC 27

28 MOH leadership for VMMC quality improvement Convened stakeholders meeting Aligned WHO assessment tool to other MoH guidelines and policies and used it to assess sites Developed harmonized tools for recording client information and reporting: Individual client form/consent form Client card for capturing clinical record VMMC theater register Adverse events grading scale Reporting forms Reconstituted VMMC National Task Force and convened regular meetings Formed Safety Monitoring Team 28

29 USAID ASSIST support for CQI in Uganda Jointly with 10 implementing partners (IPs) and district health offices, supported: Conducting baseline assessments and ongoing reassessment of sites Forming QI teams to spearhead improvement Training service providers and IP staff in CQI Regular onsite joint coaching (monthly/quarterly) Presenting learning sessions Organizing exchange visits (between good and poor sites) Offering onsite training on use of harmonized tools Training regional and district CQI coaches 29

30 Example of CQI approach: Adverse events (AEs) ASSIST conducted a root cause analysis at 30 health facilities to identify gaps: Under reporting of AEs due to fear of being penalized by IPs Sites only reporting most severe AEs Lack of standardized reporting tools Teams thought management was adequate and thus no need to report Trained and supported facility teams on application of CQI to test changes to address the gaps Together with MoH developed and distributed tools to capture AE information 30

31 Tools to capture and grade AEs 31

32 Dashboard for 30 VMMC sites Baseline Feb-May 2013 May 2015 Health Unit IP Supporting Site Management systems Supplies, equipment & environment Registration group education and IEC Individual counseling & HIV testing Male circumcision surgical procedure Monitoring & evaluation Infection prevention Management systems Supplies, equipment & environment Registration group education and IEC Individual counseling & HIV testing Male circumcision surgical procedure Monitoring & evaluation Infection prevention Site Site Site , Site Site Site Site Site Site Site Site Site Site Site Site Site , Site , Site Site Site Site Site Site Site Site Site , Site Site Site Site ,

33 Service delivery process changes tested by sites for quality management of AEs Orienting VMMC teams on grading of AEs Holding weekly meetings to review AEs Cross-checking clients understanding of AEs Informing clients during mobilization to come with tight-fitting underpants Reinforcing messages on wound care during follow-up visits Emphasizing the need for parents/guardians of minors to attend the education sessions on wound care Educating clients to cover the wound with a polythene bag during bathing (pre-packed polythene bag and tissue paper to give clients in post-operative area) Improving early detection of AEs through improved follow-up 33

34 Client follow-up and rate of AEs

35 Key steps in addressing AEs Address fears about reporting AEs Ensure that sites realize that AEs can happen to any team, regardless of skill level Establish a clear grading system and use tools for systematic, standardized identification of AEs Improve client counseling on AEs and wound care, including during mobilization (remind about need for tight-fitting underpants) Improve client follow-up post-circumcision, especially at 48 hours and seven days Analyze types of AEs to direct corrective actions Improved routine management of mild AEs prevents moderate and severe forms 35

36 Improving client follow-up post-circumcision 100% Percentage of VMMC clients that returned for 48 hour follow-up post-circumcision at a selection of sites and a general hospital in Uganda, Jan 2013-April % 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Counseling messages changed from "come back if you have a problem" to "you need to come back for bandage removal & review" Improvement team formed & mentored on client follow-up Improved record keeping and assign staff member to evaluate clients follow-up. % Followed up at 48 hr/general Hosp % Followed up at 48 hr/sites Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Denominator 1: Number of men circumcised at general hospital Denominator 2: Number of men circumcised at sites Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14

37 Improving documentation of client consent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % of clients with documented consent prior to circumcision at one general hospital % of clients with documented consent prior to circumcision at all sites mean for all sites* Baseline, Circumciser cross check for Minors informed to come with parents/guardian Consent forms available and staff oriented on documenting consent Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 Denominator: Number of men circumcised at one general hospital Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 Denominator: Number of men circumcised at all sites # of sites Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 reporting *Mean is calculated because more than half of points are 100%. Shift above mean occurs by December See Perla et al

38 Integrating tetanus vaccination in VMMC services in Central Uganda 38

39 Institutionalizing CQI in VMMC programs Standardized tool for collection and reporting of client information Integrated quality indicators into DHIS2/HMIS Number circumcised Rate of AEs Client consent Client follow-up HIV counseling and testing (individual and couple) Established a functional MoH-led Safety Monitoring Team 39

40 Improving Efficiency through Site Utilization / Capacity Assessments Dr. James Ndirangu Regional Advisor for Southern Africa USAID ASSIST Project, University Research Co., LLC (URC) 40

41 Why measure site efficiency? Despite vast government and donor investments in VMMC programs, targets are not being met Measuring efficiency helps understand the sitelevel environment relating to: - Demand generation - Human resources/staffing - MMC saturation in the catchment population A more accurate and useful monitoring measure than number of circumcisions alone

42 Site efficiency measure The site efficiency measure is the number of circumcisions performed in a site day of operation This will be measured in a monthly increment The formula for number of VMMCs done at a site per day Sites will be judged efficient or inefficient by comparing the efficiency measure to efficiency benchmarks

43 Efficiency benchmarks Efficiency benchmarks are set by the volume of the site Comparison of site efficiency can be performed by province/region, by provider (private/public), by implementing partner, or by the type of site (fixed/mobile/outreach)

44 Site capacity analysis tool (I) Tool gathers information on: Site characteristics Site investment

45 Site capacity analysis tool (II) Tool gathers information on: Site performance (last 12 months) Site productivity

46 Findings: Retrospective VMMC site-level capacity analysis Country No of Sites Site Productivity Index Site Performance Below Capacity Site Performance Above Capacity Mozambique 8 8 (100%) Nil Swaziland (88.8%) 13 (11.2%) Tanzania (100%) Nil Lesotho (86.8%) 17 (13.3%)

47 Swaziland VMMC annual performance above capacity Swaziland VMMC expected vs actual annual performance by site Number of MMCs done Lubombo Hhohho Manzini Shiselwen i Mazombiz we Maguga Clinic Cabrini Ministries JCI Clinic Expected annual performance Actual annual performance

48 Swaziland VMMC annual performance below capacity Swaziland VMMC expected vs actual annual performance by site Number of MMCs done Litsemba Letfu Nhlangano Health Center Bholi Clinic Sithobela Health Center SAPPI Clinic Mankayane Govt Hospital Motshane Clinic Matsanjeni Health Center Expected annual performance Actual annual performance

49 Swaziland VMMC site productivity index Swaziland VMMC Site productivity Index Piggs Peak Govt Hospital RFM Hospital Dvokolwako Health Center Maguga Clinic Mankayane Govt Hospital Ngomane Clinic Mkhuzweni Health Center Cabrini Ministries Good Shepherd Hospital FLAS Manzini FLAS Mbabane Nhlangano Health Center Litsemba Letfu Productivity index

50 Integrating efficiency measures in routine program monitoring To incorporate efficiency measures into routine data monitoring, programs may need to add additional elements, such as: Number of days a site is in operation in a month Classification of whether the site is low, medium, or high volume (monthly) Documentation of number of beds, number of surgeons, etc. Mode of service delivery (fixed, outreach, mobile) Whether a site is private or public Whether the site is dedicated VMMC or integrated

51 Lessons learned Site efficiency proved easy to calculate (when data elements are in place) Causes of variation in site performances need to be explored. Are there challenges with: - Demand generation? - Human resources/staffing? - MMC saturation in the catchment population? CQI is needed to gain deeper understanding as to why the majority of sites are operating below capacity, develop site action plans, and better match the demand and supply of VMMC services.

52 This work was supported by the American people through the United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID-OAA-A The contents of these presentations are the sole responsibility of URC and do not necessarily reflect the views of the United States Agency for International Development or the United States Government (USG). URC appreciates the contributions of the Ministries of Health, implementing partners, site teams, and USG staff to these results. For more information, please visit: 52

53 Q & A on presentations PRESENTERS Dr. Donna Jacobs Regional Director for Southern Africa USAID ASSIST Project, URC (DonnaJ@urc-sa.com) Dr. John Byabagambi Senior Improvement Advisor USAID ASSIST Project, URC (JByabagambi@urc-chs.com) Dr. James Ndirangu Regional Advisor for Southern Africa USAID ASSIST Project, URC (JamesN@urc-sa.com) 53

54 Short film: Introduction DOCUMENTARY FILM Dr. Isaac Choge Biomedical Prevention Advisor USAID South Africa 54

55 Scaling up and sustaining quality VMMC programs: Lessons and implications for other programs PANELISTS Dr. Alex Opio Ministry of Health Uganda Mr. Isaac Ngomane Mpumalanga Provincial Department of Health South Africa Dr. Shephard Maphisa Dr. Maphisa & Partners South Africa drmaphisaandpartners.com) Dr. Wendell Isaacs TB/HIV Care Association South Africa 55

56 THANK YOU This satellite session was hosted by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project with funding support from the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) through USAID. 56