Abstract no. WEPEE510 Applying Continuous Quality Improvement (CQI) in Voluntary Medical Male Circumcision (VMMC) in South Africa T Maartens 1, J Ndirangu 1, F Dikgale 1, J Littlefield 2, L Dayanund 3, C Bonnecwe 3, E Njeuhmeli 4, D Jacobs 1 1. USAID ASSIST Project, University Research Co., LLC; 2. USAID Southern Africa; 3. National Department of Health, South Africa; 4. Office of HIV/AIDS, USAID Washington DC This study 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-12-00101. The contents of this presentation 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. For more information, please visit: www.usaidassist.org
Background South Africa is home to 6.4 million people living with HIV and an estimated HIV prevalence of 18.9% among 15-49 year old adults. The South African National Department of Health (NDOH), in partnership with the US President s Emergency Plan for AIDS Relief (PEPFAR), rolled out voluntary medical male circumcision (VMMC) services as a key HIV prevention strategy. As the program expanded, quality issues arose and the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project applied continuous quality improvement (CQI) methodology to improve the quality and safety of VMMC services.
Methods Baseline CQI assessments in 134 facilities across nine provinces of South Africa demonstrated quality gaps in compliance with eight modified World Health Organization (WHO) quality standards for VMMC. Sites were classified for intense, light or collaborative support, based on performance. Intense support sites scoring <70% for VMMC procedure and/or <70% for infection control and/or <50% average compliance with all components, received monthly support. Light support sites scoring: 70% but <85% for MMC procedure and/or >70% but <85% for infection control and/or >50% but <85% average compliance with all components received quarterly support and collaborative support sites scoring above 85%, received bi-annual support. During CQI support visits, CQI site teams were established, quality gaps identified, analyzed and improvement interventions tested, adapted and scaled up to close gaps in: Leadership and planning, management systems, monitoring and evaluation, registration, group education and counselling, individual counselling and HIV testing, infrastructure, equipment and supplies, surgical procedure and infection prevention and control. Implementing partners played an important role in institutionalization. Four CQI trainings were conducted, attended by site representatives from six provinces. Basic CQI concepts, methodology and tools were discussed and applied during group work. Three CQI learning sessions were conducted where provinces, NDOH facilities, implementing partners and private providers shared lessons on best practices as well as challenges. During learning sessions, individuals and groups were given the opportunity to learn from colleagues and peers. Quarterly site re-assessments were conducted. Modified WHO quality standards for VMMC 1. Leadership and planning (South Africa) 2. Management systems 3. Monitoring and evaluation 4. Group education 5. Individual counselling and HIV testing 6. Infrastructure, equipment and supplies 7. Circumcision procedure 8. Infection prevention and control Current policies/guidelines relevant for VMMC in South Africa National Strategic Plan for HIV, STIs and Tuberculosis District Health Information Management Systems (DHIMS) Policy National HIV Guidelines (including HCT) Strategic Plan for the Scale up of Medical Male Circumcision Quality Improvement Guide National STI Diagnosis and Treatment Guideline Patients Rights and Responsibilities Guidelines on Informed Consent (Adults/Minors) Infection Prevention and Control Guidelines Referral System Policy Anti Tetanus Toxoid (ATT) Policy/Guidelines Supplies and Equipment Inventory
Results
Conclusions Within a 12 month period, provision of CQI led to improved compliance with modified WHO quality standards for VMMC. This resulted in improved quality of VMMC services and better collaboration between DOH and implementing partners. Team work facilitated better understanding of processes and improved ownership of the program. CQI training, learning sessions and mentorship strengthened institutionalization of CQI and created enthusiasm for VMMC scale up. Monitoring and evaluation is essential for sustainability of quality service delivery.