Webinar What s New in Scaling Up CQI for VMMC

Webinar What s New in Scaling Up CQI for VMMC The webinar will begin momentarily. If you are viewing the webinar in a group, please type in the chat box in what city and country you are located and how many people are viewing the webinar with you. 1

What s New in Scaling Up CQI for Voluntary Medical Male Circumcision PEPFAR VMMC Webinar Dr. Emmanuel Njeuhmeli, Moderator June 22, 2016 2

Introduction Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor Office of HIV/AIDS, USAID 3

Today s presentations Donna Jacobs, URC, South Africa: Progress in Rolling Out VMMC CQI in Uganda, South Africa, Malawi, Tanzania, Namibia and Mozambique; Tools and Technology to Support EQA and CQI John Byabagambi, URC, Uganda: Hot quality topics in VMMC: Adverse events, linkages to care and treatment, and tetanus risk mitigation Joseph Kundy, URC, Tanzania: Sustaining quality VMMC: New directions in CQI for Early Infant Male Circumcision (EIMC) Questions will be taken after each presentation 4

Progress in Rolling Out VMMC CQI in Uganda, South Africa, Malawi, Tanzania, Namibia, and Mozambique; Tools and Technology to Support EQA and CQI Donna Jacobs, MBChB, MPH Regional Director for Southern Africa USAID ASSIST Project, URC 5

Presentation outline Quality, quality assurance (QA), and continuous quality improvement (CQI) Progress in rolling out CQI in six countries: Uganda, South Africa, Malawi, Tanzania, Namibia, and Mozambique Tools and technology available to support VMMC CQI & external quality assessment (EQA) 6

What is quality? 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 7

Quality assurance vs. quality improvement CQI EQA, SIMS J.Amman, SIMS training Johannesburg November 2014 8

QA, QI, and CQI Guidelines, protocols, SOPs Evidence Regulation Training Competencies Standards Professional oversight Accreditation Performance review QA Aims: what are the gaps Measures: critical processes and outcomes Changes: frontline methods and activities to close the gap When improvement aim is reached innovation for increased client satisfaction, efficiency, effectiveness adapt to changes in client needs, technology and disease profile continuous process 9 IMPROVED OUTCOMES QI CQI

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 10

VMMC CQI Dashboard used for baseline and reassessments No. Quality Standards Areas Score LEGEND 1 Leadership and Planning 37.5 2 Management systems 80.0 3 Monitoring and Evaluation 91.5 4 Registration, group education and IEC 71.3 5 Individual counselling and HIV testing 75.8 6 Infrastructure, supplies, equipment and environment 61.0 7 Male circumcision surgical procedure 81.1 8 Infection prevention 65.6 Grand Total 70.5 11

Results from VMMC CQI in Six Countries 12

VMMC CQI support in Uganda ASSIST supports MoH and IPs to improve quality of VMMC Initial work in 30 sites supported by 10 IPs Ongoing Above Site support to 93 sites in 32 districts Direct support to IPs and QI teams in 27 priority sites in Northern Uganda 78% of COP15 sites are new and of lower level thus lack many items and are poorly staffed ASSIST also supporting MoH to conduct a study to integrate TT in VMMC and to mitigate risk of tetanus in VMMC 13

Uganda: Results in spread sites 14

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 2016 15

South Africa: Overall dashboard (100 sites) USAID and CDC overall dashboard score per number of assessments 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Leadership & Planning Management M&E Group Education Individual Counseling Infrastructure Surgical Procedure 1st Assesment (n=123) 48.5 69.5 75.3 80.5 80.5 79.3 77.8 77.5 2nd Assessment (n=108) 50.8 84.7 84.6 89.5 85.9 91.9 90.0 88.8 3rd Assessment (n=89) 74.2 88.1 88.4 91.7 88.6 94.3 94.5 92.9 4th Assessment (n=43) 79.9 89.4 92.0 92.8 92.0 96.3 95.7 96.4 Infection Control 16

Malawi: Baseline vs follow-on assessment at 9 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 1 54.5 33.3 100 66.7 40 64.3 60 54.5 83.3 100 83.3 93.3 71.4 66.7 2 63.6 83.3 66.7 72.2 71.9 71.4 88.9 72.7 100 100 23.5 84.8 71.4 90 3 90.9 66.7 83.3 72.2 75.8 21.4 87.5 81.8 100 66.6 72.2 96 78.6 80 4 54.5 83.3 83.3 61.1 90.6 28.6 77.8 72.7 100 100 100 96.6 71.4 80 5 63.6 83.3 66.7 88.9 78.8 85.7 66.7 90.9 100 83.3 66.6 90.9 92.8 100 6 45.5 33.3 66.7 72.2 74.2 71.4 70 81.8 100 83.3 66.6 100 92.8 90 Baseline Assessment (May & June 2015) Follow-on assessment (2 nd ) February 2016 7 27.3 33.3 25 0 66.7 50 54.5 45.5 83.3 66.7 66.7 72.7 26.6 80 8 36.4 50 50 NO 50 78.6 83.3 54.4 83.3 50 40 70 33.3 66.7 9 45.5 33.3 0 50 33.3 0 60 <50% 17 50-80% >80% Not assessed 27.3 83.3 50 50 84.8 35.7 80

Tanzania: VMMC dashboard, 10 sites in Njombe Region 18

Mozambique HP Tete HP 1 Maio Gondola 28 Apr 2015 28 Apr 2015 30 Apr 2015 1. Management Systems 30% 40% 50% 2. Facilities, Supplies and Equipment 17% 33% 50% 3. Registration, Group Education and IEC 4. Individual Counseling and HIV testing for SMC clients 5. Male Circumcision Surgical procedures 25% -- 75% 50% 33% 67% 57% 61% 55% 6. Monitoring & Evaluation 19% 12.5% 21% 7. Infection Prevention and Control 0% 67% 67% Performance Score : >80%+: Good); (50%- 80%: Fair); (<50%: Poor), (Blank = Not assessed) *Performance Score : >85%+: Good); (70%- 85%: Fair); (<70%: Poor), (Blank = Not assessed) 19

Mozambique HP Tete HP 1 Maio Gondola 16 Mar 2016 16 Mar 2016 16 Mar 2016 1. Management Systems 40% 50% 60% 2. Facilities, Supplies and Equipment 83% 33% 67% 3. Registration, Group Education and 83% 67% 50% IEC 4. Individual Counseling and HIV 50% 50% - testing for SMC clients 5. Male Circumcision Surgical 55% 74% - procedures 6. Monitoring & Evaluation 56% 75% 69% 7. Infection Prevention and Control 100% 82% - Performance Score : >80%+: Good); (50%- 80%: Fair); (<50%: Poor), (Blank = Not assessed) *Performance Score : >85%+: Good); (70%- 85%: Fair); (<70%: Poor), (Blank = Not assessed) 20

Namibia: Support to MOH, AIDSFree, and 12 private practitioner practices in Khomas Region Adapted VMMC CQI assessment tool to Namibian context Sites selected Baseline assessments begun 21

Key learning from adding CQI in VMMC programs Quality initiatives are critical components of the newly released National MMC guidelines & operational plan (Uganda, SA, Tz) 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 22

Tools and Technology to Support EQA and CQI 23

EQA mobile application development Interagency PEPFAR EQAs conducted for VMMC sites (2009-2014) Introduction of requirement for annual SIMS visits (2014 / 2015) Commencement of VMMC EQA / SIMS assessments for USAID-funded VMMC sites (2015) Identification for faster, more efficient, technologically advanced system of data collection, compilation, analysis and production of EQA reports. USAID ASSIST funded to: Develop, pilot-test and utilize a VMMC EQA mobile application (VMMC Qual) Support USG EQA teams in 7 countries to implement VMMC EQA / SIMS visits 24

Nine EQA tools incorporated in the VMMC mobile app 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) 25

Advantages of the 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 facilitylevel and country-level reports (3 weeks vs 12 months) Generation of stand-alone SIMS reports for facilities that have been assessed 26

Available CQI tools Baseline assessment tool (paper-based): Modified WHO quality assessment tool comprising 8 standards & 60 substandards Electronic (Excel) version of VMMC CQI dashboard assists with: Generating real-time site reports Aggregation of VMMC CQI reports across sites 27

CQI guidance products and tools Case studies of CQI efforts of individual sites CQI app (electronic dashboard) and web-based VMMC CQI toolkit in development Resource page on the USAID ASSIST website with current tools: www.usaidassist.org/vmmc-cqiresources 28

Q&A for Donna Jacobs Participants should use the chat function to post questions (send to All panelists ) Questions may also be emailed to Sidhartha Deka at sdeka@jhu.edu 29

Hot quality topics in VMMC: Adverse events, linkages to care and treatment, and tetanus risk mitigation John Byabagambi, MD, MPH Senior Improvement Advisor, USAID ASSIST Project University Research Co., LLC 30

Topic 1: Adverse events (AEs) VMMC is a preventive surgical intervention, and it is necessary to minimize related adverse events High rates of AEs and poor management greatly affect uptake There is generally lack of representative information about the true prevalence of VMMC AEs Fear among sites and implementing partners about acknowledging AEs 31

Gaps identified through PEPFAR EQAs in Uganda Quality gaps related to adverse events: No AE summaries/action plans at facilities Most sites had no post-mc adverse events documented When AEs documented, adverse event grade (mild, moderate, severe) not documented Many sites lacked necessary equipment and supplies for VMMC Some sites lack all or most supplies to manage patient emergencies (adrenaline, atropine, set-up for intravenous injection, oxygen, etc.) Refresher training on emergency management not provided annually 32

Interventions to address adverse events ASSIST conducted a root cause analysis at 30 health facilities to identify gaps: Under reporting of AEs due to fear of being penalized by IP 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 33

Tools to capture and grade AEs 34

Service delivery changes tested by sites for quality management of AEs Orientation of the VMMC teams on grading of adverse events Holding weekly review meetings for the 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) Improve early detection of AEs through improved follow-up 35

Results: 49 ASSIST-supported sites in Uganda 36

Improving follow-up rates in Kiwoko Hospital in East Central Uganda 37

Importance of understanding type of adverse events 38

Key steps in addressing AEs Make sure sites realize that AEs can happen to any team, regardless of skill level, and address fears about reporting AEs Put in place a clear grading system and tools to enable systematic, standardized identification of AEs Improve client counseling on AEs, including during mobilization (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 39

Topic 2: Linkages to other services VMMC links to these key services: HIV testing services Risk reduction services Health screening and treatment of STIs Distribution of and promotion of condom use TB screening Sexual and reproductive health services Active referral to care and treatment, including CD4 testing and ART initiation 40

Linkage gaps seen in CQI work in South Africa Gaps in documentation in HCT register: no indication whether HIV-positive clients linked to local clinics have been initiated or not Forms available but no referral book kept No documentation of referred clients in HCT, MMC, or follow-up registers Lack of intra-facility referral mechanisms Poor communication and hand-offs (staff not escorting clients between service points) 41

Interventions at Seshego Hospital in Limpopo Province (supported by CHAPS) All clients receive group education and individual counselling for MMC and HCT For HIV-positive clients, check date of last CD4 count; if more than 6 months, repeat before circumcision; if CD4 >350 and no OI, circumcise Escort circumcised client to wellness program for hygiene education, psychosocial support, nutritional support Adherence interventions tailored to client needs: SMS reminders WhatsApp Support groups Family involvement Home visits 42

VMMC monthly summary tool revised to include linkage for HIV-positive clients 43

Results: Improving referral for HIV care and treatment HIV positive clients referred for HIV care and treatment at Seshego, Apr 15 Mar 16 18 HTC TEST POSITIVE CD4 test done INITIATED AT WELLNESS CLINIC 17 16 14 13 12 10 11 9 11 10 8 6 4 2 0 6 6 5 4 3 3 3 3 2 2 2 2 2 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 APR.15 MAY.15 JUN.15 JUL.15 AUG.15 SEP.15 OCT.15 NOV.15 DEC.15 JAN.16 FEB.16 MAR.16 44

Key steps in improving linkages to other services, especially HIV care and treatment Support the site to improve testing rate Promote use of clinical stationary Improve documentation in the data collection tools (to facilitate tracking of patients with HIV and other health problems referred, e.g., STIs, TB, chronic illnesses, etc.) Strengthen communication between MMC sites, wellness centers, local clinics, and community points of care Strengthen data review and use of data to inform decision-making Strengthen intra-facility communication 45

Topic 3: Tetanus risk mitigation 9 cases of tetanus reported by March 2015 from 5 countries: Kenya, Rwanda, Tanzania, Uganda and Zambia 8 had consistent causal association with VMMC, 1 indeterminate; none was inconsistent association In Uganda, less than half of circumcising age (10+ years) have had DPT3 46

Interventions to mitigate risk Clean care approach Integrate TT in VMMC Use existing EPI structures Assess sites for TT readiness Modify VMMC M&E and IEC tools to capture TT data Orient service providers on TT vaccination Test changes to improve uptake of TT, return rates for VMMC, and management of tetanus cases Document all processes 47

Introduction of TT in VMMC Effectiveness of Td Dosing Schedule vis a vis VMMC 6 wks 4 wks 2 wks 1 wk Most protection 1st 2nd VMMC Day 2 wks 4 wks 1. Good protection 1st 2nd Good protection 1st 2nd Good protection 1st 2nd 2. Little protection 1st 2nd 48

Results in 22 sites in Central Uganda 49

Lessons learned to date about tetanus mitigation Addition of TT has slowed down the program Need to improve documentation of clients who receive TT1 Harmonize TT2 visit with circumcision visit Reminders between TT1 and TT2 are key 50

Q&A for John Byabagambi Participants should use the chat function to post questions (send to All panelists ) Questions may also be emailed to Sidhartha Deka at sdeka@jhu.edu 51

Sustaining quality VMMC: New directions in CQI for Early Infant Male Circumcision (EIMC) Joseph Kundy, MD USAID ASSIST Project, URC, Tanzania 52

Tanzania VMMC context High VMMC coverage in Iringa and Njombe regions AIDSFree is supporting the MOHCDGEC, Iringa RHMT, and five CHMTs to pilot EIMC services to male infants from 24hrs to 60 days of life USAID ASSIST was asked to provide support to integrate CQI into the EIMC pilot 53

Piloting EIMC services in Tanzania Coverage Achievement FY15 Targets Sustainability 16 sites in Iringa More than 4,000 male babies circumcised to date 6,000 male babies under 60 days of life EIMC integrated within Reproductive and Child Health (RCH) clinics; strategy in place to reach remaining adolescents and adults Challenges Performance varies between sites; the majority not yet reached the expected client flow targets Limited space for integration HRH scarcity - few trained for EIMC Increased workload (demand for stipend) Timing for clinic days (Monday-Wednesday) Team empowerment ASSIST support Build evidence 54 CQI can alleviate some of the existing challenges CQI integration in existing EIMC sites in Iringa To inform MOHCDGEC about EIMC and CQI scale-up and development of national EIMC tools

Rationale for CQI in EIMC services Support local teams to address program deficiencies along the continuum of care Increasing access, timeliness, effectiveness, safety and efficiencies of RCH services Support frontline health workers to monitor and control quality; encourage innovation and accountability Maximize potential of EIMC providers to achieve better outcomes for MNCH services at RCH 55

CQI focus areas in EIMC Content of care Leadership and sustainability Management systems Enabling environment for EIMC services Communication and infant care EIMC procedure Monitoring and evaluation Continuity of care: Postoperative follow-up visit Infection prevention and control 56 Process of Care Early ANC booking Access to essential ANC services among pregnant women Delivery at the health facility Early neonatal services Post-natal visit for lactating mothers Retention of HIV-positive mother-baby pairs HTC among children disaggregated by HIV exposure status Family-centered care at RCH Family planning for lactating mothers Linking infants with other services EIMC education EIMC screening and written consent Return of EIMC clients for follow-up Management of adverse events

Example of one EIMC standard and performance criteria STANDARD AREA STANDARD 1.The EIMC provider clearly explain benefit and rationale for early infant male circumcision at waiting area for ANC or post natal care COMMUNICATION AND INFANT CARE VERIFICATION CRITERIA Verify if provider explains about: Early infant male circumcision is recommended for infants 24 hours to 60 days old Male circumcision procedure for early infants is simpler than for older adolescents Healing among circumcised infants is quicker and complication rates are lower than in adults and older adolescents Wound does not need suturing Procedure in infants is not complicated by erection which may be problematic for older adolescents and adult men Infant male circumcision ensures that the wound will be healed before sexual activity begins and may put older adolescents who engaged in sexual activity before complete wound healing at risk for HIV infection Early infant male circumcision reduces risk of urinary tract infections in the first six months of life Parents should consent for their infant to be circumcised despite the benefits and cost effectiveness of the early infant male circumcision Partial protection is offered to male infants by MC against HIV transmission during adulthood and adolescent period 57

EIMC process of care indicators 1. % of eligible male infant clients circumcised each month 2. % of EIMC clients who returned for post-operative follow-up visits (2, 7 days) 3. % of EIMC clients documented and reported with moderate and severe AEs each month 4. % of EIMC clients referred and linked with appropriate services 58

Phases of CQI in EIMC in Tanzania Stakeholder Engagement 2015 Defining standards and developing CQI tools November 2015 Tool Field testing 2016 Stakeholders meeting to review standards and CQI tool (July 2016) Support development of training package and SOPs for EIMC and VMMC (Oct Dec 2016) Baseline assessment, forming teams and formulation of corrective action plan (Beg. August 2016) Quarterly on-site coaching and mentoring to support teams in testing changes Quarterly reassessment to benchmark compliance 2017 Support teams to improve processes and monitor impact on key indicators Support development of the harmonized national EIMC/VMMC CQI tool (Apr Jun 2017) Building 59 on SA CQI work to develop electronic USAID EIMC Applying tool (Apr Science Jun to 2017) Strengthen and Improve Systems

Q&A for Joseph Kundy Participants should use the chat function to post questions (send to All panelists ) Questions may also be emailed to Sidhartha Deka at sdeka@jhu.edu 60

Discussion Emmanuel Njeuhmeli Donna Jacobs John Byabagambi Joseph Kundy 61

Wrap-up and Final Remarks Emmanuel Njeuhmeli, MD, MPH, MBA Senior Prevention Advisor, Office of HIV/AIDS, USAID 62

URC appreciates the contributions of the Ministries of Health, implementing partners, site teams, and USG staff to these results. This work is made possible by the support of the American people through the USAID ASSIST Project, managed by URC with funding from the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). Responses to any questions not addressed during the webinar will be posted on the USAID ASSIST website on the event page for this webinar: https://www.usaidassist.org/content/what%e2%80%99s-newscaling-continuous-quality-improvement-voluntary-medicalmale-circumcision 63