STRENGTHENING UGANDA S SYSTEMS FOR TREATING AIDS NATIONALLY VOLUNTARY MALE MEDICAL CIRCUMCISION CHANGE PACKAGE Synthesis of the most robust and effective QI interventions to improve Voluntary Male Medical Circumcision Services at SUSTAIN supported hospitals in Uganda AUGUST 2017 The SUSTAIN project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement number 617-A-10-00007-00. The project team includes prime recipient University Research Co., LLC (URC) and sub-recipients; The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI), Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), Child Chance International (CCI Uganda), AIDS Information Centre (AIC) and ACLAIM Africa.
Quality Improvement Change Packages Series The purpose of the quality improvement packages is to provide a synthesis of the most robust and effective QI interventions for effective HIV programming. The quality improvement packages series thematic areas include: prevention of mother to child transmission, laboratory, monitoring and evaluation, adolescent friendly health services, voluntary medical male circumcision, nutrition, HIV care and treatment, supply chain, Tuberculosis, and quality improvement. USAID/SUSTAIN acknowledges the work of the project staff, technical officers at MoH, and counterparts at supported facilities who have been instrumental to the project s many successes through implementation of the quality improvement interventions. The publication and production of these packages, as well as the work of the SUSTAIN project, was made possible by the generous support of the American people through USAID. The SUSTAIN project is led by University Research Co., LLC and works in partnership with: The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI), Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), Child Chance International (CCI Uganda), AIDS Information Centre (AIC) and ACLAIM Africa, under Cooperative Agreement No. 617-A-10-00007-00. The views and opinions expressed here do not necessarily state or reflect those of USAID or the United States government. VMMC Change Package i
Contents Quality Improvement Change Packages Series... i Acronyms... iv Introduction...1 Harvest Meeting...2 Change Package for improving VMMC services...5 Intended Use...5 Improvement Aim 1: To increase the proportion of VMMC clients returning for post-operative follow up within seven days after the procedure...5 Improvement Aim 2: To reduce the proportion of circumcised clients experiencing moderate or severe adverse events from 2.6% to less than 1% by 2015...8 Key Challenges... 12 Moving Forward... 12 Appendix: List of contributors during the learning session...13 VMMC Change Package iii
List of Acronyms AE Adverse Events CME Continuing Medical Education HC Health Center MoH Ministry of Health PMTCT Prevention of mother-to-child Transmission of HIV QI Quality Improvement RRH Regional Referral Hospital SMC Safe Male Circumcision SUSTAIN USAID Strengthening Uganda s Systems for Treating AIDS Nationally TB Tuberculosis USAID United States Agency for International Development VHT Village Health Teams VMMC Voluntary Male Medical Circumcision iv VMMC Change Package
Introduction Since 2010, the United States Agency for International Development (USAID) has been working with Uganda s Ministry of Health (MoH) to improve HIV and AIDS service delivery at select health facilities through the Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) project. Over the last seven years, the SUSTAIN project has aimed to: n Support the MoH to scale up Prevention of Motherto-Child Transmission of HIV (PMTCT) and Voluntary Medical Male Circumcision (VMMC) as HIV infection prevention interventions within selected public regional referral hospitals (RRHs) and general hospitals n Ensure provision of HIV care and treatment, laboratory and tuberculosis (TB)/HIV services within selected public RRHs, general hospitals and health center (HC) IVs n Enhance the quality of PMTCT, VMMC, HIV care and treatment, laboratory, nutrition, supply chain management, and TB/HIV services within selected RRHs, general hospitals and HC IVs, and n Increase stewardship by the MoH to provide sustainable quality HIV prevention, care and treatment, laboratory and TB/HIV services at project-supported healthcare facilities. SUSTAIN provided technical assistance to 13 public hospitals to improve the quality of VMMC services, and to increase uptake of VMMC services while reducing adverse events. SUSTAIN supported hospitals have focused on: a) ensuring circumcised clients return to the hospital for post-operative follow-up, and b) reducing adverse events among circumcised clients. The technical assistance provided by SUSTAIN included: n The provision of the: National Safe Male Circumcision Policy, the Safe Male Circumcision Training Manual, and the Minimum Standards of Procedures for Safe Male Circumcision Table 1: Health facilities participating in the SUSTAIN VMMC Quality Improvement Project Name of Facility Arua Fort Portal Gulu Hoima Jinja Kabale Kawolo Lira Masaka Mbale Moroto Mubende Soroti n Secondment of a resident consultant surgeon to supervise VMMC activities daily and is responsible for providing care for in cases of adverse events n Onsite coaching and mentorship to support effective application of quality standards, as per MOH guidelines n Organizing collaborative learning among the different hospital quality improvement (QI) teams to share best practices, and n Conducting onsite supportive supervision at least once every two months. Level of Facility General hospital The project applied a continuous quality improvement approach, as guided by the Model for Improvement that uses the Plan-Do-Study-Act cycles. The VMMC & QI technical advisors from SUSTAIN supported the formation of multi-disciplinary improvement teams at all supported VMMC sites, through which QI interventions were implemented. This improvement approach, where VMMC Change Package 1
teams work to identify and address a myriad of challenges affecting the content and processes of care, is consistent with the Ministry of Health s Quality Improvement Framework and Strategic Plan. On a bi-monthly basis, the facility VMMC teams received coaching and onsite supervision and mentorship on how to identify gaps in VMMC services, how to prioritize areas for improvement, and how to develop, test, and eventually implement ideas that could lead to improvements. Hospital QI teams are supported to: (a) increase the number of clients returning for post-operative follow-up, and (b) reduce the proportion of clients experiencing moderate or severe adverse events. Harvest Meeting Following three years of continuous VMMC quality improvement support in the 13 hospitals, a 3-day harvest meeting was held in Kampala in August 2016. The meeting was designed as a platform to review performance of the different VMMC teams per hospital, and to share experiences on best practices and bottlenecks affecting the provision of quality VMMC services. During the harvest meeting, participants reflected and shared experiences on how they applied quality improvement techniques to improve VMMC services. They shared the specific ideas each team tested, and reviewed the available evidence which attributed the ideas to the observed results. The group developed their best advice based on their experience that could guide other hospital teams to improve post-operative hospital returns for VMMC clients and for reducing the occurrence of adverse events. Divided into small groups, teams discussed the ideas they had tested, the steps they followed in introducing and testing these s, and the results they observed that could be attributed to the tested s. Plenary sessions followed small-group discussions, and the tested s were further discussed and even scored based on relative importance, level of simplicity and how scalable they were. All the parameters (relative importance, simplicity and scalability) were scored 1-5 by the participants. A score of 1 (one) for any of the parameters meant the was not important, it was too complex and was not scalable. A score of 5 (five) meant the was very important, or simple and/or scalable. The average scores are presented in Tables 2 3. Tables 4 5 provide a comprehensive list and description of all the ideas tested, with notes on the specific steps taken to implement the, the observed results and the number of facilities (scale) that implemented the specific s. Figure 1: Guide to interpreting the rating of ideas 1 2 3 4 5 n Change was not n Only important n Change can n Change was n Change was important in a few aspects be important important very important n Change idea was n Change is often n Change can n Change is n Implementation too complex n Change is difficult to scale complex n Scalable with significant challenges be complex n Scaling requires effort sometimes simple n Scalable with limited effort is always smple n Change is easily scalable 2 VMMC Change Package
Table 2: Changes introduced to improve the accuracy of reports submitted by health facilities SN Change idea Number of hospitals testing Rating Criteria Relative importance Simplicity Scalability Total score Average score 1. Designated a focal person for documentation and updating registers 2. Requisition of phones and airtime for specifically calling client to return to health facility. 10 5.0 4.2 4.0 13.2 4.4 10 4.3 4.3 3.9 12.5 4.2 3. Use of safe male circumcision (SMC) champions 10 3.2 2.7 2.5 8.4 2.8 4. Continuous reminding of clients on importance of return for follow up and when to return at every stage of the VMMC care delivery process 5. Telling clients to return for dressing removal at the facility 6. Use of monthly QI meeting for follow up: Innovation sustained over a long period 7. Conducting continuing medical education (CME) sessions to improve staff knowledge on VMMC to give the right information to the clients during health education 8. Physically following up of clients by the care team in organized setting (e. g schools and prisons) 10 4.7 4.4 4.5 13.6 4.5 10 4.8 4.7 4.7 14.2 4.7 10 5.0 4.5 4.3 13.8 4.6 10 4.4 3.6 3.7 11.7 3.9 10 4.4 3.5 3.2 11.1 3.7 9. Use of nearby facilities for client follow up 10 4.1 3.0 3.0 10.1 3.4 Table 3: Changes introduced to increase completeness of facility reports submitted to MOH via DHIS2 SN Change idea Number of hospitals testing Rating Criteria Relative importance Simplicity Scalability Total score Average score 1. Appointing a focal person for documentation and management of adverse events. 2. Use of SMC champions for sensitization on adverse events 3. Use of Village Health Teams (VHT) for mobilization of clients and sensitization on adverse events 4. Putting visual aids and SOPs on prevention of adverse events at every point of the VMMC care process in the facilities 5. Use of strapping for elevating penis as an alternative for clients without tight underwear 10 5.0 4.5 4.1 13.6 4.5 10 3.3 2.8 2.8 8.9 3.0 10 3.8 3.3 3.2 10.3 3.4 10 4.1 3.8 3.8 11.7 3.9 10 4.8 4.6 4.6 14.0 4.7 continued VMMC Change Package 3
Table 3: Changes introduced to increase completeness of facility reports submitted to MOH via DHIS2, continued SN Change idea Number of hospitals testing Rating Criteria Relative importance Simplicity Scalability Total score Average score 6. Use of monthly QI meeting to review adverse event prevention 7. Use of lower level facilities to prevent and manage adverse events 8. CME session on adverse event prevention, documentation and management 10 5.0 3.9 3.8 12.7 4.2 10 4.5 3.4 3.5 11.4 3.8 10 4.8 3.7 3.3 11.8 3.9 Change Package for improving VMMC services Intended Use This package is intended to provide ideas to other improvement teams that would like to improve the quality of VMMC services at their health facilities; with a focus on improving post-operative follow-up and reducing post-operative adverse events. Teams may not necessarily replicate these ideas in Tables 2 3 above; rather, they should adapt them to suit their circumstances and context challenges. The next section of this package provides a detailed description of what s led to improvement, and how such improvement was derived. It is structured into two sub-sections, corresponding with the two improvement aims that the SUSTAIN project set out to achieve in relation to improving VMMC services in Uganda. Each sub-section outlines the QI concept applied, the problem being addressed, the ideas tested, steps followed in introducing each idea and the evidence that it led to improvement. Tables 4 5 provide a comprehensive list and description of all the ideas tested, with notes on the specific steps taken to implement the, the observed results and the number of facilities (scale) that implemented the specific s. 4 VMMC Change Package
Improvement Aim 1: To increase the proportion of VMMC clients returning for post-operative follow up within seven days after the procedure The proportion of circumcised men returning for post-operative care tremendously increased in the 13 hospitals supported by the project, as illustrated in Figure 2. Starting with a baseline of 14% in FY 13, the ideas introduced by the QI teams resulted in 87% post-operative follow-up by FY 16. Figure 2: Percentage of circumcised clients returning for post-operative care 48 hours after circumcision in the 13 hospitals, 2013 2016. 100 90 80 70 Percent 60 50 40 30 20 10 0 Q3 FY13 Q4 FY13 Q1 FY14 Q2 FY14 Q3 FY14 Q4 FY14 Q1 FY15 Q2 FY15 Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Table 4: Specific s implemented to increase the number of VMMC clients returning for post-operative follow-up visits Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Building the capacity of health workers to manage VMMC clients Health workers didn t inform clients on the importance of post-operative follow-up, partly due to lack of such knowledge among the health workers CME sessions on correct dates of post-operative appointments and points where to return Problem was highlighted during the SMC monthly meeting Identified technical persons to give the CME sessions, and schedule developed Common topics discussed were correct schedule, importance and documentation of appointments for VMMC clients. Opened QI documentation journals on adherence to scheduled appointments for VMMC clients Masaka RRH tested this and saw improvements from 50% in December 2013 to 87%in July 2015. All 13 hospitals tested this continued VMMC Change Package 5
Table 4: Specific s implemented to increase the number of VMMC clients returning for post-operative follow-up visits, continued Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Improve documentation procedures Follow-up dates documented poorly (or incorrectly) on client cards, and often with no parallel documentation in the register. Appointment of documentation focal person, followed by close training and mentorship Problem identified during the SMC monthly meeting A focal person address documentation gaps among SMC staff was identified Trainings and mentorships carried out by SUSTAIN staff, to build their capacity for the task Focal person conducted periodical random spot checks on patients and in the register to determine correct documentation of return dates With this specific, Fort Portal RRH improved from 3.1% to 100%; 12 hospitals implemented this Monthly performance reviewed in SMC meetings Active follow up of VMMC clients Failure to follow-up clients who miss their scheduled appointments Reminder phone calls to clients, or their recorded nextof-kin Problem introduced in QI monthly meeting Clients required to correctly document their phone numbers, and those of their next-of-kin Identified a person among SMC staff, and assigned the task of following up clients through phone calls Fort Portal RRH improved from 3 to 100% follow-up by implementing this All 13 hospitals tested this Breaking down barriers to communication Health workers and clients could not fully communicate with each other due to language barriers Train and involve health workers to deliver VMMC messages in the local languages. Problem introduced in QI monthly meeting and discussed with the administration, who requested SUSTAIN to recruit interpreters SUSTAIN and administration recruited and trained staff who could deliver important information fluently in the local language. Patients adherence to return dates increased with this 1 hospital tested this Bringing services closer to the clients Clients not coming for follow-up due to long distances to hospitals Follow-up of clients at nearest lower level facility or camp site Training health workers at lower facilities during inter-facility meeting and camps Advising clients to go the nearby facilities/ camp site Updating registers after follow up with phone calls in the lower health care facilities Lira RRH tested this and observed client follow-up move from 52% in 2014 to 91% in 2016. 10 hospitals tested this Designating a focal person at these facilities for follow-up 6 VMMC Change Package
Improvement Aim 2: To reduce the proportion of circumcised clients experiencing moderate or severe adverse events from 2.6% to less than 1% by 2015 The 13 health facilities have also reduced the proportion of circumcised clients experiencing moderate or severe adverse events from 2.6% in 2013 to about 0.3% by June 2016 as shown by Figure 3. The number of clients presenting with adverse events reduced from a peak of 195 in FY 13 to as low as 0 in 2016. The substantial reductions in the prevalence of adverse events is a direct result of the effectiveness of the ideas that hospital teams implemented. Figure 3: Proportion of circumcised clients experiencing moderate or severe adverse events in 13 SUSTAIN supported facilities. 25000 3 Number Circumcised 20000 Adverse Events Number Circumcised 15000 10000 Percent with Adverse Events 2 1 Percent Adverse Events 500 0 0 Q3 FY13 Q4 FY13 Q1 FY14 Q2 FY14 Q3 FY14 Q4 FY14 Q1 FY15 Q2 FY15 Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Table 5: Specific s introduced to reduce the proportion of clients with adverse events post circumcision Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Improve hygiene among clients Several episodes of adverse events linked to poor hygiene among clients Use of VMMC champions to teach the step-by-step guide to proper hygiene Problem highlighted in the SMC monthly meeting Identified willing and capable clients to act as VMMC champions Orientated them on prevention of adverse events by applying proper hygiene standards, then worked with the champions to develop a step-by-step guide Adverse events reduced from 8% to 2% among hospitals that tested this All 13 hospitals tested this Provided visual leaflets for their sensitization on proper hygiene in the communities continued VMMC Change Package 7
Table 5: Specific s introduced to reduce the proportion of clients with adverse events post circumcision, continued Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Improve hygiene among clients Several episodes of adverse events linked to poor hygiene among clients Use of VHTs to teach the message of proper hygiene practices Identified VHTs already involved in VMMC activities Trained them on prevention of adverse events through proper hygiene practices Subsequently assigned roles, responsibilities and VHT s coverage areas, and provided with visual leaflets to assist in sensitization of the community Adverse events reduced from 8% to 2% among hospitals that tested this 9 hospitals tested this Continue to build capacity of staff Cases of untrained staff performing circumcision Training of extra health workers on VMMC Problem highlighted in the SMC monthly meeting and informed administration SUSTAIN organized for the training of additional health workers to join the VMMC teams and perform circumcision procedures A total of 92 health workers were trained and performed SMC All 13 hospitals tested this Newly trained health workers continued to receive coaching and mentorship in adherence to circumcision procedures Address clients nonadherence to health workers instructions Clients often had inadequate understanding on the causes, prevention and management of adverse events Public display of standard procedures for post-operative wound care Education of clients on post-operative wound care, as they are undergoing preparation for the procedure Provision of information on accepted standards and procedures for post-operative wound care Providing clients with information on how to manage adverse events Return for follow up increased from 14% to 97% in 12 months, and occurrence of adverse events reduced to less than 1%. All 13 hospitals tested this Build the capacity of staff to detect and manage adverse events Limited knowledge among some staff on how to detect and manage adverse events in clients Conduct continuous medical education (CME) sessions on management of adverse events Knowledge gap identified among some staff during QI meetings Identification of knowledgeable person to conduct CME sessions on: causes, prevention, management, documentation and monitoring of adverse events, and dates of session scheduled A total of 92 health workers were trained to perform SMC, and the episodes of adverse events reduced substantially 12 hospitals implemented this 8 VMMC Change Package
Key Challenges It is important to note that despite the achievements made, some challenges were also realized during the implementation process and these included: n Difficulties in documenting client follow-up visits, the tools to use to document the visits, and how the resulting data can be analyzed and used n VMMC champions and VHT members often giving inaccurate advice on post-operative care Moving Forward These findings can be used by teams who are interested in improving VMMC follow up and reduction of VMMC adverse events at their facilities and are advised to consider the following recommended practices; n Identification and analysis of problem. n Review the prioritized list of s as indicated in Tables 2 3, and refer to Tables 4 5 to identify the ideas that closely relate to the specific barriers identified and then use the suggestions for implementing the s. The approach to improve VMMC follow up and reduction of VMMC adverse effects requires a multi-stakeholder approach (MoH, district and health facility teams, implementing partners and donors) to ensure spread and impact since each has a significant role they play. Health Facilities Support for facility QI teams through routine coaching and mentoring Engagement of facility leadership to ensure they prioritize VMMC client follow-up and reduction of adverse events Enhancement of supply chain management practices to ensure adequate stock of VMMC commodities, including those used in conducting surgical procedures District Teams Coordination, resource mobilization, capacity building, scale up, mentorship and supportive supervision Engaging their communities to dispel myths around VMMC procedures Ministry of Health Ensuring required tools, SOPs, guidelines and other resources are available throughout various levels of MoH Coordination, capacity building, supportive supervision, resource mobilization, and supporting scale-up of VMMC services Development Partners Technical support, capacity building and availing resources to bridge gaps in VMMC services Conducting additional scientific studies on the benefits and unintended consequences of VMMC services VMMC Change Package 9
Appendix: List of contributors during the learning session SN Participant name Position Hospital Telephone 1 Otim Choudry Medical officer Moroto RRH 0772 783 760 2 Niyigena Susan Nursing officer Moroto RRH 0774 776 320 3 Okello David Clinical officer Soroti RRH 4 Ajilong Jennifer Nursing officer Soroti RRH 0772 579 086 5 Isiagi Moses Clinical officer Kabale RRH 0781 560 600 6 Mwemembezi Johnson Counselor Kabale RRH 0782 745 949 7 Kusasira Hope Clinical officer Gulu RRH 0782 732 546 8 Oyella Roselyn Counselor Gulu RRH 0788 363 876 9 Mulyaha Adonis Clinical officer Hoima RRH 0704 891 280 10 Arim Jane Wakabi Clinical officer Jinja RRH 0772 383 206 11 Lubega John Paul Clinical officer Jinja RRH 0774 420 102 12 Jagwe Hakim Clinical officer Kawolo DH 0703 237 101 13 Lunkuse Stellah Nursing officer Kawolo DH 0785 997 198 14 Okweda Daniel Clinical officer Fort Portal RRH 0782 630 043 15 Kagooro Annet Nursing officer Fort Portal RRH 0772 389 125 16 Mugume Elly Counselor Mubende DH 0704 079 557 17 Zawedde Florence Nursing officer Masaka RRH 0772 350 865 18 Zikusoka Frederick Clinical officer Masaka RRH 0772 518 682 10 VMMC Change Package
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