assist vmmc cqi webinar 22june2016 - usaid assist · cqi reports across sites 27. usaid applying...

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Webinar “What’s New in Scaling Up CQI for VMMC”

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What’s New in Scaling Up CQI for Voluntary Medical

Male Circumcision

PEPFAR VMMC WebinarDr. Emmanuel Njeuhmeli, Moderator

June 22, 2016

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Introduction

Emmanuel Njeuhmeli, MD, MPH, MBASenior Biomedical Prevention Advisor

Office of HIV/AIDS, USAID

USAID Applying Science to Strengthen and Improve Systems

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

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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, MPHRegional Director for Southern Africa

USAID ASSIST Project, URC


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)

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USAID Applying Science to Strengthen and Improve Systems7

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


Quality assurance vs. quality improvement

EQA, SIMSJ.Amman, SIMS training Johannesburg November 2014

CQI

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RegulationStandards

Professional oversight

Accreditation

Performance review

QA

Evidence

Guidelines, protocols,

SOPs

Training Competencies

CQI

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

IMPROVED OUTCOMES

QI

QA, QI, and CQI

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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

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VMMC CQI Dashboard used for baseline and re-assessments

No. Quality Standards Areas Score

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

LEGEND

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Results from VMMC CQI in Six Countries


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

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Uganda: Results in spread sites

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South Africa VMMC CQI dashboards (baseline, 1st , 2nd , 3rd reassessments aggregate; 70 sites)

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Jun-Dec 2014 Oct 2015-Mar 2016Jan-Sep 2015


South Africa: Overall dashboard (100 sites)

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Leadership &Planning Management M&E Group

Education IndividualCounseling Infrastructure Surgical

Procedure InfectionControl

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

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

USAID and CDC overall dashboard score per number of assessments


Malawi: Baseline vs follow-on assessment at 9 VMMC sites

Baseline Assessment (May & June 2015) Follow-on assessment (2nd) October 2015

Site

Mana

geme

ntSy

stems

Supp

lies,

equip

ment

& en

viron

ment

Regis

tratio

n, gr

oup

educ

ation

& IE

C

Indivi

dual

coun

selin

g & H

IV

testin

g

Male

Circu

mcisi

onsu

rgica

l pr

oced

ure

Monit

oring

& E

valua

tion

Infec

tion P

reve

ntion

Mana

geme

nt sy

stems

Supp

lies,

equip

ment

& en

viron

ment

Regis

tratio

n, gr

oup

educ

ation

& IE

C

Indivi

dual

coun

selin

g & H

IV

Testi

ng

Male

circu

mcisi

on S

urgic

al pr

oced

ure

Monit

oring

& E

valua

tion

Infec

tion p

reve

ntion

154.5 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

390.9 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 (2nd) 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 27.3 83.3 50 50 84.8 35.7 80

<50% 50-80% >80% Not assessed17


Tanzania: VMMC dashboard, 10 sites in Njombe Region

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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

25% -- 75%

4. Individual Counseling and HIV testing for SMC clients

50% 33% 67%

5. Male Circumcision Surgical procedures

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)

Mozambique

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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 IEC

83% 67% 50%

4. Individual Counseling and HIV testing for SMC clients

50% 50% -

5. Male Circumcision Surgical procedures

55% 74% -

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)

Mozambique

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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

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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

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Tools and Technology to Support EQA and CQI


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

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Nine EQA tools incorporated in the VMMC mobile app

A. SOPs, guidelines, policiesB. Facilities, supplies and equipmentC. Clinic record reviewD. Emergency managementE. Adequacy of staffingF. Surgical equipment and proceduresG. Communication to clientsH. PrePex proceduresI. Site utilization / Site efficiency (public health impact and

efficiency)

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• 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

Advantages of the VMMC EQA app

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Available CQI tools

• Baseline assessment tool (paper-based): Modified WHO quality assessment tool comprising 8 standards & 60 sub-standards

• Electronic (Excel) version of VMMC CQI dashboard assists with:– Generating real-time site

reports – Aggregation of VMMC

CQI reports across sites27


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-cqi-resources

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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 [email protected]

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Hot quality topics in VMMC: Adverse events, linkages to care and

treatment, and tetanus risk mitigation

John Byabagambi, MD, MPHSenior Improvement Advisor, USAID ASSIST Project

University Research Co., LLC


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

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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

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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

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Tools to capture and grade AEs

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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

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Results: 49 ASSIST-supported sites in Uganda

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Improving follow-up rates in KiwokoHospital in East Central Uganda

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Importance of understanding type of adverse events

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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 forms39


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

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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)

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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

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

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Results: Improving referral for HIV care and treatment

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APR.15 MAY.15 JUN.15 JUL.15 AUG.15 SEP.15 OCT.15 NOV.15 DEC.15 JAN.16 FEB.16 MAR.16

HIV positive clients referred for HIV care and treatment at Seshego, Apr‐15 ‐Mar ‐16

HTC TEST POSITIVE CD4 test done INITIATED AT WELLNESS CLINIC


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

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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

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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

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Introduction of TT in VMMC

Effectiveness of Td Dosing Schedule vis a vis VMMC

6 wks 4 wks 2 wks 1 wkVMMC

Day 2 wks 4 wksMost protection 1st 2nd

1. Good protection 1st 2nd

Good protection 1st 2nd

Good protection 1st 2nd

2. Little protection 1st 2nd

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Results in 22 sites in Central Uganda

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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

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Q&A for John Byabagambi



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Sustaining quality VMMC: Newdirections in CQI for Early Infant Male

Circumcision (EIMC)

Joseph Kundy, MDUSAID ASSIST Project, URC, Tanzania


Tanzania VMMC context

• High VMMC coverage in Iringa and Njomberegions

• 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

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Piloting EIMC services in Tanzania

Coverage 16 sites in Iringa

Achievement More than 4,000 male babies circumcised to date

FY15 Targets 6,000 male babies under 60 days of life

Sustainability 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

CQI can alleviate some of the existing challenges

ASSIST support CQI integration in existing EIMC sites in Iringa

Build evidence To inform MOHCDGEC about EIMC and CQI scale-up and development of national EIMC tools

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Rationale for CQI in EIMC services

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Support local teams to address program

deficiencies along the continuum of care

Support frontline health workers to monitor and

control quality; encourage innovation

and accountability

Increasing access, timeliness, effectiveness, safety and efficiencies of

RCH services

Maximize potential of EIMC providers to achieve better

outcomes for MNCH services at RCH


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: Post-

operative follow-up visit Infection prevention and

control

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

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Example of one EIMC standard and performance criteria

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STANDARD AREA COMMUNICATION AND INFANT CARE

STANDARD VERIFICATION CRITERIAVerify if provider explains about:

1.The EIMC provider clearly explain benefit and rationale for early infant male circumcision at waiting area for ANC or post natal care

Early infant male circumcision is recommended for infants 24 hours to 60 days oldMale circumcision procedure for early infants is simpler than for older adolescentsHealing among circumcised infants is quicker and complication rates are lower than in adults and older adolescentsWound does not need suturing Procedure in infants is not complicated by erection which may be problematic for older adolescents and adult menInfant 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


EIMC process of care indicators

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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


Phases of CQI in EIMC in Tanzania

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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 on SA CQI work to develop electronic EIMC tool (Apr – Jun 2017)

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

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)

Stakeholder Engagement 2015

Defining standards and developing CQI tools November 2015


Q&A for Joseph Kundy



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DiscussionEmmanuel Njeuhmeli

Donna JacobsJohn Byabagambi

Joseph Kundy

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Wrap-up and Final Remarks

Emmanuel Njeuhmeli, MD, MPH, MBASenior Prevention Advisor, Office of HIV/AIDS, USAID

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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-new-scaling-continuous-quality-improvement-voluntary-medical-male-circumcision

assist vmmc cqi webinar 22june2016 - usaid assist · cqi reports across sites 27. usaid applying...

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