D Masina 1, J Ndirangu 1, I Choge 2, L Dayanund 3, C Bonnecwe 3, E Njeuhmeli 4, D Jacobs 1. Abstract no. WEPEE489

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1 Abstract no. WEPEE489 Improving client follow up in Voluntary Medical Male Circumcision (VMMC) programs through Continuous Quality Improvement (CQI): Experiences from South Africa D Masina 1, J Ndirangu 1, I Choge 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 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:

2 Background Continuous Quality Improvement (CQI) in health care is a systematic approach to making changes that lead to better patient outcomes and stronger health system performance. This approach involves the application of CQI, which provides robust structure, tools and processes to assess and accelerate efforts to test, implement and scale up. CQI is the complete process of identifying, describing and analyzing strengths and problems and then testing, implementing, learning from and revising solutions and spreading good practices. From June 2014, ASSIST has been working with more than 100 PEPFAR supported voluntary medical male circumcision (VMMC) sites in all nine provinces of South Africa to advance the quality and safety of VMMC. Based on the results of baseline CQI assessments, poor client follow up rate was identified to be a key challenge.

3 Methods CQI site teams, comprising site level staff, were set up at VMMC sites. Monthly and quarterly CQI mentoring and coaching visits were conducted by ASSIST staff, according to site performance. CQI site teams were mentored on analyzing, reviewing data, documenting program performance and problem solving. Site teams began capturing and documenting programmatic data on quality indicators such as 48 hour follow up rate. The World Health Organization recommends that a client post operatively should routinely return for follow up visits at 48 hours, 7 days and 6 weeks to receive treatment if necessary and be assessed regarding wound healing and potential adverse events. Assessing adverse events enables facilities to recognize challenges and develop action plans to limit/prevent future occurrences. Site teams are expected to collect follow up data, analyze and interpret results and act upon it. Below is the fishbone diagram used by the site teams to visualize and unpack problems. Through brainstorming, the site team is able to identify key steps involved in the process. It also explores possible causes of the quality gaps and help teams to reach consensus, make quality decisions and have confidence in those decisions to test and implement. During data review meetings, data analysis was done, quality gaps identified and fishbone (cause effect) diagrams used to establish root causes and selecting possible solutions to test, implement and monitor results. The CQI site teams adopted the PLAN, DO, STUDY, ACT (PDSA) cycle in monitoring of tested changes to improve client follow up rates.

4 Methods Examples of tested changes from the sites include: Providing clients with appointment cards listing return dates Making phone calls to remind clients of follow up visits Keeping sites open for extended hours to accommodate employed clients Collecting and analyzing client follow up data using time series charts Stressing come back messages to clients at all levels of care Reinforcing the importance of returning back for check up Using tools to capture follow up visits as a source of data Incorporating the importance of returning for follow up into demand creation messages PDSA model adapted from Langley et. al. 2009: 24, 454

5 Results Initially follow up data was not collected at the sites Since ASSIST began working with the sites, all site teams started documenting programmatic data, compiling common quality indicators, analyzing quality gaps and discussing possible interventions The figure below shows significant improvement (from 28.1% to 47.5% between February December 2015) of 48 hour follow up rate among 83 sites

6 Conclusions Since the onset of CQI support, it has been noted that site level CQI teams have gained positive attitudes and were motivated to develop interventions and site level action plans. While shown to be effective within the VMMC program, CQI tools and methodologies can be applied to all health programs as teams can implement skills gained and lessons learnt across board. Success of CQI depends on: Buy in of facility management Mentoring, coaching and capacity building of site teams Orientation of staff on importance of data collection, analysis and interpretation Capacity and motivation to act on results and manage change With regards to client follow up in VMMC: The majority of sites supported with CQI have shown improvement in client follow up rates In order to further increase the percentage of clients returning for follow up, vigorous efforts and close monitoring of PDSA cycle results on interventions are required Messages related to follow up and wound care need to be consistent and reinforced by site staff at all levels Effective management of follow up offers sites an opportunity to identify adverse events and to design action plans to reduce/prevent future occurrences Additional efforts should be made to try and contact clients not returning for post operative follow up to ensure all adverse events are identified and managed appropriately