Final Report: The Impact of Continuous Quality Improvement on Voluntary Medical Male Circumcision Services Offered in a Public Health Facility in Gauteng Province, South Africa

Zola Community Health Center (CHC), a provincial primary health care facility located in the City of Johannesburg, has been offering PEPFAR-funded VMMC services since November 2010. The facility provides comprehensive health care services, including HIV testing services, HIV and TB-related treatment, care, and support, nutrition, maternal and child health, and voluntary medical male circumcision (VMMC). Since October 2013, the USAID ASSIST Project has been providing continuous quality improvement technical assistance to VMMC sites in South Africa, including Zola CHC. The primary goals of this support were to enhance client safety and ensure service quality. A quality improvement team was established at Zola CHC to collectively develop and implement change ideas and track progress on improvement aims. The team employed various continuous quality improvement methods and tools to analyze problems and plan interventions. The quality improvement team at Zola CHC identified several strengths and challenges during the CQI baseline assessment. Strengths included the facility's catchment area map, staff knowledge of the population size, clearly defined staff roles and responsibilities, good patient flow, and adequate records of informed client consent for undergoing VMMC. Challenges included limited familiarity with VMMC strategy, incomplete physical examinations, emergency trolley lacking critical equipment, incorrect storage and limited stock of some required medications and personal protective equipment, inconsistent implementation of IPC policies, and varying knowledge of IPC techniques among VMMC team members. Following the baseline assessment, the ASSIST advisor helped the facility staff to develop an action plan matrix to identify and prioritize actions aimed at addressing quality gaps. The quality improvement team employed various CQI methods and tools to analyze problems and plan interventions. Changes tested included the introduction of standard operating procedures for managing adverse events, introduction of SOPs for IPC, placing phone calls to clients to remind them of their follow-up reviews, issuing clients with appointment cards for follow-up, reinforcing personal hygiene and wound care messages, and in-service training for VMMC staff on adverse events and IPC. Since the establishment of a quality improvement team and the adoption of CQI, adverse events were still observed at Zola CHC, but robust adverse events management and client follow-up systems have been put into place, which have ensured improved documentation, communication with clients, and better management of complications and emergencies. The 48-hour follow-up rate at Zola CHC increased significantly, from 5% in October 2015 to 100% in January 2017. The 7-day follow-up rate also increased, from 5% in October 2015 to 100% in January 2017.