title: Improving the Quality of Voluntary Medical Male Circumcision through Use of the Continuous Quality Improvement Approach: A Pilot in 30 PEPFAR-Supported Sites in Uganda.
abstract: BACKGROUND
  Uganda adopted voluntary medical male circumcision (VMMC) (also called Safe Male Circumcision in Uganda), as part of its HIV prevention strategy in 2010. Since then, the Ministry of Health (MOH) has implemented VMMC mostly with support from the United States President's Emergency Plan for AIDS Relief (PEPFAR) through its partners. In 2012, two PEPFAR-led external quality assessments evaluated compliance of service delivery sites with minimum quality standards. Quality gaps were identified, including lack of standardized forms or registers, lack of documentation of client consent, poor preparedness for emergencies and use of untrained service providers. In response, PEPFAR, through a USAID-supported technical assistance project, provided support in quality improvement to the MOH and implementing partners to improve quality and safety in VMMC services and build capacity of MOH staff to continuously improve VMMC service quality.
  
  
  RESULTS
  Sites were supported to identify barriers in achieving national standards, identify possible solutions to overcome the barriers and carry out improvement plans to test these changes, while collecting performance data to objectively measure whether they had bridged gaps. A 53-indicator quality assessment tool was used by teams as a management tool to measure progress; teams also measured client-level indicators through self-assessment of client records. At baseline (February-March 2013), less than 20 percent of sites scored in the "good" range (>80%) for supplies and equipment, patient counseling and surgical procedure; by November 2013, the proportion of sites scoring "good" rose to 67 percent, 93 percent and 90 percent, respectively. Significant improvement was noted in post-operative follow-up at 48 hours, sexually transmitted infection assessment, informed consent and use of local anesthesia but not rate of adverse events.
  
  
  CONCLUSIONS
  Public sector providers can be engaged to address the quality of VMMC using a continuous quality improvement approach.
authors.affiliation: USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC (URC), Kampala, Uganda.
authors.forename: John
authors.initials: J
authors.lastname: Byabagambi
authors.affiliation: USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC (URC), Bethesda, Maryland, United States of America.
authors.forename: Pamela
authors.initials: P
authors.lastname: Marks
authors.affiliation: USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC (URC), Kampala, Uganda.
authors.forename: Humphrey
authors.initials: H
authors.lastname: Megere
authors.affiliation: USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC (URC), Kampala, Uganda.
authors.forename: Esther
authors.initials: E
authors.lastname: Karamagi
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Sarah
authors.initials: S
authors.lastname: Byakika
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Alex
authors.initials: A
authors.lastname: Opio
authors.affiliation: Health Team, United States Agency for International Development (USAID), Kampala, Uganda.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Calnan
authors.affiliation: Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development (USAID), Washington, District of Columbia, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D002944:Circumcision, Male / Q000379:methods / Q000592:standards*; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D008297:Male; D010865:Pilot Projects; D058996:Quality Improvement; D012647:Self-Assessment; D014454:Uganda