As individual VMMC sites demonstrate gains in their CQI dashboards and in patient-level quality indicators, they may be recategorized as far as the level of external CQI support they receive. External CQI is usually focused on the poorer-performance sites. Once site performance reaches a minimum level, the site may move from “intensive support,” with biweekly or monthly coaching support, to “light support,” which might involve coaching visits every quarter.
The focus of external CQI support for every site should serve to help build the capacity of the site to apply CQI to VMMC services without external assistance. There are a number of steps that sites can take to sustain their quality gains:
- Conduct regular (at least once quarterly) checks using the CQI tool and process indicators to assess the level of performance and address any emerging gaps.
- Ensure a regular supply of VMMC commodities and equipment by including them in the health facility’s annual work plan, assigning a specific staff member to track the stock levels and ensure stock cards are kept updated, and incorporating VMMC supplies in the district procurement plan.
- Ensure that facility management and medical stores remain active members of the CQI team so that they take note of the issues requiring their attention.
- Schedule regular CQI team meetings; these could be biweekly or monthly meetings to discuss the data, changes made, and progress towards implementing action plans and to plan for actions and resources needed to continue the improvement work.
- Develop a list of roles and responsibilities for assuring the quality of VMMC services and regularly review these with the entire VMMC team. Post roles and responsibilities for individual cadres in places where staff can regularly review them.
- Develop a process for orienting new staff to these roles and responsibilities for assuring VMMC quality and safety as part of their facility onboarding.
- Regularly reporting on VMMC quality and safety performance to facility and district management.
In addition to site-level actions, program-level action to sustain quality include:
- Coordinating demand generation and site-level improvement efforts to ensure that service quality improvements are aligned with demand generation activities.
- Examining measures of site productivity and efficiency and comparing those to site CQI performance to guide ongoing site investment.
- Sharing CQI performance data with VMMC training providers to ensure that problem areas are addressed in ongoing training activities.
- Facilitating regular sharing and coordination meetings among all stakeholders to maintain focus on quality and safety performance.
- Conducting yearly external quality assessments.
Finally, CQI efforts should also be informed by strategic directions set by national and international authorities, such as the Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa and the WHO policy brief A Framework for Voluntary Medical Male Circumcision - Effective HIV Prevention and a Gateway to Improved Adolescent Boys’ & Men’s Health in Eastern and Southern Africa by 2021, which encourage VMMC programs to focus on the physical and psychosocial needs of adolescent boys and men seeking VMMC services and the need for innovative approaches to overcome current barriers to services, increase acceptability, and address inequalities in access and coverage. PEPFAR Country Operational Plans are also useful for giving direction to VMMC CQI efforts.
Why it’s important to sustain the gains: Steps taken to ensure that quality performance does not recede once external assistance is withdrawn can have other benefits for the site and for stakeholders since CQI methods can readily be applied to other program areas. Creating mechanisms for ongoing accountability for quality and safety help to sustain attention to CQI.