This step involves planning the start-up of CQI and selection of sites to begin the CQI process. If resources allow, starting all sites in a CQI process at the same time is preferable to gradual spread across regions or implementing partners. In Uganda, CQI assessments were initially done in only 30 of the over 150 USAID-supported sites providing VMMC services, while in South Africa, baseline assessments were conducted in 127 out of 160 PEPFAR-supported sites over a four-month period.
Planning for CQI baseline assessments also involves scheduling the site visits, securing the availability of national and/or district MOH staff and implementing partner staff (if applicable) to participate in the baseline assessment, and training of assessors in the use of the CQI assessment tool. Such training might involve a practice visit to a VMMC site or simply a thorough review and group discussion of each section of the tool, to ensure that all assessors have the same understanding of the assessment criteria.
It is also helpful to gather basic information about each VMMC site that will be supported through CQI, such a current volume of circumcisions, days when circumcisions are performed, and the number of staff engaged in VMMC services. The PEPFAR EQA site characteristics tool provides a useful template for recording basic information about each site.
Finally, planning the CQI baseline assessment also involves setting up the system for supporting CQI—determining who will serve as coaches and mentors to site teams as they work on improving VMMC services. Experience has shown the regular visits from an improvement coach (who may be from the district health office or implementing partner) help to increase the pace of action and improvement.
Why planning facilitates the baseline assessment: Providing advance notice of the assessment to district health management teams, implementing partners, and VMMC sites is important to gain buy-in for and secure their active participation in the CQI process. Contrary to popular belief, CQI baseline assessments that are scheduled with notice yield more accurate data, since the gaps identified when sites know they are going to be assessed are more likely to represent persistent problems for the site.
Information on site characteristics, such volume of circumcisions provided and days of operation, is also helpful for planning the baseline CQI assessment since sites with a larger number of providers may take longer to assess.
“In Malawi, one of the things we learned that we should have done from the start was engaging the implementing partners in performing assessments of their own sites. We thought at the beginning that it would not be a good idea, that it would lead to some bias, but, in reality what we found is that having the partners participate in the assessment process made them understand what gaps really existed in their sites. Not involving them led to them not understanding what the process is and what the scores mean. Later on when we involved the partner quality assurance managers in the assessments, we found a lot more receptivity to the findings and greater understanding of what the gaps were. I would definitely recommend that other countries build in the participation of implementing partners in the baseline assessments.” -- Tiwonge Moyo, ASSIST Chief of Party, Malawi