| Incomplete or no history taking and physical examination |
- Project the number of expected clients each day and ensure that there are enough staff to meet the needs of the clients
- Source for additional staff from nearby health facilities during camp activities to ensure there are enough staff to carry out the work
- Identify an appropriate and available room and convert it into a physical examination room; assign a staff member to conduct physical assessment of clients
- Evaluate client flow and develop a flow chart to map out the various steps in VMMC services, including STI assessment
- Conduct a CME and provide manuals on STI diagnosis and treatment (this can be supported by IP)
- Mentor staff on importance of STI assessment and documentation by the in-charge
- Have staff at various service points verify that STI assessment was done for each client
- Post reminders on the wall in the examination rooms
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| Providers do not document clients diagnosed with sexually transmitted infections (STIs) |
- Use the column for comments/remarks in the group education register to document the diagnosed STI cases and for following the treatment outcome of the clients diagnosed with STIs
- Have the duty nurse document the treatment outcome at follow-up visits
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| No head-to-toe medical examination of clients pre-operatively |
- Convene a meeting with the circumcisers to discuss the process of carrying out general medical examination of clients pre-operatively
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| No verification of client consent pre-operatively |
- Place reminders in the theatre for circumcisers to cross check if consent has been obtained prior to surgery
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| Protective clothing (aprons, gowns) not used by surgical team during the surgical procedure |
- Orient staff on importance of infection prevention
- Avail personal protective gear to staff
- Assign staff member to spearhead infection prevention
|
| Lack of forceps for checking for whether anesthesia has been achieved |
- Cross check all reusable surgical kit to ensure they are complete
- Identify any missing instruments and work with the health unit administration and IP to avail the missing equipment
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| Infiltration of local anesthesia not done at the right position |
- Convene a meeting with the surgical team and review the entire surgical procedure to ensure all service providers are performing the acceptable service
- If need be, contact the IP to avail an external team to provide a refresher training for the team
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| Inability to appropriately respond to emergencies |
- Work with the IP to organize training for the staff in emergency response and management
- If this is not possible, work with the health unit anesthetist to go through the management of emergencies
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| No strapping of the penis to the lower abdomen |
- Introduce regular mentorship and peer review to ensure that all providers strap the client’s penis to the lower abdomen
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| No observation of vital signs post-operatively. Clients are not checked for oozing from the site of the operation post-operatively because there is no privacy to do it. |
- Identify the missing equipment and request it from NMS or approach the IP to provide it
- Place reminders for staff to give post-operative instructions in the post-operative care room
- Allocate a staff member on the duty roster to manage post-operative sessions
- Provide an area with privacy to ensure that the clients can be checked for oozing
- Include this step on the checklist for post-operative care
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| Post-operative instructions not discussed with clients |
- Develop a list of post-operative instructions which are discussed with clients by the post-op nurse
- Develop and use a post-operative checklist that has instructions as given in the assessment tool
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| Incomplete client records |
- All circumcisers to complete the client forms immediately after surgery
- Complete client records after each procedure as opposed to completing the records after the end of the day
- Each section completed on the form should be checked for completeness at the next stage
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| No follow-up of clients post-operatively |
- Develop talking points and clear messages to share with clients so that each team member gives the same clear and consistent message
- Engage the surgeon or assistant in giving information on the importance of follow-up at 48 hours and 7 days during the meeting
- Acquire client cards from the district health office or IP and use them to indicate actual return dates
- Provide a counter book to lower-level facilities to document clients who go for follow-up
- Mentor staff at lower-level facilities on the information given to VMMC clients about follow-up and on the importance of follow-up, including documentation of adverse events
- Approach the IP to provide a telephone line; use the phone to give clients reminder calls about coming back for follow-up (Don’t use the phone the phone to conduct follow-up)
- Identify community health workers attached to the health units and sensitize them on the importance of clients coming back for follow-up; regularly give them lists of clients who are due for follow-up so that they can remind them to come back for follow-up
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