3. Supplies, Equipment, and Environment

Challenge Actions CQI Teams Took to Address the Challenge
Physical facilities inappropriate for SMC service provision/ lack of adequate space
  • Obtain partitioning screens for privacy
  • Improvise space for pre-operative assessment
  • Lobby IP to renovate VMMC theatre
  • Request the IP to avail a tent for group education
Pre-operative assessment done on the operating table
  • Meet with the in-charge of the health unit to discuss availability of space and need for an examination couch
  • Identify space for preoperative assessment
Lack of running water in the theatre
  • Use a portable hand washing health unit
  • Improvise with buckets that have been fitted with taps
Insufficient VMMC kits for the surgical procedure
  • Ask the IP to provide adequate quantity of disposable kits for SMC based on the client target for the site
No VMMC commodities like Bupivacaine, Acyclovir, Cefixime
  • Requisition for VMMC commodities from National Medical Stores (NMS) and IP
  • Generate a list of needed supplies and share it with the health unit in-charge for inclusion in the order list to NMS
No protective materials (shoes, eye wear, gowns) for staff
  • Generate requests for missing protective materials and submit it to the hospital management and implementing partner
Lack of client gowns
  • Request for linen from NMS and work with health unit management to make client gowns
  • Approach the IP for support in availing the client gowns
No petroleum-impregnated gauze
  • Request for the petroleum gauze from NMS and also approach the IP to support the procurement of the gauze
  • Get ordinary gauze and cut it into the required size. Put the gauze in a tin of petroleum jelly then autoclave using steam
No color-coded bin liners
  • Request bin liners from other health units within the district, NMS, and IP
No mackintosh on theatre beds
  • Make requests for the protective covering of the operating tables to the IP and NMS
Inadequate testing kits/stock-out of STI drugs
  • Establish minimum stock level of all key supplies and assign a staff member to track them and make order within the prescribed NMS timelines
  • Request for supplies that are at a minimum stock level before they run out of stock
  • Keep the district health office aware through regular reports on performance and stock levels of essential items like HIV test kits, condoms and drugs for STI management
  • Ask clients to buy the drugs
  • Approach the IP with required quantities and request them to supply
Lack of condoms
  • Establish minimum stock levels and regularly track the stock level
  • Request for more condoms before they run out of stock
No emergency resuscitation system/ equipment
  • Identify the required drugs based on the checklist in the assessment tool
  • Determine the missing drugs after consultations with stores
  • Place request to NMS and also request the IP to support if possible
No emergency resuscitation protocols in place in the procedure rooms
  • Discuss the management of emergencies and develop protocols as a team
  • Display emergency resuscitation protocols in the procedure rooms
  • Request the anesthetist to give a talk to team members and help in development of protocols
Having expired emergency drugs on the emergency trolley
  • Use a checklist to track the expiry dates before each day of surgery
  • Assign a team member the responsibility of ensuring that drugs are available and are not expired by routinely using the checklist prior to surgery
Staff lack skills and knowledge on handling adverse events
  • Ask experienced hospital anesthetist to prepare and share a presentation on adverse events
  • Conduct a CME on the basics of managing adverse events and the importance of documenting them
  • Organize a session in which staff who are trained in management of adverse events pass on information to the rest of the team, through a debriefing meeting
  • Orient/re-orient all VMMC team members on the adverse events grading scale and how to identify, classify, grade, and manage adverse events
Staff not trained on standard techniques for VMMC procedures
  • Request IP to train staff in VMMC procedures
  • Provide ongoing mentorship support on the dorsal slit method of circumcision with guidance of the minimum standards of procedure document
Poor communication with circumcised clients on self-care and adverse events
  • Ask counsellors to spend a little more time to deliver health education sessions and use standard IEC materials to demonstrate self-management to clients.
  • Design a health education checklist with information on signs and symptoms of adverse events to look out for and importance of returning for follow-up. This can be used by health educators.
  • Lobby the IP to provide a telephone line on which clients can call the health unit and report adverse events
  • Maintain a log of all the clients that call in to report adverse events using a counter book
Guardians and parents of minors not attending education sessions
  • Ask parents/ guardians to come with their children during mobilization
  • Emphasize the importance of having guardians and parents bring their children to the health unit
  • Tailor education sessions that target guardians and parents on their role in preventing adverse events
Tight-fitting underpants not used
  • Use the community health workers (CHWs) and mobilizers to remind clients to bring tight-fitting underpants 
  • Orient the CHWs and mobilizers on what messages to pass on before they do mobilization; including asking clients to come with tight-fitting underpants
Poor documentation of adverse events at the facility
  • Put an adverse events log book at OPD to capture any clients who return with adverse events but are not captured in the VMMC register because the VMMC register is not accessible at certain times
Lack of adverse events grading scale
  • Request the IP to provide a copy of the adverse events grading scale for each consultation room
  • Print out and make copies, laminate these copies and pin them up at all important points (procedure room examination rooms and OPD)
Clients getting hematomas after surgery
  • Obtain adhesive tape and provide them to clients who do not have tight-fitting underpants
  • VMMC assistant finds out if the client has tight underpants and if they do not, strap the penis to the abdomen using adhesive tape.
  • Inform the client about the need to keep the bandage clean to prevent infections
  • Ask team members if they are willing to contribute towards the purchase of underpants for some few prisoners who may not have.
  • Request the IP to supply the underpants
Soiling of the dressing during bathing and passing urine
  • Request the IP to provide polythene paper and toilet paper
  • Give each client pre-packed polythene bags and toilet paper in the post-operative area