6. Surgical Procedure

Challenge Actions CQI Teams Took to Address the Challenge
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
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
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
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
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
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
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
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
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
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
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
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