Improving safety and quality of Safe Male Circumcision (SMC) services in Uganda: adverse events quality improvement collaborative

BACKGROUND: In 2010, Uganda introduced Safe Male Circumcision (SMC) as part of its comprehensive HIV prevention package. In 2018, the Monitoring and Evaluation Technical Support (METS) Program in collaboration with the Ministry of Health (MoH), U.S. Centers for Disease Control and Prevention (CDC) and Implementing Partners (IPs), conducted a data quality assessment in 72 CDC-supported SMC sites. The assessment reviewed 177,952 medical records of males circumcised between October 2017 and March 2018. 970 (0.5%) experienced reportable (moderate or severe) adverse events (AE) resulting from SMC. Of which 30% (288) were correctly classified, 51% (499) misclassified, 19% (183) of reportable AEs not classified and only 9% were documented. An adverse event is any medical complication or injury that occurs during or after SMC. Based on these findings, CDC-supported SMC sites in July 2019 implemented an AE quality improvement initiative aimed at improving safety and quality of SMC services.
METHODS: Multi-pronged QI capacity building model for SMC services which included tailored trainings, post-training coaching and mentorship, periodic service and data quality assessments and learning sessions was implemented in 82 CDC-supported sites. Site teams consisting of circumcisers, counsellors, and data officers were trained in Adverse Event (AEs) identification, management, documentation and reporting. Following the training, multiple on-site mentorship and coaching visits were jointly conducted by central level coaches and IPs during which service and data quality assessments were done using the MoH service and data quality assessment tools.
RESULTS: In July 2020, 7-day follow-up post-SMC was 99% (83,462/84,305) from 80% (73,900/92,000) in September 2018, AE occurrence reduced by 44% from 0.55% (970) to 0.31% (262); AEs correctly classified improved from 30% (288) to 86% (224). The proportion of AEs reported using a site-specific improvised AE form, AE management report and AE grading scale increased from 10% (85/850) in June 2018 to 84% (207/247) in July 2020. Documentation of AE management outcome also improved from 25% (245) to 98% (219) in July 2020.
CONCLUSIONS: Collaborative implementation guided by customized AE reporting tools are vital in improving identification, classification, management and documentation of AEs following SMC. A dedicated AE management and documentation tool should be adopted across sites.