Safe Male Circumcision for HIV Prevention

QUALITY IMPROVEMENT FOR

SAFE MALE CIRCUMCISION (SMC)
FOR HIV PREVENTION
Ministry of Heat! U"an#a
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !
Safe Male Circumcision for HIV Prevention
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2
Safe Male Circumcision for HIV Prevention
Facility Name:
Facility District:
Facility Type: Hospital (fll in type) _________ Health Center _______ Other (please fll in)__________
Telephone ________________
Primary Contact
Person at site:
Telephone _______________ Email _____________
Completion Date
Individuals present
by name and
position
(use back side if
more space needed)
Name ___________________ Position _________________ Tel____________________
Name ___________________ Position _________________ Tel____________________
Name ___________________ Position _________________ Tel____________________
Completed by Name____________________________________ HQ Team member ______
Care Delivery Is the SMC eli!ere at a separate "lini" or inte#rate into primary "are$
_______Separate lo"ation an time _______Separate only by time _______%&lly Inte#rate into
primary "are
Access Ho' many ays per 'ee( is SMC pro!ie in"l&in#$ ________ ) ays per 'ee(
Partner Involvement *ist partners 'ho ha!e a sini!cant role in s&pportin# the SMC a"ti!ities
Area of support provided
Partner "ta# Trainin

$%& 'I (t)er

Data $t
Drus (t)er Detail

Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "
Safe Male Circumcision for HIV Prevention
Ta$e of %ontents
Intro&"tion++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ,
Instr&"tions -or "ompletin# the Sa-e Male Cir"&m"ision (SMC) Q&ality Stanars tool++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++.
/+ Mana#ement Systems++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 0
1+ S&pplies2 E3&ipment an En!ironment++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ /4
4+ 5e#istration2 6ro&p E&"ation an IEC+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ /7
8+ Ini!i&al Co&nselin# an HI9 testin# -or SMC Clients++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 1/
:+ Male Cir"&m"ision S&r#i"al Pro"e&re++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 1:
,+ Monitorin# ; E!al&ation+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 4<
.+ In-e"tion Pre!ention+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 41
="hie!ements o- Q&ality Stanars+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 47
/+ Mana#ement Systems++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 40
1+ S&pplies2 E3&ipment an En!ironment++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 8<
4+ 5e#istration2 6ro&p E&"ation an IEC+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 8/
8+ Ini!i&al Co&nselin# an HI9 testin# -or MC Clients++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 81
:+ Male Cir"&m"ision S&r#i"al Pro"e&re++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 84
,+ Monitorin# ; E!al&ation+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 88
.+ In-e"tion Pre!ention+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 8:
="tion Plan Matri>++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 8,
?o"&mentation @o&rnal -or QI a"ti!ities++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 8.
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #
Safe Male Circumcision for HIV Prevention
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page $
Safe Male Circumcision for HIV Prevention
Intro#&%tion
%&is tool lists t&e minimum standards for SMC for HIV prevention defined 'y t&e Ministry of Healt& (MoH) of Uganda and provides verification criteria to
guide &ealt& care providers and t&eir supervisors to measure compliance* It operationali+es t&e minimum standards of procedures for SMC as set 'y t&e
ministry of Healt&* In addition, it serves to measure actual level of compliance to standards and &elps identify t&e gaps 'et,een actual and desired
performance level*
%&e SMC standards tool is organi+ed in - areas ,it& a total of $" standards.
/rea !. Management Systems 0 ! standards
/rea 2. Supplies, 12uipment and 1nvironment 0 3 standards
/rea ". 4egistration, 5roup 1ducation and I1C 0 # standards
/rea #. Individual Counseling and HIV %esting for MC Clients 0 3 standards
/rea $. Male Circumcision Surgical Procedure 0 ! standards
/rea 3. Monitoring and 1valuation 0 # standards
/rea -. Infection prevention 0 !! standards
%&e tool also &as instructions for completing it and matrices for consolidating t&e assessment findings* /n action plan matri6 is provided to guide
addressing efforts at closing t&e identified gaps* %&en improvement plans and activities ,ill 'e recorded on t&e QI improvement 7ournal as indicated 'y t&e
national QI frame,or8 and strategic document*
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 3
Safe Male Circumcision for HIV Prevention
Instr&%tions for %o'(etin" t!e Safe Mae Cir%&'%ision (SMC) Q&aity Stan#ar#s too
1ac& standard &as instructions a'out t&e ,ay t&at information is collected and ,&et&er 'y o'servation, intervie, or revie, of records*
Completing the SMC standards tool
4ecord findings immediately as t&ey are o'served*
9rite :es (:), ;o (;), or ;ot /pplica'le (;/) in t&e columns provided*
4ecord all relevant comments, clearly and 'riefly, &ig&lig&ting t&e gaps and possi'le cause* %&is ,ill g
uide in t&e identification of causes of gaps, and &elp selection of appropriate interventions
)O NOT LEAVE ANY SPACE *LAN+
9rite Y if t&e ite' is (erfor'e# or 'eets t!e #es%ri(tion*
9rite N if t&e ite' is not (erfor'e# or #oes not 'eet t!e #es%ri(tion (in%orre%t or in%o'(ete), <or instance.
-, Not (erfor'e#.
- =oes t&e clinic 8eep a safe male circumcision register>, if t&ere is no register in t&e facility, ,rite N for t&is item*
/, )oes not 'eet t!e #es%ri(tion.
- 9as&es &ands ,it& soap and ,ater and dries t&em ,it& a clean, dry to,el*
, if t&e provider ,as&es &er?&is &ands ,it& ,ater 'ut does not use soap, and dries &er?&is &ands on &er?&is o,n clot&es, you s&ould t&erefore, ,rite N
for t&is item*
"* 0!ere a %riterion !as s&$1ite's an# 2ere not (erfor'e# or an ite' 2as not (resent.
- C&ec8 availa'ility of emergency supplies.
Hydrocortisone
@6ygen
5lucometer
/s you are c&ec8ing, if t&e emergency trolley, 'ag or supply does not &ave, ALL of t&em or ONE of t&em, you s&ould ,rite in t&e comment 'o6 2!at
ite' 2as 'issin", If t!e su'Aitem t&at ,as not performed or item ,as not present t&e standard ,as not met since t&e verification criteria ,as not
met* %&e standard s&ould 'e mar8ed N to indicate t&at t&e standard ,as not met*
9rite NA ,&en t&e item s(e%ifies a %on#ition t!at #oes not a((y to t!e %ase or fa%iity $ein" assesse#, <or instance.
- If t&e client is HIV positive*
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page -
Safe Male Circumcision for HIV Prevention
If t&e standard 'eing assessed involves a client ,&o is HIV negative, ,rite NA for t&is item*
Scoring the points and consolidation of results
%o mar8 a standard as accomplis&ed, all verification criteria must 'e mar8ed ,it& Y or NA*
/ NO (N) for any 3erifi%ation %riterion means t&at particular standard is not ac&ieved*
9&ere multiple o'servations are conducted (e6. some standards are meant to 'e o'served in t&ree clients) give one point for eac& time t&e
standard ,as correctly ac&ieved* <or e6ample, in t&e counseling standard, t&e o'servation criteria ,ere eit&er : or ;/ for t,o clients, 'ut
contained an ; for t&e t&ird client* %&e provider ,ould score 2 points for t&at standard*
How to tabulate the results
Use t&e Consoi#ation S!eets ((" 45), 'ased on t&e results from t&e completion of t&e SMC Quality Improvement tool*
In t&e column t&at synt&esi+es t&e gaps and possi'le causes in t&e section for consolidation of results.
<or eac& unmet standard, revie, t&e gaps identified 'ased on t&e items of verification t&at ,ere not complied ,it&, and t&e comments provided*
Synt!esi6e t&e follo,ing information.
- Practices t&at are not performed
-
- Practices t&at are performed incorrectly or in incomplete fas&ion*
- =ata or information incomplete or none6istent
Fi o&t t&e results (num'er of standards and B ac&ieved) in t&e consolidation of results form*
I#entify possi'le causes for eac& verification criteria t&at ,as not accomplis&ed
Fi o&t t!e A%tion Pan Matri7 ((" 89) 'ased on t&e identified gaps, causes of t&em and specific interventions to address t&e gaps* %&is s&ould follo, a
formal participatory root cause analysis*
@nce QI intervention is selected, document t&e progress of t&e improvement initiative using t&e )o%&'entation :o&rna of QI ((" 85) availa'le at t&e
end of t&is document
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page C
Safe Male Circumcision for HIV Prevention
-, Mana"e'ent Syste's
STAN)AR)S VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
-, Ree3ant SMC
Poi%ies= ;&i#eines
an# Stan#ar#s are
a3aia$e an# staff
are a2are of t!e'
Verify t&e e6istence of.
Intervie, staff and verify t&at t&e follo,ing 8ey documents are availa'le .
o Safe Male Circumcision Policy
o Quality improvement frame,or8 and strategy
o H%C guidelines
o S%I diagnosis and treatment guidelines
o Minimum Standards of Procedures for Safe Male Circumcision
o SMC ;ational %raining Manual
Staff are a,are of t&e 8ey documents and 8no, ,&ere to o'tain t&em for
reference
DDDDDDD
DDDDDDD
/, T!e site !as a
2ritten (an for SMC
ser3i%es1 SMC
Service Delivery
Plan ('ini'&' -
year (an)
Verify
%&e e6istence of a SMC plan standAalone @4 incorporated in t&e
facilitiesE ,or8 plan
%&e SMC plan include.
o 16pected client flo, ? service delivery targets
o %rained &uman resources re2uired for SMC
o Pro7ected resource needs (e2uipment, supplies, commodities)
o Mentoring, monitoring and 2uality improvement
o Community involvement
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page F
Safe Male Circumcision for HIV Prevention
-, Mana"e'ent Syste's
STAN)AR)S VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
4, T!e SMC %ini% is
a$e to 'eet
#e'an# for ser3i%es
Verify
%&e total num'er of circumcisions performed in t&e last 2uarter
Client demand num'ers are inAline ,it& SMC plan pro7ections
9aiting list is no longer t&an t,o ,ee8s
DDDDDDDD
DDDDDDDD
DDDDDDDD
8, T!e SMC %ini% or
fa%iity !as %eary
#efine# staff roes an#
res(onsi$iities
Verify t&e e6istence of.
9ritten roles and responsi'ilities (Jo' =escription) for all staff involved in
safe male circumcision services
Staff are a'le to descri'e t&eir roles and responsi'ilities

DDDDDDDD
DDDDDDDD
9, T!e SMC %ini% or
fa%iity !as t!e !&'an
reso&r%es a3aia$e
a%%or#in" to t!e SMC
ser3i%e #ei3ery (an
Verify t&e e6istence of.
/de2uate num'ers of staff for eac& functional area in t&e plan* Staffing is
appropriate for.
o 4egistration ? inta8e?group education
o %esting and counseling ? client assessment
o Circumciser
o /ssistant Circumciser and postAoperative activities
Staff meet minimum standards
o /ppropriate cadre of staff according to national standards
o Staff are trained on t&eir specific 7o' functions
DDDDDDD
DDDDDDD
GPlease document
any 'ottlenec8H
5, SMC Staff re%ei3e
'entors!i( an#
s&((ort
SMC staff is periodically provided support using a standard tool (e*g*,
t&ese performance standards, training c&ec8lists)
Staff receive individual feed'ac8 on t&eir performance at least once per
year
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !
Safe Male Circumcision for HIV Prevention
-, Mana"e'ent Syste's
STAN)AR)S VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
>, Cient fo2 %!art is
a3aia$e in t!e fa%iity,
Verify
%&e presence of a client flo, c&art for SMC*
@'serve t&at client flo, follo,s t&e client flo, c&art and.
Clients are received and directed to t&e SMC registration and inta8e area
Clients receive clear instructions on going from one station to t&e ne6t
Client flo, is organi+ed to maintain infection prevention standards
o clients ? staff not entering procedure area e6cept for procedure
o contaminated ,aste doesnEt cross pat& ,it& clients and providers
/ system for facilitating effective referral to lin8ed services is in place
o 4egisters reflect appropriate referrals to care and treatment units
o Client records s&o, clients ,&o &ave 'een referred &ave
received t&e referred services
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
?, Monitorin" ser3i%e
#ei3ery #ata are &se#
for (annin" an#
i'(ro3e'ent of ser3i%e
#ei3ery
Verify
%&e e6istence of a functional 2uality improvement team
Meeting &eld at least mont&ly to revie, data
C&anges 'een made to services 'ased on t&e feed'ac8 of t&ese data
Client satisfaction survey conducted @4 ot&er form of client feed'ac8
process (eg e6it intervie,s) is implemented at least t,ice a year
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
@, Mo#erate an# se3ere
a#3erse e3ents or
%o'(i%ations are
re3ie2e#
Management records revie,.
/ systematic process e6ists for investigating moderate or severe adverse
event to determine causes and outcomes
<ollo, up is conducted as per recommendation #C &ours and - days post
circumcision
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !!
Safe Male Circumcision for HIV Prevention
-, Mana"e'ent Syste's
STAN)AR)S VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
-A, T!e fa%iity < SMC
%ini% !as a f&n%tiona
s&((y an# eB&i('ent
or#erin" syste'
Verify.
MC instruments, medicines and supplies are integrated into routine
forecasting, procurement and management systems of t&e ;ational Medical
Stores (;MS)
4e2uisition forms for MC commodities are availa'le and used
Minimum stoc8 levels are esta'lis&ed for essential SMC commodities (at t&e
SMC service or facility level)
Commodity stoc8s records are 8ept upAtoAdate
<acility records stoc8Aouts of 8ey commodities and reports to management

DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
-, Mana"e'ent Syste's
%otal standards !
%otal o'served
%otal ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !2
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
!* T!e (!ysi%a
fa%iities are
a((ro(riate for
SMC ser3i%e
(ro3ision
@'serve.
4eception area ,it& printed and audioAvisual information on SMC for
HIV prevention
Space for &ealt& education and group counseling*
Space for individual counseling, pre and postAtest counseling ,&ic&
affords privacy for clients*
Space for preoperative and postoperative evaluation including genital
e6amination t&at affords privacy for clients, is ,ell lit, ventilated and
&as sufficient space*
Source of clean running ,ater for &and ,as&ing in t&e e6amination
room, procedure room and postAoperative area
%&ere a designated room (s) for performing t&e surgical procedure
%&eatre?operating rooms &ave ade2uate temperature control,
ventilation, sufficient lig&ting and space
/de2uate area for performing t&e surgical scru'
Iayout of surgical suites allo, for effective flo, of clients , staff and
contaminated instruments?,aste
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !"
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
/, T!e ne%essary
eB&i('ent are
a3aia$e for
(erfor'in" MC
s&r"eries
<acility &as ade2uate num'er of prepared MC instrument sets for t&e
e6pected num'er of procedures in a day (t&e day of t&e assessment)
/re t&e instrument sets complete.
P&ysically verify t&at t&e SMC instrument set contains all t&e follo,ing
instruments, in good ,or8ing condition.
! instrument tray
Sterile drapes to ,rap instrument tray
2 dissecting forceps (finally toot&ed)
# /rtery forceps (2 straig&t, 2 curved)
! curved dissecting scissors (e*g* Met+en'aumEs scissors)
! stitc& scissors
! needle &older
! scalpel 8nife &andle
! J@K drape (C cm 6 C cm, ,it& L$ cm &ole)
! gallipot for antiseptic solutions
=iat&ermy if availa'le, prefera'ly monopolar
OR
Safe Male Circumcision Mits for =orsal Slit Procedure
DDDDDDDD
DDDDDDDD
DDDDDDDD
GPlease note any
missing supplies in
t&e t&is columnH
e*g*
Missing items
Stitch scissors
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !#
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
4, T!e ne%essary
%o''o#ities are
a3aia$e for
(erfor'in"
s&r"eries
<acility &as ade2uate commodities for t&e e6pected num'er of procedures in a
day (consistent ,it& national standard)
P&ysically verify t&e follo,ing supplies.
o Plain gau+e s,a's
o PetroleumA7ellyAimpregnated gau+e
o Stic8ing plaster
o !B lignocaine ,it&out adrenaline
o *$B solution of 'upivacaine if availa'le
o Syringe, !ml
o ;eedles (!C or 2!Agauge)
o Suture material (c&romic catgut or vicryl rapidae "A and #A)
,it& "?C circle reverseAcutting needle
o Povidone iodine (!B solution) or C&lor&e6idine
o Surgical gloves, of appropriate si+es
o Mas8s,
o Caps and
o /prons
o Safety s&oes of different si+es
o Patient go,ns
o Soap or antiseptic &andAru'
o S&arps containers
o 9aste receptacles for contaminated and nonAcontaminated
,aste
o Properly color coded 'in liners
o Nuc8ets for decontamination
o Iinen saver (e*g* Mac8intos&)
DDDDDDDD
GPlease note any
missing supplies in
t&e t&is columnH
e*g*
Missing item.
Plain gau+e
/pron
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !$
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
8, A#eB&ate
s&((ies of
'e#i%ines an#
%o''o#ities (HIV
test Cits=
%on#o's) are
a3aia$e for non1
s&r"i%a as(e%ts
of MC ser3i%e
(ro3ision
Verify ,&et&er minimum stoc8 levels are maintained of t&e follo,ing
medications for S%I management and management of postAoperative
infections (eit&er in t&e MC clinic or in t&e p&armacy)
o Ciproflo6an
o Iindane !B lotion or cream
o Podop&ylin 2$B in tincture iodine
o Nen+at&ine Pencillin
o <lucona+ole ta'let
o 1ryt&romycin
o =o6ycycline
o /cyclovir ta'lets
o Metronida+ole
o /mo6icillin(ta'lets)
o Cotrimo6a+ole
o Parafcetamol (ta'lets)
o Cefi6ime
/ll t&e medications stoc8ed and dispensed ,it&in e6piration date
Medications stored according to temperature and lig&t
recommendations
Is a medication inventory system in use
/ minimum stoc8s of HIV test 8its to meet t&e e6pected demand for at
least ! day availa'le at t&e MC counseling site
/de2uate stoc8s of condoms for distri'ution to clients 'eing
disc&arged after MC or returning for postASMC follo,Aup
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
GPlease note any
missing supplies in
t&e t&is columnH
e*g*
Missing drugs.
- =o6ycycline
- Cefi6ime
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !3
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
9, An e'er"en%y
res&s%itation
syste' e7ists an#
'e#i%ations <
s&((ies are
a3aia$e 2it!
i''e#iate a%%ess
1mergency resuscitation protocols readily availa'le in t&e operating
rooms
1emergency resuscitation e2uipment?supplies and medicines are
availa'le in t&e operating room and in good ,or8ing order ? valid (i*e*,
not e6pired)
o /drenaline
o Hydrocortisone
o Sodium C&loride
o $B de6trose
o @6ygen cylinder
o @6ygen mas8s
o /m'u 'ag
o Cannulars
o IV giving sets
o /ir,ays
o 5lucometer
o Stet&oscope
o Sp&ygmomanometer
DDDDDDDD
DDDDDDDD
GPlease note any
missing supplies in
t&e t&is columnH
e*g*
Missing items.
Hydrocortisone
5lucometer
5, A#eB&ate
'eas&res are in
(a%e for
'ana"in"
'o#erate to
se3ere
%o'(i%ations
an# a#3erse
e3ents
1mergency services are availa'le 2# &ours to manage clients ,it&
complications or adverse events
%ransport arrangements are availa'le to facilitate referrals if re2uired
DDDDDDDD
DDDDDDDD
/, S&((ies= EB&i('ent an# En3iron'ent
%otal standards 3
%otal o'served
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !-
Safe Male Circumcision for HIV Prevention
%otal ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !C
Safe Male Circumcision for HIV Prevention
4, Re"istration= ;ro&( E#&%ation an# IEC
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
Client
!
Client
2
Client
"
-, T!e %ient is
%orre%ty re%or#e# in
t!e re"ister an# "i3en
a seria I) n&'$er
@'serve t&ree clients to see ,&et&er.
%&e clinic &as register to register SMC clients
Client data are completely and correctly entered into t&e register
Client are given an client card ,it& t&eir name and follo, up appointment
times
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
/, T!e fa%iity !as
a((ro(riate
infor'ation an#
e#&%ationa 'aterias
on SMC an# ot!er
re(ro#&%ti3e !eat!
@'serve ,&et&er.
Clients are provided ,it& printed ta8e &ome materials on SMC
ClientsE partners and family are provided ,it& ta8e &ome printed materials on
SMC
/t least oneA ot&er se6ual and reproductive &ealt& materials t&at provide
information and education are availa'le
DDDDDD
DDDDDD
DDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page !F
Safe Male Circumcision for HIV Prevention
4, Re"istration= ;ro&( E#&%ation an# IEC
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
Client
!
Client
2
Client
"
4, ;ro&( e#&%ation
#ei3ere# 2it! %orre%t
infor'ation
@'serve during one group education session ,&et&er.
/ppropriate segregation of clients &as 'een done according to adults and
c&ildren
Information and education 'eing given a'out male circumcision includes t&e
follo,ing.
o Nenefits and 4is8s of SMC
o =escription of t&e surgical procedure (including pain management)
o SMC is only partially protective against HIV, it is still necessary to
maintain ot&er HIV prevention strategies (e*g* continue to ,&ere
condoms, limit t&e num'er of se6ual partners etc*)
o Maintenance of an a'stinence period of at least 3 ,ee8s postAoperation
to allo, for ,ound &ealing
o %&ere are no 8no,n HIV prevention 'enefit for HIVO persons so not
recommended for persons already HIV infected
o 4evie, ot&er se6ual reproductive &ealt& information (including 'ut not
limited to <P, S%Is, fertility etc*)
o Uses appropriate /V aids
DDDDDD
DDDDD
DDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2
Safe Male Circumcision for HIV Prevention
4, Re"istration= ;ro&( E#&%ation an# IEC
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
Client
!
Client
2
Client
"
8, ;ro&( e#&%ation
#ei3ere# 2it!
a((ro(riate
te%!niB&es
@'serve during one group education session ,&et&er
Provider uses appropriate group education s8ills
o Introduces &er?&imself to t&e clients
o 16plains purpose of session
o Uses standardi+ed national SMC I1C materials
o Uses local language and terms t&at clients understand
o Confirms at intervals t&at t&e clients understand
o 1ncourages clients to as8 2uestions
o Pro7ects voice so all clients can &ear
o Summari+es 8ey points
Provider spends 2$A"$ minutes for group education
Most of t&e clients (2?") maintained for one session t&roug& out
@t&er reproductive &ealt& issues if necessary
DDDDDDD
DDDDDDD
DDDDDDD
GPlease note any
s8ills needing
improvement in
t&e t&is columnH
4, Re"istration= ;ro&( E#&%ation an# IEC
%otal standards #
%otal points ac&ieva'le 3
%otal standards o'served
%otal points ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2!
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for SMC Cients
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
-, T!e %o&nseor (ro3i#es
a((ro(riate in#i3i#&a
%o&nsein" on SMC
@'serve during t&e care of t&ree patients t&at t&e counselor emp&asi+es.
=iscussion of partial protection a'out SMC against HIV
transmission
4is8s and 'enefits of SMC
;ecessity of 3 ,ee8s a'stinence follo,ing SMC procedure
4is8 reduction measures suc& as using condoms, a'stinence,
and 'eing fait&ful
Complete t&e identifying and demograp&ic information on t&e
standardi+ed SMC Client <orm OR SMC 4egister
Complete t&e SMC counseling and ris8 assessment sections on
t&e standardi+ed SMC Client <orm OR SMC 4egister
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 22
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for SMC Cients
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
/, T!e (ro3i#er (ro3i#es
ro&tine HIV testin" for
e3ery %ient
@'serve during t&e care of t&ree clients if t&e counselor.
o Meeps a cloc8 in t&e counseling room
o Maintains confidentiality and privacy
o Provides preAtest information
o @'tains ,ritten H%C consent (Signature or t&um'print)
o 9as&es &ands or uses alco&ol &andru' solution
o Puts on gloves
o Collects 'lood sample for HIV test
o =isposes of syringes and needles or lancets in a s&arps
container
o %ests 'lood for HIV using national algorit&m
o 4ecords t&e HIV test results in t&e HC% register
o Complete t&e HIV counseling and testing section on t&e MC
Client 4ecord
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDDD
DDDD
DDDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDDD
DDDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2"
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for SMC Cients
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
4,T!e (ro3i#er is (ro(ery
"i3in" res&ts an# (ost1test
%o&nsein"
Provides postAtest counseling
HIV NE;ATIVE
If t&e man is HIV negative, counsel on preventing 'ecoming
infected 'y /NC and MC
16plain t&e ,indo, period and counsel to retest after # ,ee8s
HIV POSITIVE.
Counsels on positive living
4efers to /4% clinic for care and treatment
=iscusses t&e importance of selfAdisclosure
=iscusses ,ays to prevent HIV transmission to ot&ers
Suggests offering HIV counseling and testing to partner(s)
Suggests offering HIV counseling and testing to family mem'ers
16plains t&at if a client is HIV positive, undergoing circumcision
does not prevent transmission of HIV to se6ual partners*
Counselor emp&asi+es t&at &e is &ig&ly infective ,it&in t&e 3
,ee8 period postAcircumcision &ealing period*
@ffers t&e possi'ility of opting out of male circumcision
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2#
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for SMC Cients
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
8, T!e (ro3i#er &ses
a((ro(riate %o&nsein"
sCis t!ro&"!o&t t!e
session
@'serve during care of t&ree clients.
Provider uses appropriate counseling s8ills
5reets t&e client ,it& respect and as8 t&em to ta8e t&eir
seats (if not seated)
16plains &is?&er role as a counsellor
/s8s clients if t&ey &ave any 2uestions t&ey ,is& to as8
a'out t&eir pro'lems ,it& empat&y
/ssures t&e client t&at all information provided ,ill 'e 8ept
confidential
%ells client &o, to contact t&e &ealt& center ,&en needed
%&an8s t&e client for time and attention if leaving
%ells clients t&ey can stop &im?&er at any time if t&ey &ave a
2uestion or ,&en t&ey &ave not understood
/s8s for and ans,ers any 2uestions or concerns
9, A %ients re%ei3e
%on#o's aon" 2it!
a((ro(riate %o&nsein" an#
instr&%tions on t!eir &se
@'serve during care of t&ree clients.
Condoms readily availa'le in t&e SMC clinic
Condoms stored properly
Provider correctly demonstrate &o, to use condom
Condoms are offered to SMC clients at eac& visit
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
5, T!e (ro3i#er o$tains
Infor'e# %onsent fro'
%ients
@'serve during t&e care of t&ree clients.
%&e provider c&ec8s ,&et&er client understands t&e potential
ris8s and complications of SMC 'efore signing t&e consent form
%&e provider c&ec8s t&at parents?guardians of t&e clientA if minorA
understand t&e potential ris8s and complication of S 'efore
signing t&e consent form
Provider ensures t&at t&e client if minor understands t&e potential
ris8 and complications of SMC and &as given assent for
circumcision
%&e consent section of t&e Client 4ecord is signed for eac& client
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2$
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for MC Cients
%otal of standards 3
%otal points ac&ieva'le !C
%otal standards o'served
%otal points ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 23
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
PRE1OPERATIVE CARE
-, T!e (ro3i#er %orre%ty
taCes !istory
@'serve during t&e care of t&ree clients ,&et&er t&e provider o'tains t&e
follo,ing &istory.
Current general &ealt&
S%I &istory (current symptoms of S%I 0 dysuria,ulcers,disc&arge,
pain)
9&et&er t&e client is ta8ing any medicine
9&et&er t&e client &as any 8no,n allergies to medicines
Haemop&ilia, 'leeding disorders or anaemia
Previous operations and reaction to anaest&esia
9&et&er t&e client &as pro'lems ,it& penile erection or any ot&er
concerns a'out se6ual function
Complete client &istory section of SMC Client 4ecord
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2-
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
/,T!e (ro3i#er %orre%ty
(erfor's (re1o(eration
e7a'ination
@'serve during p&ysical e6amination ,&et&er t&e provider performs t&e
follo,ing.
%a8es t&e vital signs (Pulse, 44* NP, 9eig&t)
Performs a &ead to toe e6amination to determine t&e general
condition, c&ec8 for anaemia, enlarged lymp& nodes,
16amines genitalia to rule out anatomical a'normalities, c&ronic
parap&imosis, genital ulcer disease, uret&ral disc&arge, penile
cancer, penile ,arts, scar tissue at t&e frenulum and any ot&er
a'normalities or ot&er signs of S%Is
Verifies voluntary consent for t&e operation
If client &as a suspected S%I.
Correct diagnosis is made using syndromic approac&
Proper treatment prescri'ed and dispensed for free
Partner notification and treatment is encouraged
Case documentation is done
Complete p&ysical e6amination section of SMC Client 4ecord
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
OPERATIVE CARE
4, T!e (ro3i#er (re(ares
t!e %ient for s&r"ery
@'serve during t&e care of t&ree clients ,&et&er t&e provider.
Prepares t&e necessary e2uipment
Verifies clients details
C&ec8 for t&e consent
Ma8es sure client is clean
4eassures t&e client
Scru's and puts on protective clot&ing
Cleans genitalia and surrounding ( from um'ilicus to midAt&ig&) ,it&
povidone !B or a mi6ture of *"B &loro&e6idine gluconate, "B
cetrimide and 2*C#B Isopropyl alco&ol
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2C
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
8, T!e (ro3i#er a#'inisters
anest!eti% an# (erfor's
#orsa sit %orre%ty
@'serve t&at t&e provider.
=rapes t&e client e6posing t&e genitalia only
/dministers correct amount of anest&etic ('a7i'&' #ose of
4'"<C") at t&e 'ase of t&e penis ( at eleven and one oEcloc8
follo,ed 'y a ring 'loc8)
9aits for "A$ min for t&e anest&etic to ,or8
%est for pain sensation using toot&ed dissecting forcep
Manages pain 'y administering additional anest&etic if necessary
t&roug&out t&e procedure
Ma8es a surgical mar8ing incision at t&e level of t&e corona on a
rela6ed penis
/pplies straig&t artery forceps from " to F oEcloc8 t&e mar8 of t&e
incision ta8ing care not to grasp t&e glans ,it& it
Performs a dorsal slit at t,elve oEcloc8 up to t&e incision line
16cises fores8in along t&e mar8ed incision
9raps sterile gua+e around t&e ,ound and applies pressure for "A$
min
Provider maintains t&e aseptic tec&ni2ue t&roug&out t&e procedure
Provider a'le to ver'ali+e ,&at to do in an emergency situation (eg*
unresponsive patient)
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page 2F
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
9, T!e (ro3i#er a%!ie3es
!ae'ostasis= s&t&res t!e
2o&n# an# a((ies t!e
#ressin" %orre%ty
16poses t&e ,ound 'it 'y 'it to identify and clamp t&e 'leeders ,it&
t&e artery forceps and t&en finally pulls t&e ,&ole s8in to identify and
clamp any more 'leeders
Iigates t&e 'leeders eit&er 'y transfi6ing , underArunning or simple
ligature @4 uses diat&ermy less t&an $ 9att po,er to cauteri+e
'leeders
C&ec8s for additional 'leeding points
/lign t&e median rap&ae ,it& t&e frenulum and applies a &ori+ontal
mattress suture at 3 oEcloc8 position
/pplies a vertical mattress suture at !2 oEcloc8 t&en " oEcloc8 and
finally at F oEcloc8 positions
Put simple interrupted sutures in 'et,een t&e mattress sutures
/pplies sterile gau+e along t&e suture line and apply pressure for 2A"
min
Cleans t&e glans and genital area using normal saline if necessary
/pplies dressing using Vaseline gau+e s,a's and t&en applies
strapping
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
5, Pro3i#er is a$e to
res(on# a((ro(riatey to an
E'er"en%y Sit&ation
Providers accurately descri'es emergency resuscitation procedures
Providers &ave attended and completed an emergency management
training
DDDD DDDD DDDD
>, T!e (ro3i#er %o'(etes
t!e (ro%e#&re an# assists
t!e %ient to t!e (ost1
o(erati3e area
Straps t&e penis to t&e lo,er a'domen
Helps client to get off t&e operating ta'le
Cleans t&e 'ac8 of t&e client at t&e 'ottom
1scorts client to t&e postAoperative recovery area
DDD
DDD
DDD
DD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
POST1OPERATIVE CARE
?, T!e (ro3i#er 'onitors
i''e#iate (ost1o( %ient
@'serve during t&e care of t&ree clients ,&et&er t&e provider
@'serves t&e general condition of t&e client
Monitors t&e vital signs 'efore disc&arge ( NP, Pulse, 44)
C&ec8s t&e surgical dressing for oo+ing or 'leeding
Manages postAoperative pain 'y reassuring and providing
Paracetamol to 'e ta8en at &ome
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR) VERIFICATION CRITERIA
YES= NO= N<A
COMMENTS
Client
!
Client
2
Client
"
@, T!e (ro3i#er "i3es %ient
a((ro(riate (ost1o( %are
instr&%tions
@'serve in t&ree clients.
5ives postAoperative instructions to t&e client.
o S&o,s &o, to remove and reapply strapping 'efore and
after urinating
o /void intercourse and mastur'ation for 3 ,8s
o =ressing to 'e removed #C &ours later provided t&ere is no
'leeding or oo+ing or any ot&er complication
o 9ear clean, loose fitting under,ear ,&ic& s&ould 'e
c&anged eac& day
o =o not ,et t&e dressing for t&e first 2 days
o /fter 2 days ,as& t&e genitalia ,it& nonAmedicated soap
and lu8e,arm ,ater
o 4emem'er to come for follo,Aup visit after 2 days and one
,ee8
o %o recogni+e and return in case of any danger signs or signs
of complications (e6cessive 'leeding, difficulty in passing
urine, e6cessive pain, s,elling, oo+ing of pus)
o 4est for t,o days
4einforce HIV prevention messages
Ma8es sure t&e client 8no,s ,&ere to go if complication arise and
&as a contact p&one num'er
Provide postAop SMC leaflet
5ives ne6t appointment date (#C &our and - day follo, up
appointments)
5ives information on &o, to manage postAoperative penile erections
Provide t&e client ,it& condoms
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
-A, Cient re%or#s are
&(#ate# an# %o'(ete#
(rior to #is%!ar"e
@'serve t&e provider.
<ills in t&e follo,Aup visit dates and emergency contact num'er
on t&e client card
Completes procedure section of SMC Client 4ecord
<ills in SMC register
4ecords any postAoperative complications or adverse events on
t&e SMC Client 4ecord and SMC 4egister
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
DDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "!
Safe Male Circumcision for HIV Prevention
FOLLO0 UP VISITS
--, T!e (ro3i#er %orre%ty
'ana"es initia foo2 &(
(8? !o&r an# > #ay)
@'serve during routine follo, up care for first follo,Aup ,&et&er t&e
provider.
4etrieve and revie, SMC Client 4ecord for 'ac8ground information
on t&e client and t&e surgical procedure
Verify t&e contact information
If t&e client &as not 'een tested for HIV in t&e last # ,ee8s, offer HIV
testing and counseling on an optAout 'asis
/s8s t&e client if t&ey &ave &ad any pro'lems or complaints
4emove t&e dressing
16amine t&e site to assess &ealing and ensure t&at t&ere is no
infection
%reat any complication found during e6amination or refer client to
&ig&er level
PostAoperative instructions are reinforced on ,ound care, potential
complications and danger signs, return visits, and a'stinence ?
resumption of se6ual activity
4evie, and reinforce HIV prevention messages
Complete t&e follo,Aup notes section of t&e MC Client 4ecord
4ecord any complications or adverse events on t&e MC Client
4ecord and SMC register
OAers the "lient "onoms
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
DDD
9, Mae %ir%&'%ision s&r"i%a (ro%e#&re
%otal Standards !!
%otal points ac&ieva'le ""
%otal o'served
%otal ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "2
Safe Male Circumcision for HIV Prevention
5, Monitorin" D E3a&ation
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
-,A3aia$iity of ree3ant
toos in SMC Cini%
Verify t&e availa'ility of.
SMC Client card
H%C client card
H%C client register
SMC client form
SMC register
=HIS 2 ? HMIS !$ form
/dverse events 5rading Scale
/, )ata are %orre%ty
transferre# fro' SMC
Cient Re%or# to t!e MC
Re"isters
%&ere is a designated person responsi'le for transferring information
from t&e SMC Client record (client form) to.
%&e SMC register
H%C register
=ata is entered in t&e SMC Client Counseling, %esting and <ollo,Aup
4egister on a daily 'asis
DDDDDDD
DDDDDDD
DDDDDDD
DDDDDDD
4, Cient re%or#s are
%o'(ete an#
%orres(on# 2it! t!e
SMC Cient
Co&nsein"= Testin"
an# Foo21&(
Re"ister
Select a random sample of -A client
records and verify.
/ll ! SMC Client 4ecords are
completely and correctly filled out
/ll relevant elements from t&e
SMC Client 4ecords are correctly
completed in t&e SMC Client
4egister
! 2 " # $ 3 - C F !
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
8, )ata are %orre%ty
s&''ari6e#=
re(orte# an# fie#
Verify.
%&e mont&ly summary form is filled in every mont&
/ duplicate copy of t&e summary form filed and stored appropriately for
reference
Mont&ly summary report is su'mitted
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page ""
Safe Male Circumcision for HIV Prevention
5, Monitorin" D E3a&ation
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
$* Monitorin"
ser3i%e #ei3ery
#ata are &se# for
(annin" an#
i'(ro3e'ent of
ser3i%e #ei3ery
Verify
%&e e6istence of a functional 2uality improvement team
Meeting &eld at least mont&ly to revie, data
C&anges 'een made to services 'ased on t&e feed'ac8 of t&ese data
Client satisfaction survey conducted @4 ot&er form of client feed'ac8
process (eg e6it intervie,s) is implemented at least t,ice a year
DDDDDD
DDDDDD
DDDDDD
DDDDDD
3* Monitoring P 1valuation
%otal standards $
%otal points ac&ieva'le !#
%otal standards o'served
%otal points ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "#
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
-, T!e %on%entration an# &se
of antise(ti%s are a%%or#in"
to t!e stan#ar#s,
@'serve t&e follo,ing.
%&e antiseptic concentration is correct.
- Povidone !B
- C&loro&e6idine
/ntiseptics are prepared in small, reusa'le containers for daily use*
%&e reusa'le containers are t&oroug&ly ,as&ed ,it& soap and ,ater, rinsed ,it& clean
,ater and dried 'efore refilling*
4eusa'le containers are la'eled ,it& date eac& time t&ey are refilled*
5au+e or cotton ,ool is not store# in containers ,it& antiseptics*
Instruments and ot&er items are not store# in containers ,it& antiseptics*
Pic8Aup forceps are not store# in containers ,it& antiseptics*
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
/, T!e (ro%ess of %eanin"
roo's $et2een an# after
(ro%e#&res is (erfor'e#
a%%or#in" to t!e stan#ar#s,
@'serve in t&e procedure room.
House8eeping personnel ,ear utility gloves and ot&er personal protective e2uipment
during cleaning*
/ll ,aste is collected and removed from t&e room in closed lea8 proof containers*
PunctureAresistant s&arps containers are closed and removed ,&en Q full*
Containers ,it& *$B c&lorine solution ,it& instruments are removed from t&e room*
Soiled linen is removed in closed lea8 proof containers*
Small 'ody fluid spills are contained and cleaned ,it& a disinfectant cleaning solution*
Iarge 'ody fluid spills are flooded ,it& *$B c&lorine solution, mop up solution, and
t&en clean ,it& detergent and ,ater*
/ll &ori+ontal surfaces t&at &ave come in immediate contact ,it& a client or 'ody fluids
are cleaned ,it& lint free clot& soa8ed in a disinfectant solution*
%&e procedure 'ed is cleaned, and all surfaces and mattress pads are ,iped ,it& a
disinfectantAsoa8ed, lintAfree clot&*
Instrument trolleys are decontaminated ,it& a clot& dampened ,it& *$B c&lorine
solution and rinsed ,it& clean ,ater
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
4, T!e (re(aration of a
#isinfe%tant %eanin" so&tion
is (erfor'e# a%%or#in" to t!e
stan#ar#s,
Verify if t&e disinfectant cleaning solution is prepared as follo,s.
/ *$B c&lorine solution is prepared*
=etergent (does not contain an acid, ammonia or ammonium) is added to t&e *$B
c&lorine solution until a mild soapy cleaning solution is made*
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "$
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
8, T!e %eanin" eB&i('ent is
#e%onta'inate#= %eane# an#
#rie# $efore re&se or stora"e
a%%or#in" to t!e stan#ar#s,
@'serve if t&e mops, 'uc8ets, 'rus&es and cleaning clot&s are.
=econtaminated 'y soa8ing for ! minutes in *$B c&lorine solution or ot&er approved
disinfectant, after use*
9as&ed in detergent and ,ater after use
4insed in clean ,ater*
=ried completely 'efore reuse or storage*
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Instr&'ent (ro%essin". )e%onta'ination= Ceanin"= Sterii6ation an# Hi"! e3e #isinfe%tion (HL)).
9, T!e #e%onta'ination of
instr&'ents an# ot!er
arti%es (i''e#iatey after
&se an# $efore %eanin") is
(erfor'e# a%%or#in" to t!e
stan#ar#s,
@'serve if.
%&e concentration of c&lorine solution is *$B.
- LiB&i# %!orine. if using JIM ("*$B), ! part 'leac& for 3 parts ,ater, or
- Po2#er %!orine. if using Calcium &ypoc&lorite ("$B), !# grams 'leac& po,der for
! liter ,ater
/ ne, c&lorine solution is prepared at t&e 'eginning of eac& day or sooner as needed*
Instruments and ot&er items are soa8ed in t&e *$B c&lorine solution for ! minutes*
/fter ! minutes, instruments and ot&er items are removed from t&e c&lorine solution
cleaned ,it& soapy ,ater and rinsed ,it& clean ,ater and dried*
C&lorine solution s&ould 'e c&anged ,&enever cloudy or after 2# &ours*
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "3
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
5, T!e (ro%ess of %eanin"
instr&'ents an# ot!er ite's
is (erfor'e# a%%or#in" to t!e
stan#ar#s,
@'serve if t&e person cleaning t&e instruments complies ,it& t&e follo,ing steps and
recommendations.
9ears appropriate personal protective e2uipment.
- Utility gloves
- Mas8 and eye,ear protection or face s&ield
- Plastic apron
- Covered s&oes
Utili+es.
- Soft 'rus&
- =etergent
- 4unning ,ater
Scru's instruments and ot&er items under t&e surface of ,ater completely removing all
'lood and ot&er foreign matter
=isassem'les instruments and ot&er items ,it& multiples parts and clean in t&e
grooves, teet& and 7oints ,it& a 'rus&
4inses t&e instruments and ot&er items t&oroug&ly ,it& clean ,ater
/llo,s instruments and ot&er items to airAdry, or dry ,it& a clean to,el
9as&es &ands after removing gloves
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "-
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
>, T!e (ro%ess of (a%Ca"in"
of ite's to $e sterii6e# is
(erfor'e# a%%or#in" to t!e
stan#ar#s,
If (a%Ca"in" ite's to $e sterii6e# t!ro&"! stea' sterii6ation (a&to%a3e).
%&e instruments are clean and dry*
Clot& items &ave 'een laundered, dried and &ave no &oles*
/ll 7ointed instruments are opened or in unloc8ed position*
/ll instruments are disassem'led*
Instruments are ,rapped in t&e correct material..
- Clot& ,raps, muslin (!# t&read count). dou'le ,rapping using t,o dou'leAt&ic8ness
,raps (# layers in all), or
- Jean clot& (!3 t&read count). dou'leA t&ic8ness per ,rapper, or
- Narrier clot& (2-202CC t&read count). one t&ic8ness 'ut t,o ,raps, or
- Paper (Mraft or ot&er). dou'le ,rapping* It is not re&se#
Pac8ages are not tied tig&tly*
If (a%Ca"in" ite's to $e sterii6e# t!ro&"! #ry1!eat.
%&e types of materials used are.
- Clot& ,raps, muslin (!# t&read count). dou'le ,rapping using t,o dou'leAt&ic8ness
,raps (# layers in all), or
- Metal containers ,it& lids
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
?, T!e (ro%ess sterii6ation is
(erfor'e# a%%or#in" to t!e
stan#ar#s,
@'serve during t&e loading process if.
%&e autoclave ? dry &eat oven is loaded properly
Sterili+ation is done at t&e proper temperature ? pressure ? time
%ime, temperature and pressure gauges are functioning properly
Processed items are unloaded properly maintaining sterility
%&e sterili+ation process is monitored appropriately
/ny failure noted results in appropriate corrective measures (c&ec8ing e2uipment and
reAprocessing instruments)
9&en sterili+ation is not possi'le, &ig&Alevel disinfection is done correctly
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "C
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
@, T!e stora"e (ro%ess of
sterie or !i"!1e3e
#isinfe%te# ite's is
(erfor'e# a%%or#in" to t!e
stan#ar#s,
@'serve if.
Clean supplies are not stored ,it& sterile or &ig&Alevel disinfected items*
Un,rapped items are used immediately and are not stored*
Sterile or &ig&Alevel disinfected pac8s and?or containers &ave e6piration dates on t&em*
%&ere is a rotation and an inventory system to control t&e use of sterile or &ig&Alevel
disinfected items*
%&e pac8s are free of tears, dampness, e6cessive dust and gross oil (t&ere is an eventA
related s&elfAlife practice, regardless to t&e e6piration date)*
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page "F
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
Heat! Care 0aste Mana"e'ent
-A, 0aste is #is(ose# of <
!an#e# a((ro(riatey
@'serve in t&e rooms if.

Me#i%a 2aste (e,",= %otton 2oo= "a&6e= et%).
9aste is segregated at point of origin into &a+ardous and nonA&a+ardous ,aste
/ll medical ,aste (e*g*, gau+e, cotton ,ool, dressing, etc) is disposed in a container
,it& a lea8 proof 'ag*
Color coding.
o 4ed ('ins and 'in liners) for &a+ardous ,aste,
o Nlac8 (nonAinfectious),
o :ello, for infectious*
S!ar(s.
S&arps are placed in a punctureAresistant container (&eavy card 'o6, empty plastic
container, metal container ,it& small opening)*
Containers are closed and collected ,&en Q full* S&arps containers are not reused
House8eeping personnel ,ear personal protective e2uipment ,&en &andling medical
,aste.
- Utility gloves
- 5um'oots
- Plastic aprons
Medical ,aste is transported to t&e interim storage area or for disposal in ade2uate
closed containers.
- S&arps in punctureAresistant containers (&eavy card 'o6, &ard plastic or can
containers)
- S&arps containers are not emptied and reused
- @t&er medical ,aste (e*g*, used cotton rolls, gau+e, dressing, etc*) in lea8 proof
containers
5eneral ,aste is collected from all areas in ade2uate closed containers and transported
to t&e interim storage area or for disposal
House8eeping personnel perform &and &ygiene after &andling ,aste and removing
utility gloves.
- 9as& &ands ,it& running ,ater and soap for !0!$ seconds and dry ,it& an
individual clean to,el, paper to,el or allo,s &ands to airAdry, or
- 4u' &ands ,it& "0$ ml of an alco&olA'ased solution until t&e &ands are dry (if &ands
are not visi'ly soiled)
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR) VERIFICATION CRITERIA
RATIN;
YES<NO<NA
COMMENTS
--, T!e syste' for interi'
stora"e is a((ro(riate
@'serve if.
%&e interim storage area is not accessi'le to general staff, patients?clients and
visitors*
Containers are lea8 proof and closed ,it& tig&t lids*
%&ere is no ,aste stic8ing out of t&e containers*
DDDDDDDD
DDDDDDD
DDDDDDDD
-/, T!e fa%iity < MC %ini%
&ti'atey #is(oses of 2aste
(ro(ery
@'serve if.
%&e final disposal sites are appropriate, ,&et&er incinerated, 'uried, or
encapsulated
%&e disposal sites are ,ell secured (fenced) and a,ay from t&e traffic
9ell situated ( avoid residential areas)
/ppropriate personnel to manage t&e sites*
Properly managed (i*e*, incinerator is run for rig&t time at rig&t temperature, 'uried
,astes are not left in an open pit uncovered, etc*)
DDDDDDDD
DDDDDDD
DDDDDDDD
DDDDDDDD
DDDDDDDD
-4, )is(osa$e Mae
Cir%&'%ision +its are
#is(ose# (ro(ery
Used Safe Male Circumcision Mits.
=econtaminated in *$B c&lorine solution for ! minutes 'efore disposal
@ne of t&e 'elo, options availa'le to dispose used instruments
o Nurial of instruments in a secure instruments?s&arps pits?concrete vaults
OR
o %ransporting t&e instruments to a recycling ? smelting facility @4
o Speciali+ed encapsulation
DDDDDDDDD
>, Infe%tion Pre3ention
%otal standards !"
%otal o'served
%otal ac&ieved
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #!
Safe Male Circumcision for HIV Prevention
A%!ie3e'ents of Q&aity Stan#ar#s
<acility. DDDDDDDDDDDDDDDDDDDD ServiceDDDDDDDDDDD =ate. DDDDDDDDDSupervisor?/ssessor. DDDDDDDDDDDDDDDDDDDD
AREA
E
STAN)AR)S
E POINTS
AVAILA*LEF
E
O*SERVE)
ACHIEVE)
E GFF
! Management Systems ! !
2 Supplies, 12uipment and 1nvironment 3 3
" 4egistration, 5roup 1ducation and I1C # 3
# Individual Counseling and HIV %esting for
MC Clients
3 !C
$ Male Circumcision Surgical Procedure !! ""
3 Monitoring and 1valuation $ !#
- Infection prevention !" !"
TOTAL OF POINTS AVAILA*LE -AA
R Some standards &ave more points, due to ma8ing multiple o'servations for t&ose standards
FF Per%ent A%!ie3e# (G) is E A%!ie3e# < E O$ser3e#
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #2
Safe Male Circumcision for HIV Prevention

-, Mana"e'ent Syste's
STAN)AR)S
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* 4elevant MC Policies, 5uidelines and Standards
are availa'le and staff are a,are of t&em
!
2* %&e site &as an ,ritten service delivery plan
(minimum ! year plan)
!
"* %&e MC clinic is a'le to meet demand for services !
#* %&e MC clinic or facility &as clearly defined staff
roles and responsi'ilities
!
$* %&e MC clinic or facility &as t&e &uman resources
availa'le according to t&e MC service delivery plan
!
3*Staff receive mentoring and support
!
-* Client flo, c&art is availa'le in t&e facility !
C* Service delivery data are used for planning and
improvement of service delivery
!
F* Moderate and severe adverse events or
complications are revie,ed
!
!!* %&e facility ? MC clinic &as a functional supply and
e2uipment ordering system
!
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #"
Safe Male Circumcision for HIV Prevention
/, S&((ies= EB&i('ent an# En3iron'ent
STAN)AR)
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* %&e p&ysical facilities are appropriate for MC service
provision
!
2* %&e necessary e2uipment are availa'le for
performing MC surgeries
!
"*%&e necessary commodities are availa'le for
performing surgeries
!
#* /de2uate supplies of medicines and commodities
(HIV test 8its, condoms) are availa'le for nonAsurgical
aspects of MC service provision
!
$* /n emergency resuscitation system e6ists and
medications ? supplies are availa'le ,it& immediate
access
!
3* /de2uate measures are in place for managing
moderate to severe complications and adverse events
!
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page ##
Safe Male Circumcision for HIV Prevention
4, Re"istration= ;ro&( E#&%ation an# IEC
STAN)AR)
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* %&e client is correctly recorded in t&e register and
given a client I=
"
2* %&e facility &as appropriate information and
educational materials on MC and ot&er reproductive
&ealt&
!
"*5roup education delivered ,it& correct information
!
#* 5roup education delivered ,it& appropriate
tec&ni2ues
!
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #$
Safe Male Circumcision for HIV Prevention
8, In#i3i#&a Co&nsein" an# HIV testin" for MC Cients
STAN)AR)
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* %&e provider provides appropriate individual
counseling on MC
"
2* %&e provider provides routine HIV testing for every
client
"
"*%&e provider is properly giving results and postAtest
counseling
"
#* %&e provider uses appropriate counseling s8ills
t&roug&out t&e session
"
$* /ll clients receive condoms along ,it& appropriate
counseling and instructions on t&eir use
"
3* %&e provider o'tains Informed consent from clients "
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #3
Safe Male Circumcision for HIV Prevention
9, Mae Cir%&'%ision S&r"i%a Pro%e#&re
STAN)AR)
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
P41A@P14/%IV1 C/41
!* %&e provider correctly ta8es &istory "
2*%&e provider correctly performs preAoperation
e6amination
"
@P14/%IV1 C/41
"* %&e provider prepares t&e client for surgery "
#* %&e provider administers anest&etic and performs
dorsal slit correctly
"
$* %&e provider ac&ieves &aemostasis, sutures t&e
,ound and applies t&e dressing correctly
"
3* Provider is a'le to respond appropriately to an
1mergency Situation
"
-* %&e provider completes t&e procedure and assists
t&e client to t&e postAoperative area
"
P@S%A@P14/%IV1 C/41
C* %&e provider monitors immediate postAop client "
F* %&e provider gives client appropriate postAop care
instructions
"
!* Client records are updated and completed prior to
disc&arge
"
<@II@9 UP VISI%S
!!* %&e provider correctly manages initial follo, up "
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #-
Safe Male Circumcision for HIV Prevention
5, Monitorin" D E3a&ation
STAN)AR)S
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* /vaila'ility of relevant tools in SCM Clinic !
2*=ata are correctly transferred from MC Client
4ecord to t&e MC Client Counseling, %esting and
<ollo,Aup 4egister
!
"* Client records are complete and correspond ,it&
t&e MC Client Counseling, %esting and <ollo,Aup
4egister
!
#* =ata are correctly summari+ed, reported and filed !
$*Monitoring service delivery data are used for
planning and improvement of service delivery
!
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #C
Safe Male Circumcision for HIV Prevention
>, Infe%tion Pre3ention
STAN)AR)
Points
Synt!eses. ;a(s an# Possi$e Ca&ses
Possi$e A%!ie3e#
!* %&e concentration and use of antiseptics are according to t&e
standards*
!
2* %&e process of cleaning rooms 'et,een and after procedures is
performed according to t&e standards*
!
"* %&e preparation of a disinfectant cleaning solution is performed
according to t&e standards*
!
#* %&e cleaning e2uipment is decontaminated, cleaned and dried
'efore reuse or storage according to t&e standards*
!
Instrument processing. =econtamination, Cleaning, and Sterili+ation
$* %&e decontamination of instruments and ot&er articles
(immediately after use and 'efore cleaning) is performed according
to t&e standards*
!
3* %&e process of cleaning instruments and ot&er items is performed
according to t&e standards*
!
-* %&e process of pac8aging of items to 'e sterili+ed is performed
according to t&e standards*
!
C* %&e process sterili+ation is performed according to t&e standards* !
F* %&e storage process of sterile or &ig&Alevel disinfected items is
performed according to t&e standards*
!
Healt& Care 9aste Management
!* 9aste is disposed of ? &andled appropriately !
!!* %&e system for interim storage is appropriate !
!2* %&e facility ? MC clinic ultimately disposes of ,aste properly !
!"* =isposa'le Male Circumcision Mits are disposed properly !
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page #F
Safe Male Circumcision for HIV Prevention
A%tion Pan Matri7
Completed 'y. DDDDDDDDDDDDDDDDDDDDDDDDDDDDD
Contact num'er of person ,&o completed action plan DDDDDDDDDDDDDDDDDDDDD =ate. DDDDDDDDDDDDDDDDDDD
Performance 5aps
Identified
Intervention Selected to
<ill t&e 5ap
4esponsi'le Person or
Nody
Internal and 16ternal
Support ;eeds
%ime Iine
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page $
Safe Male Circumcision for HIV Prevention
)o%&'entation :o&rna for QI a%ti3ities
;ame of t&e <acility DDDDDDDDDDDDDDDDDDDDDDD=istrict. DDDDDDDDDDDDDDDDDDDDDD4egion. DDDDDDDDDDDDDDDDDDDDDDDD
%eam Ieader. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDD%eam Mem'ers. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
=ate for Improvement Pro7ect. DDDDDDDDDDDDDDDDDDDDDDDDDDDDD 1nd date. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
I'(ro3e'ent O$He%ti3e.
-, IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
In#i%ator for t!e O$He%ti3e.
)es%ri(tion of Pro$e'.
Nriefly descri'e t&e pro'lem 'eing addressed and gaps 'et,een t&e current situation and your improvement o'7ectives* State t&e differences 'et,een t&e
MoH standard of care and t&e current practices* /lso descri'e some of t&e c&allenges ,it& t&e current situation*
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page $!
Safe Male Circumcision for HIV Prevention
Panne# an# Teste# C!an"es.
In t&e space 'elo,, list all of t&e c&anges t&at you
are implementing to address t&e improvement
o'7ective* Use !A2 sentences to 'riefly descri'e t&e
tested c&ange*
Start
)ate.
==?MM?::
En# )ate
(if applica'le)
==?MM?::
9as t&ere any
improvement
registered>
(:es?;o)
Co''ents.
;ote &ere any potential reasons ,&y t&e
c&ange did or did not yield improvementS also
indicate any c&ange in indicator value
o'served related to t&is c&ange*
!
2
"
#
$
3
-
C
Uganda SMC Quality Improvement tool FIELD-TESTING VERSION 3.0, Jan 2!" page $2