Male Circumcision Services

Quality Assessment Toolkit

WHO Library Cataloguing-in-Publication Data
Male circumcision services : quality assessment toolkit.
1.Circumcision, Male - methods. 2.Circumcision, Male - standards. 3.Quality assurance, Health care. 4.Delivery of
health care - organization and administration. 5.Risk assessment. 6.HIV infections - prevention and control.
I.World Health Organization.
ISBN 978 92 4 159751 7 (NLM classication: WC 503.6)
World Health Organization 2009
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Male Circumcision Services
Quality Assessment Toolkit
Section 1
2
3
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Contents
Acronyms......................................................................................................................................................................................................................................................................................... 4
Acknowledgements .................................................................................................................................................................................................................................................................. 5
Section 1
Guidance on using the toolkit ................................................................................................................................................................................................................................................ 7
Purpose.............................................................................................................................................................................................................................................................................................. 8
How to use the toolkit ................................................................................................................................................................................................................................................................. 8
Who conducts the assessment? ................................................................................................................................................................................................................................. 8
How is the toolkit organized? ........................................................................................................................................................................................................................................ 9
What methods can be used to conduct the assessment? ........................................................................................................................................................................... 10
How is the score interpreted? ..................................................................................................................................................................................................................................... 12
What should be done with the assessment ndings? ..................................................................................................................................................................................... 13
How often should an assessment be done? ....................................................................................................................................................................................................... 14
Section 2
Male circumcision services quality assessment tool ............................................................................................................................................................................................... 15
Section 3
Supporting tools ..........................................................................................................................................................................................................................................................................91
4
Acronyms
ABC abstinence, being faithful, condom use
AIDS acquired immunodeciency syndrome
GUD genitourinary disease
HIV human immunodeciency virus
IEC information, education and counselling
IQC internal quality control
MC male circumcision
OR operating room
PEP post-exposure prophylaxis
STI sexually transmitted infection
VCT voluntary counselling and testing
WHO World Health Organization
5
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Acknowledgements
WHO would like to thank:
Joanne Ashton (Consultant, Joint Commission International) and Kim Dickson (Medical Ofcer, WHO) for producing this document.
Members of the WHO/UNAIDS Male Circumcision Working Group: Tim Farley, Catherine Hankins, Nicolai Lohse, George Schmid, Isabelle de
Zoysa and Bruce Dick, who provided input and guidance.
WHO is especially grateful to:
Staff of the Rakai Health Sciences Programme in Uganda and the Nyanza Reproductive Health Society in Kenya, who assisted in eld-testing
the self-assessment tool and provided valuable feedback on the contents of the assessment, based on their knowledge and expertise in
performing male circumcision services.
Jason Reed (Centers for Disease Control and Prevention, USA), Susan Settergren (Centers for Disease Control and Prevention, Co-Chair
PEPFAR Gender Working Group, USA), and Kimberly Konkel (Health and Human Sciences Center for Faith-based and Community Initiatives,
USA).
Participants in the Male Circumcision Regional Resource Team Orientation Workshop held in Johannesburg in September 2008: Naomi Bock
(Centers for Disease Control and Prevention, USA), Kasonde Bowa (University Teaching Hospital, Zambia), Chiweni Chimbwete (Consultant,
South Africa), Chester Morris (Consultant, South Africa), Vitalis Chipfakacha (South African Development Community, Botswana), David
Cownie (Consultant, Namibia), Sibongile Dludlu (UNAIDS, South Africa), Karin Hatzold (PSI, Zimbabwe), Steve Geuale (PSI, Zambia), Jessica
Greene (PSI, Swaziland), Susan Kraemer (Consultant, Malawi), Steven Langwa (Consultant, Uganda), Anthony Kinghorn (Technical Support
Facility, South Africa), Mores Loolpapit (Family Health International, Kenya). Tawanda Marufu (Consultant, Zimbabwe), Palesa Mohaleroe
(Surgeon, Lesotho), Nomasomi Mpofu (Consultant, Zimbabwe), Jabbin Mulwanda (JHPIEGO, Zambia), Alphonse Mulumba (Southern Africa
Development Community, Botswana), Maria, Nangolo-Rukoro (Consultant, South Africa), Frederick Ndede (EngenderHealth, Kenya), Morkor
Newman (WHO, Harare), Walter Odhiambo (Marie Stopes, Kenya), Brian Pazvakavambwa (WHO, Harare), Andy Seale (UNAIDS, South Afri-
ca), Marion Stevens (Health Systems Trust, South Africa) Norah Stoops (Health Information Systems Programme, South Africa) and Anne
Strode (University of Kwa-Zulu Natel, South Africa).
6
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Section 1
Guidance on using the toolkit
Section 1
8
Purpose
The male circumcision quality assessment toolkit has been developed to assist facility managers and staff to assess the quality of their services.
The toolkit can be used by programme and facility managers to guide the set-up of services and to improve current services. It helps to measure
progress towards meeting standards and can be used by external assessors to certify or accredit facilities.
How to use the toolkit
The toolkit is designed to be used in conjunction with the WHO document Male circumcision quality assurance: A guide to enhancing the safety
and quality of services (also referred to as the MC quality assurance guide).
Who conducts the assessment?
This toolkit should be used by the quality improvement team in the facility to conduct a self-assessment (see the MC Quality Assurance Guide,
section on forming quality improvement teams). The assessment team includes all categories of staff, although a subgroup can be designated
to carry out most of the work. Representatives from, for example, the supply/logistics management, pharmacy and housekeeping departments,
and from the community, should be invited to participate as appropriate.
A team leader should be appointed who is responsible for organizing the group, assigning tasks and coordinating the effort. This person is not
necessarily the facility manager. Part of the learning process occurs through this participation. If one person tries to complete the assessment
alone the process becomes an audit rather than a learning opportunity for the team. Performing the assessment together increases understand-
ing of the services and fosters team spirit and, ultimately, ownership of the ndings. When assignments of team members are being made it is
important to identify individuals who have knowledge of the specic aspect of the service which they will assess. For instance, various members
could review the availability of supplies, whereas someone skilled in male circumcision surgery would be needed to evaluate the competence of
staff in performing the procedure. A community member may be requested to conduct interviews with clients who have used the service.
The toolkit can also be used by a supervisor or other external reviewer to conduct an external assessment. An assessment conducted by some-
one who is not working in the clinic can add value to the assessment process by offering a fresh view. Regardless of who is designated to carry
out the assessment, it is best carried out with the involvement and participation of all staff members.
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
How is the toolkit organized?
The toolkit is organized into 3 sections. Section 1 describes the set up of the toolkit and provides guidance on how to use it. Section 2 is the male
circumcision quality assessment tool that is to be used in assessing the quality of services. Section 3 provides other tools including samples of
checklists, forms and other tools that support the use of the MC quality assessment tool.
The Male circumcision quality assessment tool in Section 2 is organized according to 10 standards and 36 criteria. For each standard there is an
intent statement, which assists the team to understand the standard. There is a list of key documents that should be reviewed, together with
suggested methods for eliciting the required information. The assessment team should be oriented to the data collection tool and the methods
that can be used to obtain information.
The standards and criteria are listed in bold. Under each criterion there are six main columns:
1. QUESTIONS: The rst column provides questions helping the team to determine if the criterion is met.
2. WHY IS THIS QUESTION IMPORTANT? When indicated, this question provides additional understanding or rationale for the criterion.
3. HOW IS THIS QUESTION ASSESSED? This question indicates what to look for when assessing the criterion. Tools that will be useful for a
particular assessment are cited in this column and are located in Section 3.
4. SCORE: The score (see key below) allows the team to measure the baseline and then to progress towards meeting the standards.
5. OBSERVATIONS: This column provides space for writing comments on observations that are made. This information is helpful to the team
when determining why a criterion is not met. When the score is 0 or 1, notes on the observations can assist the team to better understand
the issues identied so that they can develop plans for improvements.
6. ACTIONS TO BE TAKEN: The last column is for writing actions that can be taken to meet the standards.
Each criterion is scored by answering each of the questions according to the following scale.
Section 1
10
Scoring key
0 = No, the element does not meet the criterion
1 = Yes, some of the elements are in place, but the question is not fully satised
2 = Yes, the element fully meets the criterion
After discussion the team should determine which score best represents the answer to the question. If the score is 0 or 1 the team should place
comments in the observations column to guide actions that should be taken and as a future reference for facilitating follow-up. It is recommend-
ed that the team assess all the standards and criteria initially so as to provide a baseline for future progress toward meeting the standards.
What methods can be used to conduct the assessment?
Several data collection methodologies are necessary for gathering information to complete the assessment. Some are outlined below.
1. Observation
Observation is used to assess attitudes, knowledge and skills in clinical practice, including client-provider interaction, client management
and surgical practice. Assessing the competence of staff is a crucial element of the quality of the service. An initial competence assessment
is recommended for all staff members providing male circumcision services. Subsequently, the assessment of competence should become
a routine part of the performance appraisal process, preferably done on an annual basis. Competence assessment tools are included in this
toolkit, which can be used to assess clinical performance, e.g. counselling and surgical skills. The team has to determine how many observa-
tions of clinical practice are needed in order to assure competence. A supervisor or qualied peer then has to use one of the monitoring tools
to assess the practitioner. Further guidance on competence assessments and tools are provided in the WHO/UNAIDS/JHPIEGO Manual for
male circumcision under local anaesthesia and training package. The giving and receiving of feedback are important aspects of the process
of improving quality. Feedback helps to create an atmosphere in which practitioners welcome the observations made. These observations
should be documented and included in personnel les.
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
2. Formal and informal interviews
One-on-one interviews may be conducted with managers, staff and clients. Some of the assessment questions seek staff and client percep-
tions. These insights can be obtained through interviewing staff and clients or more formally by conducting surveys. For satisfaction surveys
the team develops a set of questions and decides the best approach to gathering the information. In either case the respondents must feel
assured that they will not be identied and that the results will remain condential.
Staff satisfaction
When staff perceptions are sought, all staff should have an opportunity to give feedback. It is best to obtain staff feedback on a regular basis,
e.g. annually. The team should develop a set of questions that it considers suitable for yielding the desired information. These questions
should be used for each survey so that the team can measure the differences in responses between assessments.
Client satisfaction
When clients are being questioned the approach should be tailored to the needs of the client, e.g. taking into account literacy, language and
the location of data collection. A sufcient number of responses is necessary for the data to be adequately generalizable. If the number of
male circumcision clients is small the team may decide to request opinions from each client, whereas for a large number it is necessary to
take a sample. A systematic approach to sampling the clients reduces the potential for bias. If client satisfaction surveys are used they should
be done on a regular basis in order to compare results over time and measure improvements in relation to the actions taken.
3. Focus group discussions
These can be used to gain an understanding of attitudes, beliefs and perceptions. They are open conversations in which each participant
has an opportunity to speak, ask questions of other participants, and respond to the comments of others, including the facilitator, who guides
the conversations and stimulates interaction among the participants by asking questions on various themes. These discussions can be held
with groups of clients or staff. Focus groups typically have from six to ten members. If a group is too small, one or two people may dominate
it, whereas the discussion can be difcult to manage with more than ten participants. Typical focus group discussions last between 60 and
Section 1
12
90 minutes. They should be held in a place where the participants feel comfortable and which is neutral relative to the topic of discussion.
For example, for a discussion about attitudes to health services a health clinic might not be a suitable venue.
4. Inventory
Inventory is a process of inspection to determine whether the essential environment, medicines, supplies and equipment are available and
to assess the storage and maintenance of supplies and equipment. This method is used to assess the condition of the facilities, the avail-
ability of space for performing the services efciently, and the safety of the environment. It is recommended that the members of the team
make rounds together in order to carry out these observations.
5. Review of documents
Some information is obtained by reviewing documents, e.g. the client register, client records, personnel les, policies, guidelines and protocols,
with a view to determining the availability and adequacy of the documents. It is important to obtain these documents and review their content.
How is the score interpreted?
The responses for each standard can be summed to determine the level of achievement:
add the 0, 1 and 2 scores for all the questions under a standard;
divide by the total points possible, i.e. the number of questions under the standard x 2 (the highest possible score per question).
For instance, for Standard 1 there are 18 questions:
the highest score possible for this standard is 36 (18 x 2);
add all the scores to the questions under this standard and divide by 36;
determine overall achievement of all the standards by adding together the scores for all the standards and dividing by 248 (the total score
possible).
An Excel spreadsheet is available to assist with these calculations.
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
What should be done with the assessment ndings?
The assessment ndings should be communicated and acted on.
Communicating the ndings
The results of the assessment should be shared with all key parties. The team should rst determine who needs the information, e.g. staff,
supervisor, partners and clients may all be key parties. Each has different needs and therefore different levels of information are required. The
team should outline:
a) who needs the information;
b) what information is needed;
c) how the information will be delivered, e.g. in a meeting, memorandum or workshop;
d) who will convey the information / feed it back;
e) when the information will be given.
Taking action
Refer to Steps for improving performance in the MC Quality Assurance Guide. The team should focus on the standards with the lowest
scores and use the results to develop an action plan (Tool 1. Action plan.) for closing gaps.
The team can be motivated by identifying quick xes, i.e. things that can be implemented easily, and working on them rst. The quality team
can benet from meeting weekly to implement the actions required to meet the standards. When most of the standards have been met the
frequency of the meetings can be reduced to fortnightly or monthly.
In some cases a report will be needed, particularly if the assessment has been facilitated by an external organization. Its format should assist
the facility staff to relate the ndings to the recommended follow-up actions for each standard. The outline may be as follows.
Section 1
14
Standard Findings Recommended actions
1. An effective management system is estab-
lished to oversee the provision of male circum-
cision services.
Patients rights are posted and staff are aware
of the requirement to maintain the condential-
ity and privacy of patients and to enable in-
formed consent.
Job descriptions are available but not up to
date.
Review and update job descriptions.
The areas in which the organization excels should be recognized as well as areas for improvement. Specic feedback is most helpful to the
facility teams in developing their action plans.
How often should an assessment be done?
Assessment is best conducted as a systematic process on a regular basis. During the initial stages the team has to measure progress toward
the goals. When most of the standards have been met the assessment may be done annually so as to ensure that they are being maintained.
15
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Section 2
Male circumcision services
quality assessment tool
Section 2
16
Male circumcision services quality assessment tool
Date: .......................................................................................................................................................................................................................................................................................................
Name of facility: ................................................................................................................................................................................................................................................................................
Location: (town, district/province) ...........................................................................................................................................................................................................................................
Name(s) of assessor(s) .................................................................................................................................................................................................................................................................
17
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
The male circumcision standards
Standard 1. An effective management system is established to oversee the provision of male circumcision services.
Standard 2. A minimum package of male circumcision services is provided.
Standard 3. The facility has the necessary medicines, supplies, equipment and environment for providing safe male circumcision services
of good quality.
Standard 4. Providers are qualied and competent.
Standard 5. Clients are provided with information and education for HIV prevention and male circumcision.
Standard 6. Assessments are performed to determine the condition of clients.
Standard 7. Male circumcision surgical care is delivered according to evidence-based guidelines.
Standard 8. Infection prevention and control measures are practised.
Standard 9. Continuity of care is provided.
Standard 10. A system for monitoring and evaluation is established.
Section 2
18
Standard 1. An effective management system is established to oversee the provision of male circumcision services.
Intent: Management systems are developed and implemented to ensure efcient and safe provision of male circumcision. Services are designed
in response to clients needs. Administrative and clinical policies and procedures are available that provide guidance to staff in carrying out their
duties. Processes are designed for efcient stafng and scheduling of procedures, and ongoing supportive supervision is provided.
1. DOCUMENTS: Ensure that the following documents are available for review.
a. Policies on condentiality, privacy and informed consent (patients rights document)
b. Staff job descriptions
c. Surgery waiting list
d. Staff duty roster
e. Surgery schedule
f. Supervisory reviews
g. Results of staff satisfaction survey
h. Results of client satisfaction surveys
i. Results of focus group discussions with community members and stakeholder groups
j. Community assessment information (e.g. numbers of males, employment patterns, circumcision prevalence)
k. Minutes and action plans of quality improvement team
2. METHODS: Suggested key methods for eliciting information include:
l. Team discussion
m. Interviews with staff
n. Document review
o. Staff satisfaction surveys
p. Client interviews, satisfaction surveys or focus group discussions
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 1. An effective management system is established to oversee the provision of male circumcision services.
Criterion 1.1. Health rights policies are available and known.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are there general
health policies available
on condentiality,
privacy and informed
consent?
Lack of condentiality and
privacy can affect clients
use of the services. All
clients have the right to be
informed about their care
and treatment and to be
involved in decision-
making.
These policies do not
need to be separate; they
could be contained in a
patients or health rights
document or in a nation-
al male circumcision
policy. The facility should
check to see if these
policies are available at
the national or district
level. If not, the facility
could draft its own.
b) Do staff know the
policies on condential-
ity, privacy and in-
formed consent?
All staff, including non-
professional staff, should
know the policies in order
to implement them.
Interview all categories of
staff to determine their
knowledge of the policies.
Section 2
20
Criterion 1.1. Health rights policies are available and known.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Do clients know the
policies on condential-
ity, privacy and in-
formed consent?
If clients are aware of their
rights they are empow-
ered to expect and
demand these standards
of care. If communities
are aware of these rights
they are more likely to
accept services.
Client interviews and/or
focus group discussions.
Criterion 1.2. Staff roles and responsibilities are clear.
a) Are there job descrip-
tions for staff delivering
male circumcision
services?
As staff need to under-
stand their roles and
responsibilities, the job
descriptions should
clearly dene how each
level of staff functions in
the health care system.
The health ministry may
have generic job descrip-
tions, copies of which
should be on site. Written
roles and responsibilities
for all staff involved in male
circumcision services,
including surgeons, nurses
and counsellors, should be
clearly dened. For those
performing male circumci-
sion, minor surgery should
be included in the job
description.
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MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 1.2. Staff roles and responsibilities are clear.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Do staff know their
expected roles and
responsibilities?
Staff should be informed
of their expected duties.
Staff should be able to
describe their roles and
responsibilities.
c) Are staff evaluated at
least annually?
Providing staff with
feedback on their perfor-
mance is vital for assist-
ing them to improve.
Performance appraisals
have been done for each
category of provider
(including clinicians,
theatre staff and counsel-
lors) and are on le.
d) Is continuous supervi-
sory support provided?
Supervisory support and
feedback are vital for
improving staff perfor-
mance. In addition to
persons who hold formal
supervisory positions,
facilitative supervisors,
e.g. consultants, can
provide guidance on the
basis of their knowledge
and expertise.
Staff interviews can be
conducted to determine
whether supervisors
provide feedback: by
participating in the
activities that they super-
vise; during regular team
meetings, staff appraisals
or consultative visits; by
management by walking
about.
Section 2
22
Criterion 1.3. Services are provided in an organized and efcient manner.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are staff available to
meet the needs for:
Counselling clients?
Performing surgery?
Infection control?
Supply management?
Record-keeping?
Using available staff in the
most efcient manner
enhances service delivery
and increases the number
of circumcisions that can
be done.
When volumes become
unmanageable with
current stafng it is
important to investigate
alternative options, e.g.
additional clinic hours,
calling in additional
trained staff.
The appropriate stafng
can be established by
identifying the ratio of
number of staff to number
of patients required for the
service and the number of
rooms available (counsel-
ling, examination and
operating rooms). For
surgery, if sufcient staff are
available, the client waiting
list should not be long (as
identied by the target set
by the facility). The maxi-
mum number of daily
surgeries per clinician
should be worked out. The
number of surgeries
cancelled because of a lack
of staff can be monitored. A
client ow analysis provides
evidence of actions taken to
improve patient ow and
the use of staff.
23
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 1.3. Services are provided in an organized and efcient manner.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is there a process for
scheduling appoint-
ments?
This process allows for
predicting the number of
staff required on a given
day to provide counsel-
ling, perform surgery and
give postoperative care.
Stafng could be checked
by reviewing the appoint-
ment book or client record
and comparing with the
duty rosters to determine if
an appropriate number of
staff is scheduled for the
number of patients sched-
uled for surgery and
counselling sessions.
c) Is there a process for
planning the effective
use of operating
rooms?
When operating rooms
are not effectively sched-
uled, the use of personnel
and time may be wasteful
and consequently fewer
operations may be
performed.
A roster exists for each
operating room, listing
scheduled surgeries;
realistic time frames are
allotted for surgeries and
clean-up between surger-
ies. The use of rooms is
tracked and changes are
made on the basis of the
findings.
Section 2
24
Criterion 1.4. Barriers to accessing care are identied and minimized.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are efforts being made
in communities to
support the provision of
male circumcision
services?
Unfavorable attitudes and
misconceptions about
male circumcision among
various groups in the
community may present
barriers to the uptake of
services or prevent clients
from seeking needed
follow-up care.
Review community
mobilization activities and
advertising campaigns.
Specic efforts should be
made to ensure that
women are involved as
partners or mothers.
b) Have particular efforts
been made to help
young men overcome
barriers to receiving the
service?
Young people obtain/seek
information in different
ways. Special means of
promotion are needed to
attract young men to the
service.
Efforts might include
using messages that are
targeted to youth and
promoted in locations
where young men congre-
gate or in the youth media
(radio, TV), implementing
youth-friendly services,
and involving parents.
25
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 1.4. Barriers to accessing care are identied and minimized.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Has a reasonable fee
been set for the ser-
vice?
The service will not be
used if it is not affordable.
Attempts should therefore
be made to assess
whether fees are realistic.
The fee for male circumci-
sion is in line with national
policy.
The opinions of clients on
affordability may be
solicited.
d) Are efforts made to
overcome myths and
misconceptions that
act as barriers to
accessing services?
Specic efforts should be
made to identify and
address the key barriers
to accessing services.
These could include
misconceptions about
loss of sexual function
and fear of pain.
Community interviews,
focus group discussions
or surveys and a review of
media could be used to
better understand and
quantify misconceptions.
e) Are efforts made to
schedule service hours
in response to the
needs of the majority of
men in the community?
It is important to under-
stand the work patterns of
men in the community and
to nd innovative ways to
offer clinic hours that are
as convenient as possible,
e.g. after-hours or week-
end clinics.
Management interviews,
community and client
interviews or surveys may
be used. Actions are
taken to improve access
and results are document-
ed.
Section 2
26
Criterion 1.5. The facility has systems for continuously improving the quality and safety of services.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the facility have a
system to receive and
address client feed-
back?
Mechanisms should be in
place to receive, collate,
review and act on clients
suggestions and com-
plaints.
This could include client
exit interviews, suggestion
boxes, and interviews with
community mobilizers,
local leaders or clinic
health committees to solicit
feedback. Minutes of
meetings could show how
feedback is used to
respond to clients needs.
b) Does a quality improve-
ment team exist which
includes all categories
of staff?
The benets of team work
include:
a more complete
working knowledge of
the process;
a greater number of
ideas for resolving
problems;
greater acceptance
and a higher imple-
mentation rate of
solutions.
All staff involved in
providing male circumci-
sion services (clinicians,
nurses, sterilization staff,
etc.) should be represent-
ed in the team. Review the
terms of reference of the
quality committee and/or
the minutes of meetings.
27
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 1.5. The facility has systems for continuously improving the quality and safety of services.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Does the quality
improvement team
meet regularly?
The improvement of
quality is a continuous
process requiring regular
meetings.
The team has a routine
meeting schedule, e.g.
weekly or monthly.
Examination of minutes
allows the regularity of
meetings to be deter-
mined.
d) Does the team review
quality and safety
information and imple-
ment actions to im-
prove the service?
Quality improvement
requires implementing
change, which is achieved
by developing and
implementing action
plans.
The team uses this
self-assessment tool or
other quality tools to
assess services, identify
gaps and make improve-
ments.
The minutes of meetings
and action plans allow
team activities to be
assessed.
Section 2
28
Standard 2. A minimum package of male circumcision services is provided.
Intent: The male circumcision service is more than just a surgical procedure. A minimum package of services should be available in all facilities
providing male circumcision. These services could be offered in different locations within the same facility. However, systems and processes
should be set up to facilitate easy client ow and referral from one point to another.
1. DOCUMENTS: Ensure that the following documents are available for review.
a. HIV/AIDS counselling guidelines
b. HIV testing guidelines
c. Laboratory quality control manual
d. Syndromic management guidelines/protocols
e. Risk reduction and safer sex counselling guidelines
2. METHODS: Suggested key methods for eliciting information include:
a. Observation
b. Client interview
c. Medical record review
29
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 2. A minimum package of male circumcision services is provided.
Criterion 2.1. HIV testing and counselling services are provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are HIV testing and
counselling services
available on site?
Comprehensive male
circumcision services
include HIV testing and
counselling on site to
ensure that they are
routinely done.
Services are posted to
inform the community of
their availability. Finger-
pricking for rapid assess-
ments is highly recom-
mended.
b) Are up-to-date HIV
testing and counselling
guidelines available?
Guidelines set the expec-
tations for staff and
provide a written refer-
ence to assist staff in
giving consistent and
accurate HIV testing and
counselling. As research
and new evidence be-
come available, facilities
should adopt the new
practices.
The testing and counsel-
ling guidelines should be
in line with national
guidelines or WHO/
UNAIDS Guidance on
provider-initiated HIV
testing and counselling in
health facilities and
should include:
information on the
three Cs (informed
consent, condential-
ity, counselling);
minimum information
provided to clients
before HIV testing
and during post-test
counselling.
Section 2
30
Criterion 2.1. HIV testing and counselling services are provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are HIV/AIDS testing
and counselling pro-
vided according to the
guidelines?
Job aids are available and
used to guide counsellors
to ensure that the three
Cs are provided. Peer
and/or supervisor obser-
vations and feedback are
recommended.
d) Are all clients routinely
offered HIV testing?
Knowledge of ones HIV
status is a critical compo-
nent of an HIV prevention
strategy and assists
counsellors to provide the
most effective and
appropriate counselling
and behaviour change. It
also serves to encourage
those in need of care and
treatment to access the
services.
Observation, client
interview and medical
records could be used.
31
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 2.1. HIV testing and counselling services are provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
e) Are HIV testing services
routinely offered to
clients partners and to
parents bringing in their
children?
When men come to the
facility with partners or
when parents bring
children the opportunity
should be used to offer
them HIV testing.
Observation, client
interviews, and medical
records could be used.
f) Is there a laboratory
quality control process?
IQC specimens should be
used at least once a week
and with new shipments,
lots and testers to ensure
that the rapid test kits are
accurately detecting HIV
antibodies.
When running controls for
HIV rapid testing it is
important to use both a
negative and a positive
control.
A site ofcer has been
assigned. When HIV
testing is done outside the
hospital laboratory the
main laboratory provides
oversight of the testing.
Laboratory standing
operating procedures are
in place and there is
evidence of staff training
and certication to
perform HIV tests.
There is a standardized
register for recording lot
numbers of test kits, test
kit expiry dates and IQC
sample results to facilitate
reference of IQC sample
data.
Section 2
32
Criterion 2.2. Syndromic management of STIs is provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is syndromic manage-
ment of STIs provided
on site?
Infections must be identi-
ed and treated before
elective operations.
Operations should be
postponed until infections
have resolved.
Services are posted to
inform the community of
their availability. Clinicians
are available who are
trained to provide syn-
dromic management.
b) Are STI syndromic
management guide-
lines/protocols avail-
able?
Guidelines set the expec-
tations for staff and
provide a written refer-
ence to assist staff in
providing consistent and
accurate STI syndromic
management. As research
and new evidence be-
come available, facilities
should adopt the new
practices.
These guidelines should
be in line with national or
WHO STI syndromic
management guidelines.
Syndromic management
protocols or algorithms
are posted on the wall
and/or are readily acces-
sible to staff in consulta-
tion rooms.
c) Is treatment provided to
patients with STIs
according to guidelines?
Documentation can be
reviewed to determine if
treatment is provided
according to protocol.
33
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 2.3. Individual risk reduction and safer sex counselling is provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is individual risk
reduction and safer sex
counseling provided on
site?
Risk reduction and safer
sex counselling should be
provided to all men
scheduled for circumci-
sion in order to ensure
that they understand their
continued risk of acquir-
ing and transmitting HIV
and other STIs. Counsel-
ling should include
specic messages for
clients to deliver to their
partners, explaining the
importance of continuing
safe sex practices even
when circumcision has
been performed.
Risk reduction and safer
sex counselling are
provided to all men
scheduled for circumci-
sion. This may be as-
sessed by observation,
review of medical records,
and/or client interviews.
b) Are risk reduction and
safer sex counselling
guidelines available?
Current guidelines indi-
cate that the following
information needs to be
provided:
male circumcision
gives the client only
partial protection
against HIV;
On-site written guidelines
include the required
information. They may be
included in HIV or other
sexual reproductive health
counselling guidelines.
Section 2
34
Criterion 2.3. Individual risk reduction and safer sex counselling is provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
lack of protection
against HIV (or
evidence of it) for the
clients partner;
importance of both
partners knowing
their HIV status;
reducing the number
of partners;
reducing contact with
the partners body
uids, including
ejaculate (semen) from
a mans penis, vaginal
uids, blood and other
types of discharge
from open sores;
condom use (male
and female);
increased risk of HIV
acquisition and
transmission if client
engages in sex before
wound is healed.
35
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 2.3. Individual risk reduction and safer sex counselling is provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are risk reduction and
safer sex counselling
provided according to
the guidelines?
Counselling should be
guided by a risk assess-
ment. Individual counsel-
ling should reinforce
clients understanding of
information given, ad-
dress clients specic
concerns and questions,
determine clients reasons
for seeking circumcision
and clear up any miscon-
ceptions.
The medical record shows
that the guidelines have
been met.
Observation of counsel-
ling sessions and inter-
views with clients may be
done to verify this crite-
rion. Tool 2. Checklist for
individual counselling
on male circumcision
and male reproductive
health.
Criterion 2.4. Male and female condoms are provided on site.
a) Are male condoms
readily available in the
facilities?
The availability of con-
doms helps to reinforce
counselling messages on
the importance of their
use in HIV/STI risk reduc-
tion and condom use
behaviour.
Observation of sources
and availability of con-
doms in locations that are
convenient for the client,
e.g. waiting rooms or
toilets; supply records on
the number of condoms
distributed.
Section 2
36
Criterion 2.4. Male and female condoms are provided on site.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Are female condoms
readily available in the
facilities?
Female condoms provide
an alternative to male
condoms and may be
preferred by some clients
and their partners.
Condoms should be
offered in a setting or
location that is accessible
to clients partners.
c) Are male and female
condoms promoted
and provided to all
sexually active clients
during consultations?
Promotion includes
informing clients about
the importance of the
consistent use of con-
doms as well as about
using them correctly.
Observations, review of
medical records, and
client interviews could be
done.
Criterion 2.5. The facility ensures that the minimum package of services is integrated and that appropriate linkages are made.
a) Does the facility
organize the services to
ensure that client ow
through the clinic is
smooth and that clients
can easily access all
minimum package
services?
Even if services are not
provided in the same
building but are in differ-
ent buildings or areas in
the facilities, there should
be a way to direct patients
so that they can access
the different services.
Attempts should be made
to bring the services
closer together to make it
easier for clients.
Walking the path taken by
clients from registration to
counselling, assessment,
surgery, postoperative
care, etc. will assist the
team to understand client
ow. Making a diagram of
client ow can be useful.
37
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 2.5. The facility ensures that the minimum package of services is integrated and that appropriate linkages are made.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Are all MC staff aware
of the components of
the minimum package
and do they know
where to direct clients
to access the different
services?
Staff should know what
services are available in
the facility and where
clients can receive them
so that they can help
clients to access them.
Ask various staff mem-
bers how they would
instruct clients about
accessing the services
provided.
c) Are all opportunities
used at every MC
service delivery point to
promote and check if
other parts of the
minimum package have
been delivered?
At every MC service
delivery point, staff should
take advantage of the
opportunity to check if
HIV testing has been
done or at least offered,
and that clients have
received counselling and
condoms.
Various assessment
methods could be used,
e.g. staff interviews,
observation of client-pro-
vider interactions, and
client interviews.
Section 2
38
Standard 3. The facility has the necessary medicines, supplies, equipment and environment for providing safe male
circumcision services of good quality.
Intent: The provision of quality care requires an infrastructure capable of supporting the activities of the client and the care provider. Leaders must
commit the resources necessary to provide safe male circumcision services, including adequate facilities, medicines, equipment and supplies.
1. DOCUMENTS: Ensure that the following documents are available for review.
a. Inventory lists
b. Equipment maintenance registers
2. METHODS: Suggested key methods for eliciting information include:
c. Inventory
d. Observation
Standard 3. The facility has the necessary medicines, supplies, equipment and environment for providing safe male
circumcision services of good quality.
Criterion 3.1. Essential medicines required for providing circumcision services are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the facility have
adequate supplies of
medicines for syndrom-
ic management of
STIs?
Clients with STIs have to
be treated before under-
going surgery. Supplies
should be available so as
to avoid surgical delays or
failure of clients to return
for treatment.
Review the current stock
and stock lists to deter-
mine whether stock is
routinely available and
whether there are stock-
outs. Required drugs are
in accordance with WHO
or national guidelines.
39
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.1. Essential medicines required for providing circumcision services are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Does the facility have
adequate broad-spec-
trum antibiotics for
postoperative infec-
tions?
Antibiotics should be
available for any postop-
erative infection that may
develop.
Review the stock of
available antibiotics. The
countrys sensitivity
patterns and national
guidelines determine
which are the most
important antibiotics to be
stocked.
c) Does the facility have
adequate medicines for
pain control?
Analgesics should be
available to manage
postoperative pain.
Review the stock of
analgesics.
d) Does the facility have
adequate local anaes-
thetics?
Local anaesthetics are
required to manage pain
during the operative
procedure.
Local anaesthetics may
be located in the phar-
macy or operating theatre.
Anaesthetics are available
and surgeries are not
cancelled due to lack of
anaesthetics.
Section 2
40
Criterion 3.1. Essential medicines required for providing circumcision services are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
e) Are all the medicines
stocked and dispensed
within their expiry
dates?
Medicines that have
expired may no longer be
effective.
Check each category of
medicines to ensure that
they are stocked within
their expiry dates.
Check shelves to see that
medicines that will be out
of date rst are stocked in
front so that they will be
used rst.
f) Are medicines stored
according to tempera-
ture and light recom-
mendations?
Medicines must be stored
properly to assure effec-
tiveness.
Check the list of medi-
cines used for male
circumcision. If any
require refrigeration or
protection from light,
check to see if they are
stored properly.
41
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.1. Essential medicines required for providing circumcision services are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
g) Is a medicine inventory
system in use?
Effective inventory sys-
tems help to ensure that
medicines are available.
A process for routine stock-
ing of medicines according
to an established level of
use is in place so that
stock is available but not in
excessive amounts that
would result in expiry
before use. This could be
done using stock cards.
Tool 3. Medicine stock
card.
Criterion 3.2. The necessary supplies and equipment are available for performing surgeries.
a) Is an inventory system
used to ensure that
adequate non-emer-
gency supplies and
equipment are avail-
able?
An inventory system helps
to ensure that supplies
and equipment are
available when needed.
A stocking inventory, e.g.
stock cards or sheets,
could be used and a
specic routine for
checking inventory and
ordering supplies/equip-
ment should be in place.
Tool 4. Supplies stock
card.
Section 2
42
Criterion 3.2. The necessary supplies and equipment are available for performing surgeries.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is a system used to
ensure that non-emer-
gency equipment is
functioning?
All equipment used for
performing surgery
should be checked to
ensure that it functions
properly, including the
sterilizer, cautery and
surgical instruments.
An equipment mainte-
nance log should be kept
to track equipment repairs
and maintenance. Observe
whether there is a routine
process for checking the
functioning of surgical
instruments, e.g. during the
sterilization process. The
sterilizer is maintained in
accordance with a planned
programme.
c) Are adequate dispos-
able supplies available
for performing circum-
cisions, including HIV
kits?
Surgeries may be delayed
or cancelled when there
are insufcient supplies.
Disposable supplies
should be reordered in a
timely manner. A robust
supply chain is neces-
sary.
Check that all the supplies
and instruments needed for
performing surgeries and
HIV testing are available and
sufcient for the daily sched-
uled procedures. Single-use
items are used once and
then discarded. Tools 5a,
5b and 5c. Supplies and
instruments (reusable and
disposable) for standard
male circumcision.
43
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.2. The necessary supplies and equipment are available for performing surgeries.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
d) Is there an adequate
inventory of reusable
supplies?
Tools 5a, 5b, 5c and 5d.
Supplies and instru-
ments (reusable and
disposable) for standard
male circumcision
e) Are HIV kits stored
according to the
manufacturers instruc-
tions?
HIV kits must be stored
properly to assure effec-
tiveness.
Check that HIV kits are
stored according to the
manufacturers instruc-
tions. If the kits require
refrigeration or protection
from light, check to see
that the kits are stored
properly. A refrigerator
temperature log should be
kept to ensure that
temperatures are main-
tained as required. Ask
staff what actions they
should take if the tem-
perature is out of the
required range.
Section 2
44
Criterion 3.3. Emergency equipment, supplies and medicines are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are emergency resusci-
tation guidelines and
protocols readily
available in the operat-
ing rooms (ORs)?
Emergency protocols
must be visible to staff to
ensure rapid treatment.
Key algorithms could be
posted on the walls or on
the resuscitation trolley so
that they can be easily
accessed and read by
clinicians.
b) Are emergency resusci-
tation equipment/
supplies and medicines
easily accessible?
Emergency equipment/
supplies must be immedi-
ately accessible in the
OR.
Emergency equipment
and supplies are available
to carry out the protocols.
Check whether the
emergency supplies/
equipment are easily
accessible (in close
proximity to or in the OR).
c) Is there a system for
checking and maintain-
ing the emergency
resuscitation supplies/
equipment and medi-
cines?
Because emergency
equipment/supplies are
not used often, a mainte-
nance process is required
to ensure their availability
and functioning when
needed.
There is a mechanism to
check the functioning of the
emergency equipment on a
routine basis. The medicines
and supplies are stored
according to a checklist and
are within their expiry dates.
The emergency supplies are
secured between uses. Tool
6. Adult emergency supply
checklist.
45
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.4. Infection prevention supplies and equipment are readily available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are there sinks, running
water and non-reusable
towels available for
staff to wash hands in
all consulting rooms?
When sinks and running
water are not close to
patient care areas, staff
are less likely to wash
their hands as required.
Drying hands on reusable
towels is a means of
transmitting germs,
therefore disposable or
non-reusable towels
should be used.
Visit consulting rooms to
determine whether running
water is available for
hand-washing. This may
be tap water or a container
with a spigot or other
method that meets the
standard for proper
hand-washing. Paper
towels or single-use towels
should be available to dry
hands (no shared cloth
towels). Antiseptic hand
rubs are also a suitable
alternative to running
water.
b) Are clean non-reusable
towels and soap
available for washing
hands after use of the
toilet?
Visit staff and client toilets
and check to see if there
are materials for washing
hands properly.
Section 2
46
Criterion 3.4. Infection prevention supplies and equipment are readily available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are plastic goggles,
aprons (or gowns) and
non-sterile and sterile
gloves available?
Sterile gloves of various
sizes are needed to
perform the surgical
procedure prociently.
Personal protective gear
needs to be available to
protect staff from undue
exposure to blood and
other body uids. If
reusable aprons are used
they should be wiped
down with an antiseptic
after each surgery.
Check the inventory of
available items. Goggles,
gowns and gloves should
be available for all staff
performing or assisting
with the procedure.
d) Are non-penetrable
containers for dispos-
ing of sharps available
and no more than
two-thirds full?
Sharps containers should
be designed to protect
staff from injury. They
should be sealed for
disposal and should never
be emptied.
Visit clinical areas where
injections and sharps are
used. Check that sharps
containers are readily
available and are non-
penetrable (hard plastic or
thick cardboard) and have
openings to insert nee-
dles/sharps that cannot be
retrieved. Check boxes to
determine if they are no
more than two-thirds full.
47
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.4. Infection prevention supplies and equipment are readily available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
e) Are medical waste
containers available,
labelled and with lids?
Regular and medical
wastes are disposed of
differently and therefore
must be separate; colour-
coding is preferable (red
is used for medical
waste).
Check containers that are
used for medical waste to
determine if they have lids
and are labelled medical
waste. Preferably the
containers can be opened
with a foot pedal.
f) Are the essential
medicines available for
post-exposure prophy-
laxis (PEP)?
Exposure to HIV is a
serious incident that
requires immediate
intervention to prevent
transmission of HIV. There
should be a PEP protocol
that includes both emer-
gency and follow-up care;
and PEP drugs should be
in stock and accessible.
Check that the essential
medicines for PEP are in
stock and that the proto-
col is readily available to
staff.
Section 2
48
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the waiting room
have adequate ventila-
tion and sufcient
lighting, space and
seating?
Patient comfort is an
important aspect of
quality services.
Visit the waiting room to
assess the availability of
seating, space and
lighting. An ideal waiting
area has a covered
seating area if outside,
seating available for all
clients, windows and light-
ing sufcient for reading,
and is not overcrowded.
b) Do the consultation /
examination and HIV
testing rooms have
adequate ventilation,
sufcient lighting and
space?
There is sufcient lighting
to examine clients, read
materials and document
ndings. A window is
preferable and a fan if air
conditioning is not avail-
able. Space is sufcient to
include a desk, two chairs
and an examination table.
49
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Do the consultation /
examination and HIV
testing and counselling
rooms and changing
rooms ensure privacy?
Privacy is one of the
clients rights. Interrup-
tions during consultations/
counselling may be
embarrassing to clients as
well as disrupting discus-
sion.
Rooms should be set up in
such a way that they
ensure auditory and visual
privacy. Preferably the
rooms have full walls and
doors, and curtains at
windows. Screens may be
used to separate the area
for changing clothing.
Methods for decreasing
interruptions might include
the use of a do not
disturb sign and/or
keeping doors closed.
d) Is there a designated
room for performing
surgical procedures?
Surgical procedures
should be performed in
an area that can be
controlled for infections.
Visit the procedure room
to determine its suitability;
it must have a door that
can be shut.
Section 2
50
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
e) Do the theatre / operat-
ing rooms have ad-
equate temperature
control and ventilation
and sufcient lighting
and space?
A source of strong adjust-
able lighting is required
for proper visibility of the
operating site.
A minor procedures light
should be available that
can be positioned or a
uorescent light should
be directly above the
operating table; adjust-
able surgical lights are
ideal. Space should be
sufcient for two clini-
cians, one at either side of
the table, with an instru-
ment tray. Exposed
patients should be warm
and comfortable and
providers should not be
perspiring. Preferably, air
should enter the OR
through a vent close to
the ceiling and should
leave via a vent near the
oor. Air conditioning
systems should have
lters that are changed
regularly.
51
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
f) Does the postoperative
care area have ad-
equate temperature
control and sufcient
lighting and space?
A space should be
allotted specically for
monitoring patients
postoperatively where
they can lie down and
recover.
There should be enough
space to accommodate
the number of patients
recovering at any one
time. Lighting should be
sufcient to permit read-
ing. If there is an overnight
facility, ensure that it also
meets these requirements.
g) Is the operating room
equipped with an
adequate table, instru-
ment table/trolley and a
oor made of materials
that are easy to clean
and disinfect?
The procedure table
should be at a height/
width that allows the
clinicians to avoid muscu-
loskeletal problems and
fatigue. Instruments
should be positioned for
easy access and prevent-
ed from dropping. The
oor must be easily
cleaned to avoid infec-
tions.
Determine whether the
table is at a height and
width convenient for
clinicians; preferably its
height should be adjust-
able. The table should be
washable and in good
repair. A standard instru-
ment trolley/table, prefer-
ably of stainless steel,
should be available, in
good condition and
structurally sound.
Preferably, the oor is made
of an impervious material
that can be easily cleaned.
Section 2
52
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
h) Is there an adequate
area for performing the
surgical scrub?
There is running water
and sufcient space, the
area is clean, there is a
liquid soap dispenser and
antiseptic soap, the tap
(faucet) can be turned off
without touching it, and
single-use towels are
available. The sink for
washing hands is not
used for washing instru-
ments or other items.
i) Does the layout of
surgical suites allow for
effective ow of both
patients and clinicians?
The surgical suite should
be set up to allow continu-
ous movement from
non-sterile to sterile
areas/rooms.
Draw a ow diagram of
the rooms and/or walk
through the areas to
assess the ow. Make
random observations of
the numbers of people in
the theatre.
j) Are toilets available for
staff and clients and in
a sanitary condition?
Toilets are clean with no
unpleasant odours.
53
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
k) Are re safety mea-
sures in place?
Patient and staff safety
should be a priority
concern. Every effort must
be made to prevent res.
If a re occurs, staff must
know how to use re
equipment and evacuate
clients safely.
Fire extinguishers are
located in all patient care
areas, are in working
condition and are checked
regularly. Ensure that
emergency exits are
available from all areas,
e.g. consulting rooms,
wards and waiting areas.
All emergency exits should
be clearly signposted and
unlocked.
l) Are the different areas
for providing services
clearly signposted?
Ease of access is impor-
tant so that clients can
easily access the right
services and nd follow-
up services.
Start at the front door of
the facility and trace the
steps that a client would
take to nd the reception
area and other services,
in order to determine if the
signs make it easy to
locate the services.
Section 2
54
Criterion 3.5. The environment is adequate for carrying out the activities required.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
m) Is the facility clean
overall?
There is no litter. Floors,
walls and doors are
unstained, and furniture and
facilities are in good order in
all areas. There is no clutter,
work services are in good
repair and cupboards are
clean and tidy.
55
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 4. Providers are qualied and competent.
Intent: A system exists for identifying staff learning needs and ensuring that plans are designed to meet these needs. Training activities are con-
ducted to prepare staff to carry out their jobs effectively. The team of staff members has the necessary competences to provide the minimum
package of male circumcision services.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Samples of personnel les of clinicians, nurses and counsellors
b. Staff training needs assessment
c. Staff training plan
d. Training attendance records
2. METHODS: Suggested key methods for eliciting information include:
e. Document review
f. Staff interviews
Standard 4. Providers are qualied and competent.
Criterion 4.1. The facility has a process in place to ensure that all staff have the appropriate qualications and competence for
their assigned tasks for male circumcision.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is there a process for
determining whether
clinicians have valid
qualications/licence/
registration to practise?
To ensure the highest
possible safety and
quality of MC services,
only clinicians with the
appropriate credentials
can provide such serv-
ices.
Evidence of the process
includes a review of
paperwork documenting
that credentials for all
clinical staff were veried
prior to their hire / service
delivery. Appropriate
credentials are as laid
down by the health ministry
or other authoritative body.
Section 2
56
Criterion 4.1. The facility has a process in place to ensure that all staff have the appropriate qualications and competence for
their assigned tasks for male circumcision.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is there a process to
verify the competence
of all staff hired to
provide male circumci-
sion services?
To ensure the highest
possible safety and
quality of MC services,
only competent staff may
provide such services
Evidence of the process
includes a review of paper-
work documenting that
competence in service
provision was met by all
staff providing such serv-
ices before their hire date or
hire/date of initial services
delivery (for volunteers). A
certicate of competence
from a recognized body or a
competence verication
process may sufce.
57
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 4.2. There is a periodic assessment of staff competences.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is the competence of
staff providing counsel-
ling as a part of male
circumcision services
routinely and periodi-
cally assessed?
Ongoing formal assess-
ment of competence
helps to ensure that
clients are receiving
accurate messages and
the appropriate care,
support and referrals.
Observation and health-
care worker interviews
and examinations. As-
sessment of performance
in relation to the protocols
should be documented in
the personnel le.
b) Is the competence of
staff performing
history-taking skills as
part of male circumci-
sion services periodi-
cally assessed?
Ongoing assessment of
history-taking skills is
necessary to ensure that
history-taking is per-
formed in a thorough and
accurate manner.
As above. The require-
ment for the assessment
may vary, depending on
the experience of the staff
and the number of clients
he or she has seen.
Competence assessment
should be done on a
regular basis (at least
annually) and formally
documented.
Section 2
58
Criterion 4.2. There is a periodic assessment of staff competences.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Is the competence of
staff performing
physical examinations
as part of male circum-
cision services periodi-
cally assessed?
Ongoing assessment of
physical examination and
assessment skills is
necessary to ensure that
examinations and assess-
ments are performed in a
clinically competent
manner and that contrain-
dications for surgery are
identied.
As above.
d) Is the competence of
staff performing
surgery or components
of surgery as part of
the male circumcision
services periodically
assessed?
Ongoing assessments of
male circumcision surgi-
cal skills are necessary
for all staff involved, in
order to ensure that the
surgery is performed in a
clinically competent
manner.
As above.
59
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 4.3. Ongoing in-service education and training are provided to assist staff to full their duties.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Has a training needs
assessment been done
in the past year for staff
providing male circum-
cision services?
Staff should receive
training on the most
up-to-date skills and
techniques employed in
delivery of the MC mini-
mum package of services
to ensure that services
are safe, efcient and of
the highest quality. An
annual training needs
assessment may reveal a
lack of knowledge or skills
or outdated knowledge or
skills.
This information might be
included in a formal
document or minutes of a
meeting where training
needs were determined.
Issues noted during
performance appraisals
or through monitoring and
evaluation activities may
provide additional evi-
dence of training needs.
b) Is there a staff training
and development plan
for staff providing male
circumcision services?
Results of the training
needs assessment should
be developed into a
training plan so that
management can antici-
pate and full the training
needs.
This information might be
included in a formal
document, e.g. an in-
service training plan or
the minutes of a meeting
where a plan for address-
ing training needs was
developed.
Section 2
60
Criterion 4.3. Ongoing in-service education and training are provided to assist staff to full their duties.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Has the staff training
and development plan
been implemented?
Implementation of the
training plan is necessary
so that staff may receive
the necessary training
and provide the safest,
most efcient and highest
quality services possible.
Written evidence, e.g. a
training attendance record
that training activities
have taken place or that
staff have attended
workshops/courses (led
in personnel records).
d) Has the effectiveness
of the training activities
been evaluated?
Staff who have attended
training activities should
integrate their new knowl-
edge and skills into
practice.
Documented evidence
that the skills have been
integrated into practice
through the monitoring of
practice. This could be a
focused assessment of
skills or could be included
in the performance
appraisal.
61
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 5. Clients are provided with information and education for HIV prevention and male circumcision.
Intent: The facility is recognized as a resource centre for promoting healthy lifestyles. The facility has a role and responsibility to develop chan-
nels for sharing sexual and reproductive health information and materials. Specic materials are available on male circumcision and are accurate,
simple, age-appropriate and consistent with the minimum package.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Samples of information and education materials
2. METHODS: Suggested key methods for eliciting information include:
b. Medical record review
c. Observations
Standard 5. Clients are provided with information and education for HIV prevention and male circumcision.
Criterion 5.1. Information is provided to clients on male circumcision, sexually transmitted infections and HIV prevention.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are clients provided
with information and
education about male
circumcision which
include the following?
Risk and benets
Surgical procedure
Partially protective
nature, necessitat-
ing maintenance of
other HIV prevention
strategies
Clients have the right to be
informed about the proce-
dure and should know how
to protect themselves from
developing infections.
Group education is effective
for providing general
information (Tool 7. Check-
list for group education
on male circumcision and
male reproductive
health.),
Assessment data can be
obtained from observa-
tion, provider interviews,
client interviews and/or
community focus group
discussions.
Section 2
62
Criterion 5.1. Information is provided to clients on male circumcision, sexually transmitted infections and HIV prevention.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
Abstinence period of
at least six weeks
post-operation to
allow for wound
healing
No known HIV
prevention benet
for HIV+ persons so
not recommended
for persons already
HIV-infected unless
medically indicated
but it should be followed by
individual information and
education sessions to allow
an opportunity for each
client to ask questions and
the health-care worker to
validate each clients
understanding. Consider-
ation should be given to the
age of clients when con-
ducting group education,
as different teaching
strategies should be used
for youth and older men.
63
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 5.1. Information is provided to clients on male circumcision, sexually transmitted infections and HIV prevention.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Are clients who are
seeking male circumci-
sion provided with
information and educa-
tion about STI screen-
ing and HIV testing?
For MC to be maximally
effective and safe for HIV
prevention, it is recom-
mended for males who
are HIV- negative, and
clients must be free of
active STIs at the time of
surgery. Testing for HIV
before surgery is therefore
highly encouraged for all
clients seeking MC.
Similarly, screening for ac-
tive STIs through history
and physical examination
is required before surgery.
Clients must receive and
understand information
about HIV testing and STI
screening before such
assessments are con-
ducted.
Evidence could be
obtained through obser-
vation of group and
individual information and
education sessions
involving staff and clients
and should be document-
ed in the client record.
Section 2
64
Criterion 5.1. Information is provided to clients on male circumcision, sexually transmitted infections and HIV prevention.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are clients partners or
parents bringing sons
for MC provided with
this information?
If a clients partner and
family are present at the
facility, the information
should be communicated
directly to them. If they are
not present, the client
should be advised about
what information to share
with them following the
visit.
As above
Criterion 5.2. Aappropriate reinforcing information and educational materials are provided.
a) Are clients provided
with printed materials
that they can take with
them to reinforce the
verbal information on
male circumcision, STIs
and HIV prevention and
testing?
Information materials that
men can take away should
be age and culturally
appropriate and in the local
language (or presented
pictorially if the clientele is
illiterate).
Take-away materials allow
clients an opportunity for
greater understanding of
information presented
verbally and may serve as
reminders and sustain
knowledge.
MC materials should be
available that men can
take with them either
before or after MC is
performed. Materials
should be age and
culturally appropriate and
in the local language.
65
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 5.2. Aappropriate reinforcing information and educational materials are provided.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Are clients partners or
parents provided with
printed materials that
they can take with them
to reinforce the verbal
information on male
circumcision, STIs and
HIV prevention and
testing?
Information materials that
partners/family can take
away should be tailored to
their roles and relation-
ship to the client, age and
culturally appropriate and
in the local language (or
presented pictorially if the
clientele is illiterate).
Take-away materials allow
partners/family an oppor-
tunity for greater under-
standing of information
presented verbally and
may serve as reminders
and sustain knowledge.
Review the MC materials
that are available for
women to take with them.
Materials should be age
and culturally appropriate
and in the local language.
NOTE: Materials for
women should specically
include information about
the risks and benets of
MC for women, so that
they are aware and can
take steps to protect
themselves and encour-
age MC among HIV-nega-
tive men in the population.
Section 2
66
Criterion 5.2. Aappropriate reinforcing information and educational materials are provided.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are male sexual and
reproductive health
materials available
which provide informa-
tion and education?
Male circumcision for HIV
prevention programmes
should provide boys and
men who traditionally do
not access male sexual
and reproductive health
care services with infor-
mation about reproductive
health, including general
information about HIV and
STIs. Persons considering
MC and those who have
had the procedure
performed should have
access to written materi-
als about male sexual and
reproductive health which
reinforce the information
and education received
during group/individual
sessions.
Review MC materials that
men can take away with
them either before or after
MC is performed. Materi-
als should be age and
culturally appropriate and
in the local language.
67
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 5.2. Aappropriate reinforcing information and educational materials are provided.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
d) Are MC client teaching
aids available in the
counselling rooms?
Teaching aids should be
available and used in
counselling rooms to help
staff in providing consist-
ently accurate and
complete information and
education to clients and
their sexual partners.
Flip charts, posters or
other teaching aids are
evidence in relation to this
question.
Criterion 5.3. Informed consent is obtained from clients.
a) Is there a process to
verify that the client or
parents/guardians of
minor children under-
stand the surgical
procedure to be
undertaken and the
potential risks and
complications before
signing the consent
form?
In addition to receiving
information about MC
surgery, clients or par-
ents/guardians of minors
must demonstrate an
understanding of the
information before provid-
ing meaningful informed
consent. Client under-
standing needs to be
assessed by asking
clients to repeat key
information back to the
staff that provided it.
Client interviews could be
conducted to determine
whether clients under-
stood the MC information
before surgery. Observa-
tion of staff obtaining
consents could also be
done.
Section 2
68
Criterion 5.3. Informed consent is obtained from clients.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is there a signed
surgical consent form
on each clients record?
It is unethical to perform
surgery on a person who
has not provided informed
consent or consented to
something he did not
understand. If clients are
to give meaningful con-
sent they must therefore
be properly educated
about (and understand)
key aspects of MC
surgery.
Evidence is obtained
through a review of a
random sample of client
records to see if consents
have been completed and
signed. Tools 8 & 9.
Informed consent forms.
69
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 6. Assessments are performed to determine the condition of clients.
Intent: An initial assessment is performed to evaluate the suitability of the client for the circumcision procedure. The assessment takes into ac-
count the social, economic and cultural background and the health risks of each client. Ongoing assessments are performed to evaluate the
clients status in relation to the surgical procedure.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Samples of client medical records
2. METHODS: Suggested key methods for eliciting information include:
a. Medical record review
b. Observations
Standard 6. Assessments are performed to determine the condition of clients.
Criterion 6.1. An initial client history is taken.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is a medical history
obtained to assess any
surgical contraindica-
tions for clients under-
going male circumci-
sion?
An accurate and appropri-
ate past medical history is
required to allow health-
care providers to assess
for surgical contraindica-
tions and potential risks
that need to managed,
e.g. allergies or diabetes.
Review a sample of
medical records to deter-
mine if medical histories
are routinely documented
on a standard form or
checklist that guides
history-taking. Tool 10.
Client assessment form
for male circumcision.
Section 2
70
Criterion 6.2. Initial physical examinations are performed.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is a physical examina-
tion performed to
assess for surgical con-
traindications on all
clients undergoing
male circumcision?
Clients must be assessed
for potential contraindica-
tions. An accurate and
appropriate physical
examination is required to
allow health-care provid-
ers to assess eligibility for
surgery.
Review a sample of
medical records to
determine if a physical
examination was com-
pleted using a standard
form that guides physical
examination.
Tool 11. Checklist for
client assessment for
male circumcision.
71
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 7. Male circumcision surgical care is delivered according to evidence-based guidelines.
Intent: Providing safe clinical care of good quality is at the heart of male circumcision services delivery. These activities require an interdisciplin-
ary approach. Each practitioners role and responsibilities are determined by: her or his professional skills, competence and credentials; the care
provided; and the programmes policies. Procedures and care are provided according to evidence-based guidelines.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Surgical procedure guidelines
b. Guidelines for management of complications
2. METHODS: Suggested key methods for eliciting information include:
a. Medical record review
b. Observations
c. Surgical review
Standard 7. Male circumcision surgical care is delivered according to evidence-based guidelines.
Criterion 7.1. Male circumcision surgical procedures are performed according to standard guidelines.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are male circumcision
surgical guidelines
available?
Guidelines set the expec-
tations for staff and
provide a written refer-
ence to assist staff in
performing the surgical
procedure properly and
under proper conditions.
As research and new
evidence become avail-
able, facilities should
adopt the new practices.
The guidelines should be
located in an area that is
easily accessible to the
clinical staff. Staff should be
aware of their location and
content. They should be
based on the most up-to-
date national and international
guidelines on performing the
preferred or standard surgical
method(s), e.g. the WHO
Manual for male circumcision
under general anaesthesia.
Section 2
72
Criterion 7.1. Male circumcision surgical procedures are performed according to standard guidelines.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is the surgical proce-
dure performed ac-
cording to standard
guidelines?
The surgical procedure is
documented. Tool 12.
Male circumcision
surgical procedure form.
Individual clinicians should
be assessed to ensure
performance according to
the guidelines. Tools
1316. Checklists for
male circumcision
procedures.
c) Was a sterile dressing
applied?
An incision is usually
covered for 2448 hours
with a sterile dressing to
reduce the potential for
infection.
Observations of the
procedure and documen-
tation in the client record.
d) Are efforts made to
protect clients privacy
and dignity during
surgery?
Clients have the right to
privacy and dignity and to
be treated with respect
during the procedure.
Observations during
surgery can be made to
determine whether
patients are routinely
covered when the proce-
dure is not under way,
ensuring that they are not
unnecessarily exposed.
Staff do not make com-
ments that could be
concerning to clients, e.g.
unnecessary remarks
about their private parts
or alarming exclamations.
73
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 7.2. Standard procedures for assessment and management of emergencies and complications are followed.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are guidelines available
for managing complica-
tions during and after
surgery?
Guidelines set the expec-
tations for staff and
provide a written refer-
ence to assist staff in
responding quickly and
effectively to manage
complications. As re-
search and new evidence
become available, facili-
ties should adopt the new
practices.
Protocols for the most
common complications,
e.g. anaphylactic reac-
tions, cardiovascular
events, bleeding and
wound infections, are
readily available. These
could be posted on a wall
or located in a convenient
place for staff to refer to
them when necessary.
b) Are standard guidelines
followed for the man-
agement of emergen-
cies and complica-
tions?
Emergencies and compli-
cations are best reviewed
immediately to establish
what happened and
identify ways to avoid
similar situations in the
future.
When a complication has
occurred, the clients
records should be re-
viewed as well as minutes
from medical review meet-
ings to determine actions
taken and any trends
(patterns of recurring
complications).
Section 2
74
Criterion 7.3. Immediate postoperative care is provided according to the standard protocol.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are guidelines available
for immediate postop-
erative care?
A standard protocol is
available that outlines
postoperative care.
Tool 17. Male circumci-
sion immediate postop-
erative care protocol.
b) Are the patients
postoperative vital
signs and condition
monitored according to
a standard protocol?
The patients vital signs
should be stable before
discharge.
The protocol should
include how often vital
signs are to be monitored
postoperatively and
before discharge.
Adherence to this protocol
can be assessed by
observation or by review-
ing the clients record.
c) Is the patients pain
assessed and managed
in an appropriate
manner postoperatively?
The patient may be reluc-
tant to complain of pain.
The staff should assess
postoperative pain and
provide treatment when
indicated. Clients should be
asked about the effective-
ness of the pain manage-
ment that they received.
The postoperative protocol
should include assessing
the clients pain postop-
eratively. Postoperative
care can be observed and
client records can be
reviewed for assessment
and treatment that was
provided.
75
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 8. Infection prevention and control measures are practised.
Intent: The facility effectively implements infection prevention and control processes by involving staff and clients in observing standard precau-
tions. Infection control surveillance, data collection and corrective measures are conducted to reduce the incidence of surgical site infections.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Infection prevention and control policies and procedures
2. METHODS: Suggested key methods for eliciting information include:
a. Document review
b. Observations
Standard 8. Infection prevention and control measures are practised.
Criterion 8.1. Infection prevention and control policies and procedures are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Are policies and
procedures available
for the following?
Hand-washing
Surgical scrub
Gowning and gloving
Decontamination
Disinfection
Sterilization
Cleaning of operat-
ing rooms
Trafc ow
Handling of needles
and sharps
New evidence of the most
effective means of pre-
venting infection is
routinely published.
Policies and procedures
should be written on the
basis of these ndings
and staff should be aware
of the current practices.
Written infection prevention
policies and procedures
dening safe practices
should be located where
health-care workers can
access them. These may
be national policies and
procedures or may be
adopted from other repu-
table sources, e.g. Centers
for Disease Control and
Prevention, USA.
Section 2
76
Criterion 8.1. Infection prevention and control policies and procedures are available.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
Waste management
Management of spills
Post-exposure
prophylaxis
Criterion 8.2. Infection prevention and control measures are practised according to policy and procedures.
Are infection control mea-
sures practised according to
guidelines and procedures?
a) Hand-washing, surgical
scrub, gowning and
gloving
One of the most common
complications of circumci-
sion is infection, which can
lead to loss of function and
death. Hand-washing is the
most effective means of
reducing the spread of
organisms; a minimum of a
two-minute surgical scrub
is recommended before
surgery. Caps may reduce
contamination to the
surgical eld. Masks may
be benecial in protecting
the wearer from exposure
to blood and body uids.
Shoe covers have not been
shown to decrease the risk
of infection.
Observations can be
made to verify whether
sterile gloves and an
apron (or gown) are worn
and changed between
cases. If plastic reusable
aprons are used they are
wiped down with 0.5%
chlorine between use.
Reusable aprons could be
used that are changed for
each patient and washed
at the end of the day.
Periodic assessment
should be done using a
checklist. Tool 18. Obser-
vation of infection
prevention and injection
safety practices.
77
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 8.2. Infection prevention and control measures are practised according to policy and procedures.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
Clothing should not be
changed in the OR, as
this can lead to airborne
dissemination of group A
streptococci.
b) Decontamination,
disinfection, steriliza-
tion, cleaning of
operating rooms, and
movement/ow of
people
Strict adherence to
cleaning and sterilization
processes is necessary to
avoid contamination. The
microbial level in the OR
is directly proportional to
the number of people
moving about in the room.
The ow of people should
therefore be minimized
and doors should be kept
shut. The importance of
routine monitoring of the
quality of sterilization
procedures has been well
established.
Use the infection preven-
tion and control assess-
ment tool to measure this
criterion.
Section 2
78
Criterion 8.2. Infection prevention and control measures are practised according to policy and procedures.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Handling of needles
and sharps, waste
management and
spills, post-exposure
prophylaxis
Needle/sharps-sticks can
be a source of transmis-
sion of HIV, hepatitis B,
etc. Poor management of
waste, including spills,
can also expose staff to
viruses. Post-exposure
prophylaxis should be
carried out immediately to
prevent transmission of
viruses.
Ask staff what they would
do following a sharps
injury to determine if they
know the PEP procedure.
Use the infection preven-
tion and control assess-
ment tool to measure this
criterion. Preferably, all
staff should have received
hepatitis B vaccination.
Criterion 8.3. Individuals are designated to be accountable for infection control activities at the facility.
a) Are there designated
individuals responsible
for infection prevention
activities including:
infection control
training, monitoring,
reviewing ndings and
taking actions to
improve infection
control practices?
Infection prevention is an
important aspect of care.
Even though all staff are
expected to follow proce-
dures, practices are more
likely to be adhered to
when there is someone
with knowledge and
expertise in the area who
is overseeing the process.
There may be one infec-
tion control practitioner or
there may be individuals
in different departments,
e.g. laboratory, central
supply, sterilization and
theatre, who are assigned
to be responsible for
infection control activities.
79
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Standard 9. Continuity of care is provided.
Intent: Systems and procedures are in place to promote effective follow-up care. Effective referrals and counter-referrals are made. Adequate
and clear information is given to clients to facilitate their home care and ongoing use of services.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Referral contact information
b. Referral records
c. Protocols for postoperative review
d. Postoperative instructions
2. METHODS: Suggested key methods for eliciting information include:
a. Document review
b. Medical record review
c. Observations
Standard 9. Continuity of care is provided.
Criterion 9.1. An effective referral system is in place.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the facility have a
protocol on referrals to
other services?
Providers are more likely
to systematically make
referrals if a clear protocol
is available.
Review of facility docu-
ments.
Section 2
80
Criterion 9.1. An effective referral system is in place.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is contact information
available for referral
facilities?
Specic information
facilitates both access to
referral services and
uptake. All staff should be
aware of referral facilities
or relevant departments in
a facility. Where appropri-
ate, staff should be aware
of the days that particular
clinics (e.g. specialist
clinics) are held. Well-
established links should
be made with these
facilities/departments.
Referral sources within the
community for meeting
psychosocial needs
identied during risk
assessments, e.g. drug
abuse or violence, HIV+
support groups, should be
established. Referral
facilities for managing
complicated cases should
be identied.
Ask the staff if they are
aware of referral facilities
and relevant departments
within the facility. Staff
should aware of the days
that particular clinics (e.g.
specialist clinics) are held.
Links between facilities and
departments can be
assessed through inter-
views with key parties. A list
of referral sources in the
community for meeting
psychosocial needs
identied during risk
assessments, e.g. drug
abuse or violence, HIV+
support groups, and
managing complicated
cases, should be available
with contact information.
Preferably, written agree-
ments should have been
established with key referral
agencies.
81
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 9.1. An effective referral system is in place.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Are client referrals
documented?
Referral records help to
ensure continuity of care.
A record should be kept
of each patients name,
age and reason for
referral. The referral
should also be recorded
in the patients record.
Review and analysis of
referral lists and client
records.
d) Is adequate written
information on the
patients condition
provided to the referral
facility?
A written referral letter or
form, containing at least
the patients name and
age, the treatment given
and the reason for refer-
ral, should be sent to the
referral facility in the
interest of continuity of
care.
Review of records for
copies of referral letters.
Section 2
82
Criterion 9.2. The client/family is given discharge instructions.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is the patient given
postoperative instruc-
tions on the following?
The importance of
wound management
for the prevention of
infection
Abstaining from
sexual intercourse
until complete
wound-healing has
been certied by a
clinician or until at
least six weeks post-
operatively
Returning to activi-
ties and work
Warning signs; e.g.
excessive bleeding,
pain, fever or pus
from the wound, and
what to do if such
signs occur
The partially protec-
tive nature of
circumcision and
the use of condoms
Clients may have difculty
in remembering all the
information provided;
written information is
helpful to reinforce the
instructions. This informa-
tion needs to be easy for
the patient to understand.
The clients usual activi-
ties and work should be
determined and the
patient should be coun-
selled on when to resume
them. Instructions should
preferably be given rst in
person and then in
writing.
Client interviews on the
patients understanding of
the information could be
conducted. Written
postoperative information
is given to the patient,
including: wound man-
agement, warning signs
of healing problems,
abstaining from sex for six
weeks, returning to work,
partial protection and use
of condoms. Documenta-
tion on the client records
could be reviewed.
Observations could also
be made. Tool 19. Post-
operative instructions
for male circumcision.
83
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 9.3. There is a well-established mechanism for follow-up of clients.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the facility have
standard protocols or
guidelines for postop-
erative review?
Protocols should outline
expectations on follow-up
and the examination and
educational and/or
counselling activities that
will take place. See the
WHO Manual for male
circumcision under
general anaesthesia.
b) Are the protocols for
follow-up carried out?
Review client records to
determine whether
follow-up protocols are
carried out and/or ob-
serve clinical practice.
Tool 20. Checklist for
postoperative review.
c) Do clients routinely
return for follow-up
visits?
It is preferable for patients
to return for follow-up
visits so that the wound
can be assessed. Follow-
up visits also provide an
opportunity to reinforce
risk-reduction measures.
If patients do not return
the facility should investi-
gate why this is so.
A process should be in
place to determine if
patients are returning for
follow-up visits and actions
should be taken if issues
are identied. Follow-up
visits should be document-
ed. Tool 21. Checklist for
male circumcision
follow-up visit.
Section 2
84
Standard 10. A system for monitoring and evaluation is established.
Intent: A process is in place to monitor and evaluate the quality and safety of services. The process includes data collection and analysis, actions
taken to improve care and services, and monitoring the effect of the actions.
1. DOCUMENTS: Ensure that the following documents are available for review:
a. Clinic register/log (service statistics)
b. Stafng and scheduling plans
c. Adverse event review process
2. METHODS: Suggested key methods for eliciting information include:
a. Document review
Standard 10. A system for monitoring and evaluation is established.
Criterion 10.1. Data are collected on services provided.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Does the clinic keep a
general client register?
The types of services and
numbers of clients are
important in service
planning, including
stafng and budgeting.
This information is also
used to evaluate the
effectiveness of service
promotion and access.
A register/log is kept to
record the patients name,
services received, date,
etc. Specic registers for
VCT counselling and HIV
testing may be useful.
Tool 22. Male circumci-
sion register.
85
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 10.1. Data are collected on services provided.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Does the clinic have a
surgical register/log
that records the date,
patients name, age,
procedure, type of
anaesthesia, surgeon
and comments?
The number and types of
surgeries performed will
assist the facility in
evaluating the use of
services and can be used
to plan future service
delivery.
A surgical register/log is
kept for the listed informa-
tion. Additional informa-
tion could be entered in
the comments, e.g.
complications.
c) Does the clinic compile
the information from
these registers for
reporting/evaluation
purposes?
Data collected in the
registers are not useful
unless compiled and
used for decision-making.
The information collected
in the registers/logs is
compiled on a regular
basis (e.g. monthly) in a
report including such data
as the numbers of pa-
tients presenting for
services, patients seen
and assessed, surgeries
scheduled and postop-
erative clients reviewed.
Section 2
86
Criterion 10.2. Data are used for planning and improvement of service delivery.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is there a process for
reviewing the data for
all the different areas of
service delivery?
The data should be
analysed to determine
who uses the services
and how they are being
used.
Evidence would include
data collected from
records for such things as
the numbers of patients
presenting for services,
patients seen and as-
sessed, surgeries sched-
uled and postoperative
clients reviewed. A
process for regular review
and discussion of data
should be established,
e.g. weekly/monthly staff
meetings, which is
evidenced in minutes.
b) Are services planned
and improved on the
basis of the data and
information?
The information is ultimately
used to improve the use,
efciency and effectiveness
of services, e.g. stafng and
scheduling plans should be
based on information
elicited from service delivery
data review as well as plans
to promote or redesign
services to meet clients
needs more effectively.
Service plans, and
minutes of management
meetings or of the quality
improvement team, could
serve as evidence.
87
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 10.3. There is a system for prompt reporting and review of adverse events.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is there a system for
recording all adverse
events?
The recording of adverse
events is the rst step in
learning from them in
order to nd ways of
preventing their recur-
rence.
Adverse events are
dened and recorded
according to severity, e.g.
no harm, moderate or
severe outcomes. A
standard format is used to
collect information on
adverse events and a le
of these events is main-
tained. Events are trended
and patterns identied as
evidenced in reports and/
or the minutes of meet-
ings. Tool 23. Adverse
event descriptions and
management, Kisumu,
Kenya.
Section 2
88
Criterion 10.3. There is a system for prompt reporting and review of adverse events.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
b) Is there a systematic
process for investigat-
ing moderate or severe
adverse events in order
to determine causes?
This process is NOT for
identifying who was at
fault but for determining
how such events oc-
curred. A cause analysis
should be conducted for
each serious event to
determine where process-
es have failed. The events
need to be trended so as
to track patterns. The
trends should be dis-
cussed by the medical
team to learn about and
nd ways of reducing the
possibility that the events
will happen again.
Review minutes or reports
on individual events and
on investigations into
(cause analysis) and
reports of trends. De-
pending on the number of
clients and adverse
events, these reports may
be produced quarterly or
biannually.
89
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Criterion 10.3. There is a system for prompt reporting and review of adverse events.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
c) Have actions been
taken to prevent future
events of this nature?
The most important
aspect of the review of
complications is to
develop plans to avoid the
problems in the future.
An action plan is developed
and carried out to prevent
further events. Minutes
show that the plans have
been implemented and that
monitoring continues to
track complications.
d) Are discussions held
with clients who have
experienced adverse
events about how these
were managed?
Patients have the right to
know what has occurred
and what actions were
taken to deal with situa-
tions. Managers and staff
should know how to
handle these situations.
Staff and client interviews
may be conducted in
order to seek this informa-
tion.
Section 2
90
Criterion 10.4. Data collection is thorough and accurate.
Rationale Look for: Score Observations Actions
Questions Why is this question
important?
How is this question
assessed?
0 1 2 Why did you give this
score?
What needs
to be done?
a) Is there a process for
assessing missing or
erroneous data?
Inaccurate data lead to
inaccurate decision-mak-
ing. A person or persons
should be assigned to
oversee the accuracy of
data collection.
Data quality standards exist.
Review the process with the
person who is responsible
for overseeing the accuracy
of data collection. A quality
check is made at least
monthly to determine if data
are collected according to
the standards.
91
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Section 3
Supporting Tools
Section 3
92
Tool 1. Action plan
Activity (What needs to be done?) How will it be done? Who is responsible? When will it be done?
93
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
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S
U
N
/
O
1
.

P
r
e
p
a
r
e

I
E
C

m
a
t
e
r
i
a
l
s
.

2
.

O
f
f
e
r

t
h
e

c
l
i
e
n
t

a
n
d

t
h
e

c
a
r
e
r
/
p
a
r
e
n
t

a

s
e
a
t

a
n
d

e
n
s
u
r
e

p
r
i
v
a
c
y
.
3
.

G
r
e
e
t

t
h
e

c
l
i
e
n
t

a
n
d

c
a
r
e
r

r
e
s
p
e
c
t
i
v
e
l
y

a
n
d

w
i
t
h

k
i
n
d
n
e
s
s
.

I
n
t
r
o
d
u
c
e

y
o
u
r
s
e
l
f

a
n
d

a
s
k

f
o
r

t
h
e

n
a
m
e

o
f

t
h
e

c
l
i
e
n
t
.
4
.

E
x
p
l
a
i
n

t
o

t
h
e

c
l
i
e
n
t

a
n
d

t
h
e

c
a
r
e
r

w
h
a
t

i
s

g
o
i
n
g

t
o

b
e

d
o
n
e

a
n
d

e
n
c
o
u
r
a
g
e

t
h
e
m

t
o

a
s
k

q
u
e
s
t
i
o
n
s
.

G
e
t

p
e
r
m
i
s
s
i
o
n

b
e
f
o
r
e

b
e
g
i
n
n
i
n
g

a
n
d

a
s
k

w
h
e
t
h
e
r

t
h
e

c
a
r
e
r

s
h
o
u
l
d

b
e

p
r
e
s
e
n
t
.
5
.

E
x
p
l
a
i
n

t
o

t
h
e

c
l
i
e
n
t

t
h
a
t

t
h
e

i
n
f
o
r
m
a
t
i
o
n

h
e

g
i
v
e
s

w
i
l
l

b
e

c
o
n

-
d
e
n
t
i
a
l

a
n
d

w
i
l
l

n
o
t

b
e

s
h
a
r
e
d

w
i
t
h
o
u
t

h
i
s

e
x
p
r
e
s
s

p
e
r
m
i
s
s
i
o
n
.

6
.

C
o
m
m
u
n
i
c
a
t
e

r
e
s
p
e
c
t

v
e
r
b
a
l
l
y

a
n
d

n
o
n
-
v
e
r
b
a
l
l
y
.
7
.

H
o
n
o
u
r

c
o
n

d
e
n
t
i
a
l
i
t
y
.
8
.

C
o
m
m
u
n
i
c
a
t
e

c
a
r
e
f
u
l
l
y

a
n
d

w
i
t
h

s
e
n
s
i
t
i
v
i
t
y
.
9
.

U
s
e

e
a
s
y
-
t
o
-
u
n
d
e
r
s
t
a
n
d

l
a
n
g
u
a
g
e

a
n
d

c
h
e
c
k

u
n
d
e
r
s
t
a
n
d
i
n
g
.
1
0
.

A
s
k

w
h
a
t

t
h
e

c
l
i
e
n
t

a
l
r
e
a
d
y

k
n
o
w
s

b
e
f
o
r
e

p
r
o
v
i
d
i
n
g

r
e
l
e
v
a
n
t

e
d
u
c
a
t
i
o
n
.
1
1
.

S
h
o
w

s
e
n
s
i
t
i
v
i
t
y

t
o

s
o
c
i
a
l

a
n
d

c
u
l
t
u
r
a
l

p
r
a
c
t
i
c
e
s

t
h
a
t

m
a
y

c
o
n

i
c
t

w
i
t
h

t
h
e

p
l
a
n

o
f

c
a
r
e
.

1
2
.

E
n
c
o
u
r
a
g
e

t
h
e

c
l
i
e
n
t

t
o

a
s
k

q
u
e
s
t
i
o
n
s

a
n
d

v
o
i
c
e

c
o
n
c
e
r
n
s
,

a
n
d

l
i
s
t
e
n

t
o

w
h
a
t

h
e

h
a
s

t
o

s
a
y
.
1
3
.

B
e

e
m
p
a
t
h
e
t
i
c
.
1
4
.

A
s
k

t
h
e

c
l
i
e
n
t
/
p
a
r
e
n
t

w
h
a
t

s
p
e
c
i

c

r
e
p
r
o
d
u
c
t
i
v
e

h
e
a
l
t
h

s
e
r
v
i
c
e

h
e

i
s

r
e
q
u
e
s
t
i
n
g
.
M
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n
1
5
.

A
s
k

t
h
e

c
l
i
e
n
t

(
o
r

t
h
e

p
a
r
e
n
t
s

i
f

t
h
e

c
h
i
l
d

i
s

t
o
o

y
o
u
n
g
)

t
o

t
e
l
l

y
o
u

w
h
a
t

h
e

a
l
r
e
a
d
y

k
n
o
w
s

a
b
o
u
t

m
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n
.
1
6
.

T
e
l
l

t
h
e

c
l
i
e
n
t
/
p
a
r
e
n
t
s

a
b
o
u
t

m
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n
:

w
h
a
t

m
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n

i
s
;

b
e
n
e

t
s

a
n
d

r
i
s
k
s

o
f

m
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n
;

h
o
w

i
t

i
s

d
o
n
e
;

p
a
i
n

r
e
l
i
e
f

o
p
t
i
o
n
s
;

h
o
w

s
o
o
n

t
h
e

p
a
t
i
e
n
t

c
a
n

g
o

h
o
m
e

a
f
t
e
r

t
h
e

p
r
o
c
e
d
u
r
e
;

p
o
s
t
o
p
e
r
a
t
i
v
e

c
a
r
e

a
n
d

f
o
l
l
o
w
-
u
p
;

h
o
w

a
n
d

w
h
e
r
e

t
o

c
o
n
t
a
c
t

h
e
a
l
t
h
-
c
a
r
e

w
o
r
k
e
r
s
.
Section 3
94
1
7
.

A
s
k

f
o
r

q
u
e
s
t
i
o
n
s

a
n
d

a
d
d
r
e
s
s

a
n
y

c
o
n
c
e
r
n
s

t
h
a
t

t
h
e

c
l
i
e
n
t

o
r

h
i
s

p
a
r
e
n
t
s

m
a
y

h
a
v
e
.
R
i
s
k

o
f

H
I
V

i
n
f
e
c
t
i
o
n
1
8
.

A
s
k

t
h
e

c
l
i
e
n
t

o
r

h
i
s

p
a
r
e
n
t
s

t
o

t
e
l
l

y
o
u

w
h
a
t

t
h
e
y

a
l
r
e
a
d
y

k
n
o
w

a
b
o
u
t

H
I
V

a
n
d

A
I
D
S
.
1
9
.

A
s
k

t
h
e

c
l
i
e
n
t

o
r

h
i
s

p
a
r
e
n
t
s

i
f

h
e

h
a
s

e
v
e
r

b
e
e
n

t
e
s
t
e
d

f
o
r

H
I
V
.
2
0
.

A
s
s
e
s
s

t
h
e

c
l
i
e
n
t

s

l
e
v
e
l

o
f

c
o
n
c
e
r
n

a
b
o
u
t

h
a
v
i
n
g
/
a
c
q
u
i
r
i
n
g

H
I
V
.
2
1
.

U
p
d
a
t
e

t
h
e

c
l
i
e
n
t

a
n
d
/
o
r

h
i
s

p
a
r
e
n
t
s

a
b
o
u
t

H
I
V

a
n
d

A
I
D
S
.

2
2
.

E
x
p
l
o
r
e

t
h
e

c
l
i
e
n
t

s

m
o
s
t

r
e
c
e
n
t

r
i
s
k

e
x
p
o
s
u
r
e
/
b
e
h
a
v
i
o
u
r
.
a
)

W
h
e
n
?
b
)

W
i
t
h

w
h
o
m
?
c
)

U
n
d
e
r

w
h
a
t

c
i
r
c
u
m
s
t
a
n
c
e
s
?
2
3
.

A
s
s
e
s
s

t
h
e

p
a
t
t
e
r
n

o
f

r
i
s
k

(
o
c
c
u
r
r
i
n
g

r
e
g
u
l
a
r
l
y
,

o
c
c
a
s
i
o
n
a
l
l
y
,

a
t
t
r
i
b
u
t
a
b
l
e

t
o

a
n

u
n
u
s
u
a
l

i
n
c
i
d
e
n
t
)
.
a
)

N
u
m
b
e
r

o
f

p
a
r
t
n
e
r
s
?
b
)

T
y
p
e

o
f

p
a
r
t
n
e
r
s
?
c
)

F
r
e
q
u
e
n
c
y

o
f

n
e
w
/
d
i
f
f
e
r
e
n
t

p
a
r
t
n
e
r
s
?
d
)

C
o
n
d
o
m

u
s
e
?
2
4
.

D
e
t
e
r
m
i
n
e

o
t
h
e
r

h
i
g
h
-
r
i
s
k

b
e
h
a
v
i
o
u
r
s

(
d
r
u
g
/
a
l
c
o
h
o
l

a
b
u
s
e
,

v
i
o
l
e
n
c
e
)
.
2
5
.

S
u
m
m
a
r
i
z
e

t
h
e

c
l
i
e
n
t

s

s
i
t
u
a
t
i
o
n

a
n
d

r
i
s
k

i
s
s
u
e
s
.
2
6
.

W
o
r
k

w
i
t
h

t
h
e

c
l
i
e
n
t

t
o

d
e
v
e
l
o
p

a

r
i
s
k
-
r
e
d
u
c
t
i
o
n

p
l
a
n

f
o
r

t
h
e

r
i
s
k

b
e
h
a
v
i
o
u
r
s

i
d
e
n
t
i

e
d

a
b
o
v
e
.

R
e
f
e
r

c
l
i
e
n
t
s

t
o

c
o
m
m
u
n
i
t
y

g
r
o
u
p
s

a
s

i
n
d
i
c
a
t
e
d
.
2
7
.

E
x
p
l
o
r
e

t
h
e

c
l
i
e
n
t

s

f
e
e
l
i
n
g
s

a
b
o
u
t

t
e
s
t
i
n
g

f
o
r

H
I
V

a
n
d

r
e
a
d
i
-
n
e
s
s

f
o
r

t
e
s
t
i
n
g
.
2
8
.

R
e
f
e
r

t
h
e

c
l
i
e
n
t

f
o
r

H
I
V

t
e
s
t
i
n
g

i
f

h
e

s
o

w
i
s
h
e
s
.
2
9
.

R
e
f
e
r

t
h
e

c
l
i
e
n
t

f
o
r

c
a
r
e

a
n
d

s
u
p
p
o
r
t

i
f

h
e

i
s

k
n
o
w
n

t
o

b
e

H
I
V
-
p
o
s
i
t
i
v
e
.
3
0
.

I
f

h
e

i
s

H
I
V
-
n
e
g
a
t
i
v
e
,

c
o
u
n
s
e
l

t
h
e

c
l
i
e
n
t

o
n

h
o
w

t
o

r
e
m
a
i
n

s
o

(
a
b
s
t
i
n
e
n
c
e
,

b
e
i
n
g

f
a
i
t
h
f
u
l
,

c
o
n
d
o
m

u
s
e

t
h
e

A
B
C

m
e
s
s
a
g
e
)
.
O
t
h
e
r

s
e
x
u
a
l
l
y

t
r
a
n
s
m
i
t
t
e
d

i
n
f
e
c
t
i
o
n
s

(
i
f

t
h
e

c
l
i
e
n
t

i
s

a
l
r
e
a
d
y

s
e
x
u
a
l
l
y

a
c
t
i
v
e
)
3
1
.

A
s
k

t
h
e

c
l
i
e
n
t

w
h
a
t

h
e

k
n
o
w
s

a
b
o
u
t

s
e
x
u
a
l
l
y

t
r
a
n
s
m
i
t
t
e
d

i
n
f
e
c
t
i
o
n
s
.
3
2
.

U
p
d
a
t
e

t
h
e

c
l
i
e
n
t

a
b
o
u
t

S
T
I
s
,

i
n
c
l
u
d
i
n
g
:

c
o
m
m
o
n

t
y
p
e
s

o
f

S
T
I
s
;

s
i
g
n
s

a
n
d

s
y
m
p
t
o
m
s

o
f

c
o
m
m
o
n

S
T
I
s
;

h
o
w

S
T
I
s

a
r
e

s
p
r
e
a
d

f
r
o
m

p
e
r
s
o
n

t
o

p
e
r
s
o
n
;

h
o
w

S
T
I
s

a
r
e

p
r
e
v
e
n
t
e
d
;

A
B
C

m
e
s
s
a
g
e
)
;

u
s
e

o
f

d
u
a
l

p
r
o
t
e
c
t
i
o
n
;

w
h
e
r
e

t
o

g
o

f
o
r

d
i
a
g
n
o
s
i
s

a
n
d

t
r
e
a
t
m
e
n
t
.
95
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 3. Medicine stock card
Item: atropine (0.6 mg/ml ampoules) Min level ________30_______
Cost per item (if applicable): Max level _______ 50_______
Storage condition: Dept Emergency Dept
Date Stock in Stock out Adjustment Balance Name Sign Comments
5/06/09 50 20 5 25 Kwame Opong 5 expired ampoules
5/10/09 25 0 0 50 Winnie Obuko
Directions
1. Use one stock card per item.
2. ITEM: List the item, including the generic name of the medicine, the strength and the medium (e.g. ampoules, vial, suppositories).
3. COST: Include the cost of each item if applicable.
4. STORAGE: Indicate if there are any storage conditions that apply to this item (e.g. refrigeration, light).
5. MIN LEVEL: Indicate the minimum level of this item that should be in stock (reorder level)
6. MAX LEVEL: Indicate the maximum level of this item that should be in stock.
7. DEPT: Indicate the department in which this item is stocked (e.g. pharmacy, recovery room).
8. When taking stock, ll in the columns as follows:
a. Date
b. Stock in how many items are received (added to the stock).
c. Stock out how many items are taken out of stock.
d. Adjustment note medicine losses that are identied.
e. Balance how many of these items are left.
f. Name print the name of the person who is doing the stocktaking.
g. Sign signature.
h. Comments any explanation of losses or other information.
Section 3
96
Tool 4. Supplies stock card
Date of stocktaking: HCW initials:
Details Quantity Comments
Stocktaking Stock card Difference
Sterile gloves
Examination gloves
(packets)
Utility gloves
Spirit bottles
Betadine bottles
Gauze rolls
Cotton wool rolls
3.0 chromic catgut
Adhesive plaster rolls
Normal saline bottles/bags
27-gauge needles
30-gauge needles
10-ml syringes
5-ml syringes
2-ml syringes
Safety pins
Taper 4/8 circle needles
JIK bottles
97
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 5a. Disposable and reusable supplies for standard male circumcision
Directions
The second column indicates the numbers of the items needed. When an item has been obtained, place a tick () in the third column.
Supplies Number Available
Instrument tray wrapped with sterile drape 1
O drape (80 cm x 80 cm drape with ~5-cm hole) 1
Drapes to cover patient before procedure 2
Gallipot for antiseptic solution (e.g. povidone iodine) 2
Kidney dishes 2
Povidone iodine (50 ml 10% solution) 1
Plain gauze swabs (ten 10 10 cm for procedure, ve 10 10 cm for dressing) 15
Petroleum-jelly-impregnated gauze (5 5 cm or 5 10 cm) (tulle gras) and sticking plaster 1
15 ml 1% plain lidocaine (without adrenaline) anaesthetic solution or marcaine 1
10-ml syringe (if single-use syringes and needles are unavailable, use equipment designed for steam sterilization) 2
Injection needles (18-gauge or 21-gauge) 2
Suture material (chromic gut or vicryl 3-0 and 4-0) with 3/8 circle reverse-cutting needle 1
Gentian violet (no more than 5 ml) or sterile marker pen 1
Crepe bandage 1
Surgical gloves (sizes 7, 7, 8 and 8) 2 pairs of each size
Surgical masks 2
Surgical caps 2
Disposable aprons 2
Assembled by: Date:
Section 3
98
Tool 5b. Reusable and disposable supplies for standard male circumcision, Rakai, Uganda (Sleeve method)
Directions
The rst column indicates the instruments required and the second column indicates the numbers needed. When an item has been obtained, place a tick () in the third column.
Instrument name Number Available
Scissors 3
JAMES TENOTOMY 1
Mayo 1
METZENBAUM DEL CVD 7 1
Needle holders 1
TC HALSEY smoolt 4 1
Forceps 16
HALSFED mosquito DEL 5 STR 6
CRILE CVD 5 4
ALLIS 5 X 6 2
ADISON serr 4 smoolt 1
ADISON tissue 1X2 teeth 4 1
ADISON bipolar 1
BALLENGER sponge DEL CVD 7 1
Knife handle 1
#3 Knife handle 1
Blades 2
Retractors 2
Joseph skin 6 2
Clamps 4
BACHAUS towel clips 5 2
EDNA towel clips non per. 3 2
SPRINGER closed w/lock 6X2 1
Assembled by: Date:
99
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 5c. Reusable and disposable supplies for standard male circumcision, Kisumu, Kenya
(forceps-guided method)
Item Description Quantity
Needle holder 4 1
Blade holder No. 3 1
Dunhill artery forceps 6 2
Mosquito artery forceps 4 6
Sponge-holding forceps 12 2
Kochers clamp 8 1
Allis tissue forceps 6 1
Toothed dissecting forceps 4 1
Suture scissors 1
Metzenbaum tissue scissors 6 1
Kidney dish (large) 1
Gulipot medium 1
Center O towel 1
Wrappers 4
Gauze 4 x 4 20
Hand towels 2
Section 3
100
Tool 5d. Reusable and disposable supplies for standard male circumcision, Orange Farm,
South Africa (forceps-guided method)
Item Description Quantity
Gloves 1
Apron 1
Drape 1
Container tub 1
Needle 1
Syringe, 22-gauge 1
Gauze
Plastic toothed forceps 1
Mosquito forceps 1
Needle holder 1
Across clamp 1
Scalpel 1
3/0 chronic gut (absorbent)
Vaseline gauze
Tape
Alcohol swabs
Compressible bandage
101
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 6. Adult emergency supply checklist
Unit
Emergency medicines and equipment Date Date Date Date
Pocket mask with one-way valve
Ambu bag with valve and mask
Oxygen mask
Assorted adult airways
Yankauer suction
Tongue depressors (2)
Atropine (0.6 mg/ml ampoules)
Adrenaline (1 in 1000 solution, 1 mg in 1 ml ampoules)
Rectal diazepam (10 mg in 2.5-ml suppositories)
50% dextrose
Hydrocortisone
Aminophylline
Intravenous saline and tubing
IV cannulas (2 each 16, 18 and 22F)
Tourniquets (2)
Alcohol swabs (6)
Adhesive tape (1 roll of 1 tape)
Water for injection (1 vial)
A portable suction machine and an oxygen source are required. Equipment for intubation may also be added to the list if the capability for intubation exists,
as well as a debrillator.
Section 3
102
Tool 7. Checklist for group education on male circumcision and male reproductive health
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Task/activity Performance
Introduction S U N/O
1. Greet the group and introduce yourself.
2. Explain what you wish to talk about.
3. Use easy-to-understand language and check understanding.
4. Encourage the clients to ask questions and voice concerns, and listen to what they have to say.
5. Describe the male reproductive health services that are available in the clinic.
Male circumcision
6. Ask a volunteer to tell you what he already knows about male circumcision.
7. Give positive feedback to the volunteer on any correct information provided and ll in the gaps on:
what male circumcision is;
benets of male circumcision;
risks of male circumcision;
relationship between male circumcision and HIV infection;
pain relief options for male circumcision;
postoperative care after male circumcision;
how and where to contact health-care workers after male circumcision.
103
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Task/activity Performance
S U N/O
8. Ask for questions and address any concerns of the participants.
HIV disease basics and prevention
9. Ask a volunteer to tell you what he already knows about HIV/AIDS.
10. Give positive feedback to the volunteer on any correct information provided and ll in the gaps.
Other sexually transmitted infections
11. Ask the group if they know of any other sexually transmitted infections.
12. Give positive feedback to the volunteer on any correct information provided and ll in the gaps on:
common STIs in the country;
symptoms and signs of the common STIs;
how STIs can be prevented (including the ABC message).
13. Tell the clients where they can receive services if they experience symptoms and signs of an STI.
14. Ask the participants for questions on MC and male reproductive health and provide additional information as needed.
15. Tell clients/parents where to go for the services that they require.
16. Thank everyone for their attention.
Section 3
104
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D
a
t
e
105
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
T
o
o
l

9
.

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Section 3
106
T
o
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1
0
.

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d
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)




































































































































107
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
P
e
n
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l
e

e
x
a
m
i
n
a
t
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P
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A
b
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f
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S
i
g
n
a
t
u
r
e


Section 3
108
Tool 11. Checklist for client assessment for male circumcision
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Task/activity Performance
Preparation S U N/O
1. Review medical record, specically client counselling information.
2. Gather all necessary materials.
3. Greet the client with respect and offer a seat.
4. Ask the client if the carer or parent can stay during the discussion. Support the clients decision on this.
5. Assure the client of condentiality of all information provided during the session.
6. Ask the client about personal information (name, address, age, marital status, etc.).
Client interview
7. Ask the client why he has come to the clinic.
8. If he has come to the clinic for male circumcision, check if he (or his parent) has given informed consent.
9. Ask if the client currently has any genitourinary symptoms.
10. If he has any of the above, nd out more about the complaint.
11. Ask the client if he has ever been diagnosed and/or treated for an STI or other genital disease.
12. Ask the client if he has ever been treated or is currently being treated for any medical illness.
13. Ask the client if he has undergone any surgery in the past (especially genital surgery).
14. Ask the client if he is currently on any special medicines (whether prescribed, over-the-counter or traditional).
15. Ask the client if he is allergic to any known drug (including lignocaine injection or iodine).
109
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
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Section 3
110
Tool 13. Checklist for male circumcision procedure
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Task/activity Performance
Getting ready S U N/O
1. Gather all needed equipment.
2. Greet the client and/or parent(s) respectfully and with kindness.
3. Describe your role in the male circumcision procedure.
4. Ask the client or parent(s) if they have any questions they wish to ask about the procedure.
5. Review the clients records (history, examination ndings, laboratory reports).
6. Verify the clients identity and check that informed consent was obtained.
7. Check that the client has recently washed and rinsed his genital areas.
Preoperative tasks
8. Prepare instrument tray and open sterile instrument pack without touching items.
9. Ask the client to lie on his back in a comfortable position.
10. Cover the patient to maintain dignity.
11. Wash hands thoroughly and dry them with a clean dry towel.
12. Put on a sterile gown or apron.
13. Put on two pairs of sterile or high-level disinfected surgical gloves.
14. Apply antiseptic solution (e.g. Betadine solution) twice to the genital area.
15. Retract the foreskin and apply antiseptic solution, making sure that the inner surface and the glans are clean and that the skin is dry.
111
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Task/activity Performance
16. Remove the outer pair of gloves.
17. Apply a centre O drape to the genital area and pull the penis through the O drape. If there is no O-drape, apply four smaller drapes to form a small square
around the penis.
18. Perform a gentle examination of the external genitalia.
19. Perform a subcutaneous ring block or a dorsal penile nerve block using an appropriate predetermined quantity of 1% plain lidocaine, paying special attention to
the ventral nerve.
20. Check the anaesthetic effect of the nerve block and top up as needed.
21. Throughout the procedure, talk to and reassure the client (verbal anaesthesia).
Postoperative tasks
22. Dispose of contaminated needles and syringes in a puncture-proof container.
23. Place soiled instruments in 0.5% chlorine solution for ten minutes for decontamination.
24. Dispose of waste materials in a covered leak-proof container or plastic bag.
25. Immerse both gloved hands in 0.5% chlorine solution and remove gloves by turning inside out.
a) If disposing of gloves, place in a leak-proof container or plastic bag.
b) If reusing gloves (not recommended), submerge in chlorine solution for decontamination.
26. Wash hands thoroughly and dry them with a clean dry towel.
27. Observe the clients vital signs and record the ndings.
28. Answer the clients questions and concerns.
29. Advise the client on postoperative care of the penis.
30. When the patient is stable, discharge him home on mild analgesics.
31. Ask the client to come back for follow-up after 48 hours or any time earlier if any complications occur.
32. Complete operation notes and other client record forms.
Section 3
112
Tool 14. Checklist for dorsal slit procedure
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Performance
Surgical procedure S U N/O
1. Hold the prepuce with two mosquito forceps, one on each lateral aspect.
2. Make a curved mark (1 cm proximal and parallel to the coronal sulcus) to outline the planned surgical cut.
3. Apply straight mosquito forceps to crush the prepuce at 12 oclock and remove after 1 minute.
4. Using a pair of surgical scissors, make a dorsal slit in the prepuce, proceeding from the preputial orice to the dorsal corona sulcus.
5. Excise the prepuce with a surgical blade along the previous mark.
6. Identify bleeders, and clamp and tie them. Suture and, if necessary, ligate them with 3/0 plain catgut.
7. After ligating all the bleeders, irrigate the area with normal saline and then inspect for more bleeders. If any are identied, tie them.
8. Using 3/0 chromic catgut on a taper 4/8-circle needle, make an inverted U-shaped horizontal mattress stitch on the ventral side of the penis (frenulum) to join the
skin at the V-shaped cut. Tie and tag with mosquito forceps.
9. Insert vertical mattress stitches at the 12, 3 and 9 oclock positions and tag the four quarters.
10. Insert simple stitches between the vertical mattress stitches to close the gaps (total of about 16 stitches).
11. Irrigate the area with normal saline and add other simple stitches as required.
12. Dress the wound with Sofratulle, followed by a regular dressing bandage and a strapping.
13. Advise the client to rest for 30 minutes.
113
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 15. Checklist for forceps-guided male circumcision procedure
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Performance
Surgical procedure S U N/O
1. Hold the prepuce with two mosquito forceps, one on each lateral aspect.
2. Make a curved mark (1 cm proximal and parallel to the coronal sulcus) to outline the planned surgical cut.
3. Clamp the prepuce along the mark with a Kocher clamp while retracting the glans, ensuring that the glans itself is not clamped.
4. Excise the prepuce distal to the clamp using a surgical blade along the mark.
5. Identify bleeders, and clamp and tie them. Suture and, if necessary, ligate them with 3/0 plain catgut.
6. After ligating all the bleeders, irrigate the area with normal saline and then inspect for more bleeders. If any are identied, tie them.
7. Using 3/0 chromic catgut on a taper 4/8-circle needle, make an inverted U-shaped horizontal mattress stitch on the ventral side of the penis (frenulum) to join the
skin at the V-shaped cut. Tie and tag with mosquito forceps.
8. Insert vertical mattress stitches at the 12, 3 and 9 oclock positions and tag the four quarters.
9. Insert simple stitches between the vertical mattress stitches to close the gaps (total of about 16 stitches).
10. Irrigate the area with normal saline and add other simple stitches as required.
11. Dress the wound with Sofratulle, followed by a regular dressing bandage and a strapping.
12. Advise the client to rest for 30 minutes.
Section 3
114
Tool 16. Checklist for sleeve resection male circumcision procedure
Place a in performance box if step/task is:
Satisfactory (S): Performs the step or task according to the standard procedure or guidelines
Unsatisfactory (U): Unable to perform the step or task according to the standard procedure or guidelines
Not observed (N/O): Step, task or skill not performed by participant during evaluation by trainer
Performance
Surgical procedure S U N/O
1. Make a curved mark with a sterile disposable marking pen, dabs of gentian violet, the back of a surgical blade or pinch-marks of an artery forceps, outlining the
outside of the foreskin at a level just below the corona.
2. On the underside (ventral surface) of the penis, the skin is marked with a V shape pointing towards the frenulum. The apex of the V should correspond with the midline raphe.
3. Retract the foreskin and mark the inner (mucosal) incision line 12 mm proximal to the corona. At the frenulum the incision line crosses horizontally.
4. Using a scalpel blade, make incisions along the two lines, taking care to cut through the skin to the subcutaneous tissue but not deeper. Ask the assistant to help
to retract the skin with a moist gauze swab as you make the incisions.
5. Using a pair of dissecting scissors, join the two incisions.
6. Hold the sleeve of foreskin under tension with two artery forceps and dissect it off the shaft of the penis, using a pair of dissecting forceps.
7. Identify bleeders, and clamp, tie and/or under-run them.
8. After ligating all the bleeders, irrigate the area with normal saline and then inspect for more bleeders. If any are identied, tie them.
9. Using 3/0 or 4/0 chromic catgut on a taper-cut or round-body needle, make a U-shaped horizontal mattress stitch on the ventral side of the penis (frenulum) to
join the skin at the V-shaped cut. Tie and tag with mosquito forceps.
10. Using the same chromic catgut, place vertical mattress stitches at the 12, 3 and 9 oclock positions and tag accordingly.
11. Close the gaps between the tagged stitches with two or more simple sutures (total of about 16 stitches).
12. Irrigate the area with normal saline and add other simple stitches as required.
13. Dress the wound with Sofratulle/Vaseline gauze, then with a regular dressing bandage and a strapping.
14. Advise the client to rest for 30 minutes.
115
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 17. Male circumcision immediate postoperative care protocol
1. Receive the client from the theatre.
2. Review the client record.
3. Check the blood pressure, respiration and pulse twice at 15-minute intervals.
4. Check the surgical dressing for oozing or bleeding.
5. Ask about pain and treat if indicated.
6. Observe the general condition of the client.
7. Provide bland carbohydrates and liquids to raise blood sugar levels.
8. Handle the client gently when moving him.
9. Make the client comfortable.
10. Complete the client record forms.
11. Review postoperative instructions and wound care with the patient.
12. Verify that the client is able to pass urine before leaving the clinic.
13. Before the client is discharged, assess his ability to walk and verify whether he feels faint. Do not discharge the client until he is fully mobile.
14. Ensure that the client takes home a copy of the wound care instructions and a note of the date and time of the next appointment.
15. Check the blood pressure, respiration and pulse just before discharge.
16. Document the clients condition at the time of discharge and note the time of discharge and the type of transportation used.
Section 3
116
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s
y
r
i
n
g
e
/
n
e
e
d
l
e

d
o
w
n

b
e
f
o
r
e

d
i
s
p
o
s
a
l
)

i
n
t
o

a

p
u
n
c
t
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r
e
-
p
r
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o
f

b
o
x

i
m
m
e
d
i
a
t
e
l
y

a
f
t
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r

u
s
e
?
Y
N
H
a
n
d
-
w
a
s
h
i
n
g
8
.

D
o

t
h
e

h
e
a
l
t
h
-
c
a
r
e

p
r
o
v
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s

w
a
s
h

h
a
n
d
s

o
r

u
s
e

h
a
n
d

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b

w
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d
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c
a
t
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d

(
e
.
g
.

b
e
f
o
r
e

a
n
d

a
f
t
e
r

p
a
t
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e
n
t

c
a
r
e
,

b
e
f
o
r
e

p
u
t
t
i
n
g

o
n

g
l
o
v
e
s
,

w
h
e
n

v
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s
i
b
l
y

d
i
r
t
y
)
?
Y
N
9
.

W
h
e
n

w
a
s
h
i
n
g

t
h
e
i
r

h
a
n
d
s
,

d
o

t
h
e

h
e
a
l
t
h
-
c
a
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e

p
r
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v
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u
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s
o
a
p

a
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n
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g

w
a
t
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r
?
Y
N
1
0
.

A
f
t
e
r

t
h
e

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a
n
d
s

a
r
e

w
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s
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d
,

a
r
e

t
h
e
y

d
r
i
e
d

w
i
t
h

a

p
a
p
e
r

t
o
w
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l

o
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a

c
l
e
a
n

p
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r
s
o
n
a
l
i
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e
d

t
o
w
e
l

o
r

a
r
e

t
h
e
y

a
i
r
-
d
r
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e
d
?
Y
N
U
s
e

o
f

g
l
o
v
e
s
1
1
.

A
r
e

g
l
o
v
e
s

w
o
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n

w
h
e
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v
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n
t
a
c
t

w
i
t
h

b
l
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d

o
r

b
o
d
y

u
i
d
s

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s

a
n
t
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c
i
p
a
t
e
d
?
Y
N
1
2
.

A
r
e

u
t
i
l
i
t
y

g
l
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s

w
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r
n

w
h
e
n

c
o
n
t
a
m
i
n
a
t
e
d

i
n
s
t
r
u
m
e
n
t
s

a
n
d

o
t
h
e
r

i
t
e
m
s

a
r
e

h
a
n
d
l
e
d
,

m
e
d
i
c
a
l

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r

h
a
z
a
r
d
o
u
s

w
a
s
t
e

a
n
d

l
i
n
e
n
s

a
r
e

h
a
n
d
l
e
d
,

h
o
u
s
e
k
e
e
p
i
n
g

c
h
o
r
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s

a
r
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p
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r
f
o
r
m
e
d
,

a
n
d

c
o
n
t
a
m
i
n
a
t
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d

s
u
r
f
a
c
e
s

a
r
e

c
l
e
a
n
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d
?
Y
N
A
n
t
i
s
e
p
t
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c
s

a
n
d

d
i
s
i
n
f
e
c
t
a
n
t
s
1
3
.

A
r
e

a
n
t
i
s
e
p
t
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c
s

u
s
e
d

o
n
l
y

o
n

s
k
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n

a
n
d

m
u
c
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s

m
e
m
b
r
a
n
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s
?
Y
N
1
4
.

A
r
e

d
i
s
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n
f
e
c
t
a
n
t
s

u
s
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d

f
o
r

p
r
o
c
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s
s
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g

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n
s
t
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s

a
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d

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m
s

f
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d

f
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h
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s
e
k
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e
p
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n
g

a
c
t
i
v
i
t
i
e
s
?
Y
N
117
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
A
s
s
e
s
s
m
e
n
t

i
t
e
m
s

F
o
r

i
t
e
m
s

n
o
t

o
b
s
e
r
v
e
d

w
r
i
t
e

N
/
A


i
n

t
h
e

r
e
m
a
r
k
s

c
o
l
u
m
n
C
i
r
c
l
e

e
i
t
h
e
r


Y

(
Y
e
s
)

o
r

N

(
N
o
)
R
e
m
a
r
k
s

1
5
.

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r
e

a
n
t
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s

a
n
d

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f
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t
a
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s

h
a
n
d
l
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d

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n

a

m
a
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t
h
a
t

r
e
d
u
c
e
s

c
o
n
t
a
m
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n
a
t
i
o
n
?
Y
N
P
r
o
t
e
c
t
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v
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c
o
v
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r
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n
g
1
6
.

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e

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s

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d

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n

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h
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g

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f

b
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d
y

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x
p
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c
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d
?
Y
N
1
7
.

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r
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i
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r

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a
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a
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y

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c
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n

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h
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g
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d

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t
w
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n

p
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d
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s
?
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N
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q
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1
8
.

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a

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d

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s
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d
a
y
,

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c
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h
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h

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n
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s
?
Y
N
1
9
.

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)

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N
2
0
.

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2
1
.

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m
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?
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2
2
.

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,

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m
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m
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y

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t
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n
,

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?
Y
N
2
3
.

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s

t
h
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y

w
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t
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n

a
n
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p
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c

s
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l
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?
Y
N
2
4
.

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a

s
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m
a
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d
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g

a
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s
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a
l
/
c
l
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p
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d
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s
?
Y
N
2
5
.

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r
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Y
N
2
6
.

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p
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m
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n
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p
m
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2
7
.

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n

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g
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c
a
l

p
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d
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e

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r
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s
?
Y
N
I
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s
t
r
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m
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n
t

p
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s
s
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g
2
8
.

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r
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t
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e

p
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n
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w
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p
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s

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s
t
r
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m
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n
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s

(
c
l
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n
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g

a
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d

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t
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r
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l
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z
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g
)

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a
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d

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p
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t
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c
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r
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y

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t

t
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p
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c
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d
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s
?
Y
N
2
9
.

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t
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d
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s
.
)
Y
N
Section 3
118
A
s
s
e
s
s
m
e
n
t

i
t
e
m
s

F
o
r

i
t
e
m
s

n
o
t

o
b
s
e
r
v
e
d

w
r
i
t
e

N
/
A


i
n

t
h
e

r
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m
a
r
k
s

c
o
l
u
m
n
C
i
r
c
l
e

e
i
t
h
e
r


Y

(
Y
e
s
)

o
r

N

(
N
o
)
R
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m
a
r
k
s

3
0
.

A
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e

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n
s
t
r
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s

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d

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m
s

d
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c
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a
m
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d

b
y

p
l
a
c
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g

t
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m

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n

a

0
.
5
%

c
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m
m
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d
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m

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f
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t
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n

m
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(
n
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t

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n
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y

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s
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n
)
?
Y
N
3
1
.

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m
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c
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b
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a

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o
f
t

b
r
u
s
h
,

d
e
t
e
r
g
e
n
t

a
n
d

w
a
t
e
r
,

a
n
d

r
i
n
s
e
d

t
h
o
r
o
u
g
h
-
l
y

w
i
t
h

c
l
e
a
n

w
a
t
e
r

b
e
f
o
r
e

s
t
e
r
i
l
i
z
a
t
i
o
n

o
r

h
i
g
h

l
e
v
e
l

d
i
s
i
n
f
e
c
t
i
o
n
?
Y
N
S
t
e
a
m

s
t
e
r
i
l
i
z
a
t
i
o
n
*
3
2
.

F
o
r

s
t
e
a
m

s
t
e
r
i
l
i
z
a
t
i
o
n
,

a
r
e

i
n
s
t
r
u
m
e
n
t
s

a
n
d

o
t
h
e
r

i
t
e
m
s

p
a
c
k
e
d

i
n

a

w
a
y

t
h
a
t

a
l
l
o
w
s

s
t
e
a
m

t
o

r
e
a
c
h

a
l
l

s
u
r
f
a
c
e
s
?
Y
N
3
3
.

A
r
e

t
h
e

a
p
p
r
o
p
r
i
a
t
e

p
a
r
a
m
e
t
e
r
s

f
o
l
l
o
w
e
d

f
o
r

s
t
e
a
m

s
t
e
r
i
l
i
z
a
t
i
o
n

(
t
i
m
e
,

t
e
m
p
e
r
a
t
u
r
e
,

p
r
e
s
s
u
r
e
)
?
Y
N
3
4
.

A
r
e

a
p
p
r
o
p
r
i
a
t
e

p
a
r
a
m
e
t
e
r
s

f
o
l
l
o
w
e
d

f
o
r

d
r
y
-
h
e
a
t

s
t
e
r
i
l
i
z
a
t
i
o
n

(
t
e
m
p
e
r
a
t
u
r
e
,

t
i
m
e
)
?
Y
N
3
5
.

I
s

t
h
e

s
t
e
r
i
l
i
z
a
t
i
o
n

e
q
u
i
p
m
e
n
t

p
r
o
p
e
r
l
y

m
o
n
i
t
o
r
e
d

a
n
d

m
a
i
n
t
a
i
n
e
d

(
m
a
i
n
t
e
n
a
n
c
e

l
o
g
)
?
Y
N
3
6
.

I
f

g
l
o
v
e
s

a
r
e

s
t
e
a
m
e
d
,

a
r
e

t
h
e
y

p
l
a
c
e
d

i
n

t
h
e

s
t
e
a
m
e
r

s
o

t
h
a
t

s
t
e
a
m

c
a
n

c
o
n
t
a
c
t

a
l
l

s
u
r
f
a
c
e
s

a
n
d

a
r
e

t
h
e
y

s
t
e
a
m
e
d

f
o
r

2
0

m
i
n
u
t
e
s
?
Y
N
3
7
.

A
r
e

i
n
s
t
r
u
m
e
n
t
s

a
n
d

o
t
h
e
r

i
t
e
m
s

s
t
o
r
e
d

i
n

a

w
a
y

t
h
a
t

l
i
m
i
t
s

t
h
e

r
i
s
k

o
f

c
o
n
t
a
m
i
n
a
t
i
o
n

(
s
t
o
r
e
d

a
b
o
v
e

o
o
r

l
e
v
e
l
)
?
Y
N
C
h
e
m
i
c
a
l

s
t
e
r
i
l
i
z
a
t
i
o
n
3
8
.

I
s

a

p
r
o
p
e
r
l
y

p
r
e
p
a
r
e
d

c
h
e
m
i
c
a
l

s
o
l
u
t
i
o
n
,

s
u
c
h

a
s

a

p
r
o
d
u
c
t

c
o
n
t
a
i
n
i
n
g

g
l
u
t
a
r
a
l
d
e
h
y
d
e
,

u
s
e
d

f
o
r

c
h
e
m
i
c
a
l

s
t
e
r
i
l
i
z
a
t
i
o
n
?
Y
N
3
9
.

A
r
e

t
h
e

i
n
s
t
r
u
m
e
n
t
s

a
n
d

o
t
h
e
r

i
t
e
m
s

d
r
y
,

o
p
e
n
e
d

o
r

d
i
s
a
s
s
e
m
b
l
e
d
,

a
n
d

c
o
m
p
l
e
t
e
l
y

s
u
b
m
e
r
g
e
d

i
n

t
h
e

s
o
l
u
t
i
o
n
?
Y
N
4
0
.

A
r
e

t
h
e

i
n
s
t
r
u
m
e
n
t
s

a
n
d

o
t
h
e
r

i
t
e
m
s

s
o
a
k
e
d

i
n

t
h
e

c
h
e
m
i
c
a
l

s
o
l
u
t
i
o
n

f
o
r

t
h
e

t
i
m
e

i
n
d
i
c
a
t
e
d

i
n

t
h
e

m
a
n
u
f
a
c
t
u
r
e
r

s

i
n
s
t
r
u
c
t
i
o
n
s

a
n
d

t
h
e
n

r
i
n
s
e
d

w
i
t
h

s
t
e
r
i
l
e

w
a
t
e
r
?
Y
N
M
e
d
i
c
a
l

w
a
s
t
e

m
a
n
a
g
e
m
e
n
t
4
1
.

I
s

t
h
e

f
o
r
e
s
k
i
n

d
i
s
p
o
s
e
d

o
f

i
n

a

m
e
d
i
c
a
l

w
a
s
t
e

c
o
n
t
a
i
n
e
r
?
Y
N
4
2
.

I
s

t
h
e
r
e

a

s
y
s
t
e
m

f
o
r

s
e
p
a
r
a
t
i
n
g

i
n
f
e
c
t
i
o
u
s

w
a
s
t
e

f
r
o
m

n
o
n
-
i
n
f
e
c
t
i
o
u
s

w
a
s
t
e

a
t

t
h
e

s
o
u
r
c
e

o
f

g
e
n
e
r
a
t
i
o
n

(
r
e
d

b
a
g
s
/
c
o
n
t
a
i
n
e
r
s
,

w
e
l
l

m
a
r
k
e
d
)
?
Y
N
4
3
.

A
r
e

s
h
a
r
p
s

c
o
n
t
a
i
n
e
r
s

n
o

m
o
r
e

t
h
a
n

t
w
o
-
t
h
i
r
d
s

f
u
l
l
?

Y
N
4
4
.

A
r
e

s
h
a
r
p
s

b
o
x
e
s

t
h
a
t

a
r
e

r
e
a
d
y

f
o
r

d
i
s
p
o
s
a
l
/
i
n
c
i
n
e
r
a
t
i
o
n

p
r
o
p
e
r
l
y

s
e
a
l
e
d

a
n
d

s
t
o
r
e
d

i
n

l
o
c
k
e
d
/
s
e
c
u
r
e

a
r
e
a
s

i
n
a
c
c
e
s
s
i
b
l
e

t
o

t
h
e

p
u
b
l
i
c
?
Y
N
119
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
A
s
s
e
s
s
m
e
n
t

i
t
e
m
s

F
o
r

i
t
e
m
s

n
o
t

o
b
s
e
r
v
e
d

w
r
i
t
e

N
/
A


i
n

t
h
e

r
e
m
a
r
k
s

c
o
l
u
m
n
C
i
r
c
l
e

e
i
t
h
e
r


Y

(
Y
e
s
)

o
r

N

(
N
o
)
R
e
m
a
r
k
s

4
5
.

I
s

a
l
l

w
a
s
t
e

c
o
n
t
a
i
n
e
d

(
l
i
d
s
)

s
o

t
h
a
t

s
h
a
r
p
s

a
n
d

m
e
d
i
c
a
l

w
a
s
t
e

a
r
e

n
o
t

o
b
s
e
r
v
e
d

i
n

o
p
e
n

c
o
n
t
a
i
n
-
e
r
s
,

o
n

t
a
b
l
e
s
,

o
n

o
o
r
s

o
r

e
l
s
e
w
h
e
r
e

e
x
p
o
s
i
n
g

s
t
a
f
f

t
o

n
e
e
d
l
e
-
s
t
i
c
k

i
n
j
u
r
i
e
s
?
Y
N
4
6
.

A
r
e

a
l
l

u
s
e
d

s
y
r
i
n
g
e
s

a
n
d

n
e
e
d
l
e
s

o
u
t
s
i
d
e

t
h
e

f
a
c
i
l
i
t
y

o
r

a
t

t
h
e

d
i
s
p
o
s
a
l

s
i
t
e

c
o
m
p
l
e
t
e
l
y

b
u
r
i
e
d

o
r

i
n
c
i
n
e
r
a
t
e
d

(
r
e
d
u
c
e
d

t
o

a
s
h
e
s
)
?
Y
N
4
7
.

A
r
e

l
i
q
u
i
d

w
a
s
t
e
s

a
n
d

h
a
z
a
r
d
o
u
s

c
h
e
m
i
c
a
l

w
a
s
t
e
s

r
o
u
t
i
n
e
l
y

p
o
u
r
e
d

d
o
w
n

t
h
e

d
r
a
i
n

o
r

b
u
r
i
e
d

i
n

a

p
i
t
?
Y
N
4
8
.

A
r
e

m
e
d
i
c
a
l

w
a
s
t
e

c
o
n
t
a
i
n
e
r
s

c
l
e
a
n
e
d

w
i
t
h

d
i
s
i
n
f
e
c
t
a
n
t

c
l
e
a
n
i
n
g

s
o
l
u
t
i
o
n

a
n
d

r
i
n
s
e
d

w
i
t
h

w
a
t
e
r

d
a
i
l
y
,

o
r

m
o
r
e

f
r
e
q
u
e
n
t
l
y

i
f

v
i
s
i
b
l
y

c
o
n
t
a
m
i
-
n
a
t
e
d
?
Y
N
4
9
.

I
s

t
h
e

d
i
s
p
o
s
a
l

s
i
t
e

s
e
c
u
r
e
d
?
Y
N
5
0
.

I
s

m
e
d
i
c
a
l

w
a
s
t
e

p
r
o
p
e
r
l
y

b
u
r
n
e
d
,

b
u
r
i
e
d

o
r

t
r
a
n
s
p
o
r
t
e
d

t
o

a

w
a
s
t
e

m
a
n
a
g
e
m
e
n
t

s
i
t
e
?
Y
N
C
l
e
a
n
i
n
g
5
1
.

A
r
e

m
o
p

h
e
a
d
s

l
a
u
n
d
e
r
e
d

e
a
c
h

t
i
m
e

t
h
e
y

a
r
e

c
o
n
t
a
m
i
n
a
t
e
d

w
i
t
h

b
o
d
y

u
i
d
s
,

o
r

w
e
e
k
l
y
?
Y
N
5
2
.

A
r
e

b
u
c
k
e
t
s

c
l
e
a
n
,

d
r
y

a
n
d

i
n
v
e
r
t
e
d

a
f
t
e
r

u
s
e
?
Y
N
5
3
.

A
r
e

c
l
e
a
n
i
n
g

p
r
o
d
u
c
t
s

N
O
T

d
e
c
a
n
t
e
d
?
Y
N
5
4
.

I
s

t
h
e

m
e
d
i
c
i
n
e
/
d
r
e
s
s
i
n
g

t
r
o
l
l
e
y

w
i
p
e
d

w
i
t
h

d
i
s
i
n
f
e
c
t
a
n
t

b
e
t
w
e
e
n

p
r
o
c
e
d
u
r
e
s
?
Y
N
5
5
.

A
r
e

s
u
r
f
a
c
e
s

(
t
a
b
l
e
s
,

o
o
r
s
,

w
a
l
l
s
,

c
e
i
l
i
n
g
s
,

l
i
g
h
t
s
)

c
l
e
a
n
e
d

a
f
t
e
r

e
a
c
h

o
p
e
r
a
t
i
o
n
?
Y
N
5
6
.

I
f

s
u
r
f
a
c
e
s

h
a
v
e

b
e
e
n

v
i
s
i
b
l
y

s
o
i
l
e
d
,

a
r
e

t
h
e
y

w
i
p
e
d

w
i
t
h

d
i
s
i
n
f
e
c
t
a
n
t
?
Y
N
5
7
.

I
s

m
e
d
i
c
a
l

e
q
u
i
p
m
e
n
t

l
e
f
t

i
n

t
h
e

O
R

c
o
v
e
r
e
d

a
t

t
h
e

e
n
d

o
f

t
h
e

d
a
y
?
Y
N
*
B
o
i
l
i
n
g

i
s

n
o
t

r
e
c
o
m
m
e
n
d
e
d

u
n
l
e
s
s

i
t

i
s

t
h
e

o
n
l
y

o
p
t
i
o
n

a
v
a
i
l
a
b
l
e
.
Section 3
120
T
o
o
l

1
9
.

P
o
s
t
o
p
e
r
a
t
i
v
e

i
n
s
t
r
u
c
t
i
o
n
s

f
o
r

m
a
l
e

c
i
r
c
u
m
c
i
s
i
o
n

1
.

O
n
c
e

y
o
u

r
e
t
u
r
n

h
o
m
e
,

r
e
s
t

a
t

h
o
m
e

f
o
r

o
n
e

o
r

t
w
o

d
a
y
s
.

T
h
i
s

w
i
l
l

h
e
l
p

t
h
e

w
o
u
n
d

t
o

h
e
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121
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
T
o
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2
0
.

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1
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.
1
6
.

W
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.
1
7
.

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1
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.

G
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.
Section 3
122
T
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2
1
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_
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d
a
y
s
123
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
4
.

H
a
s

t
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e

p
a
t
i
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Y
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s

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k
n
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R
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:

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5
.

H
a
s

t
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p
a
t
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n
t

h
a
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x
u
a
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s
e

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c
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c
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s
i
o
n
?

Y
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s

N
o

R
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f
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d

t
o

a
n
s
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Y
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s
,

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.

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7
.

I
s

a
n
y

t
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e
a
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m
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t

n
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d

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Y
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s

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f

Y
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s
,

d
e
s
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r
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e




































































































8
.

N
a
m
e

o
f

p
e
r
s
o
n

c
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n
d
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t
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g

f
o
l
l
o
w
-
u
p

v
i
s
i
t
:






















































C
l
i
n
i
c
a
l

n
o
t
e
s
:

Section 3
124
Tool 22. Male circumcision register
Date
(dd/mm/yy)
Patient
ID
Number
(from card)
Surname Given
name(s)
Age Procedure:
DS, FG, or S*
Type of
anaesthesia
Start
time
End
time
Surgeon Assistant Comments
* DS = dorsal slit FG = forceps-guided S = sleeve
125
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Tool 23. Adverse event descriptions and management, Kisumu, Kenya
Adverse event and severity Description Management
Abnormal pain
Mild Pain scale of 3 to 4 Reassure the client
Moderate Pain scale of 5 to 6 Increase paracetamol to four-hourly, reassure the client
Severe Pain scale of 7 and above Add Bruffen 400 mg TID; injections are not necessary
Excessive swelling
Mild Swelling limited to 2 cm around incision, minimal discomfort Elevate, reassure
Moderate Swelling involving glans and part of the shaft Elevate, give Bruffen, reassure the client, review in 23/7 days
Severe Swelling involving glans and most of the shaft Elevate, give Bruffen, reassure, see on alternate days
Infection
Mild Erythema 1 cm beyond incision line or wetness with serosanguineous
discharge
Clean with betadine
Moderate Purulent discharge from the wound Irrigate, clean with betadine, dress, antibiotics, review in
23/7 days
Severe Cellulitis with wound necrosis Irrigate, do surgical debridement, antibiotics, dress every
two days
Haematoma
Mild Swelling less than 1cm in diameter, minimal discomfort Reassure the client
Moderate Substantial swelling but not more than 2 cm in diameter Allow to ooze with gentle pressure, clean and dress, review
in 23/7 days
Section 3
126
Adverse event and severity Description Management
Severe Massive swelling, diameter exceeding 2 cm Re-exploration under local anaesthesia
Bleeding
Mild Most of dressing covered in blood at visit but no active bleeding, or
bleeding easily controlled by gauze
Reassure the client, do examination and dressing
aseptically
Moderate Bleeding requires return to clinic, active but controlled by pressure dressing Dress with moderate pressure under aseptic conditions
Severe Bleeding not controlled by dressing, requires re-exploration Needs re-exploration, admission or transfusion
Difculty in urinating
Mild Mild to moderate transient pain Increase paracetamol dose to four-hourly
Moderate Severe pain on passing urine Add Bruffen for pain
Severe Inability to pass urine Canulate with small catheter, give analgesics
Wound disruption
Mild One or two continuous stitches missing Clean with betadine
Moderate Three to ve continuous stitches missing Re-stitch if less than 72 hours, clean with betadine, dress
Severe Five or more continuous stitches missing Re-stitch if less than 72 hours, antibiotics, dress every two
days
Delayed healing
Mild 34 weeks before healing, sinus or raw wound present Give antibiotic, do HIV test, follow up 1 week
Moderate 46 weeks before healing, sinus or raw wound present Give antibiotic, do HIV test, follow up 1 week
Severe >6 weeks before healing, sinus or raw wound present Give antibiotic, do HIV test, follow up 1 week, may need
operation
127
MALE CIRCUMCISION SERVICES
QUALITY ASSESSMENT TOOLKIT
Adverse event and severity Description Management
Problem with appearance
Mild Some concern, no discernable abnormality Reassure client
Moderate Scarring, cosmetic problem but operation not required Reassure client
Severe Rotation or other problem requires cosmetic treatment Corrective surgery needed, REFER
Injury to the glans
Mild Abrasion/laceration, no active bleeding No treatment needed, reassure
Moderate Laceration of the glans, bleeding Continuous stitch with a Round Body
Severe Excision of part of glans or shaft with active bleeding Continuous mass suture on Round Body , Surgicel
Section 3
128
ISBN 978 92 4 159751 7