Initiating a Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods Study:

Background:Few data exist for referral processes in resource-limited settings. We utilized mixed-methods to evaluate the impact of a standardized algorithm and training module developed for locally identified needs in referral/counter-referral procedures between primary health centers (PHCs) and a Guatemalan referral hospital. Methods: PHC personnel and hospital physicians participated in surveys and focus groups pre-implementation and 3, 6, and 12 months post-implementation to evaluate providers’ experience with the system. Referred patient records were reviewed to evaluate system effectiveness. Results: A total of 111 initial focus group participants included 96 (86.5%) from PHCs and 15 from the hospital. Of these participants, 53 PHC physicians and nurses and 15 hospital physicians initially completed written surveys. Convenience samples participated in follow-up. Eighteen focus groups achieved thematic saturation. Four themes emerged: effective communication; provision of timely, quality patient care ...