Honduras | Referral Systems Collaborative-Comayagua | USAID Health Care Improvement Portal
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Honduras | Referral Systems Collaborative-Comayagua

Collaborative Profile
Norma Aly and María Elena Banegas
USAID Health Care Improvement/USAID/Honduras

Topics: Active management of the third stage of labor, Acute malnutrition management, Birth preparedness, Community health workers, Cultural responsiveness/adaptation of delivery care, Emergency obstetric care, Emergency treatment assessment and triage (ETAT), Essential newborn care, Essential obstetric care, Growth monitoring/growth promotion, Human Resources/Workforce Development, Infection prevention in delivery care, Maternal sepsis/infection, Maternal, Newborn and Child Health, Neonatal sepsis/infection, Newborn resuscitation/asphyxia, Post-partum care, Post-partum hemorrhage, Pre-eclampsia/eclampsia

Region and Country: Honduras

Date improvement activities began: 
December, 2008

To strengthen the referral and counter referral system for obstetric complications in the Comayagua Region; specifically, for 50% of users referred to the hospital with a reference to receive a counter-referral response, documented in their chart.

Implementation package/interventions: 

This improvement process began in the Hospital Santa Teresa during one rapid cycle with their Quality Improvement (QI) Committee. The work later spread to five maternal clinics and then eleven health centers.

Identification of the problem: One of the most important problems that prevented the linkage of health facilities and clinics was the lack of response (back-referrals) to the initial referrals sent by health facilities. The system had a collection of issues including lack of confidence between health facilities and between community workers and facilities, poor community perceptions about hospital services and the lack of a database to track the referrals and back-referrals from the different points of care in the system. Additionally, community health workers (CHWs) were not making referrals to the hospital, as they did not believe hospital staff would perceive their referrals as important. Finally, there was no standardized referral form.

Intervention-Initial phase: Within the hospital system: During the latter portion of 2008, pre-work began in collaboration with the Hospital Directors to collect baseline data and to prepare staff for the upcoming collaborative work.

Second phase: Between the hospital and 5 maternal clinics: In the beginning of 2009, it was decided that the Customer Service Unit of the hospital would take responsibility for the coordination and follow-up of the referral process. A standard back-referral form, process for receipt, delivery and communications, roles and responsibilities and training for staff was organized and put into place for the health centers, maternal clinics and the hospital. A management agreement was signed between the hospital and the Ministry of Health (SESAL). This legal document outlines the roles of each health worker as well as what SESAL will provide. Defined indicators are included as an annex to the agreement.

Third phase: Between one hospital, 5 maternal clinics, and 11 health units. In April 2011, the aims of the collaborative shifted and a proposal was developed in coordination with the Health Region of Comayagua to improve referrals for obstetric and neonatal complications specifically. This decision was made because staff monitoring data for the region found that maternal deaths were on the rise and there was an immediate need for provider training, medication supply and a re-evaluation of and alterations in the referral process. While the hospital was improving, other levels were not so interventions at the maternal clinics and health centers were prioritized. This shift in priorities led to the re-training of medical and nurse staff at five maternal clinics and implementation of processes for the following:
1) Timely detection of obstetric complications during prenatal care
2) Ambulatory handling of obstetric complications.
3) Initial handling and referral of obstetric emergencies from the community level, CESAR, and CESAMO until reaching the hospital.
4) Implementation of emergencies kit at the level of Health Units (so that they are able to provide care for obstetric emergencies) including:
i. Necessary medications for the manual extraction of placenta.
ii. Magnesium Sulfate for women with the complication of preeclampsia or eclampsia.
iii. Oxytocin for AMTSL
5) Organization of community committees for transferring emergencies (women and children) from the community to the hospital.
6) Monitoring system in new health facilities.
7) Improved communication via telephone between the referring provider and the specialist at the hospital
8) The chief OB/GYN specialist at the hospital visited the maternal clinics and health centers to provide follow-up and feedback on referrals to providers


The first and second phase: The CQI team at Hospital Santa Teresa implemented a database to track referrals, documenting the name, the age, residence, type of complication and result; in addition, the teams also tracked if the referrals were completed correctly.
Third phase: The regional quality coordinator identified a set of indicators to track and report on regarding the management of obstetric complications, these included:
• % of the women with an obstetric complication referred to Santa Teresa Hospital in Comayagua to receive written response for posterior care at the original facility of referral
• % of women with obstetric complications, including high blood pressure, proteins in urine, anemia, UTIs, and vaginosis, among others, who were treated accord to standards
• % of women who presented an obstetric emergency and received an initial treatment and were referred to the hospital immediately.

Spread strategy: 

The improvement collaborative for the internal referral system of the Hospital of Santa Teresa in the Comayagua Health Region began in 2009. This referral work was later extended to 5 maternal clinics and 11 health centers and is now moving to become a region wide movement. A key reason for this expansion has been because of the implementation of a database for processing referrals and the close working relationship between the CQI Hospital team and the CQI coordinator of the health region. There were three main spread phases:
1. Intra-hospital: The referral and response system spread from the OB/GYN service to other services.
2. Intra-network: The changes spread first to maternal clinics, then to primary health centers.
3. Inter-regional: From December 2011 to April 2012, HCI trained health centers in the other four priority regions on the Comayagua changes, including the standards and indicators measured as a part of the process. Within each region, certain municipalities with high mortality were prioritized.

Phase 1: The database for referral, which began in infant/maternal services, has now expanded to the rest of the services provided by the hospital. Since this process adoption, the number of referrals received has doubled. The hospital now has a database to track referrals, including those coming from the private sector, making the system more effective and easier to utilize.
There was also a focus on the management of obstetric and neonatal complications. This was introduced in Comayagua once it was determined that the referral process was working, and it was expanded simultaneously as other changes in Phases 2 and 3.

Phase 2: Health centers and maternal clinics began to track referrals sent to the hospital for follow up. The health region was looking to expand the best practices of this work to other health centers and to each of the 30 health facilities in Comayagua.

Phase 3: Health centers in 4 other regions implemented a referral system, though as of May 2012 have not yet begun to track these referrals. To spread knowledge from Comayagua, the changes implemented at those facilities, their standards and indicators, and their implementation “tips” were shared.

In early 2011, a regional meeting was held for hospital directors, were the Hospital Santa Teresa of Comayagua presented their successes. After the meeting, other hospitals began to implement the same changes and replicate these results. This presentation led to a knowledge exchange in May 2011 between Santa Teresa and Hospital La Esperanza of Intibucá.

Number of sites/coverage: 

When this work began, it included one hospital, four public maternal-infant clinics, and one private emergency clinic with a population catchment of about 352,881 people (total geographic area of Comayagua); the work has since expanded to an additional 11 health centers. The goal in the future is to expand to all health centers of the health regions (30 health centers). In April 2011, the collaborative expanded to a total of 45 centers in 4 additional regions where HCI works, as well as the Hospital La Esperanza in Intibuca region. The work will expand to an additional three hospitals in those same priority regions in June 2012.


HCI provided support to the Comayagua Region in its efforts to improve referral and counter-referral processes between the St. Teresa regional hospital and the region’s five maternal health clinics through the provision of QI and technical support visits. HCI did coaching visits at each clinic in Comayagua; giving regional-level assistance through workshops in the other 4 regions in late 2011 and early 2012.

Learning sessions & communication among teams: 

The first activity done by HCI was to train the CQI team in the quality improvement collaborative process. In October 2010, for the third phase of the project, HCI provided support to the Comayagua health region to develop a plan for an improved “Referral and Response System” for the region. This work included setting standards and indicators for staff, including community health workers, to utilize and follow for their day-to-day work. The main objective of this last workshop was to strengthen the knowledge and abilities of the staff of the addressed health units to manage the obstetric complication in a better way, putting emphasis on handling them at the ambulatory level, initial handling of emergencies and referral to the hospital. Helping Babies Breathe (HBB) training was also a part of the training process for the maternal clinics.


During 2009 the Santa Teresa Hospital received 2,456 referrals, 748 were referred by 5 maternal clinics in the health region of Comayagua. 65% of the referrals of the maternal clinics ended in normal childbirth, 8% in miscarriage, 12% in C-Section, and the 15% in other type of resolution. Collecting and utilizing this type of data allowed the CQI teams to adjust their care processes to be in line with the needs of the patients and well as to development standards for the referral system. Regularly monitoring and discussion the results of the data permitted the staff to take action, especially in 2011 when they found a progressive increase in the number of maternal death in the health region of Comayagua occurring in the transition to the hospital from the community level. This monitoring then lead to the training of 66% of the medical personnel of these units to be trained in handling obstetric complications and for all health units to have specialized emergency kit with medications to treat these common complications.

Best practices/conclusions: 

• Using the Customer Service Unit, an existing hospital department, played an important role in the management of referrals inside the hospital as this provided a venue for ownership of the process by the hospital staff.
• This referral work began with children and maternal services references, but it soon spread to other referral systems including other referrals systems for adults, such as for Surgery and General Medicine.
• The Hospital Executive Council has made the referrals and back referrals system a topic for discussion each week. This has been important to institutionalize this work.
• The collaborative work has made the staff proactive with regards to taking care of referrals; this has been an improvement over waiting for the Hospital Statistics department to report the referrals.
• The collaborative has helped to establish trust and open communication among health providers at various levels of the system including at the ambulatory, maternal clinics and hospital obstetric service levels.

Some of the best practiced identified include:
1. Managing references through the Client Service Unit
2. Installing a references “mailbox”
3. Standardizing reference forms across facilities and services
4. Following up with referring providers by providing feedback
5. Connecting the specialist and referring doctor by telephone so that the hospital knows to expect the patient and to provide extra information to the specialist
6. Including referrals as part of the job profile