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Inpatient and Outpatient Services

Heather Craig Alonge, PhD, MPH, MCHES

Walden University

Thomas A. Clobes, PhD

California State University, Channel Islands

“A hospital may be a place of illness, but it’s also a place of healing, hope, and humanity.”

– Komarock Modern HealthCare

 

Learning Objectives

●Explain the scope of services for inpatient and outpatient services

●Discuss licensure, certifications, and accreditation

●Identify the facilities that provide inpatient and outpatient services

●Understand operational processes and quality measures

Introduction

The terms ‘inpatient’ and ‘outpatient’ might sound similar, but within a healthcare setting these words are not interchangeable. Both inpatient and outpatient services focus on providing direct care to a patient, but the setting in which the care is provided, how the patient is monitored and how the visit is billed vary between the two terms. Knowing the difference between these terms will help providers, administrators, and patients plan for and manage healthcare services in a much more diligent and cost-effective way. This also allows facilities and health service organizations to better manage resources, staffing, and facility capacity.

Inpatient care occurs within a hospital or an associated facility that has been intended to provide direct bedside care for patients who require anywhere from an overnight to prolonged stay. The duration of an inpatient’s stay can be anything from one night to several — this all depends on their condition, recovery requirements, support system, and recovery time (Bates et al., 2023). Patients receiving inpatient care are usually under close supervision from a team of medical staff including physicians, mid-level practitioners, nurses, and therapists. As a patient in an inpatient care setting, they will receive continuous medication administration, monitoring, and treatment for conditions such as surgery, procedures for chronic conditions, maternity care, or emergency injuries or conditions such a s stroke, heart attack, car accident, or burn. Patients in inpatient care discharged from the inpatient organizations once they no longer require such a high level of care. Upon discharge, patients will receive instructions for follow-up appointments, prescription medicine adherence, and whether any additional services such as home health care are needed in an outpatient care setting.

Outpatient care is usually performed in medical facilities that are co-owned or in association with hospitals and health service organizations. Outpatient facilities can accommodate treatment and procedures that can be done within one day and which do not require an overnight stay (Paras & Butler, 2020). Examples of outpatient facilities include walk-in clinics, ambulatory or outpatient surgery centers, physical therapy clinics, and physicians’ offices. Typical outpatient services are shorter in length, do not require prolonged monitoring, medication administration, or skilled care. Examples of outpatient services include chemotherapy, dialysis, physical therapy, a routine medical exam, or even a visit to the emergency room department.

In the United States, outpatient surgeries are on the rise. According to the Agency for Healthcare Research and Quality, in 2012 51.5% of surgical procedures performed were done on an outpatient status versus 48.9% done as inpatient. (Inpatient vs. Outpatient Surgeries | Agency for Healthcare Research and Quality (ahrq.gov)). Most surgeries on the eye, ear, nose/mouth/pharynx, and skin were performed in an outpatient setting. Most obstetrical, respiratory, and cardiovascular surgeries were performed in the inpatient setting. With improved technology and advances in anesthesia and pain control, many less invasive surgical procedures are now being performed on an outpatient, or ambulatory basis. Common procedures that are now routinely performed on an outpatient basis include tonsillectomies, hernia repairs, gallbladder removals, some cosmetic surgeries, and cataract surgeries. Given the millions of procedures performed every year, complications from outpatient procedures are relatively uncommon. <<<Insert pop out inpatient vs outpatient surgeries.docx here>>> This chapter will discuss the evolution of outpatient and inpatient healthcare.

Inpatient Services

Inpatient services are services that involve an overnight stay or prolong ed stay of a patient in a licensed healthcare facility. Historically, in the United States, inpatient services are provided by hospitals and outpatient services provided by physicians or mid-level practitioners. As the healthcare system evolved, hospitals became the backbone of healthcare delivery, with many patient encounters being inpatient (Milella et al., 2021). Although the original focus for hospitals was inpatient services, the need for cost containment and more patients preferring services outside the hospital led to more outpatient services being offered by hospitals. Hospitals have advanced in the types of care offered and the technology utilized. Inpatient services typically focus on acute care, which includes secondary and tertiary care levels that most likely require inpatient care. Inpatient care is very expensive and, throughout the years, has been targeted for cost containment measures. Hospitals have begun offering more outpatient services that do not require an overnight stay and are less financially taxing on the healthcare system. U.S. healthcare expenditures have increased as part of the gross domestic product, and consequently, more cost containment measures have evolved. Outpatient services have become more popular because they are less expensive, and they are preferred by patients.

Hospitals can be classified by the type of ownership, average length of stay, and the type of services provided. Inpatient services generally focus on acute care, which includes secondary and tertiary care levels that most likely require inpatient care. Inpatient care is costly and therefore a focus for cost containment (Carroll et al., 2020). To control costs, hospitals have started to offer more outpatient services that mitigate the need for an overnight stay and are less financially demanding on the healthcare system, payer, and patient. <<<Insert pop out types of hospital ownership.docx here>>>

Hospitals, the most common healthcare facility for inpatient services, are very distinctly divided into well-defined spaces, known as units (Dean et al., 2021). Each hospital provides a wide range of services via functional units. These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery. This diversity is reflected in the breadth and specificity of regulations, codes, and oversight that govern hospital construction and operations. In addition to the wide range of services that must be accommodated, hospitals must serve and support many different users and stakeholders.

Types of Hospital Providers

There are four general areas of focus in medical specialties within hospital settings. Surgical or internal medicine involves diagnosis and treatment achieved through major surgical procedures, such as cardiothoracic surgeons, neurosurgery, oral and maxillofacial surgery. Age range of patients focuses on care and treatment of specific groups, such as neonatologists, pediatric surgeons, or geriatrics. Diagnostic or therapeutic specialists focus mainly on examinations, such as pathology or radiology. Organ based or technique-based specialties focus on symptoms and diseases of a particular organ, such as allergists, cardiologists, or dermatologists (Milella et al., 2021).

Based on medical condition and need, those with inpatient status may receive inpatient services from one of these specialty areas of medical care:

●Allergists – allergy and asthma

●Anesthesiology — general anesthesia or spinal block for surgeries and some forms of pain control

●Cardiology — heart disorders

●Dermatology — skin disorders

●Endocrinology — hormonal and metabolic disorders, including diabetes

●Gastroenterology — digestive system disorders

●General surgery — common surgeries involving any part of the body

●Hematology — blood disorders

●Immunology — disorders of the immune system

●Infectious disease — infections affecting the tissues of any part of the body

●Nephrology — kidney disorders

●Neurology — nervous system disorders

●Obstetrics/gynecology — pregnancy and women’s reproductive disorders (can be primary provider)

●Oncology — cancer treatment

●Ophthalmology — eye disorders and surgery

●Orthopedics — bone and connective tissue disorders

●Otorhinolaryngology — ear, nose, and throat (ENT) disorders

●Physical therapy and rehabilitative medicine — for disorders such as low back injury, spinal cord injuries, and stroke

●Psychiatry — emotional or mental disorders

●Pulmonary (lung) — respiratory tract disorders

●Radiology — x-rays and related procedures (such as ultrasound, CT, and MRI)

●Rheumatology — pain and other symptoms related to joints and other parts of the musculoskeletal system

●Urology — disorders of the male reproductive system and urinary tract and the female urinary tract

Outpatient Services

Outpatient services occur in a facility or setting where there is not a need for an overnight stay. The types of procedures and tests, offered usually within a few hours, include wellness and prevention services, such as annual exams; diagnostic services, such as lab tests and imaging scans; treatment, such as day surgeries or chemotherapy; and, rehabilitation, such as physical therapy or addiction treatment. Because no overnight stay is involved outpatient services usually cost less (George et al., 2021). Some facilities specialize in one kind of treatment or procedure, such as orthopedic surgery center, although many can be provided in one place.

Primary care is the entry point into the healthcare system and is one of the most utilized outpatient services. Primary care clinics are the point of delivery of individual care, based on care over time and is not disease oriented, but rather focus on both preventive and sick visits. Primary care providers see patients who do not require immediate medical care for life-threatening conditions. The definition of primary care, adopted by the IOM Committee on the Future of Primary Care states: “primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community (1978). Characteristics of primary care encompass care that is accessible, comprehensive, coordinated, and continuous.

Urgent care centers provided extended hour, walk-in services of acute care. Some urgent care facilities have on-site laboratories and diagnostic equipment. Urgent medical conditions that require care within 24 hours include accidents, falls, sprains and strains, breathing difficulties, back pain, bleeding, eye irritation, vomiting, diarrhea, COVID-19 and fever or flu. In some clinics, minor broken bones and fractures can be treated. Other conditions my include urinary tract infections, skin rashes, infections, sore throat, and cough.

Another outpatient service is dental health. Doctor of Dental Surgery (DDS) and Doctor of Dental Medicine (DMD) are two medical degrees offering very similar training. Dentists may work either in partnerships with other dentists or in solo private practices, which they often own. Dental services offer a wide variety of care including checkups, cleanings, fillings, root canals, crowns, bridges implants and extractions. Periodontal disease and emergency dental care are also treatments offered in the dental outpatient setting.

Hospital laboratories perform tests on specimens from admitted patients. Outpatient laboratories receive samples of specimens’ order by physicians for analysis, although when more specialized analysis is required, samples may go to a research laboratory. The multiple specialties of laboratory medicine are divided into anatomical and clinical pathology. Alcohol and substance abuse treatment centers provide several types of therapies aimed at treatment of addiction. Physical therapy centers offer rehabilitation to help strength, mobility and fitness, they also offer occupational therapy to help with daily activities and speech-language therapy to help with speaking, understanding, reading, writing and swallowing. Rehabilitation centers also offer treatment for pain.

Home health care helps older adults live independently for as long as possible. Home health care may include occupational and physical therapy, speech therapy, and skilled nursing care. Home health care involves helping older adults with activities of daily living (ADL), such as bathing, dressing, and eating and often assistance with cooking, cleaning, housekeeping and monitoring medication regimens.

Hospice care helps the terminally ill with less than six months to live their remaining days with dignity (Tobin et al., 2021). Hospice workers assist the family or other caregivers, usually in the patient’s home. There are also hospice residences and sections within the hospital setting. Hospice care combines symptom and pain management with emotional and spiritual support. Hospice teams develop a care plan to address the individual needs of the patient.

Types of Outpatient Care Providers

Different types of outpatient care providers treat patients based on age and medical need. Examples of providers include:

●Family practitioners, or family medicine doctors, care for patients of all ages, from infants, children and teens to adults and the elderly.

●Pediatricians care for babies, children, and teens.

●Internists, or internal medicine doctors, care for adults, but some see patients who are in their late teens.

●Adolescent medicine specialists are pediatricians or internists who have additional training in caring for teens.

●Obstetricians and gynecologists specialize in women’s health issues and are sometimes primary care physician for girls who have started menstruating.

● Nurse practitioner or physician assistant sometimes is the main provider at a medical office.

●Dentist is a licensed professional qualified to treat the diseases and conditions that affect the teeth and gums

●Home health nurse is a nursing specialty in which nurses provide multidimensional home care to patients of all ages

●Hospice nurse is a health care professional that care for patients at the end of their lives

●Physical therapist is a licensed allied health professional qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery

●Occupational therapist is a licensed allied health professional qualified to deliver therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life

●Licensed mental health counselor is a licensed professional works with individuals and groups to promote optimum mental and emotional health

Licensure, Certification, Privileging, and Accreditation

Licensing, credentialing, certification, and privileging are used by regulatory agencies and private entities to ensure that practitioners in both inpatient and outpatient settings have the required training, knowledge, and experience to perform as a provider in that field. These requirements have been used mainly in the medical and healthcare settings to ensure competency and protect patients and consumers. Depending on the profession and the state, the terms licensing, credentialing, and privileging may be used interchangeably at times. There are, however, differences among them as they are generally understood within the healthcare setting.

Licensing

Licensing is the formal acknowledgement by a regulatory agency or body that a person has passed all the qualifications to practice that profession in that state. Licensure requirements include some combination of education, training or practicum hours and examination(s) to establish competency in that profession (Karamali et al., 2020). Licensure requirements also include documented continuing education credits, training. If a practitioner licensed in one state pursues licensure in another state, the existing license and any disciplinary records are considered as part of the licensing process in the new state.

Credentialing

Credentialing is the process by which an employer, most frequently a hospital or health maintenance organization (HMO), verifies that a practitioner has the required education, training, and experience to practice in the state (Regnier et al., 2022). State or local laws and rules can specify the types of credentials and verification processes that a hospital or other healthcare provider must address in credentialing a practitioner. Credentialing is typically done when a practitioner is first employed with an entity and may be updated periodically.

Privileging

Privileging occurs when hospitals, HMOs, and other healthcare facilities allow a practitioner to practice in a capacity associated with their institution (Regnier et al., 2022). The granting of privileges to a practitioner will define the scope of permitted activities the practitioner may engage in while at the facility. A practitioner’s credentials are checked as part of the privileging process.

Certification

A Certification is a credential that a practitioner may seek in addition to their primary qualifying degree and examination. For example, a physician may seek certification in a medical specialty, like endocrinology, in addition to a medical degree. Certifications are commonly administered by national boards that specify the education, training, competency, and examination requirements to achieve certification and re-certification (Baily & DeSantis, 2021). Certification may or may not be required as part of the licensure process.

Accreditation

Accreditation is the recognition by an independent professional organization or nongovernmental agency that a healthcare entity has met established standards. Magnet status, one of the most common accreditations for hospitals in the United States, is an award developed and given by the American Nurses Credentialing Center (ANCC). It was developed in 1990 as the Magnet Hospital Recognition Program for Excellence in Nursing Services and recognized 14 characteristics that create an environment that is conducive to attracting and retaining qualified nurses who promote quality care. (Learn About the ANCC Magnet Recognition Program | ANA (nursingworld.org)). When a hospital or medical facility has earned Magnet status, it means the hospital has satisfied a rigorous set of criteria designed to measure the strength and quality of nursing (American Nurses Credentialing Center, 2022). While Magnet is largely recognized as a nursing-driven achievement, it requires an organizational culture to support the accomplishment. Magnet signifies the valuing of staff nurses by their leaders and by the organization, educational level of nursing to include bachelors, masters, and doctoral, and the strength of knowledge they contribute both individually and together for the advancement of nursing practice. Magnet status highlights an environment that supports delivery of excellence in patient care, staff nurse involvement in evidence-based practice, and decision making in support of optimal patient outcomes.

Magnet designation helps to direct the approach organizations take to quality improvement interventions and measurable outcomes. It supports and provides a platform of shared governance and inclusion of leaders and staff in a collective vision. Leaders come together and bring ideas to the table that are in direct support of evidence-based practice in pursuit of positive patient outcomes.

Healthcare Quality Measures

Improving healthcare quality and safety is a growing focus for both inpatient and outpatient providers as medical facilities aim to achieve efficiency, reduce healthcare costs, and ensure high-quality patient outcomes no matter the setting in which the care is delivered. With advances in technology over the last decade, the incorporation of healthcare quality measures in both inpatient and outpatient services have grown significantly (Ullah et al., 2021). When healthcare providers analyze patient data to come up with a plan to reduce risk and improve outcomes, this is an example of a quality improvement initiative. Examples of healthcare quality measures include:

▪Reduction in medication-related adverse events

▪Optimization of sepsis care

▪Decreased number of urinary catheter infections

▪Reduced hospital readmissions

▪Decreased medication administration errors

▪Improved electronic medical record documentation

▪Improved care coordination among departments

Many of the quality improvement measures in healthcare are guided by a framework developed by the Institute of Medicine (IOM), which identifies six primary goals for patient care. (Six Domains of Healthcare Quality | Agency for Healthcare Research and Quality (ahrq.gov))

According to the framework, patient care should be:

1. Safe: Avoiding harm to patients during their medical treatment.
2. Effective: Providing medical services to patients who could benefit from them and avoiding the use of services that are unlikely to result in better patient outcomes.
3. Timely: Reducing wait times and delays for appointments and treatment.
4. Efficient: Avoiding waste of medical equipment, supplies, time and energy.
5. Equitable: Ensuring that quality of care does not vary because of patient characteristics like gender, ethnicity, geography and socioeconomics.
6. Patient-centered: Respecting individual patient preferences and ensuring that patients are valued and involved in decisions related to their care (Institute of Medicine, 2001).

Importance of Quality Improvement Measures

By using quality improvement measures, healthcare facilities and providers can create significant change within the scope of delivery of services and outcomes that benefit both the patient and the organization which allows for quality assurance (Hussein et al., 2021). By using quality improvement measures, providers can prepare an institution to handle a large-scale emergency or medical event, as demonstrated during the COVID-19 pandemic. When COVID-19 case numbers are at the peak, medical systems around the world used quality improvement processes and measures like data analysis to adjust their methods of care, determine protocols for inpatient and outpatient services, reduce patient deaths and ICU stays, keep more hospital beds open and ensure the safety of all patients and staff. Quality improvement measures ensure optimal delivery of care no matter the scope of service or setting.

Future of Healthcare Delivery

One of the biggest challenges facing healthcare is the need to improve cost and value for patients who receive both inpatient and outpatient services. Facilities and providers of care are grappling with rising costs and fluctuating quality outcomes (Brekke et al., 2021). As providers of inpatient and outpatient services work on improving value, they will need to make certain that the care delivery model ensures positive patient outcomes without an increase in costs. This will require consolidation. The new care delivery model will need to optimize clinical operations and automate consistent workflows between providers, departments, and services. An inefficiency in the delivery of healthcare increase costs and outcomes. By transforming healthcare delivery, facilities can improve patient access to healthcare services and make these services more affordable for the patients by offering more outpatient services and transforming the inpatient experience (Ullah et al., 2021).

One proposed model views patients as consumers. And, like most consumers, patients will also demand value from healthcare service providers. They will have expectations, and they will want the right to choose and the right to make their own decisions. The future of healthcare will thus see a more informed patient, a patient who will demand better outcomes (Bokhour et al., 2022). Healthcare providers can provide this value and improve patient outcomes by ensuring accurate and well-informed diagnoses, optimal treatment planning, a more supportive clinical work environment, greater transparency, continuity of care, improved patient support and connected care.

The digitalization of healthcare will be prominent moving into the future. Artificial intelligence will become a vital part of healthcare services. The healthcare data will be more effectively used with the help of new and improved digital tools, allowing a change to when and how care delivery and treatment of diseases and conditions occur (Sharma & Patten 2022). The healthcare industry today is faced with the challenge of improving value. It is dealing with aging populations, increased prevalence of chronic diseases and increased healthcare spending. There is the added pressure to deliver better and more improved care without increasing costs. Digital technologies can help the healthcare industry meet the needs of patients and providers by:

▪Improving access for both patients and providers to outpatient services

▪Enabling remote monitoring of patients to avoid inpatient treatment

▪Giving patients ownership of their health and outcomes

▪Increasing accuracy, standardization and efficiency in care delivery for both inpatient and outpatient services

Conclusion

The healthcare industry is dealing with rising costs and demands for improved quality of care. The ultimate goal is to improve patient value, and the only way the healthcare industry will achieve this is by digitalizing healthcare, leveraging artificial intelligence and by better using healthcare data for more effective diagnoses and treatment. These four strategies can go a long way towards transforming healthcare and help this industry accept and embrace the digital revolution.

Knowledge Check

1. Ambulatory care is also know as________:

2. Describe why more patient services are being done on an outpatient status.

3. Provide three examples of ambulatory services.

4. Why is medical credentialing important?

5. Define quality improvement.

Key Words

Outpatient Services: Medical procedures or tests that can be done in a medical center without an overnight stay.

Inpatient Services: Medical services, nursing services, or other health- related services provided to a patient in a health care facility either overnight or for a period of time.

Accreditation: Process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accreditation organization.

Certification: is a credential that a practitioner may seek in addition to their primary qualifying degree and examination.

Credentialing: is the process by which an employer, most frequently a hospital or health maintenance organization (HMO), verifies that a practitioner has the required education, training, and experience to practice in the state.

Healthcare Facility: Places that provide health care. They include hospitals, clinics, outpatient care centers, and specialized care centers.

Licensure: is the formal acknowledgement by a regulatory agency or body that a person has passed all the qualifications to practice that profession in that state.

Quality Assurance: Initiatives designed to analyze health care requirements, determine ways of ensuring that protocols are followed throughout the organization, have a system in place to audit the protocols for compliance and institute performance improvement plans when standards are not met.

References

American Nurses Credentialing Center (2022). Magnet recognition program. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/

Bailey, K. D., & De Santis, J. P. (2021). Certification for Nurse Leaders:: Recommendations for Practice. Nurse Leader, 19(3), 264–268. https://doi.org/10.1016/j.mnl.2021.02.009

Bates, D. W., Levine, D. M., Salmasian, H., Syrowatka, A., Shahian, D. M., Lipsitz, S., Zebrowski, J. P., Myers, L. C., Logan, M. S., Roy, C. G., Iannaccone, C., Frits, M. L., Volk, L. A., Dulgarian, S., Amato, M. G., Edrees, H. H., Sato, L., Folcarelli, P., Einbinder, J. S., Reynolds, M. E., … Mort, E. (2023). The Safety of Inpatient Health Care. The New England journal of medicine, 388(2), 142–153. https://doi.org/10.1056/NEJMsa2206117

Bokhour, B. G., Hyde, J., Kligler, B., Gelman, H., Gaj, L., Barker, A. M., Douglas, J., DeFaccio, R., Taylor, S. L., & Zeliadt, S. B. (2022). From patient outcomes to system change: Evaluating the impact of VHA’s implementation of the Whole Health System of Care. Health services research, 57 Suppl 1(Suppl 1), 53–65. https://doi.org/10.1111/1475-6773.13938

Brekke, K. R., Canta, C., Siciliani, L., & Straume, O. R. (2021). Hospital competition in a national health service: Evidence from a patient choice reform. Journal of Health Economics, 79. https://doi.org/10.1016/j.jhealeco.2021.102509

Carroll, N. W., Hearld, L. R., & Joseph, R. (2020). Hospital ownership of postacute care providers and the cost of care. Health Care Management Review, 45(4), E35–E44.

Dean, J.M., Hreha, K., Hong, I., Li, C., Jupiter, D., Prochaska, J., & Reistetter, T. (2021). Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study. BMC Health Services Research, 21(1), 1–11.

https://doi.org/10.1186/s12913-021-06159-z

George, R. R., Winden, T. J., Manos, L., Herrman, A., Campos, M., & Dittrich, C. B. (2021). Improving coordination during care transition between ambulatory and inpatient care facilities: Evaluating the utilization and scope of EHR facilitated longitudinal plan of care. International Journal of Nursing Education, 13(3), 153–160.

Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC Health Services Research, 21(1), 1–12. https://doi.org/10.1186/s12913-021-07097-6Inpatient vs. Outpatient Surgeries. Content last reviewed August 20. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/data/infographics/outpatient-surgery.html

Institute of Medicine (U.S.). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press.

IOM (Institute of Medicine). A Manpower Policy for Primary Health Care: Report of a Study. Washington, D.C.: National Academy Press, 1978.

Karamali, M., Bahadori, M., Ravangard, R., & Yaghoubi, M. (2020). Knowledge mapping of hospital accreditation research: a coword analysis. International Journal of Health Care Quality Assurance, 33(6), 429–445.

Milella, F., Minelli, E. A., Strozzi, F., & Croce, D. (2021). Change and Innovation in Healthcare: Findings from Literature. ClinicoEconomics and outcomes research : CEOR, 13, 395–408. https://doi.org/10.2147/CEOR.S301169

Paras, E., & Butler, M. (2020). Emergency management for the outpatient health care environment. Disaster Medicine & Public Health Preparedness, 14(5), 596–600.

Regnier, K., Travlos, D. V., Pace, D., Powell, S., & Hunt, A. (2022). Leading Change Together: Supporting Collaborative Practice through Joint Accreditation for Interprofessional Continuing Education. Journal of European CME, 11(1), 2146372. https://doi.org/10.1080/21614083.2022.2146372

Sharma, P., & Patten, C. A. (2022). A Need for Digitally Inclusive Health Care Service in the United States: Recommendations for Clinicians and Health Care Systems. The Permanente journal, 26(3), 149–153. https://doi.org/10.7812/TPP/21.156

Tobin J, Rogers A, Winterburn I, Tullie S, Kalyanasundaram A, Kuhn I, Barclay S. Hospice care access inequalities: a systematic review and narrative synthesis. BMJ Support Palliat Care. 2021 Feb 19:bmjspcare-2020-002719. doi: 10.1136/bmjspcare-2020-002719. Epub ahead of print. PMID: 33608254.

Ullah, Z., Khan, M. Z., & Khan, M. A. (2021). Towards service quality measurement mechanism of teaching hospitals. International Journal of Healthcare Management, 14(4), 1435–1440. https://doi.org/10.1080/20479700.2020.1763235