Top

BMC Health Services Research

Published in:

Open Access 01-12-2015 | Research article

High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement

Authors: Natalie Taylor, Robyn Clay-Williams, Emily Hogden, Jeffrey Braithwaite, Oliver Groene

Published in: BMC Health Services Research | Issue 1/2015

Abstract

Background

High performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement.

Methods

Methods used to collect and summarise the evidence contributing to this review followed the ‘enhancing transparency in reporting the synthesis of qualitative research’ protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes.

Results

A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued.

Conclusions

This review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.

Available only for authorised users

Groene O, Skau JK, Frolich A. An international review of projects on hospital performance assessment. International J Qual Health Care. 2008;20(3):162–71.

Aghaei Hashjin A, Kringos DS, Manoochehri J, Aryankhesal A, Klazinga N. Development and impact of the Iranian hospital performance measurement program. BMC Health Serv Res. 2014;14(1):448.PubMedPubMedCentral

Braithwaite J, Matsuyama Y, Mannion R, Johnson J, editors. Healthcare reform, quality and safety: perspectives, participants, partnerships and prospects in 30 countries. Farnham, Surrey: Ashgate; 2015.

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.PubMed

Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100–5.PubMed

Birkmeyer JD, Dimick JB. Understanding and reducing variation in surgical mortality. Annu Rev Med. 2009;60(1):405–15.PubMed

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–20.PubMedPubMedCentral

Braithwaite J, Marks D, Taylor N. Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. Int J Qual Health Care. 2013;26(3):321–9.

Braithwaite J, Westbrook J, Iedema R. Restructuring as gratification. J R Soc Med. 2005;98(12):542–4.PubMedPubMedCentral

10.

Bradley EH, Curry LA, Webster TR, Mattera JA, Roumanis SA, Radford MJ, et al. Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. Circulation. 2006;113(8):1079–85.PubMed

11.

Jha AK, DesRoches CM, Shields AE, Miralles PD, Jie Z, Rosenbaum S, et al. Evidence of an emerging digital divide among hospitals that care for the poor. Health Aff. 2009;28:w1160–70.

12.

Rosenthal MB, Landrum MB, Meara E, Huskamp HA, Conti RM, Keating NL. Using performance data to identify preferred hospitals. Health Serv Res. 2007;42(6p1):2109–19.PubMedPubMedCentral

13.

Peters TJ, Waterman RH. In search of excellence: lessons from America’s best-run companies. New York: Harper & Row; 1982.

14.

Brand CA, Barker AL, Morello RT, Vitale MR, Evans SM, Scott IA, Stoelwinder JU, Cameron PA: A review of hospital characteristics associated with improved performance. Int J Qual Health. 2012;24:483–494

15.

Jha AK, Orav EJ, Li Z, Epstein AM. The inverse relationship between mortality rates and performance in the hospital quality alliance measures. Health Aff. 2007;26(4):1104–10.

16.

Groene O, Botje D, Suñol R, Lopez MA, Wagner C. A systematic review of instruments that assess the implementation of hospital quality management systems. Int J Qual Health Care. 2013;25(5):525–41.PubMed

17.

Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12(1):181.PubMedPubMedCentral

18.

SIGN 1993–2013: Search filters. [http://www.sign.ac.uk/methodology/filters.html].

19.

Hawker S, Payne S, Kerr C, Hardey M, Powell J. Appraising the evidence: reviewing disparate data systematically. Qual Health Res. 2002;12(9):1284–99.PubMed

20.

Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008, 8(45).

21.

Noblit GW, Hare RD: Meta-ethnography: Synthesizing qualitative studies. Newbury Park, California: Sage; 1997.

22.

Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R: Using meta ethnography to synthesise qualitative research: a worked example. J Health Serv Res Policy 2002, 7(4):209-215.

23.

Monty S, Barrett P. Applying rich picture diagrams to model case studies of construction projects. Eng Construct Architect Manag. 2007;14(2):164–79.

24.

Braithwaite J, Hindle D, Iedema R, Westbrook J. Introducing soft systems methodology plus (SSM+): why we need it and what it can contribute. Aust Health Rev. 2002;25(2):191–8.PubMed

25.

Monk A, Howard S. Methods & tools: the rich picture: a tool for reasoning about work context. Interactions. 1998;5(2):21–30.

26.

Checkland P, Scoles J. Soft systems methodology in action. Chichester: John Wiley and Sones; 1990.

27.

Hindle D, Braithwaite J. Soft Systems Methodology plus (SSM+): a guide for Australian health care professionals. Sydney: Centre for Clinical Governance Research, University of New South Wales; 2002.

28.

Checkland K. System thinking, system practice. Chichester: Wiley; 1981.

29.

Checkland K, Scholes J. Soft systems methodology in action. Chichester: Wiley; 2005.

30.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.PubMed

31.

Rangachari P. Knowledge sharing networks related to hospital quality measurement and reporting. Health Care Manage Rev. 2008;33(3):253–63.PubMed

32.

Landman AB, Spatz ES, Cherlin EJ, Krumholz HM, Bradley EH, Curry LA. Hospital collaboration with emergency medical services in the care of patients with acute myocardial infarction: perspectives from key hospital staff. Ann Emerg Med. 2013;61(2):185–95.

33.

Puoane T, Cuming K, Sanders D, Ashworth A. Why do some hospitals achieve better care of severely malnourished children than others? Five-year follow-up of rural hospitals in Eastern Cape, South Africa. Health Pol Plann. 2008;23(6):428–37.

34.

Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007;82(12):1178–86.PubMed

35.

Parsons ML, Cornett PA. Sustaining the pivotal organizational outcome: magnet recognition. J Nurs Manag. 2011;19(2):277–86.PubMed

36.

VanDeusen LC, Engle RL, Holmes SK, Parker VA, Petzel RA, Nealon Seibert M, et al. Strengthening organizations to implement evidence-based clinical practices. Health Care Manage Rev. 2010;35(3):235–45.

37.

Sautter KM, Bokhour BG, White B, Young GJ, Burgess Jr JF, Berlowitz D, et al. The early experience of a hospital-based pay-for-performance program. J Healthc Manag. 2007;52(2):95–107. discussion 107–108.PubMed

38.

Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011;154(6):384–90.PubMedPubMedCentral

39.

Robbins J, Garman AN, Song PH, McAlearney AS. How high-performance work systems drive health care value: an examination of leading process improvement strategies. Qual Manag Health Care. 2012;21(3):188–202.PubMed

40.

Kramer M, Schmalenberg C, Maguire P, Brewer BB, Burke R, Chmielewski L, et al. Structures and practices enabling staff nurses to control their practice. West J Nurs Res. 2008;30(5):539–59.PubMed

41.

Adelman K. Promoting employee voice and upward communication in healthcare: the CEO’s influence. J Healthc Manag. 2012;57(2):133–47. discussion 147–138.PubMed

42.

Hockey PM, Bates DW. Physicians’ identification of factors associated with quality in high- and low-performing hospitals. Joint Comm J Qual Patient Saf. 2010;36(5):217–23.

43.

Stanger SHW, Yates N, Wilding R, Cotton S. Blood inventory management: hospital best practice. Transfus Med Rev. 2012;26(2):153–63.PubMed

44.

Mannion R, Davies HT, Marshall MN. Cultural characteristics of “high” and “low” performing hospitals. J Health Organ Manag. 2005;19(6):431–9.PubMed

45.

Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM, et al. Organizational characteristics of high- and low-performing anticoagulation clinics in the veterans health administration. Health Serv Res. 2012;47(4):1541–60.PubMedPubMedCentral

46.

Bates BR, Romina S, Ahmed R, Hopson D. The effect of source credibility on consumers’ perceptions of the quality of health information on the Internet. Med Informat Internet Med. 2006;31(1):45–52.

47.

Baumann M, Evans S, Perkins M, Curtis L, Netten A, Fernandez JL, et al. Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge. Health Soc Care Community. 2007;15(4):295–305.PubMed

48.

Olson DM, Constable M, Britz GW, Lin CB, Zimmer LO, Schwamm LH, et al. A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke. J Neurosci Nurs. 2011;43(6):329–36.PubMed

49.

Mannion R, Davies H, Marshall M. Impact of star performance ratings in English acute hospital trusts. J Health Serv Res Pol. 2005;10(1):18–24.

50.

Keroack MA, McConkie NR, Johnson EK, Epting GJ, Thompson IM, Sanfilippo F. Functional alignment, not structural integration, of medical schools and teaching hospitals is associated with high performance in academic health centers. Am J Surg. 2011;202(2):119–26.PubMed

51.

Doherty R, Loughrey C, Higgins P. Organisational culture: a review of the literature. Belfast: Department of Health, Social Services and Public Safety; 2013.

52.

Braithwaite J, Hyde P, Pope C, editors. Culture and climate in health care organisations. London: Palgrave Macmillan; 2010.

53.

Schein EH. Organizational culture and leadership. San Francisco: Jossey-Bass; 1985.

54.

Schwendimann R, Milne J, Frush K, Ausserhofer D, Frankel A, Sexton JB. A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study. Am J Med Qual. 2013;28(5):414–21.PubMed

55.

Frankel A, Grillo SP, Pittman M, Thomas EJ, Horowitz L, Page M, et al. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res. 2008;43(6):2050–66.PubMedPubMedCentral

56.

Thomas E, Sexton JB, Neilands T, Frankel A, Helmreich R. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res. 2005;5(1):28.PubMedPubMedCentral

57.

Zimmerman R, Ip I, Daniels C, Smith T, Shaver J. An evaluation of patient safety leadership walkarounds. Healthc Q. 2008;11(3 Spec No):16–20.PubMed

58.

Mannion R, Marshall MN, Davies HT. Cultures for performance in health care: evidence on the relationships between organisational culture and organisational performance in the NHS. York: University of York, Centre for Health Economics; 2003.

59.

Mannion R, Braithwaite J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English national health service. Intern Med J. 2012;42(5):569–74.PubMed

60.

West MA, Borrill C, Dawson J, Scully J, Carter M, Anelay S, et al. The link between the management of employees and patient mortality in acute hospitals. Int J Hum Resource Manag. 2002;13(8):1299–310.

61.

Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from US hospitals. Qual Saf Health Care. 2004;13(1):26–31.PubMedPubMedCentral

62.

Mugford M, Banfield P, O’Hanlon M. Effects of feedback of information on clinical practice: a review. BMJ. 1991;303(6799):398–402.PubMedPubMedCentral

63.

Balas EA, Austin Boren S, Brown GD, Ewigman BG, Mitchell JA, Perkoff GT. Effect of physician profiling on utilization. J Gen Intern Med. 1996;11(10):584–90.PubMed

64.

Axt-Adam P, van der Wouden JC, van der Does E. Influencing behavior of physicians ordering laboratory tests: a literature study. Med Care. 1993;31(9):784–94.PubMed

65.

Kanouse DE, Jacoby I. When does information change Practitioners’ behavior? Int J Technol Assess Health Care. 1988;4(01):27–33.PubMed

66.

Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:CD000259. doi: 10.1002/14651858.CD000259.pub3.

67.

Bart CK, Bontis N, Taggar S. A model of the impact of mission statements on firm performance. Manag Decis. 2001;39(1):19–35.

68.

Peters TJ, Waterman RH, Jones IR. In search of excellence: lessons from America's best-run companies. London: Harper & Row; 1982.

69.

Gittell JH, Seidner R, Wimbush J. A relational model of How high-performance work systems work. Organ Sci. 2010;21(2):490–506.

70.

Reagans R, Argote L, Brooks D. Individual experience and experience working together: predicting learning rates from knowing who knows what and knowing how to work together. Manag Sci. 2005;51(6):869–81.

71.

West MA, Guthrie JP, Dawson JF, Borrill CS, Carter M. Reducing patient mortality in hospitals: the role of human resource management. J Organ Behav. 2006;27(7):983–1002.

72.

Bassi LJ, Van Buren ME. The 1998 ASTD state of the industry report. Train Dev. 1998;52(1):21.

73.

Kalleberg AL, Moody JW. Human resource management and organizational performance. Am Behav Sci. 1994;37(7):948–62.

74.

Delaney JT, Huselid MA. The impact of human resource management practices on perceptions of organizational performance. J Acad Manag. 1996;39(4):949–69.

75.

Harel GH, Tzafrir SS. The effect of human resource management practices on the perceptions of organizational and market performance of the firm. Hum Resour Manage. 1999;38(3):185–99.

76.

Lawler EE, Mohrman SA, Ledford GE. Creating high performance organizations: practices and results of employee involvement and total quality management in Fortune 1000 companies. San Francisco: Jossey-Bass; 1995.

77.

Lawler EE, Mohrman SA, Ledford GE. Strategies for high performance organizations: the CEO report: employee involvement, TQM, and reengineering programs in fortune 1000 corporations. San Francisco: Jossey-Bass Publishers; 1998.

78.

Arthur Jr W, Bennett Jr W, Edens PS, Bell ST. Effectiveness of training in organizations: a meta-analysis of design and evaluation features. J Appl Psychol. 2003;88(2):234–45.PubMed

79.

Bass BM, Riggio RE. Transformational leadership. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2006.

80.

Gilmartin MJ, D’Aunno TA. 8 leadership research in healthcare. Acad Manag Ann. 2007;1(1):387–438.

81.

Neal A, Griffin MA. A study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels. J Appl Psychol. 2006;91(4):946–53.PubMed

82.

Michie S, West MA. Managing people and performance: an evidence based framework applied to health service organizations. Int J Manag Rev. 2004;5(2):91–111.

83.

Alimo-Metcalfe B. Leadership in the NHS: what are the competencies and qualities needed and how can they be developed? In: Dopson S, Mark A, editors. Organisational behaviour in health care: the research agenda. Basingstoke: Basingstoke: Macmillan; 1999.

84.

Yukl GA. Leadership in organizations. 4th ed. London: Prentice Hall; 1998.

85.

Borrill C, West M, Shapiro D, Rees A. Team working and effectiveness in health care. Br J Healthc Manag. 2000;6(8):364–71.

86.

Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83.

87.

Edmondson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 1996;32(1):5–28.

88.

West MA, Wallace M. Innovation in health care teams. Eur J Soc Psychol. 1991;21(4):303–15.

89.

Aiken LH, Smith HL, Lake ET. Lower medicare mortality among a Set of hospitals known for good nursing care. Med Care. 1994;32(8):771–87.PubMed

90.

Roberts KH, Madsen P, Desai V, Van Stralen D. A case of the birth and death of a high reliability healthcare organisation. Qual Saf Health Care. 2005;14(3):216–20.PubMed

91.

Preuss GA. High performance work systems and organizational outcomes: the mediating role of information quality. Ind Labor Relat Rev. 2003;56(4):590–605.

92.

Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145–63.PubMedPubMedCentral

93.

Harmon J, Scotti DJ, Behson S, Farias G, Petzel R, Neuman JH, et al. Effects of high-involvement work systems on employee satisfaction and service costs in veterans healthcare. J Healthc Manag. 2003;48(6):393–406. discussion 406–397.PubMed

94.

Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs Jr GR, Burant C. Predicting registered nurse Job satisfaction and intent to leave. J Nurs Adm. 2003;33(5):271–83.PubMed

95.

Morrison RS, Jones L, Fuller B. The relation between leadership style and empowerment on Job satisfaction of nurses. J Nurs Adm. 1997;27(5):27–34.PubMed

96.

Patterson MG, West MA, Wall TD. Integrated manufacturing, empowerment, and company performance. J Organ Behav. 2004;25(5):641–65.

97.

Laschinger HKS, Wong C. Staff nurse empowerment and collective accountability: effect on perceived productivity and self-rated work effectiveness. Nurs Econ. 1999;17(6):308–16. 351.PubMed

98.

Patrick A, Laschinger HKS. The effect of structural empowerment and perceived organizational support on middle level nurse managers’ role satisfaction. J Nurs Manag. 2006;14(1):13–22.PubMed

99.

Spreitzer GM. Psychological empowerment in the workplace: dimensions, measurement, and validation. J Acad Manag. 1995;38(5):1442–65.

100.

Spreitzer GM, Kizilos MA, Nason SW. A dimensional analysis of the relationship between psychological empowerment and effectiveness, satisfaction, and strain. J Manag. 1997;23(5):679.

101.

Laschinger HKS, Finegan JE, Shamian J, Wilk P. A longitudinal analysis of the impact of workplace empowerment on work satisfaction. J Organ Behav. 2004;25(4):527–45.

102.

Braithwaite J, Westbrook MT. A survey of staff attitudes and comparative managerial and non-managerial views in a clinical directorate. Health Serv Manage Res. 2004;17(3):141–66.PubMed

103.

Southon G, Braithwaite J. The end of professionalism? Soc Sci Med. 1998;46(1):23–8.PubMed

104.

Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Med Care. 1998;36(8):AS4–12.PubMed

105.

Dutton RP, Cooper C, Jones A, Leone S, Kramer ME, Scalea TM. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma-Injury Infection Crit Care. 2003;55(5):913–9.

106.

Armitage S, Williams L. Communication in primary health care. Nurs Stand. 1990;5(1):34–5.PubMed

107.

Gerteis M, Edgman-Levitan J, Daley J, Delbanco T. Through the patient’s eyes: understanding and promoting patient-centered care. San Francisco: Jossey-Bass; 1993.

108.

Gittell JH, Fairfield KM, Bierbaum B, Head W, Jackson R, Kelly M, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807–19.PubMed

109.

Kane NM, Clark JR, Rivenson HL. The internal processes and behavioral dynamics of hospital boards: an exploration of differences between high- and low-performing hospitals. Health Care Manage Rev. 2009;34(1):80–91.PubMed

110.

Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Patient characteristics associated with oral anticoagulation control: results of the veterans affairs study to improve anticoagulation (VARIA). J Thromb Haemost. 2010;8(10):2182–91.PubMed

111.

Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Risk-adjusted percent time in therapeutic range as a quality indicator for outpatient oral anticoagulation: results of the veterans affairs study to improve anticoagulation (VARIA). Circ Cardiovasc Qual Outcomes. 2011;4(1):22–9. doi:10.1161/circoutcomes.110.957738.PubMed

112.

Cherlin EJ, Curry LA, Thompson JW, Greysen SR, Spatz E, Krumholz HM, Bradley EH: Features of high quality discharge planning for patients following acute myocardial infarction. J Gen Intern Med. 2013;28(3):436-443.

Title: High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement
Authors: Natalie Taylor
Robyn Clay-Williams
Emily Hogden
Jeffrey Braithwaite
Oliver Groene
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: BMC Health Services Research / Issue 1/2015
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-015-0879-z

At a glance: The STEP trials

Springer Medicine

High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2015

Awareness, experiences and perceptions of telehealth in a rural Queensland community

Knowledge and perceptions of the intrauterine device among family planning providers in Nepal: a cross-sectional analysis by cadre and sector

Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya

From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home

Risk factors for delay in age-appropriate vaccinations among Gambian children

A first country-wide review of Diabetes Mellitus care in Bhutan: time to do better