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Quality

Confronting Competing Demands To Improve Quality: A Five-Country Hospital Survey

Abstract

 
This paper reports on a 2003 comparative survey of hospital executives in Australia, Canada, New Zealand, the United Kingdom, and the United States. Reflecting higher spending levels, U.S. hospitals as a group stand out for generally more positive ratings of facilities and finances and short or no waiting times. Yet U.S. hospital executives are also the most negative about their country’s health care system. Hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality. Asked about future strategies to improve quality, executives in all five countries expressed support for making information technology an investment priority.

To facilitate this learning process, the 2003 Commonwealth Fund International Health Policy Survey interviewed executives in larger hospitals in Australia, Canada, New Zealand, the United Kingdom, and the United States. As the sixth in a series of surveys in these five English-speaking countries, the survey sought administrators’ views on current resources, quality of care, waiting times, staffing shortages, medical error, public disclosure of performance data, and efforts to improve quality.² The findings reveal areas of shared concern but also differences across countries that coincide with countries’ resource levels and recent trends.

Varying Country Contexts

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
Hospitals in all five countries face pressures to improve care while containing spending and operate in diverse health systems. To varying extents, each of these countries is engaged in initiatives to improve patient quality and safety.³ A brief overview of recent trends in each country’s hospital sector helps provide a context for understanding the comparative survey findings.

Australia. Public hospitals form the foundation of hospital care in Australia but also compete with private hospitals in a system financed by a universal public insurance system supplemented by private insurance.⁴ Australia’s national health spending has grown at relatively rapid rates over the past decade, with hospital spending per capita near the Organization for Economic Cooperation and Development (OECD) median.⁵ At the time of the survey, public hospitals were preparing to negotiate prospective five-year operating budgets. Australia is also in the midst of a malpractice crisis resulting from the bankruptcy of a major insurer.

Canada. Canadian hospitals, organized as public or not-for-profit, operate under annual budgets set by provincial and regional health authorities. During the 1990s Canada’s health system contracted, including hospital closings and bed reductions.⁶ In 2002 and again in 2003 the federal government supported major increases in health spending, with a share devoted to reinvestment in hospitals.

New Zealand. New Zealand’s national reforms have focused on primary care, with recent spending increases directed toward primary and public health needs and away from hospitals. Public hospitals operate under annual global budgets set by district health boards. Among the five countries, New Zealand had the lowest per capita health spending in 2000 ($1,623, compared with $1,763 in the United Kingdom, $2,211 in Australia, $2,535 in Canada, and $4,631 in the United States).⁷

United Kingdom. U.K. hospitals operate as self-governed public trusts within the National Health Service (NHS). Starting in 2002–03 there has been a major increase in NHS funding, with the five-year goal of increasing real spending by 7.4 percent per year to raise the share of gross domestic product (GDP) spent on health to 9.4 percent by 2007–08 (up from 7.3 percent in 2000).⁸ The NHS has also embarked on a major effort to improve quality of hospital care, reduce waiting times, renovate aging facilities, and invest in information technology (IT).⁹ National initiatives include quality targets along with public reporting and rating of performance.¹⁰

United States. U.S. hospitals operate within highly decentralized, competitive insurance and delivery systems in which revenues depend on volume and patient mix. U.S. hospitals stand out for high costs (three times the OECD median cost per day and twice the OECD cost per capita), low rates of hospital admissions, and short lengths-of-stay.¹¹ Reimbursement incentives have encouraged a migration of care to freestanding centers and emergence of niche hospitals. National health spending has risen sharply over the past several years, fueled by rapid increases in hospital costs.¹²

Survey Methods

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
Because the management and technology issues that larger hospitals face are different from those encountered by smaller ones, the survey aimed to interview hospital executives of larger hospitals. The study drew random samples from lists of the largest general or pediatric hospitals, excluding specialty hospitals. In each hospital, Harris Interactive and its international affiliates conducted telephone interviews (averaging twenty minutes) with the chief operating officer or top administrator during April and May 2003.¹³

We varied the definition of "large" relative to each country’s hospital distribution, to ensure an adequate sample size. In Australia and Canada just over 200 general hospitals were eligible to participate, with a cutoff of 100 beds or more. In the United Kingdom and the United States we set the cutoff at 200 beds or more. In New Zealand we included all of New Zealand’s thirty-four District Health Board hospitals regardless of bed size (some had fewer than 100 beds).¹⁴ Reflecting their dominant roles, the U.K. sample includes only NHS trust hospitals, and New Zealand, only District Health Board hospitals. The Australian, Canadian, and U.S. samples include public and private hospitals.¹⁵ In the United States the initial list was stratified by region and teaching status. Because the universe of larger hospitals was so small, data were not appropriate to reweight.

The study was jointly developed by researchers at the Harvard School of Public Health, the Commonwealth Fund, and Harris Interactive. A Health Research and Educational Trust (HRET) research team contributed to the questionnaire design and to securing hospital lists and sampling decisions.¹⁶

The exhibits display survey results with statistical tests for differences between countries. In general, results were compared using T-tests. In some instances where questions included multicategory responses, the analysis compares the overall distribution of responses using chi-square tests.

Survey Findings

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
System views. Asked about satisfaction with the country’s health care system overall, U.S. hospital administrators were notably more negative than their counterparts in the other four countries. Half of U.S. hospital administrators said they were (somewhat or very) dissatisfied, compared with 12 percent or fewer in the other countries. Notably, hospital administrators elsewhere were more positive about their countries’ systems than patients were in a recent 2002 survey.¹⁷ However, few administrators in any of the five countries were "very satisfied" (Exhibit 1).

Asked about competitive pressures for patients, only U.S. and Australian hospital executives expressed concern. The U.S. hospital group stands out for concerns about losing patients to freestanding facilities. Australians were mainly concerned about competition with other hospitals (Exhibit 1).

The financial health of hospitals varied widely across the five countries. The U.S. group stood out, with a strong majority reporting profits and ability to maintain services. In the other four countries, half or more of respondents said that they had insufficient funds to maintain current levels of services.

Hospital executives in Canada and New Zealand were the most likely to indicate widespread financial stress. At least seven out of ten respondents there reported a deficit (or inability to stay within budget), and similar proportions said that they had insufficient resources to maintain current service levels. Although hospitals’ financial health appeared to be more positive in Australia and the United Kingdom, in these countries one-third of respondents or more reported a deficit, and half or more said they could not maintain current service levels.

In Australia and the United States, assessments of hospitals’ financial health were less homogeneous than in the other three countries. In Australia approximately equal proportions of hospital executives reported a surplus or a deficit, and they were mixed in their reports about ability to maintain services. While most U.S. respondents reported a profit, one-quarter said that they had a deficit in the past year, and one-third said that they could not maintain current service levels. In both countries, hospitals with a reported deficit were more likely than those with a reported surplus to be publicly owned.

In all five countries about half or more of respondents said that their facility needed major renovations. Yet 11 percent (or less) of hospital executives in Australia, Canada, New Zealand, and the United Kingdom and only one-third of those in the United States said that current finances were sufficient for improvements or expansion. The perceived need for major renovations was most widespread in Canada.

The survey also asked hospital executives to rate the quality of several key areas of their hospitals: intensive care units (ICUs), operating rooms, diagnostic equipment, and emergency departments (EDs). Although self-assessed quality of resources at respondents’ own facility may vary from more objective measures, the relative ratings across countries and areas indicate areas of diverse and shared concern. Regarding ICUs, operating rooms, and diagnostic resources, U.S. administrators were the most confident about current quality; they were more likely to rate these facilities as excellent (or excellent/very good), and few rated them as fair or poor. Similarly, few in the other four countries rated service in these three areas negatively.

The one area that hospital administrators in all five countries tended to be more critical of was their ED (Exhibit 2). Canadians were the most critical, with half giving the ED a negative rating compared with 17–30 percent of executives in the other four countries. These ED concerns repeat those voiced by physicians in these countries in a 2000 survey.¹⁸

Waiting times. Previous surveys in these five countries found evidence of long waiting times for hospital admission in several countries. The current survey asked respondents about waiting times in their own facility. Except in the United States, sizable shares reported long waits in their hospitals for elective admissions. Waits of six months or more for elective surgeries were reported to occur "very often" or "often" by 26–57 percent of executives in the four non-U.S. countries; only 1 percent of U.S. hospitals reported this (Exhibit 3). Although these estimated waiting times may reflect the fact that uninsured U.S. patients may be discouraged altogether from seeking elective surgery, these reports repeat patterns observed in earlier patient surveys.¹⁹

Changes in waiting times. Although the U.K. respondents reported some of the longest waiting times for elective surgery, they were also the most likely to perceive that waiting times for elective admissions had gotten shorter in the past two years (86 percent, compared with 9–29 percent in the other countries). Canadians were the most likely to report that waiting times had become longer.

ED, discharges, and patient diversions. The survey also asked about perceived waiting times in the hospital ED, delays in discharge because of limited availability of posthospital care, and diversion of patients to other facilities because of a lack of capacity. These indicators also serve as indirect measures of how well hospitals are integrated or coordinated with primary care and other community resources.

ED waiting times appear to be of particular concern to Canadian, U.K., and U.S. respondents. Two-fifths or more of respondents in each of these countries reported average waits of two hours or more. Australian and New Zealand respondents were much less likely to report such long waits. Of note, one-quarter of executives in Australia, where there has been a nationwide effort to reduce ED waiting times, reported an average waiting time of thirty minutes or less (data not shown).²⁰

Asked about diversion of patients to other hospitals, U.S. respondents were more likely than those in the other four countries to report frequent diversions because of a lack of capacity. Majorities of respondents elsewhere said that diversion rarely or never occurred in their hospitals. Frequent delays or problems at discharge because of lack of posthospital care were a common concern in all countries except New Zealand.

Medical errors. A 2002 survey of patients found sizable numbers in all five countries reporting experience with medical and medication errors.²¹ This survey asked about policies to inform patients about errors and to assess the effectiveness of hospitals’ efforts to find and address preventable errors.

The survey finds that all hospitals had some type of system for finding and addressing medical errors. Written policies to inform patients or their families if a preventable medical error resulting in serious harm is made in their care were widespread in the United Kingdom (74 percent) and the United States (88 percent). However, only about half of executives in Australia, New Zealand, and Canada said that they had such a policy (Exhibit 4).

Improving Quality And Disclosing Quality Data

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
To gauge hospital executives’ views of different initiatives to improve the quality of patient care, the study asked respondents to rate the effectiveness in their hospital of four initiatives recommended by experts to improve quality of care: electronic medical records, electronic or computerized ordering of drugs, treatment guidelines for common conditions, and comparisons of medical outcomes with other hospitals. The survey also asked about support for public disclosure of data on hospitals’ quality performance.

Information technology. In all five countries, strong majorities (80 percent or more) viewed the use of electronic medical records (EMRs) and electronic prescribing/ordering of medications as at least somewhat effective. Half or more viewed use of either type of IT as "very effective" in improving quality of care.²³ Notably, given recent initiatives under way in the NHS, U.K. administrators were the most enthusiastic, with two-thirds seeing EMRs as "very effective" (Exhibit 5).²⁴

Views on the effectiveness of government policies to improve quality of care varied widely across countries. U.S. and Canadian respondents were the least likely to rate government policies as effective, with more than half of respondents in both countries saying that policies or quality targets were "not very" or "not at all" effective. U.K. respondents were the most supportive, with 75 percent saying that policies or targets were at least somewhat effective. Few respondents (no more than 5 percent) in any country rated public policies as very effective.

Information disclosure. When respondents were asked whether hospitals should be required to publicly disclose information on several quality-of-care measures, support varied. It was highest for patient satisfaction ratings, frequency or volume of procedures, and waiting times. Mandatory disclosure of information on mortality, medical error, and nosocomial infection rates received considerably less support in Australia, Canada, and New Zealand (Exhibit 5).

Notably, the share of respondents opposing public disclosure of medical error, infection, and mortality rates was highest in Australia and the United States, the only two countries where malpractice costs were cited as top problems facing the health care system and loss of patients to competition is a concern. Generally, U.S. hospital executives showed the weakest support of public disclosure. Even on waiting times, respondents in the United States, the country with the shortest waits, were the most likely to oppose disclosure.

Staffing issues. At the outset of the survey, hospital executives identified staff shortages as a top concern. Asked about specific occupations, shortages of nurses, pharmacists, and medical specialists were reported to varying degrees in the five countries (Exhibit 6). Nurse staffing continues to be of concern: 80 percent or more of hospitals in each country reported a nurse shortage. More than one-fifth of Australian and U.K. hospital executives and nearly one-third of Canadian and U.S. executives reported serious shortages. A majority of executives (53–79 percent) in all countries reported a shortage of pharmacists. More than two-thirds of respondents in all five countries reported moderate or serious shortages of specialist or consultant physicians. Shortages of lab technicians were less prominent.

Executives expressed guarded optimism about their nursing shortages and indicated that they used a variety of strategies to recruit and retain nurses. Majorities in all five countries reported that their nurse staffing levels either had gotten better or were about the same as they were two years ago. The proportion saying that their nurse staffing levels were worse than two years ago ranged from 15 percent in the United Kingdom to 28 percent in Australia.

Almost all respondents reported that their hospital used flexible scheduling or job sharing to recruit and retain nurses. Redesigning nursing jobs is also a widespread practice. Majorities in all but the United Kingdom reported assisting with nursing school tuition. The United States was the only country in which sign-up bonuses were widespread.

The survey also asked hospital executives to rate the morale of doctors at their hospitals. On this measure, U.S. and Canadian respondents were the most likely to say that it was only fair or poor, followed by the United Kingdom. Australian executives were the most positive about physician morale.

Priorities to improve quality of care. Recognizing that hospitals face competing demands to improve quality of care, the survey asked an open-ended question about what their top priority would be if they were to receive new funds for "a one-time capital investment to improve quality of care for patients." In all five countries, investment in some form of IT led the list of top priorities (Exhibit 7). From one-third (Australia) to nearly two-thirds (U.S.) of executives said that they would spend funds on some type of IT. In the United States, IT emerged as a dominant priority. In the other countries, substantial shares of hospitals also named as priorities EDs (one-quarter of Australian and U.K. respondents) and other critical care areas.

U.S. respondents were more likely than their counterparts in the other four countries to view doctors’ resistance to change as a barrier. Privacy and lack of training of administrative staff were of concern but were less likely to be seen as major barriers in any of the five countries.

Discussion

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
As care systems confront common challenges, findings provide several implications for health care policymakers across the five countries surveyed.

Financing issues. First, the survey found that hospitals in all five countries see themselves as underfunded. Regardless of current financial status or national financing systems, hospital executives named inadequate funding (or reimbursements in the United States) as a top concern. This finding is perhaps most striking in the United States, where hospitals as a group report better financial health than in the other four countries. An underlying theme across the various domains of the survey is that hospital executives are likely to continue to place pressure on government to increase expenditures to meet competing demands.

Spending levels and system responsiveness. The survey findings also underscore a finding in previous Commonwealth Fund surveys that overall views of national care systems do not correlate well with national spending levels or measures of system responsiveness, such as waiting times. U.S. hospital leaders were the most negative about their health care system despite their more positive views of their own hospital’s financial health, quality of resources, or waiting times.

The United States stands apart from the other four countries on short hospital waiting times. Although respondents’ perceptions of actual waiting times may depart from external measures, the rankings are similar to those found in patient surveys. Given the fact that the United States has comparable use rates of inpatient hospital care, with shorter lengths-of-stay, yet spends much more on hospital care, specialized resources, and same-day alternatives to hospital care, these findings suggest that governments in the other four countries continue to face critical decisions regarding waiting times. How much are they willing to spend to reduce patient queues? The U.S. model of specialized care and outpatient capacity is clearly much more costly. Are there more cost-efficient ways to address waiting times?

U.S. reports on waiting times also do not take into account the barriers faced by the uninsured, a population that receives less hospital care and fewer life-saving therapies than the insured receive.²⁵ If the forty-three million uninsured Americans were covered, demand for hospital care could increase.²⁶ The study indicates opportunities to learn as countries seek to reduce queues and as the United States, along with the other four countries, seeks to meet patient demand.

Staffing and safety issues. Nurse staffing, as well as staffing overall, emerges as a key concern across the five countries. Long-term solutions are likely to require national policy efforts to address nurse and broader skilled staffing concerns.

The survey indicates continued need for national policy leadership to improve patient safety. Hospital executives’ relatively weak ratings of their own hospital’s efforts to find and address medical errors in all five countries suggest a need for public policy initiatives, including more effective monitoring of outcomes.

Competition and spending levels. U.S. policymakers likewise face a choice in the future. The survey results clearly indicate that the more competitive U.S. hospital system is not leading to lower spending. The question for U.S. policymakers is whether they wish to sustain the current competitive hospital system or introduce more constraints that could lead to lower levels of spending.

Quality of care. On a positive note, the survey finds that the majority of hospitals in all five countries endorse releasing quality-of-care data to the public. Notably, given malpractice concerns and more competitive environments, U.S. and Australian hospital executives tended to express the most reluctance. This weaker support suggests that governments in these two countries will likely need to take a strong leadership role in moving toward public disclosure.

Care management. The findings on EDs and delays at discharge point to an area of shared concern. Here U.S. hospital leaders join Australia, Canada, and the United Kingdom in reports of long waits and poor quality in the ED, discharge delays attributable to lack of posthospital care, and patient diversions because of lack of capacity. The survey suggests that New Zealand may be having better success in addressing problems of care coordination. New Zealand’s recent effort to change how its hospital system functions, with an emphasis on primary care, may offer insights as other countries seek to improve management of care.

Role for national leadership. Lastly, the survey points to the potential value of national leadership to improve quality through IT. Hospitals place a high priority on upgrading their IT systems and see IT as a way to improve quality of care. Yet they also cite lack of uniform standards and financing as major barriers. The question for governments is what role they should play in the standardization of this technology or special financing for hospitals in this area. Government intervention may be particularly needed in countries where the hospital systems are more competitive and decentralized because of the difficulties in reaching consensus and implementation. In the United Kingdom, where quality has become a widely publicized national priority, the national commitment appears to be paying off in terms of hospital leaders’ more positive views of public policy, the direction of change, and the endorsement of disclosure of quality measures. As countries move forward on IT, this is clearly an emerging area for cross-national cooperation and learning.

Editor's Notes

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 
Robert Blendon (rblendon{at}hsph.harvard.edu) is a professor in the Harvard School of Public Health, in Boston. Cathy Schoen is vice president and Robin Osborn is assistant vice president of the Commonwealth Fund in New York City. Catherine DesRoches is a research associate, and Elizabeth Raleigh is a research assistant, at the Harvard School of Public Health. Kinga Zapert is vice president of Harris Interactive in New York City.

An earlier version of this paper was presented at the Commonwealth Fund 2003 International Symposium on Health Care Policy, "Hospitals and Health Care Delivery Systems: Spotlight on Innovation," 22–24 October 2003, in Washington, D.C.

NOTES

Top Editor's Notes Varying Country Contexts Survey Methods Survey Findings Improving Quality And Disclosing... Discussion NOTES

 

1. U.E. Reinhardt, P.S. Hussey, and G.F. Anderson, "Cross-National Comparisons of Health Systems Using OECD Data, 1999," Health Affairs 21, no. 3 (2002): 169–181.[Abstract/Free Full Text]
2. The other five surveys are K. Donelan et al., "The Cost of Health System Change: Public Discontent in Five Nations," Health Affairs 18, no. 3 (1999): 206–216; [Abstract] K. Donelan et al., "The Elderly in Five Nations: The Importance of Universal Coverage," Health Affairs 19, no. 3 (2000): 226–235; [Abstract] R.J. Blendon et al., "Physicians’ Views on Quality of Care: A Five-Country Comparison," Health Affairs 20, no. 3 (2001): 233–243; [Abstract/Free Full Text] R.J. Blendon et al., "Inequities in Health Care: A Five-Country Survey," Health Affairs 21, no. 3 (2002): 182–191;[Abstract/Free Full Text] and R.J. Blendon et al., "Common Concerns amid Diverse Systems: Health Care Experiences in Five Countries," Health Affairs 22, no. 3 (2003): 117–121.[Abstract/Free Full Text]
3. For more detailed discussions, see D. Blumenthal et al., The Five Nation Hospital Survey: Commonalities, Differences, and Discontinuities (New York: Commonwealth Fund, forthcoming, May 2004).
4. A. Podger, "Australia’s Balance between Public and Private Arrangements," Health Affairs 19, no. 3 (2000): 124–125.[Medline]
5. G.F. Anderson, V. Petrosyan, and P.S. Hussey, "Multinational Comparisons of Health System Data, 2002," October 2002, www.cmwf.org/programs/pub_highlight.asp?id=877&pubid=582&CategoryID=5 (31 March 2004); and G.F. Anderson and P. Hussey, "Multinational Comparisons of Health Systems Data, 2000," October 2000, www.cmwf.org/programs/international/comp_chartbook_431.asp (10 March 2004). Both draw from OECD data.
6. Reinhardt et al., "Cross-National Comparisons"; G.F. Anderson et al., "It’s the Prices, Stupid: Why the United States Is So Different from Other Countries," Health Affairs 22, no. 3 (2003): 89–105;[Abstract/Free Full Text] and C. Tuohy, "The Costs of Constraint and Prospects for Health Care Reform in Canada," Health Affairs 21, no. 3 (2002): 32–64.[Abstract/Free Full Text]
7. Anderson et al., "It’s the Prices, Stupid," 91.
8. S. Stevens, "Reform Strategies for the English NHS," Health Affairs 23, no. 3 (2004): 37–44.[Abstract/Free Full Text]
9. NHS Confederation, "The National Strategy for IT in the NHS," Briefing Note, August 2003, www.doh.gov.uk/ipu/programme/briefing88.pdf (10 February 2004).
10. For U.K. hospital ratings, see Dr. Foster, "Your Hospital Guide," www.drfoster.co.uk/hospital_guide/main/choosehospital.asp (10 February 2004).
11. Ibid.; and Reinhardt et al., "Cross-National Comparisons."
12. K. Levit et al., "Health Spending Rebound Continues in 2002," Health Affairs 23, no. 1 (2004): 147–159.[Abstract/Free Full Text]
13. Response rates were as follows: Australia, 41 percent; Canada, 46 percent; New Zealand, 82 percent; United Kingdom, 40 percent; and United States, 20 percent. Because the size of the hospital population in the United States was so large, there was a possibility that the hospitals randomly selected would not provide a representative sample. Thus, to solve this problem, the sample was stratified by two different dimensions: institutions by different regions, and those that were teaching and nonteaching hospitals. With the stratification, the characteristics of the sample in this study are representative of the hospital population that was surveyed. See H.F. Weisberg, J.A. Krosnick, and B.D. Bowen, An Introduction to Survey Research, Polling, and Data Analysis, 3d ed. (Thousand Oaks, Calif.: Sage Publications, 1996), 45–46.
14. The number of hospitals that met study criteria per country were as follows: Australia, 246; Canada, 229; New Zealand, 34; United Kingdom, 192 (includes multihospital trusts); and United States, 1,407.
15. The public/private split was as follows: Australia, 62 public, 38 private; Canada, 32 public, 70 nonprofit; and United States, 35 public, 15 for-profit, and 155 nonprofit.
16. The HRET team included Mary Pittman, Jon Gabel, and Lashawn Alexander. Exact question wording is available from Robin Osborn, ro{at}cmwf.org.
17. Blendon et al., "Common Concerns amid Diverse Systems." In 2002 the shares of dissatisfied sicker patients were as follows: Australia, 35 percent; Canada, 36 percent; New Zealand, 48 percent; United Kingdom, 31 percent; and United States, 44 percent.
18. Blendon et al., "Physicians’ Views on Quality of Care." In 2000, 34 percent of Australian, 47 percent of Canadian, 33 percent of New Zealand, 46 percent of U.K., and 27 percent of U.S. physicians rated EDs as fair or poor.
19. Blendon et al., "Common Concerns"; and Blendon et al., "Inequities in Health Care."
20. See National Institute of Clinical Studies, "NICS Projects," www.nicsl.com.au/projects.aspx (10 February 2004).
21. Blendon et al., "Common Concerns."
22. P. Davis et al., "Acknowledgement of ‘No Fault’ Medical Injury: Review of Patients’ Hospital Records in New Zealand," British Medical Journal 326, no. 7380 (2003): 79–80.[Free Full Text]
23. The survey asked those already using the technology in some areas of the hospital how effective they thought it was and those not yet using the technology how effective they thought it would be improving quality of care.
24. NHS Confederation, "The National Strategy for IT."
25. Institute of Medicine, Insuring America’s Health (Washington: National Academies Press, 2004).
26. R. Mills and S. Bhandari, "Health Insurance Coverage in the United States: 2002," September 2003, www.census.gov/prod/2003pubs/p60-223.pdf (10 March 2004).

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