I 
I 
Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
FEBRUARY  1993  OFFICE OF INSPECIOR  GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated  by Public Law 95-452, as 
amended, is to protect  the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries sewed by those programs.  This 
statutory  mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three  OIG operating  components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation  and Inspections.  The OIG also informs 
the Secretary of HHS of program and management  problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Semites  (OAS) provides all auditing services for HHS, either  by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance  of HHS programs and/or its grantees  and contractors  in 
carrying out their respective responsibilities and are intended  to provide independent 
assessments of HHS programs and operations  in order to reduce waste, abuse, and 
mismanagement  and to promote  economy and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Office of Investigations (01)  conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries  and of 
unjust enrichment  by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  lhe 01 also oversees State Medicaid fraud 
control units which investigate and prosecute  fraud and patient  abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECIIONS 
The OIGS Office of Evaluation  and Inspections (OEI)  conducts short-term  management  and 
program evaluations  (called inspections) that focus on issues of concern  to the Department, 
the Congress, and the public.  The findings and recommendations  contained  in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs.  : 
This report  was prepared  under the direction of Mark R. Yessian, Ph.D., the Regional 
Inspector  General,  and Martha  B. Kvaal, Deputy Regional Inspector  General,  Boston Region, 
Office of Evaluation  and Inspections.  Participating  in this project were the following people: 
Boston Region  Headquarters 
David Veroff, Project Leader  Alan Levine 
David Schrag, Lead Analyst 
For additionalmpies of this repo~  please contact the Boston Regional Office at 
(617) 56S-1050. 
  Depafiment  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  PRACTITIONER  DATA BANK:

USEFULNESS  AND  IMPACT  OF  REPORTS

TO  HOSPITALS

FEBRUARY  1993  OEI-01-90-00520
  EXECUTIVE  SUMMARY 
PURPOSE 
The  purpose  of this  study  is to  assess  the  utility  to  hospitals  of the  information  in the 
National  Practitioner  Data  Bank. 
BACKGROUND 
Since  September  1, 1990, the  National  Practitioner  Data  Bank  has  received  and 
maintained  records  of malpractice  payments  and  adverse  actions  taken  by hospitals, 
other  health  care  entities,  licensing  boards,  and  professional  societies  against  licensed 
health  care  practitioners.  It provides  hospitals  and  other  health  care  entities  with 
information  relating  to the  professional  competence  and  conduct  of physicians, 
dentists,  and  other  health  care  practitioners.  It is operated  by a contractor  to the 
Health  Resources  and  Sewices  Administration  (FIRSA)  of the  Public  Health  Setice 
(PHS). 
Under  the  Health  Care  Quality  Improvement  Act  of 1986, hospitals  are  required  to 
query  the  Data  Bank  about  every  physician  and  dentist  who  applies  for  privileges. 
Hospitals  must  query  about  all practitioners  with  clinical  privileges  at  least  once  every 
two years.  They  have  the  option  of querying  about  any practitioner  with  privileges  (or 
who  is seeking  privileges)  at  any time.  The  Data  Bank  information  is intended  to help 
hospitals  make  decisions  about  hiring,  credentialing,  and  disciplining  practitioners. 
There  has  been  much  debate  about  the  utility  of this  information  to  hospitals  and 
about  how  they  use  it.  Some  observers  note  that  much  of the  information  was  already 
readily  available  through  other  sources.  Critics  of the  current  reporting  requirements 
have  argued  that  reports  of malpractice  payments,  particularly  of small  dollar 
settlements,  are  not  useful  in determining  the  professional  competence  or  conduct  of 
practitioners.  Some  practitioner  groups  are  worried  that  Data  Bank  reports  prejudice 
hospitals  against  the  reported  practitioners,  while  hospitals  and  others  argue  that 
hospitals  do  not  make  judgments  based  solely  on the  reports  and  that  they  follow  up 
on the  reports  to get  more  detaiL 
This  report  answers  basic  questions  about  the  usefulness  and  impact  of the 
information  in the  Data  Bank  to hospitals  at  an  early  stage  in the  Data  Banks 
operation.  The  results  are  based  on  a survey  of hospitals  who  have  received  reports 
of malpractice  payments  or adverse  actions  from  the  Data  Bank.  We sampled  200 
matches  -- instances  when  a querying  hospital  received  a report  of a specific  incident 
-- from  the  universe  of 19,122 hospital  matches  from  the  initiation  of the  Data  Bank 
through  March  19, 1992 and  received  142 responses.  our  findings  can  be  projected  to 
this  universe  of matches.  Appendix  A gives details  of our  methodology  and  provides 
information  about  the  reports,  practitioners,  and  hospitals  included  in this  study. 
i  FINDINGS 
USEFULNESS  TO HOSPITAS:  A  majo~  of Data  Bank reprts  were usejid  to 
hospitals 
Measured  by both  objective  and  subjective  criteria,  the  Data  Bank  appears  to be 
providing  valuable  information  to  hospitals. 
Forty  percent  of Data  Bank  reports  have  provided  information  previously 
 
unknown  to hospital  staffs. 
The  Data  Bank  has  delivered  accurate  reports  to hospitals. 
The  Data  Banks  average  response  time  has  been  improving  steadily.  Over  an 
 
18 month  period,  median  response  time  has  dropped  from  123 days to  26 days. 
Hospital  officials  found  58 percent  of Data  Bank  reports  to be  useful.  As the 
 
Data  Banks  response  time  has  improved,  so has  the  proportion  of reports 
rated  useful. 
The  most  frequently  cited  reason  for  Data  Bank  reports  usefulness  was  that 
 
they  confirmed  information  about  practitioners  that  hospital  officials  already 
knew.  Other  reasons  cited  include  the  reports  help  in making  judgments  about 
practitioners  competency  and  their  provision  of information  not  already  known. 
Neither  the  source  of reports  nor,  for  malpractice  reports,  the  payment  amount 
 
affected  the  proportion  of Data  Bank  reports  that  hospital  officials  rated  useful. 
IMPACT  ON DECISIONS:  Data  Bank reprb  rarely led hmpitak  to make p-g 
&cisions  they would not have made  without the reprts,  even when the reprls  provided 
information  that hospital  did not already know. 
We  evaluated  impact  on  decisions  by asking  hospitals  the  following  question:  Would 
your  decision  regarding  the  practitioner  have  been  different  if you  had  not  received 
the  Data  Bank  report? 
According  to hospital  officials,  if hospitals  had  not  received  the  Data  Bank 
 
reports,  their  privileging  decisions  would  have  been  different  one  percent  of the 
time. 
Eighty  percent  of Data  Bank  reports  had  little  chance  to  have  an  impact  on 
 
hospitals  privileging  decisions.  Each  of these  reports  either  arrived  after  the 
decision  was made  or  duplicated  available  information. 
Nineteen  percent  of Data  Bank  reports  arrived  before  hospitals  decisions  were 
 
finalized  and  contained  information  that  neither  the  practitioner  involved  nor 
ii  any other  sources  had  provided,  but  did  not  have  an  impact  on hospitals 
privileging  decisions. 
RECOMMENDATIONS 
our  findings  indicate  that  the  usefulness  and  impact  of the  information  in the  Data 
Bank  are  strongly  affected  by the  timeliness  of the  reports.  Our  recommendations 
identify  steps  that  PHS  and  hospitals  need  to take  to  improve  the  timeliness  of Data 
Bank  reports,  since  PHS  shares  the  responsibility  for  timeliness  with  the  hospitals  that 
query  the  Data  Bank. 
The PHS should seek to reduce jiudwr  the time  between  query and rayxms~  and shod 
make  tti  a high ptirity  in its next contract for o~ration  of the Dati  Bank  W  PHS 
shouki pubtih  recently estabbm  peflomumce  Waters  dzting  to response tiine in ti 
annual  rep~  on the Data  Bank 
%  Joint Commiksio n for Accreditation  of Healthcare  Organ&ations  (JCAHO)  shod 
establish guidelines  on how qukkly  hospital  should quq  the Data  Bank  afler receivikg 
applkations  for pniikges. 
COMMENT3  ON THE  D~  REPORT 
We  received  comments  on our  draft  report  from  the  Public  Health  Service  (PHS),  the 
Assistant  Secretary  for  Management  and  Budget  (ASMB),  the  Assistant  Secretary  for 
Planning  and  Evaluation  (ASPE),  the  Joint  Commission  on Accreditation  of 
Healthcare  Organizations  (JCAHO),  the  American  Hospital  Association  (AHA),  and 
the  American  Medical  Association  (AMA).  The  PHS  and  JCAHO  are  examining 
ways to implement  the  recommendations  we directed  to them.  In appendix  C, we 
reproduce  each  set  of comments  in full and  provide  our  responses  to  them. 
. .. 
111  .  TABLE  OF  CONTENTS 
EXECUTIVE  SUMMARY 
INTRODUCTION  ..- . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . . . .  1 
FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . . . .  3 
Usefulness  to Hospitals  . . .  .*  *.*,*  . . . . . . . . . . . . . . . .  3 
...0  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
Impact  on  Decisions  . .  .*  *.*.*  .  7 
.  .  .  .  .  .  .    .  .  .  .  .  .  .  .  .  .  .  .  .  .  ..0.0.  .0  ..0..  .  . 
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12 
COMMENTS  ONqHEDRAIV  REPORT  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14 
APPENDICES 
A.  Methodology  . ,.  ..,..  . . . . . . .  ,00 .*  ..*..  ..  A-1 
  -O..*.  0.,..  .  .  .  .  .  . 
B.  Summary  of Hospitals  Responses  to  OIG  Mail  Survey  .  B-1 
.  .  .  .  .  .  .  .  .  .  .  .  . 
c.  Detailed  Comments  on the  Draft  Report  and 
OIG  Response  to the  Comments  .* ..*..  ..*  . . . . . . . ,.  c-1 
.0...  .  .  .  .  .  . 
D.  Notes  . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . .,  D-1 
...0    .  .  ...0.    0.... 
. 
.   INTRODUCTION 
PURPOSE 
The  purpose  of this  study  is to assess  the  utility  to hospitals  of the  information  in the 
National  Practitioner  Data  Bank. 
BACKGROUND 
Since  September  1, 1990, the  National  Practitioner  Data  Bank  has  received  and 
maintained  records  of malpractice  payments  and  adverse  actions  taken  by hospitals, 
other  health  care  entities,  licensing  boards,  and  professional  societies  against  licensed 
health  care  practitioners.1  It provides  hospitals  and  other  health  care  entities  with 
information  relating  to the  professional  competence  and  conduct  of physicians, 
dentists,  and  other  health  care  practitioners.  The  Data  Bank  was  established  by Title 
IV of the  Health  Care  Quality  Improvement  Act  of  1986 (P.L.  99-660),  as amended, 
and  is funded  by user  fees  and  Federal  outlays.  It is operated  by Paramax  Systems 
Corporation  (a subsidiary  of Unisys  Corporation)  under  contract  to  the  Health 
Resources  and  Sexvices  Administration  (HRSA)  of the  Public  Health  Service  (PHS). 
Hospitals  are  required  to request  information  from  the  Data  Bank  about  every 
physician  and  dentist  who  applies  for  appointment.  Hospitals  must  query  about  all 
medical  and  dental  staff  and  other  health  care  practitioners  with  clinical  privileges  at 
least  once  every  two years.  They  have  the  option  of querying  about  any practitioner 
with  privileges  (or who  is seeking  privileges)  at  any time.  The  Data  Bank  is intended 
to provide  information  to  hospitals  to help  them  make  decisions  about  hiring,  granting 
privileges  to,  and  disciplining  practitioners. 
As of March  19, 1992, hospitals  had  received,  in response  to queries,  19,122 reports  of 
malpractice  payments  or  adverse  actions  against  physicians,  dentists,  and  other  health 
care  practitioners.  We  summarized  in detail  the  profile  of these  matches  in a report 
released  in April  1992.2 
There  has  been  much  debate  about  the  utility  of this  information  to  hospitals  and 
about  how  they  use  it.  Some  observers  note  that  much  of the  information  was  already 
readily  available  through  other  sources.  Critics  of the  current  reporting  requirements 
have  argued  that  reports  of malpractice  payments,  particularly  of small  dollar 
settlements,  are  not  useful  in determining  the  professional  competence  or  conduct  of 
practitioners.  Some  practitioner  groups  are  worried  that  Data  Bank  reports  prejudice 
hospitals  against  the  reported  practitioners,  while  hospitals  and  others  argue  that 
hospitals  do  not  make  judgments  based  solely  on the  reports  and  that  they  follow  up 
on  the  reports  to get  more  detail. 
1  METHODO~Y 
This  report  answers  basic  questions  about  the  usefulness  and  impact  of the

information  in the  Data  Bank  to hospitals  at  an  early  stage  in the  Data  Banks

operation.  The  report  does  not  address  the  utility  of responses  from  the  Data  Bank

that  state  that  no information  is on file for  the  practitioners  involved.  The  results  are

based  on a survey  of hospitals  that  have  received  reports  of malpractice  payments  or

adverse  actions  (also  known  as disciplinary  actions)  from  the  Data  Bank.  We  sampled

200 matches  -- instances  when  a querying  hospital  received  a report  of a specific

incident  -- from  the  universe  of  19,122 hospital  matches  from  the  initiation  of the  Data

Bank  through  March  19, 1992.  We  received  142 responses.  our  findings  can  be

projected  to  this  universe  of matches.

Our  sample  was  stratified  to include  equal  numbers  of malpractice  and  adverse  action 
reports.  Because  there  have  been  far  more  malpractice  reports  than  adverse  action 
reports  received  by hospitals,  when  we analyzed  the  responses  we gave  each  response 
about  an  adverse  action  report  much  less weight  than  each  response  about  a 
malpractice  payment  report.  Appendix  A gives details  of our  methodology  and 
provides  information  about  the  reports,  practitioners,  and  hospitals  included  in this 
study. 
This  report  is one  in our  series  of studies  on  the  National  Practitioner  Data  Bank.  In 
April  1992, we released  two final  reports  entitled  National  Practitioner  Data  Bank: 
Malpractice  Reporting  Requirements  (OEI-01-90-00521)  and  National  Practitioner 
Data  Bank:  Profile  of Matches  (OEI-01-90-00522).  We  have  also  produced  a report 
on  the  utility  to  State  licensing  boards  of Data  Bank  information  (OEI-01-90-O0523). 
our  review  was  conducted  in accordance  with  the  Interirn Standards for Inspections 
issued  by the  Presidents  Council  on  Integrity  and  Efficiency. 
2
 FINDINGS

USEFULNESS  TO HOSP~XLS:  A  majody  of Data  Bank rep~  were usejid  to 
hospilak. 
Whether  a report  from  the  Data  Bank  is useful  to a hospital  depends  on  several 
fidctors.  Some  factors  can  be  determined  objectively,  such  as whether  the  report 
provides  new  information  or duplicates  other  reports,  whether  it is accurate,  and 
whether  the  report  arrives  at  the  hospital  in time  to be  used  in the  privileging  process. 
Other  factors  are  more  subjective,  such  as whether  the  information  is relevant  to  the 
reported  practitioners  competency  and  professionalism.  Measured  by both  objective 
and  subjective  criteria,  the  Data  Bank  appears  to be  providing  valuable  information  to 
hospitals. 
Forty  percent  of Data  Bank  reports  have  provided  information  previously 
 
unknown  to  hospital  staffs. 
When  it created  the  Data  Bank,  Congress  perceived  that  hospitals  were  not  obtaining

complete  information  about  the  practitioners  to whom  they  granted  privileges.  One

measure  of the  Data  Banks  usefulness,  therefore,  is the  extent  to which  it adds  to

hospitals  knowledge  by providing  information  hospitals  do not  obtain  elsewhere.  So

far,  a substantial  number  of reports--4O  percent  overall--have  given  hospitals

information  that  no  other  sources  had  provided  to them.

Hospitals  find  that  practitioners  often  fail to reveal  their  own  histories  of malpractice

payments  and  adverse  actions.  Forty-seven  percent  of Data  Bank  reports  gave

hospitals  information  that  the  practitioners  named  in those  reports  did  not  provide.3

These  practitioners  did not  necessarily  break  any rules.  Whether  complete  disclosure

is required  of practitioners  depends  on  individual  hospitals  application  procedures.

Hospitals  also  find  that  they  do not  always  get  important  information  from  their  own

State  licensing  boards.  When  hospitals  received  reports  on  adverse  actions  from  the

Data  Bank  that  were  originally  submitted  by licensing  boards  in the  hospitals  own

States,  the  Data  Bank  reports  represented  the  hospitals  only knowledge  of the

adverse  actions  twenty  percent4  of the  time.  Another  10 percents  of the  time,

hospitals  learned  of the  board  actions  from  sources  other  than  the  Data  Bank,  but  not

from  the  boards  themselves.  Whether  this  communication  gap  is the  fault  of boards

(for  not  providing  information  to  hospitals)  or of hospitals  (for  not  requesting

information  from  boards),  we cannot  say.

Hospitals  have  even  more  trouble  learning  of other  hospitals  clinical  privilege  actions.

Half  of the  Data  Bank  reports  on  clinical  privilege  actions  provided  information

otherwise  unavailable.b

3
 Surprisingly,  hospitals  were  more  likely to be  aware  of malpractice  payments  and 
adverse  actions  occurring  in other  States  than  of payments  and  adverse  actions 
occurring  in their  own States.  Hospitals  were  aware  of information  contained  in 
85 percent  of reports  from  other  States,  but  in only S5 percent  of reports  from  their 
own States.8  There  is no  clear  explanation  for  this,  except  that  because  most  of the 
reports  came  from  sources  within  the  same  State,  a small  number  of out-of-state 
reports  about  which  hospitals  had  information  drove  the  difference.9 
The  Data  Bank  has  delivered  accurate  reports  to hospitals. 
 
During  the  planning  and  early  implementation  of the  Data  Bank,  some  observers 
feared  that  erroneous  information  about  practitioners  could  be  relayed  from  the  Data 
Bank  to Data  Bank  queriers.l  But  the  Data  Banks  safeguards,  such  as allowing 
practitioners  to  dispute  reports  against  them,  seem  effective  in preventing  the  release 
of incorrect  reports.  Hospitals  had  almost  no  complaints  about  the  reliability  of 
information  in Data  Bank  reports.  No hospital  in our  sample  responded  that  the  Data 
Bank  report  it received  was inaccurate.11  Hospitals  evaluated,  or had  a chance  to 
evaluate,  the  accuracy  of the  information  by comparing  it to  information  they  had 
already  received  or by making  inquiries  of other  sources  after  they  received  the 
reports.  Their  judgments,  therefore,  are  good  indicators  of the  accuracy  of the 
reports. 
Furthermore,  there  is some  evidence  that  reporters  to the  Data  Bank--malpractice 
insurers,  licensing  boards,  and  so on--are  complying  fully with  reporting  requirements. 
only  one  hospital  said  that  the  response  it received  from  the  Data  Bank  was 
incomplete,  i.e., that  the  Data  Bank  should  have  had  additional  information  on the 
practitioner  in question.12  We  cannot  judge,  however,  whether  or  not  underreporting 
is a significant  problem.  Although  it seems  that  the  Data  Bank  has  full information  on 
those  practitioners  who  are  reported,  there  remains  the  possibility  that  practitioners  . 
who  should  have  been  reported  to  the  Data  Bank  never  were. 
The  Data  Banks  average  response  time  has  been  steadily  improving.  Over  an 
 
18 month  period,  median  response  time  has  dropped  from  123 days  to  26 days. 
Timeliness  is an  important  factor  in the  usefulness  of Data  Bank  reports.  In specifying 
the  timing  of required  queries,  Federal  regulations  imply  that  information  from  the 
Data  Bank  should  be  used  when  hospitals  consider  practitioners  applications  for 
clinical  privileges.  For  Data  Bank  reports  to be  used  in this  manner,  they  must  arrive 
at  hospitals  before  the  privileging  decisions  are  made.  When  the  Data  Bank  first 
opened,  it was not  responding  efficiently  to queries.13  For  queries  submitted  in the 
third  quarter  of  1990, just  44 percent  of reports  arrived  before  hospitals  made  the  final 
decisions  on  the  practitioners  involved.14  The  proportion  arriving  in time  rose  to  66 
percent*5  in the  first  quarter  of  1992. 
The  Data  Banks  performance  is better  reflected  by response  time  than  by on-time 
arrivals,  because  Data  Bank  operators  have  no control  over  the  time  allowed  by 
4  hospitals  between  submitting  a query  and  making  a final  decision.  If a hospital 
submits  a query  just  a day before  making  a decision,  the  Data  Bank  has  no  chance  to 
respond  in time.  The  Data  Bank  has  shown  great  improvement  in response  time  since 
its opening.  Median  response  time  was  123 days for queries  that  were  submitted  in 
the  third  quarter  of  1990, but  by the  first  quarter  of  1992, median  response  time  had 
fallen  to  26 days.]b 
The  Data  Banks  poor  response  time  early  in its history  was partly  due  to  the  problem 
of partial  matches.  A partial  match  occurs  when  a query  and  a report  match  on 
some  pieces  of identifying  information,  but  on too  few to confirm  that  the  practitioners 
named  in the  query  and  in the  report  are  the  same  person.17  Partial  matches  require 
human  review  to  determine  if they  are  indeed  true  matches.18  They  constituted 
about  40 percent  of all matches  through  March  1992, and  at  least  25 percent  of the 
reports  received  by our  suxvey respondents.  Until  Januaxy  1992, the  Data  Bank 
computers  could  not  be  programmed  to  accept  the  results  of human  reviews,  and  all 
queries  resulting  in partial  matches  were  placed  on hold.  This  means  some  queries 
made  in  1990 and  1991 did not  generate  reports  in response  for  over  a year.  Now 
that  the  needed  computer  program  has been  written,  partial  matches  are  resolved  with 
approximately  one  weeks  delay. 
Hospital  officials  found  58 percent  of Data  Bank  reports  to be  useful.  As the 
 
Data  Banks  response  time  has  improved,  so has  the  proportion  of reports 
rated  useful. 
Measured  by hospital  officials  assessments,  a moderate  majority  (58 percent)  of Data 
Bank  reports  received  between  September  1, 1990, and  March  19, 1992, have  been 
useful.  A key determinant  of a reports  usefulness  is its timeliness.  As response  times 
have  fallen  since  1990, usefulness  ratings  have  risen.  None  of the  reports  that 
matched  queries  made  in the  third  quarter  of  1990 were  judged  useful,  compared  with 
74 percentlg  of reports  that  matched  queries  made  in the  first  quarter  of  1992 (figure 
1). 
The  most  frequently  cited  reason  for  Data  Bank  reports  usefulness  was  that 
 
they  confirmed  information  about  practitioners  that  hospital  officials  already 
knew.  Other  reasons  cited  include  the  reports  help  in making  judgments  about 
practitioners  competency  and  their  provision  of information  not  already  known. 
of  the  reports  hospital  officials  considered  useful,  60 percentw  were  deemed  useful 
at  least  in part  because  they  confirmed  other  available  information.  The  next  most 
frequently  cited  reasons  were  that  they  helped  hospitals  to judge  practitioners 
competency  (37 percent2*  of useful  reports)  and  that  they  provided  information 
unavailable  elsewhere  (30 percent22  of useful  reports).= 
Not  all hospital  officials  valued  reports  that  confirmed  available  information.  Of the 
reports  considered  not  useful,  hospital  officials  considered  52 percentx  not  useful 
precisely  because  they  were  duplicative. 
5  FIGURE  1 
As  Response  Time  Decreased,  Usefulness  of 
130 Data  Bank  Reports  Increased  r
1  100 
-$0 
llo -
-80 
1oo-
90- -70 
80-
-60 
70-
-50 
60-
50- - -40 
40-
-90 
30-
-20 
20-
lo- -10 
0  Lu  1  !  1  !  1  I  -o 
1990:Q3  1wo:m  1991:Ql  1991:a2  1991:Q3  1991:Q4  1992Q1 
n-4  ~.7  n-l 9  n.=  n-s)  n-2s  n-l 8 
Quarter of Query
SOURCE:  OIG  Survey  of Hospitals,  Spring  1992 
Neither  the  source  of reports  nor,  for  malpractice  reports,  the  payment  amount 
 
affected  the  proportion  of Data  Bank  reports  that  hospital  officials  rated  useful. 
There  were  no  significant  differences  in the  percentage  of reports  judged  useful 
because  of the  type  of incident  involved  (payment  vs. adverse  action),  amount  of 
malpractice  payment,  location  of report  (in-State  vs. out-of-State),  or  type  of adverse 
action  (table  1).  These  results  are  contrary  to  expectations.  We  anticipated that 
certain  types  of information  held  in the  Data  Bank  would  prove  more  useful  to 
hospitals  than  others.  We  thought  that  reports  of adverse  actions  would  be  more 
useful  than  reports  of malpractice  payments,  for  example,  and  that  reports  of large 
malpractice  payments  would  be  more  useful  than  reports  of small  ones. 
Some  groups,  notably  the  American  Medical  Association  and  the  Physicians  Insurance 
Association  of America,  have  argued  that  small  malpractice  payments  are  not 
indicative  of incompetence  and  should  not  be  reported  to the  Data  Bank.  The  equal 
amounts  of large  and  small  malpractice  payments  rated  useful  confirms  our  conclusion 
that  small  payments  should  continue  to be  reported.  (For  further  discussion  of 
malpractice  payment  reporting,  see  our  April  1992 report,  National  Practitioner  Data 
Bank:  Malpractice  Reporting  Requirements.) 
6  TABLE  1 
USEFULNESS  TO HOSPITALS  OF DIFFERENT  TYPES 
OF DATA BANK REPOR~ 
Type  of report  Reports considered useful 
Incident involved 
Malpractice  payment  59% 
I  Adverse  action  I  57%  I 
Amount of malpractice payment 
Less than  $30,000  57% 
I  $30,000  or more  I  61%  I 
I  I 
I Typ  of adverse  action 
I  Board  licensure  action  I  53%  I 
Hospital  privileges  action  64% 
Location of report 
Out-of-State  81% 
I  In-State  I  56%  I 
Note:  None  of these  differences  is significant  at  the  95 percent  confidence  level. 
SOURCE:  OIG  Survey  of Hospitals,  Spring  1992 
IMPACT  ON DECISIONS:  Data  Bank  rep~  rare~ lid  hmpitdk  to make privikging 
&cimims  they would  not huve made  without  the reprts,  even when the repmls provided 
information  that hospitak  did not aliea@  know. 
z 
The  impact  that  receiving  information  from  the  Data  Bank  has  on hospitals  can  be 
characterized  in several  ways.  Impact  may  include  giving hospital  administrators 
confidence  that  they  have  complete  information  about  their  medical  staffs.  It may 
include  adding  information  to practitioners  files that  could  be  used  in the  future 
should  questions  arise.  But  Data  Bank  reports  can  have  their  most  direct  impact  by 
affecting  the  outcome  of decisions  on practitioners  who  have  just  applied  for  new  or 
continued  hospital  privileges.  For  this reason,  we asked  hospitals  the  following 
question:  Would  your  decision  regarding  the  practitioner  have  been  different  if you 
had  not  received  the  Data  Bank  report?  Because  our  measurement  of impact  focused 
on the  privileges  decisions,  we  did not  include  in this  analysis  any  situations  when  the 
decisions  were  still pending.  Sixteen  percent  of Data  Bank  reports  involved  practitioners  for whom  the  hospitals  privileging  decisions  were  still pending  at  the 
time  of our  survey. 
According  to hospital  officials,  if hospitals  had  not  received  the  Data  Bank 
 
reports,  their  privileging  decisions  would  have  been  different  one  percent  of the 
time. 
Some  hospitals  that  made  adverse  decisions  on privileges  would  have  made  them  even 
in the  absence  of a report  from  the  Data  Bank.  Eight  percentx  of Data  Bank 
reports  were  on practitioners  whose  privileges  were  later  revoked,  denied,  or  restricted 
by the  hospital  requesting  the  report.  A small  proportion  of these  reports  (one 
percent  of all reports)  provided  information  that  caused  hospitals  to  deny,  revoke,  or 
restrict  privileges  that  they  otherwise  would  have  granted.  In these  cases,  the 
information  provided  by the  Data  Bank  was a key factor  in the  decision  (see  box,  next 
, 
page). 
Eighty  percent  of Data  Bank  reports  had  little  chance  to have  an  impact  on 
 
hospitals  privileging  decisions.  Each  of these  reports  either  arrived  after  the 
decision  was made  or duplicated  available  information. 
There  were  a variety  of reasons  why it was unlikely  for Data  Bank  reports  to  have  an 
impact  on  privileging  decisions.  When  hospitals  received  reports  after  their  privileging 
decisions  had  been  made,  the  reports  clearly  could  not  affect  the  initial  granting  of 
privileges.  Theoretically,  reports  received  after  a decision  to grant  privileges  could 
have  caused  hospitals  to  decide  to revoke  privileges,  but  according  to a credentialing 
expert  at  the  Joint  Commission  for Accreditation  of Hospitals,  revoking  privileges 
once  they  have  been  granted  is an  extremely  difficult  process.  When  hospitals  were 
already  aware  from  other  sources  of the  information  in the  Data  Bank  reports,  the 
reports  themselves  were  unlikely  to  affect  privileging  decisions.  Hospital  officials  who 
received  confirming  information  may  have  felt  more  confident  about  decisions  they 
were  planning  to make,  but  they  probably  would  not  alter their  decisions  based  on 
duplicative  information. 
Eighty  percent  of the  reports  had  little  chance  of having  an  impact  on decisions,  for 
the  following  reasons: 
Eight percent27  of reports  named  practitioners  who  did not  go through  the 
privilege  decision  process.  These  practitioners  either  withdrew  their 
applications  (6 percent)  or requested  only temporary  privileges  (2 percen~). 
Th.irty-ei@t  percent  of reports  were  not  received  prior  to hospitals  making 
decisions.  For  eighteen  percent,  the  hospitals  did not  query  the  Data  Bank 
until  after  the  decisions  and  for  twenty  percent,  they  queried  in advance  of the 
decisions, 
8  WHEN  THE  DATA  BANK  MAKES  A DIFFERENCE 
The  information  in National  Practitioner  Data  Bank  reports  has  caused  some 
hospitals  to revoke  practitioners  privileges.  The  following  three  cases  were 
included  in our  sample: 
E  In January  1991, a physician  was put  on five year  probation  by a State 
medical  licensing  board.  The  board  reported  this  information  to  the  Data 
Bank  citing  the  physicians  incompetence,  malpractice,  and/or  negligence. 
Eleven  months  later  he  applied  for  hospital  credentials  within  the  same 
State  and  did  not  disclose  this  information.  The  hospital  made  a query  to 
the  Data  Bank  12 days  after  receipt  of the  application  and  received  a 
response  16 days later.  The  response  included  notice  of the  probation 
along  with  5 other  reports.  The  hospital  was not  aware  of the  probation 
from  any  other  source.  Six days later  his application  was denied. 
  In August  1991, a physician  who  had  applied  for  privileges  in December 
1989 was granted  them  after  an  extensive  delay  due  to an  incomplete 
application.  Also  in August,  the  hospital  learned  from  the  Data  Bank  that 
the  physician  had  resigned  from  another  hospital  six months  earlier  while 
he was  under  investigation  for  incompetence  or  misconduct.  The  Data 
Bank  also  reported  two  other  incidents.  The  hospital  was not  aware  of 
the  resignation  from  any other  source.  The  next  month,  the  hospital 
revoked  the  physicians  privileges. 
F  In October  1990, a physician  applied  for  privileges  to  a hospital  which 
queried  the  Data  Bank  in November  1990.  The  hospital  granted 
tempora~  privileges,  with  the  final  decision  pending  review  of the  Data 
Bank  information.  In December  1990, the  physician  resigned  privileges  at 
another  hospital  where  he was under  investigation  for incompetence  and 
this  hospital  reported  the  information  to the  Data  Bank.  The  Data  Bank 
response  detailing  this  action  came  to  the  querying  hospital  in February 
1991 and  provided  information  the  hospital  had  not  received  from  any 
other  source.  At  this  time  the  hospital  acted  to suspend  the  physicians 
privileges  indefinitely.  Before  the  suspension  could  be  resolved,  the 
physician  resigned. 
SOURCE:  C)IG Survey  of Hospitals,  Spring  1992 
9  Thirty-four percent  of reports,  though  received  by hospitals  before  credentialing 
decisions  were  made,  provided  only information  already  known  to  the  hospitals. 
The  remaining  20 percent  of reports  were  received  prior  to the  decision  and  provided 
information  that  was  not  available  elsewhere.  These  reports  had  the  potential  for 
having  an  impact  on  hospital  privileging  decisions.  One  percent  x  of the  reports  did 
cause  hospitals  to  alter  decisions  (see  above),  leaving  nineteen  percent  which  had  the 
potential  to have  an  impact  on decisions  but  did not. 
Nineteen  percent  of Data  Bank  reports  arrived  before  hospitals  decisions  were 
 
finalized  and  contained  information  that  neither  the  practitioner  involved  nor 
any  other  sources  had  provided,  but  did not  cause  the  hospitals  to  alter  their 
9 
privileging  decisions. 
Some  hospitals  explain  that  the  Data  Bank  reports,  even  when  they  are  received  prior 
to the  decision  and  do  not  duplicate  information  from  other  sources,  are  not  useful. 
About  half  of such  reports  were  considered  not  useful,  most  often  because  they  could 
not  help  judge  competency  or professionalism.  Hospitals  found  the  other  half  useful, 
but  did not  alter  decisions  based  on the  information.  In all of these  cases,  regardless 
of whether  they  found  the  reports  useful,  hospitals  granted  full privileges  to  the 
practitioners  named  in the  reports.29 
Although  Data  Bank  reports  are  not  necessarily  in themselves  firm  evidence  of 
incompetence  or unprofessionalism,  practitioners  who  do not  disclose  information 
contained  in the  reports  may be  misrepresenting  their  applications  for  privileges.w 
Practitioners  are  expected  to inform  hospitals  of the  malpractice  payments  and 
adverse  actions  that  are  reported  to the  Data  Bank.31 
Many  reports  that  provided  new  information  but  did  not  affect  privileging  decisions 
involved  small  malpractice  payments  ($30,000  or less)  or minor  adverse  actions  (for 
example,  a small  fine  for  having  submitted  a false  medical  claim).  It appears  that 
some  hospital  boards  do not  believe  that  either  these  incidents  or the  practitioners 
failures  to  disclose  them  are  serious  enough  to warrant  adverse  privilege  decisions. 
Other  reports  detail  serious  actions  that  alone  might  call into  question  the 
practitioners  ability  or behavior  and,  because  they  were  not  disclosed  by the 
practitioners,  could  also  raise  concerns  about  the  practitioners  trustworthiness.  For 
example,  one  doctor  resigned  his privileges  at  a hospital  just  before  a scheduled 
disciplinary  hearing  at which  he  faced  a three-month  suspension.  Nine  months  later, 
he  applied  to another  hospital  and  failed  to report  his earlier  resignation.  In another 
case,  a dentist  had  been  barred  by a State  licensing  board  from  practicing  on young 
children  except  within  a hospital  setting.  He  failed  to report  this  action  in his 
application.  In both  of these  cases,  hospital  officials  said  that  the  reports  of these 
incidents  they  got  from  the  Data  Bank  were  useful  because  they  provided  information 
unavailable  elsewhere.  In the  first  case,  a hospital  official  said  the  Data  Bank 
information  helped  the  hospital  judge  the  doctors  professionalism  and  that  it led  to an 
10  investigation  of the  circumstances  surrounding  the  previous  resignation.  Nevertheless, 
both  practitioners  were  granted  privileges  as requested. 
11  RECOMMENDATIONS

Our  findings  indicate  that  the  usefulness  and  impact  of the  information  in the  Data 
Bank  are  strongly  affected  by the  timeliness  of the  reports.  In fact,  this  is the  only 
area  the  Data  Bank  administrators  can  affect  that  appears  to need  improvement  and 
has  an  impact  on  the  usefulness  of the  Data  Bank  reports. 
Our  recommendations,  therefore,  identify  steps  that  PHS  and  hospitals  need  to take  to 
improve  the  timeliness  of Data  Bank  reports,  since  PHS  shares  the  responsibility  for 
timeliness  with  the  hospitals  that  query  the  Data  Bank.  Hospitals  also  have 
responsibility  for  much  of the  impact  of the  Data  Bank.  Reports  from  the  Data  Bank, 
particularly  those  that  provide  information  not  available  from  other  sources,  should  be 
important  considerations  in hospitals  privileging  decisions. 
?he PHS shod  seek to reduce fidm  the time  between  query and rapons~  and should 
makz  thh a high pti~  in its next con~act for o~ration  of the Data  Bank  l%e PHS 
should publish  recently established Pefoimance  indicaton  rekiting to ruponse  time  in ti 
annual reprt  on the Data  Bank 
While  we are  encouraged  by the  improvements  PHS  has  made  in response  time,  this 
progress  must  continue.  The  PHS  and  its contractor  have  contractual  standards  for 
turnaround  time  (5 working  days for  single  name  queries  and  20 working  days for 
multi  le name  queries).  The  contractor  is currently  meeting  them  most  of the 
f
time.  2  The  contractor  processes  queries  by reentering  information  submitted  on 
paper  into  their  computerized  system.  While  current  standards  may  represent  the 
limits  of timeliness  in a paper-based  system,  the  PHS  could  likely improve  overall 
response  time  if the  querying  and  reporting  system  were  electronic.  The  PHS  has 
recently  completed  testing  a new  system  for  handling  electronic  queries  and  began 
implementing  diskette  and  telephone  queries  in September  1992.  We  welcome  these 
innovations  and  suggest  that  the  PHS  consider  testing  on-line  queries  and  responses. 
The  PHS  could  also  focus  on ways to  reduce  the  number  of partial  matches,  which, 
unlike  most  matches,  require  human  intervention  to  complete. 
The  PHS  is in the  process  of determining  priorities  and  strategies  for  procuring  its 
second  contract  for  administration  of the  Data  Bank  (the  current  contract  expires  on 
December  31, 1993).  The  PHS  should  assure  that  timeliness  is given  a primary  focus 
in the  next  contract. 
The  PHS  recently  established  performance  indicators  concerning  response  time.  The 
PHS  tracks  the  average  response  time  on  a weekly  basis.  In order  to  assure  public 
accountability,  the  PHS  should  include  these  statistics  in the  Data  Bank  annual  report 
and  report  them  at  the  Data  Bank  Executive  Committee  meetings. 
12
 h?  Joint Comrni%sion for Accreditatwn  of Healthcare  Organizations  (JCAHO)  shouki 
eistablkh guideliiws  on how quckly hospitak  query the Data  Bank  a@r  receiving 
shotdii 
applihatwns for privileges. 
In order  for  the  Data  Bank  reports  to be  useful,  they  have  to be  available  to hospitals 
at  key decision  points.  Hospitals  that  make  queries  to the  Data  Bank  after  privileging 
decisions  limit  themselves  to  retrospective  disciplinary  actions.  Sixteen  percent  of 
reports  were  received  after  the  privi]e  ing decisions  were  made  because  the  hospitals
!
did  not  query  until  after  the  decisions.  3 
The  JCAHO  is responsible  for  reviewing  hospitals  policies  and  procedures  and  thus 
quali&ing  them  for  Federal  reimbursement.  The  JCAHO  in its current  hospital 
accreditation  manual  does  not  mention  the  National  Practitioner  Data  Bank,  but  it 
does  in a supplemental  guide  which  clarifies  the  intent  of the  manual.  According  to 
this guide,  hospitals  are  expected  to request  information  from  the  Data  Bank  for  every 
new  applicant  and  are  expected  to query  at  least  once  every  two years  for  currently 
credentialed  staff  (in compliance  with  Federal  law).  The  JCAHO  encourages  hospitals 
to  consider  this  information  when  making  decisions  on applications.  The  JCAHO 
manual  and  supplement  do not  speci~  how quickly  this inquiry  should  be  made  after 
receipt  of the  application.  Therefore,  hospitals  may be  fully complying  with  the  intent 
of JCAHO,  yet  may  not  have  any chance  of receiving  information  before  making  their 
decisions.  The  JCAHO  should  establish  guidelines  to make  it likely  that  hospitals 
receive  information  prior  to making  a decision. 
13  COMMENTS  ON  THE  DRAFT  REPORT 
From  within  the  Department  of Health  and  Human  Semites,  we received  comments 
on our  draft  report  from  the  Public  Health  Service  (PHS),  the  Assistant  Secretary  for 
Management  and  Budget  (ASMB),  and  the  Assistant  Secretary  for  Planning  and 
Evaluation  (ASPE).  We  also  received  comments  from  the  Joint  Commission  on 
Accreditation  of Healthcare  Organizations  (JCAHO),  the  American  Hospital 
Association  (AHA),  and  the  American  Medical  Association  (AMA).  In appendix  C, 
we reproduce  these  comments  in full and  provide  our  responses  to  them. 
The  PHS  concurred  with  our  recommendations  and  has  begun  to implement  th~m. 
The  ASMB  concurred  with  our  recommendations  and  suggested  three  additional 
recommendations.  We  agree  with  the  intent  of ASMBS suggestions,  and  direct  PHSS 
attention  to them.  Nevertheless,  as we explain  in appendix  C, we chose  not  to 
incorporate  ASMBS recommendations  into  our  report. 
The  ASPE  raised  concerns  about  whether  our  report  successfully  answers  the  question 
of how  useful  Data  Bank  information  is to  hospitals.  At ASPES suggestion,  we have 
provided  more  precise  statistical  information  than  was contained  in the  draft  report. 
For  reasons  provided  in appendix  C, however,  we disagree  with  some  of ASPES 
interpretations  of our  results. 
The  JCAHO,  in response  to  our  recommendation,  will consider  adding  guidelines  on 
the  timeliness  of queries  to the  Data  Bank  in its next  accreditation  survey. 
The  ~  though  pleased  that  the  Data  Bank  is providing  complete  and  accurate 
information,  perceives  the  Data  Bank  as merely  a back-up  tool in hospital 
credentialing  and  questions  whether  the  Data  Banks  usefulness  justifies  its costs. 
We  believe  that  the  high  percentage  of reports  supplying  new  information 
demonstrates  that  the  Data  Bank  is more  than  a back-up  tool.  The  AI-IA also 
questions  the  wisdom  of developing  new  JCAHO  guidelines  for  querying  when  many 
hospitals  have  already  established  such  guidelines  on their  own.  We  believe  that 
action  by JCAHO  would  simplify  rather  than  complicate  hospital  policy  establishment. 
The  AMA  criticized  our  sampling  methodology  and  questioned  our  interpretation  of 
some  of our  survey  results.  We  explain  in appendix  C that  our  sampling  methodology 
was appropriate  given  the  purpose  of our  study,  and  we offer  further  explanation  of 
our  interpretations.  APPENDIX  A 
METHoDomGY 
We  collected  the  data  presented  in this  report  through  a mail  survey  of hospitals 
conducted  from  April  to June  1992.  our  survey  sample  was  drawn  from  the  universe 
of all Data  Bank  matches  involving  hospitals  between  September  1, 1990, and  March 
19, 1992.  A match  is a pairing  of a report  and  a query  to  the  Data  Bank  that  name 
the  same  practitioner.  We  requested  and  received  from  Paramax  Systems  Corporation 
a computer  file containing  records  of all Data  Bank  queries  and  reports  that  identified 
the  same  practitioner.  We  restructured  and  analyzed  the  data  using  Version  6.04 of 
the  SAS System  for  Personal  Computers. 
We drew  a stratified  random  sample  of 200 matches  from  the  universe  of 19,122 
matches.w  The  sample  consisted  of  100 matches  involving  malpractice  payment 
reports  and  100 matches  involving  adverse  action  reports. 
In April  1992, we mailed  a questionnaire  about  each  report  to  the  hospital  involved. 
There  were  195 hospitals  that  received  questionnaires;  five hospitals  were  each  sent 
questionnaires  on  two different  practitioners.  We  followed  this with  a second  mailing 
to  nonrespondents,  then  follow-up  telephone  calls to remaining  nonrespondents.  All 
responses  used  in the  analysis  were  received  by June  12.  Appendix  B shows  the 
questionnaire  and  simple  frequencies. 
Questionnaires  were  addressed  to the  person  whose  name  appeared  on the  original 
query  to the  Data  Bank.  Most  respondents  held  the  position  of medical  staff 
coordinator  or  the  equivalent.  A few respondents  were  the  chief  executive  officers  of 
their  hospitals. 
our  response  rate  was  71 percent.  Responses  were  evenly  split  by type  of Data  Bank 
report  (72 adverse  action  reports  and  70 malpractice  payment  reports).  The  reports 
on which  we received  responses  appear  to represent  fairly  the  reports  in the  universe 
of matches.  For  example,  of the  70 responses  about  malpractice  payment  reports,  53 
percent  were  for  payments  of $50,000  or  less; overall,  47 percent  of the  matches  were 
for  payments  of $50,000  or less. 
Fifty-seven  percent  of the  respondents  queried  the  Data  Bank  because  of mandatory 
two-year  review  requirements,  42 percent  queried  on initial  privileging  or  employment 
applications,  and  one  queried  for  professional  review  purposes.  Of the  72 responses 
based  on  adverse  actions,  51 percent  were  state  licensing  board  actions,  47 percent 
were  hospital  clinical  privileges  actions  and  1 was a professional  society  membership 
action.  The  most  commonly  specified  reason  for  adverse  action  was 
incompetence/malpractice/negligence  (14 percent);  the  most  commonly  cited  type  of 
act  or omission  cited  in the  malpractice  actions  was  surgery-related  (36 percent). 
Ninety-seven  percent  of the  respondents  queried  about  physicians  (the  other 
A-1  practitioners  were  dentists  and  podiatrists).  The  specialties  of the  physicians  are  listed 
in table  A. 
Analysis  of nonrespondents  showed  no significant  differences  between  respondents  and 
nonrespondents  according  to bed  size, teaching  status,  hospital  ownership,  or services 
offered.  (We  obtained  this  information  on all hospitals  in our  sample  from  the 
American  Hospital  Associations  Guide  to the Health  Care Field,  1992 edition.) 
There  were  141 hospitals  represented  in the  responses.  Of the  five hospitals  that  had 
been  sent  two questionnaires,  one  returned  both  and  four  did  not  respond  at  all. 
Respondent  hospitals  are  profiled  in table  B.
. 
Because  adverse  action  matches  represented  51 percent  of the  survey  responses  but 
only  11.5 percent  of the  universe,  we assigned  weights  to  each  observation  that  allow 
us to  extrapolate  tothe  universe  of matches.  These  weights  equaled  1.80 for 
malpractice  payment  matches  and  0.23 for  adverse  action  matches.  All statistics 
presented  in this  report  were  computed  using  these  weights,  except  for  those  statistics 
that  pertain  only to either  the  subsample  of malpractice  payment  matches  or to  the 
subsample  of adverse  action  matches. 
Without  the  weights,  the  analyses  would  have  been  overly  representative  of adverse 
actions.  In some  cases,  this would  not  have  made  much  of a difference.  For  example, 
58.4 percent  of reports  were  rated  useful  when  weighting  was done,  while  57.7 percent 
were  rated  useful  without  weighting.  The  weighting  was more  important  in other 
cases.  Using  weighted  figures,  47 percent  of reports  yielded  information  that  the 
practitioners  named  in those  reports  did  not  provide;  using  unweighed  figures, 
52 percent  of reports  yielded  this  type  of information.  Table  C compares  some  of the 
weighted  and  unweighed  figures. 
Unless  otherwise  noted,  suxvey results  presented  as percentages  have  a margin  of 
error  of approximately  7 percent  at  a 90 percent  confidence  level.  For  example,  we 
are  90 percent  confident  that  the  true  percentage  of Data  Bank  results  judged  useful 
is between  51 and  65 percent  (58 percent  plus  or minus  7 percent). 
A-2
 TABLE  A 
TYPES  OF PRACTITIONERS 
Type  of practitioner  Number of  Percentage  of 
matches  matches 
TOTAL  142  100.0 
PHYSICIANS  137  96.5 
General  Surgery
 23  16.2 
Family  Medicine
 21  14.8 
Internal  Medicine
 12  8.5 
Orthopedic  Surgery
 11  7.8 
Emergency  Medicine
 9  6.3 
Pediatrics
 7  4.9 
Neurological  Surgery
 7  4.9 
Obstetrics  and  Gynecology
 7  4.9 
Urology
 5  3.5 
General  Medicine
 4  2.8 
Anesthesiology
 4  2.8 
Ophthalmology
 3  2.1 
Radiology
 3  2.1 
Other  or Missing
 3  2.1 
Cardiac  Surgery
 2  1.4 
Cardiology
 2  1.4 
Gynecology  (Osteopathic)
 2  1.4 
Gastroenterology
 2  1.4 
Eye,  Ear,  Nose,  and  Throat
 2  1.4 
Plastic  Surgery
 2  1.4 
Psychiatry
 2  1.4 
Thoracic  Surgery
 2  1.4 
Oncology
 1  0.7 
Allergy
 1  0.7 
DENTISTS  and  ORAL  4  2.8 
SURGEONS 
PODIATRISTS  1  0.7 
SOURCE:  OIG  Suxvey of Hospitals,  Spring  1992 
A-3
 TABLE  B 
PROFILE  OF RESPONDENT  HOSPITALS 
TEACHING  STATUS 
Status  Number  of Hospitals  Percent  of All Hospitals 
Teaching  43  30.3 
Non-Teaching  98  69.0 
HOSPITAL  OWNERSHIP 
Control  Number  of Hospitals  Percent  of All Hospitals 
Government- 23  16.2 
owned 
Nongovernment  96  67.6 
Not-for-profit 
Investor-owned  22  15.5 
Partnership  1  0.7 
Corporation  21  14.8 
BED  SIZE  - TOTAL  FACILITY 
Bed  Size  Number  of Hospitals  Percent  of All Hospitals 
Under  100 Beds  25  17.6 
100-199  Beds  33  23.2 
200-299  Beds  29  20.4 
300-399  Beds  22  15.5 
400-499  Beds  9  6.3 
500 or  More  Beds  23  16.2 
SOURCE:  OIG  Suxvey of Hospitals,  Spring  1992 
A-4  . 
TABLE  C 
WEIGHTED  VS. UNWEIGHED  RESUL7S 
Analysis  Weighted  Unweighed 
How  many  reports  were  rated  useful?  58.4%  57.7% 
How  many  reports  were  actively  reviewed  by at  74.0%  73.2% 
least  one  hospital  official? 
How  many  reports  that  were  received  on time  86.5%  88. 1% 
were  actively  reviewed  by at  least  one  hospital 
official? 
Of reports  found  useful,  how many  reports  59.6%  54.9% 
were  judged  so at  least  in part  because  they 
confirmed  other  available  information? 
Of reports  found  useful,  how  many  reports  37.4%  31.7% 
were  judged  so at  least  in part  because  they 
were  helpful  in judging  competency? 
How  many  reports  gave  hospitals  information  39.7%  38.7% 
that  was  otherwise  unavailable? 
How  many  reports  gave  hospitals  information  47.1%  52.1% 
that  the  practitioner  involved  in the  report  did 
not  provide? 
How  many  reports  had  a direct  impact  on  a  0.5%  2.1% 
hospitals  credentialing  decision? 
How  many  reports  were  on  practitioners  whose  8.1%  11.3% 
privileges  were  revoked,  denied,  or restricted  by 
the  hospital? 
How  many  reports  had  little  chance  of making  80.3%  82.8% 
a direct  impact  on a privileging  decision? 
Source:  OIG  Survey  of Hospitals,  Spring  1992 
A-5   APPENDIX  B 
SUMMARY  OF HOSPIT~  RESPONS~  TO OIG MAIL  SURVEY 
B-1  U.S. DEPARTMENT  OF  HEALTH  AND  HUMAN  SERVICES 
USE  AND  UTILITY  OF THE 
NATIONAL  PRACTITIONER  DATA  BANK 
NOTE:  The  first 29 questions  in this surveyconcern the case of practitioner A whoseidentity is givenon 
the last page of this questionnaire.  Unless othenvise specified, please confine your responses to your 
knowledgeof the particular practitioner and event referred to on that page. 
BASIC FACTS AND CHRONOLOGY 
1  What  is Practitioner  As specialty?  27 diflerent specialties  repr~ented  1 
2  On  what  date  did  Practitioner  A sign an  application  None:  5  2 
requesting  privileges  (either  new  or continued)  at  Ekdiest:   
your  hospital?  10/18/89 
Latest:  4/27/92 
No answez  3 
3  on  what  date  did you  request  information  about  Eadiest:  7/11/W  s 
Practitioner  A from  the  National  Practitioner  Data  Latest: 2/29/92 
Bank?  No answm  6 
4  on  what  date  did you  receive  a response  from  the  Nwer  receivd  2  A 
Data  Bank?  (Write NR if you  have not yet  received  Eadkst  11/9/90 
a response.)  Latest: 512/92 
No  am=  9 
5  On  what  date  did  the  hospital  board  make  its initial  No deckion  5 
decision  regarding  Practitioner  As privileges?  necessay:  13 
(Write  PENDING  if boardh  initial decision  has not  Still pending:  20 
yet  been made,  then skip to 14.)  Earliest:5/21/90 
Lutat: 4/23/92 
No anmwz  2 
6  Was  the  hospital  boards  initial  decision  a  Ya:  13  6 
temporary  one  pending  further  information?  No:  98 
Not  app.: I 
No answtm 30 
7  (Skip if you  answered ATOto 6)  still perldhg:  1  7 
on  what  date  did  the  hospital  make  its final  Eadikst:  1/2/91 
decision  regarding  Practitioner  As privileges?  Lutes: 2/6/92 
(Write PENDING Y boardk  final  decision  has not  No answec  129 
yet  been made,  then answer 8 through 13 with respect 
to the boardh  initial decision.) 
B-2  8  Were  privileges  granted  to Practitioner  A as  Ya:  %  8 
requested  by Practitioner  A?  No:  15 
Not  app.: I 
other I 
No  amwer  29 
9  (skip  ijyouanswered  YES to 8)  Ya:  7  9 
Were  Practitioner  As privileges  denied  (for  initial  No:  8 
application)  or  revoked  (for  renewal  application)?  Not  app.: 1 
No  ammz  126 
10  (Skip if you  answered  YES to 8 or 9)  Ya:  8  10 
Were  Practitioner  As privileges  restricted  or  No:  2  0 
amended  in any way?  Not  app.: 1 
No  answer  131 
11  (Skip if you  answered  YES to 8 or 9 or NO  to 10)  11 
In what  way were  Practitioner  As privileges  restricted  or amended? 
a  All privileges  suspended  (IF  YES,  FOR  HOW  Ya:  1  a 
LONG? 
) 
b  May  not  perform  certain  procedures  Ya:  5  b 
c  May  perform  certain  procedures  only with  another  Ya.= O  c 
practitioner 
d  May  co-admit  patients  only  Ya.= O  d 
e  Mandatory  consultation  for  certain  conditions  Ya.= O  e 
f  Mandatory  review  before  patient  admission  or  Y=:  O  f 
discharge 
g  Proctor  assigned  to review  Practitioner  As work  Ya.= 1  g 
h  Other  (IF  YES,  SPECIFY:  Ya:  4  h 
) 
12  (Skip if you  answered  YES to 8 or 9 or NO to 10)  Yw:  2  12 
Were  these  restrictions  on  Practitioner  As  No:  5 
privileges  in place  prior  to the  application?  oh  I 
No answer  134 
. 
B-3  13 
(Skip ifyou answered  YES108  or 9 or NO  to IO)  (Check  one)  13 
Which  of the  following  best  describes  the 
restrictions  applied  to Practitioner  As privileges? 
a  Routine  (e.g., procedure(s)  not  approved  at  this  5  a 
hospital,  restriction  applied  to all new hires,  etc.) 
b  Specific  to Practitioner  A (e.g., applied  because  of  3  b 
particular  event(s)  in Practitioner  As history) 
14	 Were  any other  actions  taken  with  regard  to  Ya:  18  14 
Practitioner  As employment,  privileges,  or  No: 110 
credentials  (e.g., education  requirements,  drug  Not app.: 1 
testing,  etc.)?  Otha 2 
(IF  YES,  EXPLAIN:  No answer  11 
)

AVAIIABIWIY  AND ACCURACY OF INFORMATION 
15	 Were  you  aware,  from  sources  other  than  the  Data  Y@: 84  15 
Bank,  of the  adverse  action  or malpractice  payment  No:  55 
mentioned  on  the  last  page  of this form?  other 2 
No anmwm 1 
B-4
 16	
(Sk@ if you  answered NO  to 15j
 16 
From  which  of the  following  sources  were  you aware  of the  adverse

action  or malpractice  payment?

a 
Practitioner  A (self-report)  Ya:67 
a 
No:  17

other I

No answm  57

b 
Licensing  board  in your  state  Ya:31  b 
No:  54

No  anmwm 57

c 
Licensing  board  in another  state  Ya:3  c 
No:  82

No answer  57

d 
Malpractice  insurer  in your  state  Y=:  7  d 
No:  77

other  I

No answer  57

Malpractice  insurer  in another  state  No:85
 e 
No answez  57

Other  hospital  in your  state  Y=:  16  f 
No:  69

No  answm  57

Hospital  in another  state	 Y=:  3
 g 
No:  82

No armwm  57

Professional  society  in your  state  Y6:  3  h 
No:  82

No  answm  57

Professional  society  in another  state  No:  85  i 
No answer  57

Other  source  in your  state  Y=:  12
 j 
(IF  YES,  SPECIFY:  No:  73

)  No answer  57

k 
Other  source  in another  state  Y~:  1  k 
(IF  YES,  SPECIFY:  No:  w 
)  No  ansmm  57

B-5
 17  (s@  VYOU  answered NO  to IS)  Ya:  3  17 
Was the  information  you  received  in  the  Data  Bank  No:  82 
response  inconsistent  in any way with  the  other  1 
information  reported  by any of the  above  sources?  No answm  56 
(IF  YES,  WHICH  SOURCES? 
Ractitwnm  I 
Ihsurer in-State:  1 
No answer: l) 
18  Did  you  make  additional  inquiries  (for  example,  to  Y=:  32  18 
a malpractice  insurer  or  another  hospital)  to  No:  108 
confirm  the  accuracy  of the  Data  Bank  response  or  other 1 
to obtain  more  detailed  information  on  its content?  No answer  1 
19  (Wp  ifyou answered  NO to 18)  Ya:  28  19 
Did  your  additional  inquiries  show the  Data  Bank  No:  I 
response  to be  accurate?  other 3 
(IF  NO,  EXPLAIN:  No answz  110 
) 
NOTE: Questions 20-23 refer to the entire Data Bank response, not just to the report attached to 
this questionnaire.  Therefore, if you received more than one report from the Data Bank on 
Practitioner  ~  please consider them all in answering Questions 20-23. 
20  Were  you  aware  of any disciplinary  actions  or  Ya:  9  20 
malpractice  payments  involving  Practitioner  A that  No:  131 
were  ~  contained  in the  response  from  the  Data  Not  app.: 1 
Bank?  No answer  I 
21  (Wp  ifyou answered NO  to 20)  21 
How  many  disciplinary  actions  and  malpractice  payments  were  you 
aware  of that  were  ~  contained  in the  response  from  the  Data 
Bank? 
a  Number  of disciplinary  actions  0: S  a 
1:3 
b  Number  of malpractice  payments  O: 2  b 
1:4 
2:1 
5:2 
B-6  22  (sk~  fyou  answered NO to 20)  22 
How  many  of these  disciplinary  actions  and  malpractice  payments 
occurred  after  September  1, 1990? 
a  Number  of disciplinary  actions  0:7  a 
b  Number  of malpractice  payments  O: 6  b 
4:1 
23  (Skb  ~you  answered NO  to 20)  23 
Which  of the  following  sources  provided  information  about  disciplinary 
actions  or malpractice  payments  that  were  @  contained.  in the 
response  from  the  Data  Bank? 
a 
Practitioner  A (self-report)  Y=.= 7 
b 
Licensing  board  in your  state  Y~:  O 
c 
Licensing  board  in another  state  Ya:  O 
d 
Malpractice  insurer  in your  state  Ya:  O 
e 
Malpractice  insurer  in another  state  Y=:  1 
f 
Other  hospital  in your  state  Ya:  O 
g  Hospital  in another  state  Ya:  1 
h 
Professional  society  in your  state  Ya:  O 
i 
Professional  society  in another  state  Ya:  O 
j  Other  source  in your  state  Ya:  2 
(IF  YES,  SPECIFY: 
k 
Other  source  in another  state  Ya:  1 
(IF  YES,  SPECIFY: 
B-7  CONSIDERATION  OF INFORMATION 
24  Based  on  the  notes  in Practitioner  As file and  your  personal  24 
knowledge  of Practitioner  As application,  which  of the  following 
people  or groups  had  access  to and  used  the  response  from  the  Data 
Bank  in making  a decision  regarding  Practitioner  As  implication? 
a 
Department  chair  Y=:  80  a 
No:  46 
Not  app.: 8 
other 2 
No answer  6 
b 
Chief  of medical  staff  Ya:  71  b 
No: 58 
Not  app.: 5 
Othec2 
No amwen  6 
c  Hospital  administration  (CEO,  Vice  President,  etc.)  Ya:  67  c 
No: 62 
Not  app.: 5 
other 2 
No amver  6 
d  Credentials  committee  Ya:  80  d 
No: 45 
Not  app.: 9 
other 2 
No answm  6 
. 
e  Medical  staff  executive  committee  Ya:  66  e 
No: 62 
Not  app.: 6 
other 2 
No anmw  6 
. 
f 
Hospital  board  subcommittee  Ya:  28  f 
No:  90 
Not  app.: 15 
other 2 
No  answez  7 
t!  Full  hospital  board  Ya:  59  g 
No: 69 
Not app.: 5 
other 2 
No answer  7 
B-8  UTILIW  OF INFORMATION 
25  Including  the  report  on the  last  page,  how many  25 
Data  Bank  reports  on Practitioner  A did you  Mean= 1.53 
receive  in total  from  this  request?  S.D.: 1.02 
26  (Skip ifyou answered  1to 25)  Ya:  24  26 
Overall,  was the  information  conta.i ned  in the No: 14 
complete  Data  Bank  response  (i.e., all reports  other 1 
combined)  useful  to you?  No answer  103 
IF YES,  WHY?  (Check all that 
appty) 
a  Information  was unavailable  elsewhere  5  a 
b  Information  confirmed  other  reports  that  were  16  b 
available  elsewhere 
c  Information  helped  us to judge  practitioners  10  c 
competency 
d  Information  helped  us to judge  practitioners  10  c1 
professionalism 
  Other  (EXPLAIN:  )  2  e 
IF NO,  WHY  NOT?  (Check alI that 
apply) 
f  Information  was  available  elsewhere  10  f 
g  Information  was inaccurate  o  i? 
h  Information  did not  help  us to judge  practitioners  7  h 
competency  or professionalism 
i  Information  was not  provided  in a timely  manner  7  i 
J  Other  (EXPLAIN:  )  3  j 
B-9  27	 (Sk(p ~you  answered  1to 25)  YG: 2  27 
Would  y(mr decision  regarding  Practitioner  A have 
No:  35 
been  different  if you  had  @  received  the  reports 
Otha 3
from  the  Data  Bank?  (IF  YES,  HOW?) 
No answer  102 
(~ Es,  check one.) 
a 
Would  have  granted  requested  privileges 
1 
b 
Would  not  have  granted  requested  privileges 
o  I 
c 
Would  have  restricted  privileges 
o 
d 
Would  not  have  restricted  privileges 
o  ( 
e  Other	 [EXPLAIN:  ) T 
\  1
)  1
28	
overall,  was the  information  contained  in the  Data 
_ Y=:  82
Bank  report  on  the  last  page  useful  to you? 
No: 54 
Othez4

No answer  2

IF YES,  WHY?  (Check al! that 
apply) 
a 
Information  was unavailable  elsewhere 
28 
b 
Information  confirmed  other  reports  that  were 
45 
available  elsewhere 
c  Information  helped  us to judge  practitioners 
26 
competency 
d 
Information  helped  us to judge  practitioners 
17 
professionalism 
e  Other  (EXPLAIN: 
)  8 
IF NO,  WHY  NOT? 
(Check a!! that 
apply) 
f 
Information  was available  elsewhere 
34 
g  Information  was inaccurate 
1 
h  Information  did  not  help  us to judge  practitioners 
26 
competency  or professionalism 
i  Information  was not  provided  in a timely  manner 
26 
J  Other  (EXPLAIN: 
)  12 
B-10
 n 
29  Would  your  decision  regarding  Practitioner  As  Ya:  3  29 
privileges  have  been  different  if you had  @  No: 120 
received  the  report  on the  last  page  from  the  Data  Not app.: 2 
Bank?  (IF  YES,  HOW?)  other 11 
No amwer  6 
(~ YES, check one.) 
a  Would  have  granted  requested  privileges  2  a 
b  Would  not  have  granted  requested  privileges  o  b 
c  Would have  restricted  privileges  o  c 
d  Would  not  have  restricted  privileges  o  d 
  Other  (EXPLAIN:  1  e 
) 
NOTE:  The  remaining  questions  do  not  concern  the  specific  case  of Practitioner  ~ 
but  rather  your  general  experience  with  and  attitudes  about  the  Data  Bank. 
GENERAL QUESTIONS  ON THE 
NATIONAL PRACTITIONER DATA BANK 
30 
How,  if at  all, have  the  other  parts  of your  credentialing  procedures  30 
been  affected  by the  availability  of the  Data  Bank? 
fiirty-jour  said the process  has been slbwed  down; 20 of these specifkaUy 
attdwted  the problkm  to &kys  in Data  Bank rapons~.  Ten mentioned 
the additional  cost of qu?m. 
B-n  31  Please  rate  the  following  four  types  ofinformation  maintained  in the  31 
Data  Bank  in terms  of their  usefulness  to you--in  practice  or in 
theory--in  the  practitioner  credentialing  process.  (Let  1 =  extremely 
useful  and  4 =  not  at  all useful.) 
a  Hospital  disciplinary  actions/privilege  restrictions  RATING:  a 
Meam  I. 79 
S.D.: 1.08 
b  Licensing  board  actions  RATING:  b 
Mearu 1.85 
S.D.: 1.08 
c  Malpractice  payments  RATING:  c 
M- 221 
S.D.: 1.10 
d  Professional  society  disciplinary  actions  RATING:  d 
Mea=  250 
S.D.: 1.18 
32  What  kind  of information  @  currently  maintained  by the  Data  Bank  32 
would  be  useful  to you? 
No specifii  type of tifonnatibn  was mentioned  by more than 6 
respondents 
33  Please  list any additional  comments  and  suggestions  you  have  about  33 
the  operation  of the  National  Practitioner  Data  Bank. 
The most  common sugedoq  made by 20 respondents,  was to impmve 
the timeliitem  of Data  Bank respmwx  Other areas h  which 
irq.provement k desiki  iWIude Data  Bank forms,  the help ~  and 
billing procedures.  Eizch was mentiond  by II  respou. 
This  is the  end  of the  survey.  Thank  you  for  taking  the  time  to  complete  it. 
B-12  APPENDIX  C 
DETAILED  COMMENTS  ON  THE  DRAFT  REPORT  AND 
OIG  RESPONSE  TO  THE  COMMENTS 
In this  appendix,  we present  in full the  comments  on  the  draft  report  offered  by the 
Public  Health  Service  (PHS),  the  Assistant  Secretary  for  Management  and  Budget 
(ASMB),  the  Assistant  Secretary  for  Planning  and  Evaluation  (ASPE),  the  Joint 
Commission  on  the  Accreditation  of Healthcare  Organizations  (JCAHO),  the 
American  Hospital  Association  (AHA),  and  the  American  Medical  Association 
(AMA).  We  also  present  our  response  to each  set  of comments. 
c-1  DEPARTMENTOF WTH  & HUMAN SERVICES  l%Wl+l#th-
Memorandum 
OEC  8  !992 
D8te   
From  Assistant  Secretary  for Health 
Office of Inspector General (OIG) Draft Report National 
Subject	
practitioner  Data  Bank--usefulness  ~d  ~pact  of  Reports  to 
Hospitals,    OEI-01-90-O0520 
To 
Acting  Inspector  General,  OS 
Attached are the PHS comments on tie stiject ~IG draft report

on the usefulness and impact of the infomtion  in the

National Practitioner Data BanJc(Data B~)  to hospitals.

We concur with the OIG reports recommendations and are

implementing the corrective actions to (1) further reduce the

time between query and response  uci  make  t~is  a  high priority 
in the  next contract for operation of tie Data Bank, and 
(2) publish the established perfo~ce  indicators relating to

the response time in the annual report of the Data Bank.

In addition, we plan to (1) provide a  of the final OIG 
copy 
report to the Joint  comssion  on  ACCr~itatiOn  of  Healthcare 
Organizations, and (2) recommend that they consider 
incorporating standards into Weir  Upcofing  Scoring  guidelines 
and Accreditation mual  for Hospitals addressing how quickly 
hospitals should query the Data Bank after receiving 
applications for privileges. 
/7

P ov%AfppDrpH
times  O. Mzmon,  m 
  
Attachment

c-2   
COMMENTS OF THE PUBLIC HEALTH SERVICE ON THE OFFICE OF

INSPECTOR GENERAL [OIG) DWU?T  REPORT  NATIONAL  PMCTITIONER

DATA BANK -- USEFULNESS AND IMPACT OF REPORTS TO HOSPITALS

0EI-01-90-O0520

OIG RECOMMENDATION

The  should seek to further reduce the time between query 
PHS 
and responset and should make this a high priority in its next 
contract for operation of the Data Bank. 
PHS COMMENT

We concur.  AS acknowledged by C)IG  in  the  draft report, we

have already initiated actions to further reduce the time

between query and response by automating the query process.

Software for providing electronic queries is being distributed

to approximately  2,000  hospitals  and,  so  far, over 500

electronic  queries  have  been  processed  with  positive  results.

The  first  set  of  electronic  queries  was  processed within 48

hours of their receipt.  We are also pla~ing  to design and

implement electronic query responses before the end of the

current Data Bank contract.

We have also initiated  action8  to  make  the  reduction  of  time  a 
high  priority  in  the  next  contract  for  operation  of  the  Data 
Bank.  In  June  1992,  HRSA  asse.mbl~  a  team to focus on the 
competition for the next Data Bank contract. 
The team has

held several workshops and meetings to assess the needs and 
preferences of the  Data Bank users.  Based on interactions 
with the users, the team is well aware  of the need for and the 
importance of reducing the time between query and response. 
AS the team proceeds to develop the request for proposals for 
a new Data Bank contract, primary consideration is being given 
to providing direct on-line transmission of queries and 
reports, and of system outputs. 
The  turnaround  the  between 
Wery  and  response  will  be  greatly reduced by using the on-
line approach.  : 
OIG RECOMMENDATION

The  PHS should publish recently established performance 
indicators relating to the response time in its annual report 
on the Data Bank. 
PHS COMMENT 
We  concur.  We will work with the contractor to include the 
performance indicator statistics in (1) the Data Banks annual 
reportt and (2) reports to the Data Bank Executive Committee. 
c-3  .  # 
2 
OIG RECOMMENDATION 
The Joint Commission on Accreditation of Healthcare 
Organizations  (JCA.HO)should establish ~idelines  on how 
quickly hospitals should query the Data Bank after receiving 
applications for privileges. 
PHs  COMMENT 
We  concur.  We will recommend to JMO  that  they  consider 
incorporating standards into their upc~ng  Scoring  guidelines 
and Accreditation Manual for Hospitals addressing how quickly 
hospitals should query the Data Bank after receiving 
applications for privileges.  The recommendation is consistent 
with JC.AHOSefforts to stren~en  credentials review and 
professional peer review proces8e8.  Upon receipt of the final 
OIG report, we plan to send a copy  of  the  report  together with 
our recommendation as stated abcve to JCA.HO. 
c-4  OIG  RESPONSE  TO  PHS  COMMENTS 
We  are  encouraged  by PHSS actions  to  date  toward  minimizing  response  times  and  its 
pledge  to  publish  related  performance  indicators.  We  direct  PHSS attention  to 
comments  on  our  report  from  ASMB,  which  contain  additional  suggestions  for  PHS. 
Although  we have  not  added  these  suggestions  to our  report,  we believe  they  may 
have  merit. 
. 
c-5  % 
* ,t-~lctf  ~ 
.if!t
DEPARTMENT  OF  HEALTH&  HUMAN  SERVICES  Office of the  Secretary 
~7bv,la  Washington,  D.C. 20201 
0CT231$IW 
MEMOWWDT,JM  TO:  Bryan B. Mitchell  n 
Principal Deputy Ins e tor G  er 
 
FROM  Arnold R. Tompkins Wh+ 
Assistant Secretary  for  anagexnentand u get 
SUBJECT    OIG Draft Report:  ltNva ional Practito  r Data  
 
Bank: Usefulness and Ihpact of Repor @  to 
Hospitalssl0EI-01-90-O0520 
Thank you for the opportunity to review  draft report, 
yOUr 
llNationalPractitioner Data Bank: Usefulness and Impact of 
Reports to Hospitals.ti Overall, we concur with the findings and 
recommendations contained in the report.  We would, however, like 
to offer some comments and several additional recommendations 
(attached). 
If your staff have any questions about this response, please have 
them call Neil J. Stillman, Deputy Assistant Secretary for 
Information Resources Management, at 690-6162, or Joanne ~ato~ 
Office of Information Resources Management, at 690-835s. 
Attachment 
. 
C-6  OIG  Draft  Report 
fNational  Practitioner  Data  Bank: 
Usefulness  and  Impact  of  Reports  to Hospitalsll 
Overall, we concur  with  your  findings.  We  would,  however,  like 
to  suggest  several  additional  recommendations,  as  follOWs: 
One  of  your  recommendations  suggests  that  PHS  make  improving 
query  response  time  a  high  priority  in  the  next  contract.  We 
agree,  but  believe  that  this  should  also  be  a  high priority  for 
the  current  contract.  We  agree  that  PHS  has  made  considerable 
improvement  in  this  area  over  the  first  18  months.  Since 
contractual  standards  for  turnaround  time  exist,  we  think  that 
additional  emphasis  for  timeliness  needs  to  be  placed  on  the 
current  contractor  and  that  the  contractor  be  held  accountable 
for  maintaining  this  standard.  The  report  indicates  that  the 
current  system  contract  expires  in  December,  1993.  However,  PHS 
is  in  the  process  of  requesting  a  ten-month  extension  to  the 
current  contract.  We  would not want to delay the enforcement of 
this requirement  for two years or more. 
- A  recent  GAO study  concluded  that  timeliness  would  be  improved 
considerably  if  the  Data  Bank  required  the  use  of  Social  Security 
Numbers  (SSN)  for  inquiries.  This  would  allow  for  more  accurate 
matching  of  data  and  fewer  exception reports (which require 
manual  investigation  to  resolve).  A  major  reason  for  delayed 
response  time  to  queries is that the inquiry does not always 
contain enough unique identifying  info~ation  to  result  i.n  an 
accurate  match.  This  problem  is  greatly  reduced  by  the  use  of 
the  SSN.  The  use  of  the  SSN  is  currently  voluntary.  We 
recommend  that  PHS  be  encouraged  to  seek  legislative  authority 
that  would  require  the  use  of  Social  Security  Numbers  for  reports 
and  inquiries  to  the  Data  Bank. 
Although  hospital  officials  found  58  percent  of  Data  Bank 
reports  useful,  your  report  indicates  that  Data  Bank  reports  -
rarely  affected  hospital  privileging  decisions.  The  report  goes 
on to say that those hospitals that did not consider the reports 
useful felt this  reports did not help them to 
way  because  the 
judge  the  competency  or  professionalism  of  the  applicant.  We

suggest  that  PHS  work  with  Data  Bank  customers  in  defining

additional  data  needs  that  will  increase  the  usefulness  of  these

reports,  as  part  of  the  new  system  design  requirements.

c-7  , 
As noted in your report, PHS  is  currently in the process of 
determining priorities and strategies  for procuring  its  second 
contract for administration of the Data  Bank. 
The  Office  of 
Information  Resources  Management  has  been  given  the 
responsibility  to  provide  technical  SUppOrt  to  this  effort.  It 
is our opinion that the new system  design  should  support a 
Virtually  paperless  environment  and  provide  interactive  access  to 
the  user.  We  believe  that  this  type  of  design  will  not  only  cut 
down  on  errors  significantly,  but  can  also  reduce  costs  and 
increase  the  timeliness  of  responses  to  our  customers. 
-2-
C-8  OIG  RESPONSE  TO  ASMB  COMMENTS 
We agreewith  the  spirit  of all of ASMBS suggestions;  nevertheless,  we have  not 
incorporated  them  into  our  report.  We  believe  that  PHS,  by introducing  electronic 
querying  capabilities,  is already  striving  to improve  response  time  during  the  current 
contract.  We  believe  that  PHSS work  with  the  Data  Bank  Executive  Committee  and 
regular  communications  with  user  groups  constitute  sufficient  efforts  to identify 
additional  data  needs.  (Furthermore,  the  hospitals  we surveyed  were  given  the 
opportunity  to  identify  useful  additional  data,  but  no type  of data  was  identified  by 
more  than  a handful  of respondents.)  Finally,  although  we recognize  that  the  use  of 
Social  Security  Numbers  could  speed  the  matching  of reports  and  queries,  we cannot 
endorse  this  proposal  without  analyzing  its costs,  benefits,  and  privacy  implications. 
c-9  DEPARTMENT OF l-iEALTH& HUMAN SERVICES  Officeof the  Sacretary 
# 
77J*V4Q,  Washington,  D.C.  20201 
DEC 241992 
TO:  Bryan B. Mitchell 
Principal Deputy Inspector General 
FROM:  Assistant  Secretary  for 
Planning  and  Evaluation 
SUBJECT  :  Comments  on  the  Draft  Report,  National  practitioner 
Data  Bank:  Usefulness  and  Impact  of  Reports  to 
Hospitals 
This  OIG  report  addresses  an  important  issue,  the  usefulness  of 
the  data  from  the  National  Practitioner  Data  Bank  (NPDB)  to 
hospitals  and  entities  who  grant  privileges  to  practitioners. 
Unfortunately,  for  the  reasons  detailed  below,  I  am  concerned 
that  the  information  provided  in  the  draft  report  fails  to 
materially  deal  with,  and  does  not  substantially  answer,  the 
issue  of  concern.  Indeed,  those  data  used  by  OIG  to  conclude  the 
NPDB  is  useful  could  be  used  as  well  to  support  the  opposite 
conclusion:  because  the  NPDB  data  generally  have  not  been 
employed  as  key  components  in  hospitals  privileging 
determinations,  the  purpose  intended  by  Congress,  the  NPDBs 
usefulness  has  been  low. 
First, the reader has no basis for determining the extent to 
which the sample matches queried accurately reflect, 
statistically, the universe.  Absent a power analysis, or at 
least confidence intervals, the appropriateness of weighting 
responses up to the universe of hospitals is unclear. 
Second,  the  usefulfless  dimension  lacks  precision,  operational 
substance  and  specificity.  The  key  determinant  used  in  the 
report  to  test  accuracy  seems  to  be  whether  hospital  respondents 
believe  the  NPDB  data  were  accurate.  To  determine  accuracy  by 
polling  opinion,  the  real  basis  of  OIGS  conclusion  here, lacks 
any substantial rigor. 
. 
On the dimension of uniqueness, providing data not elsewhere 
available, the NPDB appears to have scored well:  nearly 40 
percent of respondents indicated the  reports provided at 
NPDB 
least some information not otherwise available to them and 
approximately half indicated the NPDB gave them info~ation  not 
provided by the involved practitioner. 
c-lo  Page 2 - Bryan B. Mitchell 
These data, however, seem to have had ~  modest decisional 
consequences.  Only 2 percent (3 of 142) said they would have 
made a different decision without the data bank report -- that 
is, with virtually no exception, the data bank report did not 
make a difference to the granting of privileges. 
Moreover, 
approximately 40 percent of respondents said the information was 
not useful (questions 26 and 28).  And, for those respondincr~t 
the data were useful, the modal explanation given w~s tha< the 
NPDB report confirmed information secured elsewhere. 
In sum, conclusions of the OIG report -- U  the data on which it 
is based are statistically valid -- seem to support are three-
fold: 
1.  Information on which decision makers  appear  to  have 
made  their  privilege  determinations  was  readily 
available  from  other  sources. 
2.  Hospitals  did  not  use  the  NPDB  information  in  the  way 
Congress intended, i.e., to determine the competence of 
physicians.  They indicated that inforxnationabout 
small payments  (defined as $30,00C)on page  7) is useful 
generally (page 7) but not in determining the 
competence of practitioners  (page 10, where small 
payments are redefined, without explanation, as less 
than $20,000). 
3.  On balance, based on hospitals reported responses, the 
data bank seems to provide nice-to-know information 
which has had  littl&  impact  in  deciding  whether  to 
grant privileges. 
If  you  have  any  questions regarding these  comments,  please 
contact Elise D. Smith at 690-6870. 
(  c 
Gerry 
C-II  OIG  RESPONSE  TO  ASPE  COMMENTS 
The  ASPE  notes  that  although  a majority  of hospitals  surveyed  rated  the  reports  they 
received  useful, a very  low number  of hospitals  cited  an  effect  of Data  Bank  reports 
on privileging  decisions.  The  ASPE  argues  that  these  data  lead  the  reader  to 
opposite  conclusions]. 
This  argument,  we believe,  confuses  the  distinction  we make  in the  report  between 
usefulness  and  impact.  Usefulness  measures  the  reliability  and  uniqueness  of Data 
Bank  reports  and,  more  importantly,  hospital  officials attitudes  toward  them.  Impact, 
on the  other  hand,  measures  the  actions  that  hospital  officials  took  after  receiving 
reports.  A report  that  has  no  impact  can  still be  useful  if the  user  perceives  it to be 
so. 
The  ASPE  criticizes  our  definition  and  measurement  of usefulness.  We  disagree 
with  ASPES criticism.  We  believe  it was appropriate  for  us to  allow  our  survey 
respondents  to  interpret  our  questions  on usefulness  as they  saw fit.  What  ASPE  sees 
as a lack  of precision,  operational  substance,  and  specificity,  we see  as a chance  for 
hospitals  to  assess  the  Data  Banks  information  on their  own terms. 
We  question  ASPES second  conclusion  on  page  2 of its comments.  our  results  do  not 
necessarily  demonstrate  that  hospitals  are  not  using  the  Data  Bank  to determine  the 
competence  of physicians.  True,  few hospitals  have  denied  privilege  requests  from 
physicians  who  have  been  reported  to the  Data  Bank.  But  Congress  surely  did not 
intend  that  the  privileges  of all or  even  most  practitioners  reported  to the  Data  Bank 
be  denied.  Furthermore,  Congress  likely  did not  intend  that  reports  from  the  Data 
Bank  be  sufficient  information  on which  to base  privileging  decisions.  We  believe  that 
by contributing  to  the  information  available  to hospitals  the  Data  Bank  is helping 
hospital  officials  to judge  the  conduct  and  character  of practitioners,  even  when  the 
officials  ultimately  decide  to grant  privileges  as requested. 
At  ASPES suggestion,  we have  changed  our  report  so that  we consistently  define  small 
malpractice  payments  as being  under  $30,000.  We  have  also  provided,  in the 
methodology  section  and  with  endnotes,  confidence  intervals  for  the  statistics  we 
present. 
C-12  , 
hint  Wmnisslon 
o~ AcrJrultarw  Qt Htmarr  t?qumwws 
I 
. 
November  b,  1992 
3~ax~ 3.  $iicckell 
principalDeputy Inspector Gmerai 
Office  of  the  ~nspector  GeneraL 
Dapartmnc  Of kbA~th  and  Human se~ices 
l?ilbuc  J.  Cohen  Building  - I@.  SZSO 
330  Independence  Ave.,  S.W. 
Vashingcom,  DC  ?0?01 
This  is  in  response  co  your  le~cer  of  Octobez  5,  199Z which  invites tb= 
comments of theJointCommission on Acc%sditationof iiealthca~e 
0zganiza~~0n3  on  your  draftinspection repart.~Nationalp~act~t:one~ 
DataBank: Usefulnessand  Impact  of  Reports  to  HospiUiM.m  ThXs  reparc 
recommends  that  the  Jofnt  Commission  establ~sh  @dellnes  on  how  @ckly 
hospi~als  should  query  tha  Data Bank (NPDB)  after  receiting  app~iCac~OnS 
for  privileges. 
Joint Cvuuuis6ion  acczeditarinn  standards for hospitalspresen~lytequi~e 
chattherebe medicalstaff,and gwernlng bodybylawsand that these 
corn~lemencadroycuments  specifythe timef~~s withinwhich requests  foz 
medical  scaf~  rnebership  ~md prt~~leges  be actedupQn. We wouldbe 
pleasedto consi&r i~CIUS~~nGf & sp==if~==t~c~  ~= C:p ~ccredi~tzon 
sumey  scoring  guidelines chat  would  direct  attan~ion  to the need forthe 
t$melyseeking uf Lnformatiori  from the  Nl?IX  as  an integral  of  evaluting 
applications  for  privileges. 
We commend you and your acaff  fm  this  ehozough ad  thoughtful  review  of 
the  opetac+on  of the NPDB, and trustthat  the foregoing  response  will  be 
helpfulto you. 
\ 
President  . 
C-13  American  Hospital  Association 
  .. -.  _- 
s-lo  X0111)  I .ILL  \llt)l  Ll)ll\L  l,)  ..111\\lll  L1,lLlL@)olw 
(  111( ,1$(),  llllll(ll\  (>()(11  I 
1( 1( ld)l)ll,  :1.2  .!so  (d)()(l 
(  .Il~l(  ,\,l(lr~s~  .\Alt  I( )S1 
November  25,  1992 
Mr.  David  R.  Veroff 
Office  of Inspector  General 
Office  of Evaluation  and Inspections 
Region  1 
John  F.  Kennedy  Federal  Building 
Boston,  MA  02203 
Re:  NationaPlractitioDnaetar Bank:  Usefulness  and Impact  of Reports  to Hospitals 
Dear  Mr.  Veroff 
On behalf  of the American  Hospkal  Association  (AHA) and its more than  5,200  hospitals,  I 
welcome  the opportunisty to comment  on your draft  report  National  Practitioner  Data Bank: 
Usefulness  and Impact  of Reports  to Hospitals.   Since AHA members  are principal  users of 
Data Bank information  and the chief financial  SUppOrtfor Data Bank operations,  the AHA  k 
very  interested  in knowing  how  hospitals  Use Data  Bank  information  and  whether  hospitals 
find the information  useful  during  their  credentialing  and privileging  process. 
WithrespecttoUsefulnetsosHospitalst,heOfficoefInspectGoernera(lOIG)makesthe 
followifnigndingtshattheAHA wishestocommenton: 
  Forty  percent  of Data  Bank  reports  have provided  information  previously  unknown  to 
hospital  staffs. 
  The  Data  Bank  has delivered  accurate  reports  to hospitals. 
a  The  lMa  13anks average  time  has been  improving  ste~dily. 
  Hospital  officials  found  58  percent  of  Data  Bank  reports  to  be  useful  (e.g.,  they 
confirmeidnformatioent,c.) 
MM  Comments:  One ofthepurposeosftheDataBankk tobecomea nationraelpository 
foradverseactionand malpractiicneformationS.inceindividusatlatehsavedifferent 
reporticnrgiteriitah,asbeendifficuilfnto,timpossiblfeo,rhospitailnsonestatteoreceive 
practitioinnefrormatifornomhospitainl sa second  state.  We are pleased  that the Data Bank 
is meeting  this challenge  and is filling  this  information  gap. 
Since  hospitaslismplydonothavethecapacittyoverifayllinformatitohnatcomestothem 
fromnumeroussourcesw,e arepleasetdhatthesystemsetupbytheData Bank is providing 
hospitawlisthaccuratreeportasndconfirmiinngformatihoonspitahlasdreceivefdromother 
sources. 
C-15  OIG  RESPONSE  TO  JCAHO  COMMENTS 
We thank  JCAHO  for  considering  a specification  related  to  timely  querying  of the 
Data  Bank.  We direcJtCAHOS attentitoonPHSScomments,whichdetaiPlHSS 
intenttoworkwithJCAHO onthismatter. 
C-14  Mr.DavidR.Veroff 
November25,1992 
Page2 
With  respect  to  Impact  on Decisions,  the OIG made the following  findings: 
	 If  hospitals  had not  received  the  Data  Bank  reports,  their  privileging  decisions  would 
have  been  different  one  percent  of  the  time. 
  Eighty  percent  of Data  Bank  reports  had  little  chance  to  have  an impact  on  hospitals 
privileging  decisions. 
. 
  Nineteen  percent  of Data Bank reports  arrived  before  hospitals  decisions  were finalized 
and  contained  information  that  neither  the practitioner  involved  nor  any  other  sources 
had provided,  but did not have an impact  on hospitals  privileging  decisions. 
AHA Comments:  We find this part  of the OIG report  to be most telling.  We were  surprised 
that  although  hospitals  may  have  received  information  they  did  not  already  have  on 
practitioners,  the information  did not affect the hospitals  privileging  decisions.  This may be 
due,  in part,  to the  newness  of the  Data  Bank  and  the  need  for  hospitals  to  integrate  Data 
Bank reports  into their  privileging  processes.  On the other  hand,  this may also speak  to the 
care  and attention  hospitals  already  devote  to credentialing  and the  sufficiency  of physician 
information  provided  by other  sources. 
With  the  Data  Bank  playing  only  a  supplemental  role,  as  a  back-up  tool  to  compare 
practitioner  information,  we question  whether  the  Secretary  of Health  and Human  Services 
can justify  the  high  administrative  and  financial  burdens  on hospitals  to  support  a back-up 
tool.  If  the  Data  Bank  should  expand  to  include  licensing  data  on  all  practitioners,  the 
administrative  and  financial  burdens  would  increase,  whereas  the  utility  of the  information 
during  the credentialing  process  would  still remain  questionable. 
Finally,  the OIG recommends  that the Public  Health  Service  seek to further  reduce  the time 
between  query  and response  and that  the Joint  Commission  for Accreditation  of Healthcare 
Organizations  (JCAHO)  should establish  guidelines  on how quickly  hospitals  should query the 
Data  Bank  after  receiving  applications  for  privileges.  We  agree  that  the  time  between 
querying  and  Data  Bank  response  should  be  improved.  This  will  become  more  of  an 
imperative  if  the  Data  Bank  should  expand  to  include  licensing  information  on  all 
practitioners.  The AHA,  however,  has reservations  with the recommendation  that the JCAHO 
develop  querying  guidelines  for hospitals,  since most hospitals,  by now,  have developed  their 
own procedures  for  querying  and  reporting  to the Data  Bank.  These  procedures  may vary 
from  one institution  to another,  depending  upon the  Size of the institution  and the number  of 
practitioners  who  are  privileged  and  credentialed.  To  request  that  the  JCAHO  establish 
guidelines,  could  further  complicate  the  already  complex  querying  responsibilities  placed 
upon  hospitals  by the Health  Care  Quality  Improvement  Act. 
The  OIG  and  Public  Health  Service  will  need  to  study  the  long  term  effect  the  Data  Bank 
has upon peer  review  to determine  how Data Bank reports  are used by hospitals  in privileging 
practitioners.  The  AHA  has  recently  distributed  a  survey  to  a  small  number  of  hospitals 
that will  look further  at the effect  of the Data Bank on peer  review,  operational  concerns  of 
hospitals,  cost/benefit  ratios,  and  suggested  Data  Bank  improvements.  Once  we  have 
reviewed  the results  of that  survey,  we will be in a better  position  to comment  on the effects 
of the Data  Bank. 
In  summary,  although  we are  pleased  that  the  Data  Bank  is able  to  furnish  hospitals  with 
practitioner  information  they  may  not  already  have,  we  are  concerned  that  this  information 
has not had a more  positive,  influential  redentialing  and privileging.  No fhrther 
  Mr.  David  R.  Veroff 
November25,  1992 
Page  3 
expansions  would  appear  to  be justifiable  at  this  time  given  the  current  questions  raised 
concerning  the  Data  Banks  utility.  Another  study  looking  at this  direct  effect  should  be 
instituted  by the OIG within  the next two years. 
If  you  shouldhaveanyquestionrsegardinogurcomments,feelfreetocontacItlaS. 
Rothschild  at 312/280-6682. 
/
. 
. 
72j&  -
Frednc  J.  tin 
Senior  Vic  President 
and General  Counsel 
C-17  OIG  RESPONSE  TO  AHA  COMMENTS 
Although  the  AHA  is pleased  with  the  information  that  the  Data  Bank  is providing,  it 
questions  the  cost-effectiveness  of the  Data  Bank  as a back-up  tool.  We  believe  our 
report  makes  clear  that  in many  cases  the  Data  Bank  provides  information  unavailable 
through  any other  source,  and  that  in at least  three  cases  it alone  has  led  hospitals  to 
deny  privileges  to practitioners.  We believe  the  Data  Bank  is much  more  than  a back-
up  tool. 
We  disagree  that  guidelines  from  JCAHO  will complicate  hospitals  querying  practices. 
Instead,  we believe  that  such  guidelines  will highlight  the  importance  of timely 
querying  and  will establish  minimum  standards  in that  regard.  We  trust  that  JCAHO 
will consider  the  concerns  of all sizes  and  types  of hospitals  in formulating  its 
guidelines. 
C-18
 American  Medical  Association 
ltl~slci:in>dedicated[0 the health Of.Wericu 
JiiIIW S, T~ddM,I)  515Iiorth MiteStreet 
(XM1O 
Exwutiyc \iccImiddnt  Chicago,Illinois 
January  5,  1993 
Bryan  B. Mitchell 
Acting  Inspector  General 
Department  of Health  and Human  Services 
Office  of Inspector  General 
330 Independence  Avenue,  SW 
Washington  DC  20201 
RE :  Draft  Report,  NPDB:USEFULNESS  &  IMPACT  OF  REPORTS  TO 
HOSPITALS 
Dear Mr. Mitchell: 
The American  Medical  Association  (AMA) is pleased  to respond  to 
your  request  for  comments  on  the  Office  of  the  lnSPector 
Generals  (OIG) draft  report,  NATIONAL  PRACTITIONER  DATA  BANK: 
USEFULNESS  AND IMPACT OF REPORTS TO HOSPITALS,  September,  1992. 
The  stated  purpose  of this  study was  to assess  the utility  to 
hospitals  of the information  in the National  Practitioner  Data 
Bank  (NPDB) . 
After  carefully  reviewing  the  September  draft  report,  the AMA 
concludes  that  the  draft  report  only  partially  fulfilled  its 
intended  purpose.  There  are serious  flaws in the draft  report 
that should be corrected  before  release  of a final draft. 
The  most  serious  deficiency  in  the  draft  report  is  that  it 
totally  ignores  the  overwhelming  majority  of  NPDB  reports  to 
  hospitals  (over 1.5  million)  and  uses  as  its  survey  universe 
only the small number of reports that indicate an adverse action 
or malpractice  payment  (19,122)  .  In fact, the draft report does 
not  even disclose  the number  of reports  sent to hospitals  that 
indicated  no adverse  actions  or malpractice  payments  on behalf 
of a practitioner. 
There  is no good rationale  presented  in the draft  for excluding 
some  99%  of  NPDB  reports  from  the  survey  universe.  A  valid 
measure  of the utility  of the NPDB  to hospitals  would  require 
the  inclusion  of all users  who  are required  to query,  to pay, 
and who receive  information. 
The survey  results  presented  in the draft may be misleading  as 
a consequence  of the narrow  survey universe.  The draft 
C-19  Bryan B. Mitchell 
Page 2 
concludes  that  a  majority  of  NPDB  reports  were  useful  to 
hospitals.  The definition  of usefulness includes reports that 
merely  confirm  what  the  hospital  already  knew.  This definition 
of usefulness  is equally  applicable  to hospitals  that  receive 
reports  confirming  that  there  were  no  adverse  actions  or 
malpractice  payments.  Whether  or  not  the  majority  of  such 
reports  would  be  considered  useful  is an  importa.n
 t  question

.

left unanswered  by the draft report.

The inappropriately  narrow survey universe also affects the most

significant  and relevant  finding in the draft--the proportion  of

reports  that  had  any  impact  at  all  on  the  credentialling

decision.  The  draft  states  that  the  reports  in  its  survey 
universe  rarely led hospitals  to make credentialling  decisions 
they  would  not  have  made  without  the  reports.  The  actual 
weighted  result  was  that  only  0.5% of  reports  in  the  survey 
universe  (of 19,122  reports)  had  any  impact.  If  the  survey 
universe  had included  the 1.5 million  reports that indicated  no 
adverse  actions  or malpractice  payments,  a truer picture  of the

impact  of  NPDB  reports  would  emerge  and  the  drafts

characterization  of actual  impact being  rare would be seen as

a gross exaggeration.

Another  deficiency  of the survey is that the question  regarding 
the  usefulness  of  NPDB  reports  had  little  relation  to  the 
central  purpose  of  assessing  the  utility  of  the  NpDB  tO 
hospitals.  The finding that a majority  of surveyed  reports were 
found  useful  is  nearly  meaningless.  Usefulness  includes 
everything  from reports  that merely  confirm information  already

known,  but  which  was  not  felt  to  have  any  bearing  on  the

credentialling  decision,  to  reports  that  contained  previously

unknown  information  helpful  in  judging  competency.  An

assessment  of  the  utility  of  the  NPDB  should  focus  on  the

purpose  for which  it was  created.  Otherwise,  even an ordinary

telephone  directory,  which  verifies  the correct  address  of the

practitioner  could  be  found  as  useful  to  hospital

credentialling  as the NPDB.

The draft also misinterprets  the survey results regarding  large 
and small malpractice  payment  reports and erroneously  concludes 
that  small  malpractice  payments  (less  than  $30,000)  should 
continue  to be reported.  The draft bases this conclusion  on the 
finding  that  an  equal  amount  of large  and small  payments  were 
rated  useful.  
Two  additional  relevant  findings  suggest  the  opposite 
conclusion:  First,  the draft  states  that many  of the reports 
that provided  information  not previously  known to the hospital, 
but  did  not  affect  privileging  decisions,  involved  small

malpractice  payments.  The draft concludes  that hospital  boards

apparently  do  not  consider  these  incidents  serious  enough  to

C-20  Bryan B. Mitchell 
Page 3 
warrant adverse privilege  decisions.  Second,  in a footnote,  the 
draft reveals  that, even among hospitals  that rated malpractice 
payment  reports  useful, only 25% found small payments  helpful 
in judging  competency.  (Large malpractice  judgments  showed  an 
equally weak correlation with judging competence  but this hardly 
justifies  reporting  small  malpractice  payments,  which  account 
for 44% of reports but only 4% of payments. ) 
We  urge  you  to  consider  our  comments  carefully  in  order  to 
assess adequately  the utility to hospitals  of the information  in 
the NPDB.. 
Jehes  S . Todd , MD 
C-21  OIG  RESPONSE  TO  AMA  COMMENTS 
We  drawanimportandtktinctiboentweentheutiliotfytheDataBanktohospitals 
andtheutilittoyhospitaolfsthe information  in the  Data  Bank.  In this  study,  we 
hoped  to  determine  which  of the  many  types  of information  collected  by the  Data 
Bank  were  most  helpful  to users.  (As it turned  out,  there  were  no  significant 
differences  among  the  types  of information  we evaluated.)  We  surveyed  only hospitals 
that  had  experienced  matches  because  only they  had  been  exposed  to this  information. 
We also  examined  what  impact,  if any, reports  from  the  Data  Bank  have  had  on 
privileging  decisions.  We  assumed  there  would  be  no  impact  on decisions  about 
practitioners  who  had  never  been  reported  to the  Data  Bank,  so there  was  no  need  to 
include  nonmatches  in our  sample. 
The  AMA  takes  issue  with  our  definition  of usefulness.  As we stated  above  in our 
response  to  comments  from  ASPE,  we think  that  usefulness  is properly  defined  by 
users. 
The  AMA  argues  against  our  conclusion  that  small  malpractice  payments  continue  to 
be  reported  to  the  Data  Bank.  Its argument  is based  on our  findings  that  reports  of 
small  payments  do not  cause  hospitals  to make  adverse  decisions  on privileging  and 
rarely  help  hospitals  judge  the  competence  of practitioners.  But  there  are  valid 
reasons  for  retaining  information  in the  Data  Bank  even  under  those  circumstances, 
such  as judging  the  veracity  of statements  made  on practitioners  applications.  In any 
case,  we believe  that  hospitals  are  best  qualified  to judge  the  utility  of small  payment 
reports.  We  remind  AMA  that  57 percent  of the  recipients  of small  payment  reports 
considered  those  reports  useful,  and  that  small  payment  reports  are  apparently  just  as 
useful  as any other  type  of report. 
We  agree  with  AMA  on two  points:  (1) that  the  utility  of nonmatches  remains 
unknown,  and  (2)  that  adverse  privileging  decisions  resulting  from  Data  Bank  queries 
are  even  rarer  than  is suggested  by our  report.  These  questions  could  be  addressed  in 
a future  study  of the  Data  Bank,  one  which  considers  nonmatches  as well  as matches. 
We  feel,  however,  that  such  a study  would  be  premature  at  this point.  The  Data 
Banks  current  match  rate  is artificially  low because  it has  not  had  time  to  accumulate 
a significant  number  of reports  and  because  its users  are  apparently  still learning  how 
best  to utilize  the  information  it provides. 
c-22  APPENDIX  D 
NOTES 
1.  Actions  that  must  be  reported  include  adverse  decisions  on hospital  privileges, 
including  voluntary  resignation;  actions  taken  by State  licensing  boards  on 
licenses,  including  suspension,  denial,  restriction,  and  revocation;  and  losses  of 
membership  in professional  societies. 
2.  OIG  Final  Inspection  Report,  National  Practitioner  Data  Bank:  Profile  of 
Matches,  OEI-01-90-00522. 
3.  The  percentage  of reports  yielding  information  not  provided  by practitioners 
(47)  is larger  than  the  percentage  of reports  not  provided  by any source  (40) 
because  hospitals  can  be  informed  of a malpractice  payment  or  disciplinary 
action  by sources  other  than  the  practitioner. 
4.  Ninety  percent  confidence  internal:  8 percent  to  32 percent. 
5.  Ninety  percent  confidence  interval:  1 percent  to  19 percent. 
6.  Ninety  percent  confidence  intexval:  35 percent  to  65 percent. 
7.  Ninety  percent  confidence  internal:  69 percent  to  100 percent. 
8.  This  difference  is statistically  significant  (Pearsons  chi-squared  =  4.38, d~ =  1, 
P  =  .036).  Adverse  action  reports  were  defined  as coming  from  out  of State  if 
the  State  of the  reporting  entity  was different  from  the  hospitals  State. 
Because  many  physicians  use  out-of-State  insurance  companies,  malpractice 
payment  reports  were  defined  as coming  from  out  of State  if the  hospitals 
State  was  different  from  the  practitioners  work  state. 
9.  Hospitals  responding  to  our  survey  were  already  aware  of the  six malpractice 
reports  from  out-of-State  sources.  Because  of our  weighting  scheme,  these 
reports  overshadowed  the  out-of-state  adverse  action  reports,  which  hospitals 
. 
were  less likely to know  about. 
10.  M. Holoweiko,  The  malpractice  data  bank  is turning  into  a Frankenstein, 
Medical  Economics,  May  6, 1991, pp.  120-133. 
11.  One  hospital  answered  no to the  question  of whether  the  Data  Bank  report 
was  accurate.  The  respondent  explained  that  the  Data  Bank  report  had 
disclosed  a letter  of admonition  from  a State  licensing  board  that  the  board 
itself  had  not  disclosed  to  the  hospital.  Although  the  Data  Bank  report  was 
inconsistent  with  another  source  of information  in this case,  it was not 
inaccurate. 
D-1 
-- 12.  This  hospital  said  it knew  of four  malpractice  payments  made  on one 
practitioners  behalf  since  the  Data  Bank  opened  that  were  not  mentioned  in 
the  Data  Bank  response.  The  hospital  found  out  about  these  payments  from 
the  practitioner  involved  and  from  another  hospital. 
13.  All references  to queries  in this report  refer  to queries  about  practitioners  who 
had  been  reported  to the  Data  Bank.  We do not  have  any information  about 
queries  to  the  Data  Bank  that  did not  result  in matches. 
14.  This  proportion  is calculated  from  only 4.06 weighted  observations.  The  margin 
of error  is 41 percent. 
15.  Ninety  percent  confidence  interval:  49 percent  to  83 percent. 
16.  We  defined  response  time  as the  time  a hospital  had  to wait  between 
submitting  a query  to the  Data  Bank  and  receiving  a report.  We  report  the 
median  rather  than  the  mean  because  the  mean  was affected  by a small 
number  of very  long  response  times. 
The  Data  Bank  operators  use  a different  measure  of response  time  to  assess 
their  performance,  because  they  have  no control  over  the  time  that  queries  and 
responses  are  in the  mail.  They  look  only at the  time  between  a querys  arrival 
at their  facilities  and  the  time  they  mail  a response  back  to the  querier.  For  a 
further  discussion  of response  and  processing  times,  see  page  12 and  note  21. 
17.  For  example,  they  might  match  on  name  and  date  of birth,  but  not  on license 
number  or  other  unique  identifier  fields. 
18.  Human  operators  can  examine  information  such  as address  and  medical  school. 
Partial  matches  are  only considered  true  matches  if two operatom  reach  that 
conclusiionndependently. 
19.  Ninetypercenctonfidencinete rval:  58 percent  to  90 percent. 
20.  Ninetypercenctonfidencinete rval:  51 percent  to  69 percent. 
21.  Ninetypercenctonfidencinete rval:  28 percent  to  46 percent. 
22.  Ninetypercenctonfidencinete rnal:  22 percent  to  38 percent. 
23.  Totals  do  not  add  to  100 percent  because  respondents  could  give multiple 
answers. 
24.  Ninety  percent  confidence  interval:  41 percent  to  63 percent. 
25.  These  reports  were  also  rated  similarly  in terms  of usefulness  in judging 
competency.  Twenty-five  percent  of reports  on malpractice  payments  under 
$30,000  were  found  to  useful  because  they  helped  judged  competency,  while  23 
D-2  percent  of reports  on  payments  of $30,000  or more  were  found  useful  for  this 
reason.  Twenty-nine  percent  of the  smaller  dollar  payments  were  found  not 
useful  because  they  did  not  help  judge  competency  or professionalism,  while  20 
percent  of larger  payments  were  judged  not  useful  for  this  reason. 
26.  Ninety  percent  confidence  interval:  4 percent  to  12 percent. 
27.  Ninety  percent  confidence  interval:  4 percent  to  12 percent. 
28.  Ninety  percent  confidence  interval:  O percent  to 2 percent. 
29.  In one  case,  the  practitioners  requested  credentials  were  restricted  somewhat 
because  the  hospital  did not  perform  certain  procedures. 
30.  In some  cases,  practitioners  did  not  fail to disclose  requested  information.  In 
these  cases,  the  application  forms  were  worded  so that  complete  disclosure  was 
not  required.  For  example,  they  may  have  been  required  to  say whether  or not 
a malpractice  payment  had  been  made  on their  behalf,  but  not  required  to give 
the  details  of the  payment  that  were  available  in the  Data  Bank. 
31.  The  Joint  Commission  on Accreditation  of Healthcare  Organizations  (JCAHO) 
rates  each  hospital  on the  rigor  of the  hospitals  reporting  requirements.  It 
expects  hospitals  to  require  physicians  to fully disclose  disciplina~  actions, 
voluntary  surrenders  of licenses  or privileges,  and  malpractice  judgments  and 
settlements. 
32.  On  pages  4 and  5, we note  that  recent  response  times,  as reported  by hospitals 
in our  survey,  average  26 days.  We calculated  response  time  as the  number  of 
days between  the  dates  our  respondents  requested  information  from  the  Data 
Bank  and  the  dates  they  received  Data  Bank  reports  (see  questions  3 and  4, 
appendix  B, page  B-2).  Response  time,  therefore,  includes  the  time  it takes  to 
mail  queries  to the  Data  Bank  and  the  time  it takes  to mail  responses  to 
hospitals  as well as the  processing  time  at the  Data  Bank.  Unisys  turnaround 
time  is only the  processing  time.  Therefore,  our  finding  is not  necessarily 
inconsistent  with  the  PHS  reports  that  show it is usually  meeting  its goals.  : 
33.  This  figure  differs  from  the  18 percent  cited  on page  10 because  pending 
decisions  were  not  included  in the  analysis  on page  10. 
34*  Although  the  universe  of hospital  matches  as of March  19, 1992, numbered 
19,122, our  sample  was drawn  from  only  19,111 of those  matches.  There  were 
11 matches  involving  hospitals  that  were  excluded  from  the  universe  when  our 
sample  was  drawn  because  at that  time  they were  erroneously  coded.  We do 
not  believe  that  the  exclusion  of this  small  number  of matches  introduced  bias 
into  our  study.  To  remain  consistent  with  our  earlier  Profile  of Matches 
reportw,hichgavethecorrecftig ure,  we refer  in this  report  to  the  true 
universoef19,12r2athetrhant he  sample  pool  of  19,111. 
D-3