Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

HOSPITAL REPORTING TO THE 

NATIONAL PRACTITIONER 

DATA BANK 

@ SERVICE$ 

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~w JUNE GIBBS BROWN ~ 

s Inspector General 

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2 FEBRUARY 1995

OEI-01-94-00050 

I 
OFFICE OF INSPECTOR 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 served 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 OIG’S Office of Audit Services (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 OIG’S Office of Investigations (01) conducts criminal, civil, and admkistrative 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, adrnhlistrative sanctions, or 

civil money penalties. The 01 also oversees State Medicaid fraud control units which investigate and 

prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’S 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., 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 

Barry McCoy Alan Levine 

David Veroff 

For additional copies of this report,please contact the Boston regionalofllce by telephone at 

(617) 565-1050, or byfm at (617) 565-3751. 
EXECUTIVE SUMMARY 

PURPOSE 

To conduct a preliminary inquiry to help the Public Health Service determine how


hospitals are responding to their legal obligation to report to the National Practitioner Data


Bank adverse actions they take against health care practitioners.


BACKGROUND 

Under the direction of the Health Resources and Services Administration in the Public 

Health Service, the National Practitioner Data Bank has been operating since September 1, 

1990. Since that time it has received and maintained records of medical malpractice 

payments and adverse actions taken by hospitals, other health care entities, licensure 

boards, and professional societies against licensed health care practitioners. At the same 

time, the Data Bank has been making these data available to hospitals, other health care 

entities, and licensure boards to facilitate their credentialing and investigatory activities. 

As indicated in the Health Care Quality Improvement Act of 1986, which established the 

Data Bank, hospitals have a particularly important role to play in determining its 

effectiveness. For each practitioner seeking clinical privileges, they must query the Data 

Bank to determine if it has any information on that person. Once a practitioner receives 

privileges, they must then make a follow-up query every two years. In addition, 

hospitals, as well as other health care organizations, must report to the Data Bank all 

adverse actions they take that affect a practitioner’s clinical privileges for more than 30 

days. Hospitals that fail to meet their reporting responsibilities, risk losing the liability 

protections afforded their professional review activities under the Health Care Quality 

Improvement Act. 

In this report, we focus on the hospitals’ responsibilities to report information to the Data 

Bank. We do that because the Health Resources and Services Administration asked us to 

conduct a preliminary investigation to determine if there might be any basis for concern 

about how hospitals were responding to the Data Bank reporting requirements. 

EXTENT OF HOSPITAL REPORTING 

From September 1, 1990 to December 31, 1993, about 75 percent of all hospitals in the 

United States never reported an adverse action to the Data Bank. 

The State-by-State variti”on in the rate of nonreporting hospitals is considerable ­

ran~”ngfrom 93.2 percent of all hospitals in South Dakota to 51.7 percent in New 

Jersey. The median rate is 76.4 percent. 

i 
Among the nonreporting hospitals are many large ones. For instance, in Massachusetts, 

among 112 hospitals that did not report an adverse action to the Data Bank in its first 3 

1/3 years of operation, 18 have 300 or more beds. 

Less populated and/or predominately rural States are heavily represented among those 

with the highest level of nonreporting. On the other end, among the States with the 

lowest rates of nonreporting, the more populous and/or more urban ones are strongly 

represented. 

From September 1, 1990 to December 31, 1993, the approximately 6,500 hospitals in the 

United States submitted 3,154 adverse action reports to the Data Bank. This represents 

2.6 reports per 1,000 hospital beds during the 3 1/3 year period. 

With the focus on the number of reports rather than on number of nonreporting hospitals, 

the State-by-State picture changes somewhat. For instance, New Jersey, which ranks first 

in the proportion of hospitals sending at least one report to the Data Bank, ranks 18th in 

the number of reports per 1,000 hospital beds. 

Repoti”ng rates per 1,000 hospital beds vary greatly State to State - ranging from 8.5 in 

Nevada to .7 in South Dakota. In most States, the repoti”ng rate is between 1.5 and 

4.0. The median rate is 2.5 adverse action reports. 

Some of differences among States are considerable. For example, in California, the State 

with the largest number of hospital beds, the rate of adverse actions is 3.7 per 1,000 beds. 

In New York, the State with the second largest number of hospital beds, the rate is much 

less -2.1. In Ohio, the rate is 2.9; in nearby Illinois, it is 1.5 

BASIS FOR CONCERN 

Our review suggests a sufficient basis for concern about the hospitals’ response to the 

Data Bank reporting requirements. The wide variation in reporting rates from State to 

State is in itself troubling. It could suggest differences in the quality of care rendered or 

perhaps in the capacity or willingness of hospitals to submit reports to the Data Bank. 

The explanation is unclear. 

Further, the level of reporting in the nation as a whole may be unreasonably low. 

�	 In a 1989 planning document submitted to the Office of Management and Budget, 

the Public Health Service estimated there would be 5,000 hospital adverse action 

reports a year. Others had estimated levels more than twice that. The actual 

average has been about 1,000 a year. 

�	 During the September 1, 1990- December 31,1993 period, when hospitals 

reported 3,154 practitioners to the Data Bank, State medical boards took 

disciplinary actions against about 8,000 physicians. 

ii 
�	 A 1991 Harvard Medical Practice study of hospitalized patients in New York State 

found that in 1984, one percent of the hospitalizations in its random sample 

involved adverse events caused by negligence. On the basis of this sample, the 

study team estimated that during 1984, negligent care in the State accounted for 

27,179 injuries, including 6,895 deaths and 877 instances of “permanent and total 

disability. ” 

ISSUES WARRANTING FURTHER ANALYSIS 

That there is a basis for concern is not the same as finding there is a problem that must be 

addressed. To determine if that is, indeed, the case, fiu-ther inquiry is necessary. On the 

basis of our own preliminary review, we have identified four issues that warrant further 

analysis. 

There may be few practitioners with serious pe~ormance problems. The current level of 

reporting may be appropriate. The early estimates, based on little hard evidence, may 

simply have been unrealistic. Further, hospital quality assurance efforts may be 

contributing significantly to improved practice. 

Some hospitals may be responding to poorly pe~orrning practitioners in ways that do not 

require repoti”ng to the Data Bank. They may be taking preventive actions that lessen 

the need for adverse action. Another possibility is that some may be circumventing the 

reporting requirements by deliberately taking actions that fall below the threshold that 

calls for reporting. 

Some hospitals may be reemphasizing or avoiding adverse actions against poorly 

pe~orming physicians. The reporting requirements raise the stakes associated with an 

adverse action and thus may serve as a deterrent to such action. Continuous quality 

improvement programs, in seeking to create a safe environment for physicians to assess 

practice data, may discourage hospital actions against outliers. 

Some reportable actions may not in fact be reported to the Data Bank. In one State 

where we were able to get some information, we found that because of administrative 

mix-ups, some reportable actions were not submitted to the Data Bank. It is not clear 

how often such failures occur in other States. It is clear that neither the Medicare 

Conditions of Participation for Hospitals, nor the standards of the Joint Commission on 

Accreditation of Healthcare Organizations specify hospital responsibilities concerning the 

Data Bank. 

... 

111

RECOMMENDATIONS 

The Public Health Service, through the Health Resources Services Administration, 

should suppoti further inquiry to foster a better understanding of the factors in.uencing 

hospital repo~”ng to the Data Bank. Intensive case studies that examine the extent and 

nature of adverse actions, and more generally of peer review efforts in particular 

hospitals, probably offer the best approach. Although they would not result in 

generalizable findings, they could result in deeper insights into hospital practices that 

could facilitate effective implementation of the Data Bank law. 

The Public Health Service should sponsor a conference to focus attention on issues 

influencing reporthzg to the Data Bank. The conference should include representatives 

from the Public Health Service and the Health Care Financing Administration as well as 

representatives from the American Hospital Association, the American Medical 

Association, the Joint Commission on Accreditation of Heahhcare Organizations, the 

Federation of State Medical Boards, and other organizations. The conference should pay 

particular attention to the issues identified in this report as warranting firther analysis. It 

should also address actions that might be taken to ensure that hospitals meet their 

reporting responsibilities as called for in the Health Care Quality Improvement Act of 

1986. 

The Public Health Service and the Health Care Financing Administrah”on should work 

together to ensure that the Joint Commission on Accredit&”on of Healthcare 

Organizatz”onsassesses more fully hospitals’ compliance with the intent and pati”culars 

of the Data Bank law. Toward this end, they might consider the following options: 

A Letter. Send a joint communication to the Joint Commission urging that it incorporate 

the Data Bank requirements into its standards, conduct a more thorough review of hospital 

peer review efforts and adverse actions as part of its survey process, and seek to identify 

any indications of hospitals circumventing the intent of the Data Bank’s reporting 

requirements. 

Regulatory Change. Amend the Medicare Conditions of Participation in a manner that 

will specify hospitals’ responsibilities under the Data Bank law. This, in turn, would call 

for the Joint Commission to devote greater oversight to the hospitals’ performance of their 

responsibilities. 

Legz”shztz”on.Propose legislation that would call for hospitals’ Data Bank responsibilities 

to be addressed in the Medicare Conditions of Participation and for the Joint Commission 

to focus more attention on the fulfillment of these responsibilities during its survey 

process. 

iv 
COMMENTS ON THE DRAFT REPORT 

We solicited and received comments on the draft report from the Public Health Service 

(PHS), the Health Care Financing Administration (HCFA), the Joint Commission on 

Accreditation of Healthcare Organizations (JCAHO), the American Hospital Association 

(AHA), Public Citizen’s Health Research Group (PCHRG), and the American Medical 

Association (AMA). Their comments appear in fill in appendix B. Below we summarize 

the comments, and, in italics, our responses. 

Recommendation #1 Calling for PHS to Conduct Further Inquiry 

PHS concurred but suggested that the case study analysis we suggested be deferred until a 

study it has underway is completed. The JCAHO and PCHRG strongly supported further 

inquiry. The AHA and AMA did not comment specifically on the recommendation. We 

continue to urge that PHS give high priori~ to an in-depth case study inquiry. The AHA, 

in its comments, provides jimther rationale for such inquiry by emphasizing that concerns 

about insufficient immunity protections are exerting a “powe@d disincentive” for hospital 

peer review activi~. Focused case reviews could help indicate the extent and nature of 

this problem. 

Recommendation #2 Urging PHS to Sponsor a Conference 

The PHS agreed with the thrust but not the specific content of the recommendation. It 

stated that in the near-term it will be holding ad hoc meetings at professional associations 

that would provide a better opportunity for discussion. At a later point, it indicated, a 

conference, as we call for, might be more desirable. The JCAHO supported a conference 

as “a solid first step toward defining the reporting problem. ” The AMA regarded it as 

premature. Others did not comment. We strongly urge that PHS consider the conference 

as a near-term priority. It could help frame the agenda for firther inquiry. And, if 

accompanied by a report on conference deliberations that were widely disseminated, it 

could help hospitals around the country examine more fully the factors that may be 

in.uencing peer review and Data Bank reporting in their own settings. 

Recommendation #3 Calling for PHS and HCFA to Ensure that JCAHO Assess More 

Fully Hospitals’ Compliance with the Data Bank Law 

The PHS and HCFA agreed with the recommendation and agreed that a joint letter to 

JCAHO was the best means of follow-up action at this time. The HCFA added that a 

joint letter should also be sent to the American Osteopathic Association (AOA), which 

accredits 150 hospitals for Medicare purposes. The JCAHO and AMA regarded any such 

follow-up action as premature. The PCHRG urged strong follow-action involving a 

change in the Medicare Conditions of Participation. The AHA did not comment on this 

point. We regard a joint letter to be a reasonable means of follow-up at this time. 

Although our inquiry did not address AOA accreditation practices, we suppofl a joint 

letter to it as well lf PHS and HCFA jind that appropriate. We have retained the options 

v 
involving regulatory and legislative change. Over the long term, depending on the 

response to the joint letter, they may still warrant consideration. 

Methodology 

The AHA and AMA raised some methodological objections. Both questioned the 

relevance of the “considerations” we offered in supporting our finding that there is a 

sufficient basis for concern about the hospitals’ response to Data Bank reporting 

requirements. In this regard, they cited as misleading our references to prior estimates of 

adverse action reports from hospitals, the Harvard Medical Practice study, and the number 

of disciplinary actions taken by State medical boards (only AMA cited the latter). Both 

AHA and AMA sought more refined measures of hospital reporting than we offered. We 

recognize the potential value of more rejined measures of hospital reporting. Our 

purpose, as indicated, was to conduct a limited inquiry to help PHS determine how 

hospitals are responding to their Data Bank obligations. Given that about 75 percent of 

the hospitals in the United States never reported an adverse action during the first 3113 

years of the Data Bank’s operation and the wide variation in reporting levels among the 

States, we continue to find that there is sufficient basis for our modest recommendations. 

vi 
TABLE OF CONTENTS


EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . ,.. .


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . .


FINDINGS


. Extent of Hospital Reporting . . . . . ,. ... ,.. ,.. .


� Basis for Concern . . . . . . . ..*C . ...! . . . . . . .


. Issues Warranting Further Analysis . . . . . . . . . . . . .


RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . 

COMMENTS ON THE DRAFT REPORT . . . . . . . . . .


APPENDICES


A: Hospital Adverse Action Reporting, by State . . . . . . . .


B: Complete Comments on the Draft Report . . . . . . . . . .


C: Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. . . . ,.. . . . . . . . . i 

. . . . . . . . . . . . . . . 1 

. . . . ,.. . . . . ,.. 3 

. . . . ,.. . . . . . . . 4 

. . . . . . . . . . . . . . 5 

. . . . . . . . . . . . . . 7 

. . . . . . . . . . . . . . 9 

. . . . . . . ,.. . A-1 

. . . . . . . . . . . . . B-1 

. . . . . . . . . . . . ..
 C-l
INTRODUCTION 

PURPOSE 

To conduct a preliminary inquiry to help the Public Health Service determine how 

hospitals are responding to their legal obligation to report adverse actions to the National 

Practitioner Data Bank. 

BACKGROUND 

In the Health Care Quality Improvement Act of 1986, Congress called for the 

establishment of the National Practitioner Data Bank (hereafter referred to as the Data 

Bank). It did so to help health care entities and licensing boards make well- informed 

decisions concerning the credentialing, the licensing, and, where necessary, the 

disciplining of health care practitioners. Toward that end, it stipulated that information on 

practitioners reported to the Data Bank would be made available, upon request, to health 

care entities and State licensing boards. 1 For hospitals in particular, Congress went 

t?.mtherand mandated that they regularly query the Data Bank as part of the application 

process for physicians, dentists, and other practitioners seeking clinical privileges and 

every two years for those having such privileges. 

The Congress also specified the types of information that had to be reported to the Data 

Bank. The Data Bank was to include medical malpractice payments, sanctions taken 

against practitioners by professional societies and State medical and dental boards, and 

adverse actions taken against practitioners by hospitals and other health care entities. The 

adverse actions reportable by hospitals and other health care entities would be those that 

affected a practitioner’s clinical privileges for a period greater than 30 days. They would 

also include cases where a practitioner surrendered such privileges while an investigation 

was underway or in exchange for not conducting an investigation. 

Hospitals that fail to carry out their responsibilities to report to the Data Bank risk losing 

the liability protections afforded to their professional review activities under the Health 

Care Quality Improvement Act. The regulations implementing the Act calls for the 

Secretary of the Department of Health and Human Services (1) to investigate hospitals that 

appear to be violating their reporting responsibilities, (2) to provide them with an 

opportunity to correct their practices if they are found to be in noncompliance, and (3) to 

remove the liability protections if the noncompliance continues. 2 

The Data Bank, administered under the direction of the Health Resources and Services 

Administration of the Public Health Service (PHS), began operation on September 1, 

1990. In late 1992 and early 1993, we issued reports examining the usefulness and impact 

of the Data Bank to hospitals and licensing boards during the first year and a half of its 

operation.3 Currently, at the request of PHS, we are updating that work by examining its 

usefulness and impact in the ensuing period. 

1

In this brief report, we focus on one discrete and very significant aspect of the Data 

Bank’s operation: hospitals’ reporting of adverse action information to the Data Bank. 

We do that because the Health Resources and Services Administration asked us to 

determine if there might be a basis for concern associated with the hospitals’ response to 

the reporting requirements. Any evidence, for example, of hospitals not complying with 

the requirements would certainly cause concern. These would also be a basis for concern 

if hospitals are taking actions that serve to circumvent the general intent of the law to 

identify practitioners who may pose a danger to the public. 

The hospitals’ full cooperation in carrying out the reporting requirements is vital for a 

number of reasons. One is the sheer number of hospitals involved. With about 6,500 

hospitals across the country, they represent a major potential source of information for the 

Data Bank. A second reason has to do with the nature of the information reported. A 

loss or reduction in clinical privileges is a serious action that raises important questions 

about the competence and/or professionalism of a practitioner. Finally, and more 

basically, hospitals have considerable data on the medical practice patterns of physicians 

and are in a good position to identify those practitioners who are poor performers. 

APPROACH AND METHODOLOGY 

Per our understanding with the PHS our inquiry was a limited one intended to help it 

begin its consideration of hospital reporting issues. In that context, we focused our 

examination on the extent of hospital reporting during the first 3 1/3 years of the Data 

Bank’s operation.4 In the first section of the report we present data indicating (1) the 

number of hospitals that made no reports or 1 or more reports during the 3 1/3 year 

period and (2) the number of reports per 1,000 hospital beds. In both cases, we indicate 

the variation among the States. 

After presenting the data, we seek, in the second section, to help PHS assess if they 

present sufficient basis for concern. We draw on interviews with representatives of 

national organizations, State governments, and PHS; and include a review of pertinent 

literature concerning health care quality assurance. 

We close with three recommendations. Two directed to PHS and the other jointly to PHS 

and the Health Care Financing Administration. 

Our review was conducted in accordance with the Quality Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

2

FINDINGS 

EXTENT OF HOSPITAL REPORTING 

From September 1, 1990 to December 31, 1993, about 75 percent of all hospitals in the 

United States never reported an adverse action to the Data Bank. 

The nonreporting hospitals include all types of hospitals in urban and rural locations. And 

they include many large ones as well as small ones.5 For example, in Massachusetts, 

among the 112 hospitals that did not report an adverse action to the Data Bank in its first 

3 1/3 years of its operation, 18 have 300 or more beds. 

The State-by-Stute vatin in the rate of nonrepti”ng hospitals is considemble ­

rangz”ngfmm 93.2 percent of all hospitals in South LMwkz to 51.7 percent in New 

Jersey. The mediun tie is 76.4 percent. 

Among the States with the highest level of nonreporting, the less populated and/or 

predominately rural ones are heavily represented. In addition to South Dakota, they 

include Idaho, Montana, Mississippi, Alaska, Alabama, and North Dakota. On the other 

end, among the States with the lowest rates of nonreporting, the more populous and/or 

more urban ones are very much in evidence. Along with New Jersey, they include the 

District of Columbia (classified as a State for purposes of this study), Maryland, New 

York, California, Ohio, and Rhode Island (see appendix A, table 1). 

Fmm September 1, 1990 to December 31, 1993, the approximately 6,500 hospitals in the 

United States submitted 3,154 adverse action repotis to the Data Bank. This represents 

2.6 repotis per 1,000 hospkl beds during the 3 1/3 year period. 

When the frame of reference shifts from nonreporting hospitals to the total number of


reports per hospital, the State-by-State picture changes somewhat. For example, we find


that New Jersey, which ranks first in the proportion of hospitals sending at least one


report to the Data Bank, ranks 18th in the number of reports submitted per 1,000 hospital


beds. Even more striking is that New York shifts from 4th to 33rd.


Looking more closely, we find that in New Jersey, among the 58 hospitals that submitted


adverse action reports to the Data Bank, 25 submitted only 1. In New


York, among the 110 hospitals reporting, 57 submitted only 1 (see appendix A, table 2).


Repo~”ng ties per 1,000 hospdal beds vary greatly fmm State to State - ran~”ngfrom 

8.5 in Nevada to .7 in South Dakota. In most States, the repo~”ng rate is between 1.5 

and 4.0. The medhm mte is 2.5 adveme action reports. 

Some of the differences among States are considerable (see appendix A, table 2). For 

instance, the rate of adverse action reports in California, the State with the largest number 

of hospital beds, is 3.7 per 1,000 beds; the rate in New York, the State with the second 

3

largest number of hospital beds, is considerably less -2.1. In Ohio, the rate is 2.9; in 

nearby Illinois it is 1.5. In Virginia, the rate is 4.2; in neighboring Tennessee, which 

has about the same number of hospi~ls and hospital beds, the rate is 1.3. 

BASIS FOR CONCERN 

Our review suggests that there is sufficient basis for concern about the hospitals’ response 

to the Data Bank’s reporting requirements. 

This is most clearly the case because of the wide variation in hospital reporting rates from 

&ate to State. The reporting period for these data is long enough - more than 3 years - to 

discount short-term aberrations in the States. What, then, might account for the extensive 

variation? Does it reflect differenws in the quality of care being rendered in hospitals? 

In the capacity or willingness of hospitals to take adverse actions? In other factors 

associated with the reporting requirements? The answers are not at all clear. 

Whatever the State-to-State differences, there is alSOreason to suspect that the level of 

reporting in the nation as a whole may be unreasonably low. Some considerations which 

may support such a suspicion are as follows: 

.	 During the planning stage for the Data Bank, the PHS, in a 1989 planning 

document submitted to the office of Management and Budget, estimated there 

would be 5,000 adverse action reports a year from hospitals.b Other estimates 

from other sources were even higher. Although all estimates were based on little 

empirical evidence, the gap between them and the actual yearly average of about 

1,000 adverse action reports is striking. 

.	 During the 1990 to 1993 period, when hospitals reported about 3,154 practitioners 

to the Data Bank, State medical boards took disciplinary actions against about 

8,000 physicians. 7 These numbers are not directly comparable, but, again, the 

discrepancy is sufficiently large to raise legitimate questions about whether 

hospitals are being sufficiently rigorous in taking adverse actions against 

practitioners on their staffs.g 

.	 A 1991 Harvard Medical Practice study of hospitalized patients in New York State 

found that, in 1984, one percent of the hospitalizations in its random sample 

involved adverse events caused by negligence. On the basis of its sample, the 

study team estimated that during 1984, negligent care provided in New York State 

hospitals was responsible for 27,179 injuries, including 6,895 deaths and 877 

instances of “permanent and total disability. “g TO be sure, all of these cases did 

not warrant the hospital taking an adverse action against the practitioners involved. 

Yet, in contrast, it is striking to find that in the first 3 1/3 years of the Data Bank’s 

operation, close to three-fourths of the hospitals in the country have not reported a 

single physician to the Data Bank. 

4


1 
RECOMMENDATIONS 

The effectiveness of the Data Bank depends greatly on the cooperation of hospitals. They


must query the Data Bank in a timely manner when they review the credentials of


practitioners. And they must identify and report to the Data Bank practitioners


responsible for serious quality-of-care problems. This report supports further inquiry and


oversight to determine if hospitals are cooperating fully in carrying out their reporting


responsibilities. Toward that end, we offer the following three recommendations.


The Public Health Service, through the Health Resources and Services Administrti”on, 

should support further inquiry to foster a better understanding of the factors influencing 

hospital repoti”ng to the Data Bank. 

Given the lack of any central repository of information on hospital peer review actions and 

the considerable diversity among States and hospitals (even within the same State), 

intensive case studies probably offer the best near-term approach for further examination. 

Case studies of hospitals in a few States could help to elucidate the extent and nature of 

adverse actions and more generally of peer review efforts in particular hospitals. They 

could also identify some of the operational realities that influence hospital disciplinary 

efforts. In this context, the case studies could provide information that facilitates effective 

implementation of the Data Bank law and of broader quality assurance objectives of the 

Department of Health and Human Services. 

In choosing case study sites, it may be particularly helpful to include States with 

substantially different rates of hospital reporting to the Data Bank. Although the results 

would not allow for generalizable conclusions on a national scale, they could allow for 

deeper insights into what factors contribute to differential rates of reporting. 

The Public Health Service should sponsor a conference to focus attention on issues 

influencing reporting to the Data Bank. 

The conference should include representatives from the Public Health Service and the 

Health Care Financing Administration as well as representatives from the American 

Hospital Association, the American Medical Association, the Joint Commission on 

Accreditation of Healthcare Organizations, the Federation of State Medical Boards, and 

other organizations. The conference should pay particular attention to the issues identified 

in this report as warranting further analysis. It should also address actions that might be 

taken to ensure that hospitals meet their reporting responsibilities as called for in the 

Health Care Quality Improvement Act of 1986. 

The Public Health Service and the Health Care Financing Administration should work 

together to ensure that the Joint Commission on Accreditation of Healthcare 

Organizations assesses more fully hospitals’ compliance with the intent and particulars of 

the Data Bank law. 

7

Given that the Joint Commission’s efforts serve as the Department’s vehicle for overseeing 

hospital compliance with the Data Bank law and given its current limitations hi that 

regard, this recommendation calls for a strengthening of the Joint Commissions’s reviews 

that apply to hospital reporting to the Data Bank. 

In 1994, the Joint Commission amended its scoring guidelines for surveyors by specifying 

that hospital queries and reports to the Data Bank should be “timely” and by spelling out 

more precisely some facets of the Data Bank law. 14 At the same time, the Joint 

Commission considered including the Data Bank requirements in its statement of 

standards, but chose not to do so. Such action would have given more prominence to and 

underscored the importance of the hospitals’ obligations under the Data Bank law. 

Because of its ongoing accreditation reviews of hospitals, the Joint Commission is in a 

good position to help the Federal government better understand if there are problems 

associated with hospitals’ reporting to the Data Bank. But to take advantage of this 

opportunity, the Joint Commission clearly must devote greater attention to this issue 

during its survey visits to hospitals. We recommend that the Public Health Service and 

the Health Care Financing Administration collaborate on how best to achieve this end. 

Among the options they might consider are the following: 

A Letter. Send a joint communication to the Joint Commission urging that it incorporate 

the Data Bank requirements into its standards, conduct a more thorough review of hospital 

peer review efforts and adverse actions as part of its survey process, and seek to identify 

any indications of hospitals circumventing the intent of the Data Bank’s reporting 

requirements, 

Regulatory Change. Amend the Medicare Conditions of Participation in a manner that 

will specify hospitals’ responsibilities under the Data Bank law. Those responsibilities are 

not addressed at present in the Medicare Conditions of Participation. This inclusion 

would compel the Joint Commission to devote greater oversight to hospitals’ performance 

of the responsibilities. 

Legislation. Propose legislation that would call for hospitals’ Data Bank responsibilities 

to be addressed in the Medicare Conditions of Participation and for the Joint Commission 

to focus more attention on the fidfillment of these responsibilities during its survey 

process. 

Each of these approaches has been taken previously with respect to other matters - for 

example, discharge planning and organ recovery procedures. The first would most likely 

be the quickest to carry out and may have a stimulative effect, but it would lack the 

authority of the second or third measures. The third would be the most authoritative 

approach with the greatest likely impact, but would be likely to take longer to have an 

effect. The second represents a likely mid-point between the other two in terms of time to 

implement, expected impact, and degree of authority. 

8

COMMENTS ON THE DRAFT REPORT 

We solicited and received comments on the draft report from the Public Health Service 

(PHS), the Health Care Financing Administration (HCFA), the Joint Commission on 

Accreditation of HealthCare Organizations (JCAHO), the American Hospital Association 

(AHA), the Public Citizen’s Health Research Group (PCHRG), and the American Medical 

Association (AMA). We include the complete text of the comments in appendix B. 

Below we summarize the comments of the respondents and then, in italics, offer our 

responses. We do that first, and at most length, with respect to our recommendations. 

We then summarize and respond to the methodological concerns raised by two 

respondents. 

RECOMMENDATIONS 

Recommendation #1: The Public Health Service, through the Health Resources and 

Services Adxrinistration, should support further inquiry to foster a better 

understanding of the factors influencing hospital reporting to the Data Bank. 

The PHS agreed but indicated that consideration of the in-depth case study analysis we 

suggested is best deferred until a current study they are supporting is completed and the 

results reviewed. The JCAHO was more enthusiastic about further inquiry, indicating that 

it should be a “first priority” and was “an essential prerequisite to any informed action” 

concerning hospital reporting. The PCHRG also expressed strong support. The HCFA, 

AHA, and AMA did not comment specifically on this recommendation. 

We urge PHS to give higher priority to near-term irquiry lhat would examine in some 

&pth the fwtors influencing hospital reporting to the Dtia Bank. Such inquiq is likely to 

reqw”remore than ~he survey work it curretily has underway and, as we suggest in the 

report, would call for focused inquiry at particular hospitals. 77teAHA, even though it 

did not comment specljically on this recommendation, o~ers additional rationale for the 

kind of inquiry we suggest. It poirued out tti tti peer review immunity provisions set 

forth in the Health Care Quulity Improvernen/ Act of 1986 have proven to be insuficieti 

and have served as a “powerjid disincetiive “for hospital peer review activity. l?z 

PCHRG raised a similar concern. Focused case studies could examine the extent and 

ruuure of the problems associated with the immunity provision, along with other factors. 

We incorporated this con.rideration into the text of thisjinal report. 

Recommendation #2: The Public Health Service should sponsor a conference to focus 

attention on issues influencing reporting to the Data Bank. 

The PHS agreed with the thrust but not the specific content of this recommendation. It 

noted that it “will be engaged in a series of ad hoc work group meetings and presentations 

at various professional society meetings. ” It pointed out that such efforts would reach a 

broader audience and allow for more one-on-one interaction. It further noted that if these 

9 
efforts prove unsuccessful, it would consider the conference approach we recommended. 

The JCAHO was more supportive, calling a conference “a solid first step toward defining 

the reporting problem. ” The AMA regarded a conference as “premature,” given its 

concerns about the “accuracy and completeness” of data. Others did not comment 

specifically on this recommendation. 

We strongly suggest that PHS reconsider our conference recommetition and, in fact, 

accord it a higher pn”on”tythan our jirst recommendation. Such a conference, attended by 

knowledgeable participants jlom the various sectors, would allow for more concefled 

attention and interaction than the ad hoc meetings PHS cited. It could help outline the 

scope of a subsequent, in-depth inquiry. And, if accompanied by a report on the 

deliberations that were then widely distributed, it could help others around the count~ 

examine more fi.dly the factors (such as insufficient immuni~ protection) that may be 

influencing hospital reporting in their own settings. 

Recommendation #3: The PHS and HCFA should work together to ensure that the 

JCAHO assesses more fully hospitals’ compliance with the intent and particulars of 

the Data Bank law. (We elaborated on three possible options toward this end: (1) a joint 

letter to JCAHO calling for it to give greater attention to hospital compliance with Data 

Bank reporting laws, (2) regulatory change involving an amendment to the Medicare 

Conditions of Participation, and (3) legislation calling for hospitals’ Data Bank 

responsibilities to be addressed in the Medicare Conditions. ) 

The PHS supported the letter option and indicated that it already has had initial discussion 

with HCFA concerning it. The HCFA also expressed support for a letter and added that 

in addition to JCAHO, it should be sent to the American Osteopathic Association, which 

accredits 150 hospitals for Medicare purposes. The JCAHO regarded each of the options 

as “somewhat premature, ” without a better understanding of the problem. The AMA, 

even more strongly, felt that the options were premature. On the other hand, PCHRG 

sought action stronger than a letter and called for changes in the Medicare Conditions of 

Participation. The AHA did not comment on this recommendation. 

We welcome the commitment of PHS and HCFA to proceed with a joint letter. Our 

inquiry did not address the accreditation practices of the American Osteopathic 

Association (AOA). If HCFA and PHS jiind it appropriate to send the joint letter to AOA 

as well as JCAHO, we certainly support their action. We have still included the 

regulatory and legislative options under the recommendation; they could be reasonable 

longer term actions depending on the results of further inquiry and the joint letter. 

METHODOLOGY 

Both the AHA and the AMA raised methodological concerns associated with our report. 

Both sets of concerns, in effect, have to do with the factors we rely upon to support our 

finding that “there is sufficient basis for concern about the hospitals’ response to the Data 

Bank’s reporting requirements. ” The AHA pointed out the lack of any reliable estimates 

of adverse action reports from hospitals, the inadequacy of reporting rates per 1,000 

10 
hospital beds as a measure of hospital reporting, and the inappropriateness of the Harvard 

Medical Practice study as a point of comparison. The AMA indicated concerns with both 

tables we presented, noting that they do not reflect adjustments for the size of 

nonreporting hospitals or the size of the medical staffs. As did AHA, it raised concerns 

about our reference to the prior estimates of hospital reporting (even with the caveats we 

offered) and our use of the Harvard study as a point of comparison. It also found our 

reference to the number of disciplinary actions taken by medical boards to be misleading. 

We recognize that an understanding of the hospital reporting issue could be advanced 

through jimther analysis and more rejined measures of hospital reporting. We would 

welcome additional inquiry of that sort. Our own purpose, as stated, was to conduct a 

preliminary inquiry. Given the limits of our data, we deliberately did not make an 

unqualified assertion that there was a problem involving the extent of hospital reporting. 

Instead, we concluded that there was sufficient basis for concern. Such concern, we 

added, was sufficient to warrant ji.wther inquiry by PHS (through a study and a 

conference), and, more immediately, some joint action by PHS and HCFA to assess more 

fully hospital compliance with the Data Bank law. Given that 75 percent of the hospitals 

never reported an adverse action during the jirst 3 1/3 years of the Data Bank’s 

operation, given the wide variation in reporting levels among the States, and given the 

other “considerations” we noted, we continue to find that there is adequate basis for our 

modest recommendations. 

11 
APPENDIX A 

HOSPITAL ADVERSE ACTION REPORTING, BY STATE 

TABLE 1


HOSPITALS SUBMITTING NO ADVERSE ACTION REPORTS TO THE


DATA BANK, BY STATE, SEPTEMBER 1, 1990- DECEMBER 31, 1993


1 1 I


S. DAKOTA 59 55 93.2%


! I I I


IDAHO 52 48 92.3%


MONTANA 59 54 91.5% 

MISSISSIPPI	 I 114 I 103 I 90.4% II
 (


ALASKA 34 30 88.2%


I I I I


MINNESOTA 158 138 87.3%


ALABAMA 137 119 86.9% 

LOUISIANA 181 157 86.7%


1 1 I


N. DAKOTA 56 48 85.7%


I 1 I


TENNESSEE 147 126 85.7% 

NEBRASKA 102 87 85.3% 

IOWA I 127 I 107 I 84.3% II


OKLAHOMA 160 132 82.5%


I I I I


ARKANSAS 85 70 82.4% 

KANSAS 153 125 81.7% 

N. CAROLINA 157 127 80.9%


I 1 \ 1


HAWAII 26 21 80.8%


I I I I


NEW MEXICO I 61 I 49 I 80.3% II


MISSOURI 158 I 126 I 79.8% II


TEXAS I 540 I 429 I 79.4% II 

WYOMING 29 23 79.3% 

I I I I


W. VIRGINIA 62 49 79.0%


1 I I I


WISCONSIN I 148 I 114 I 77.0% II


S. CAROLINA I 78 I 60 I 76.9% II


MASSACHUSETTS I 146 I 112 I 76.7% II


KENTUCKY I 123 I 94 I 76.4% II


A-1 
NEVADA


GEORGIA


ILLINOIS


UTAH


VIRGINIA


VERMONT


PENNSYLVANIA


FLORIDA


CONNECTICUT


38 29 76.3% I 

197 150 I 76.1% II 

233 176 I 75.5% II 

I 58 I 43 I 74.1% II 

138 100 72.5% 

18 13 72.2% 

I 277 I 198 I 71.5% II 

I 314 I 222 70.7% II 

I 54 I 38 I 70.4% II 

NEW HAMPSHIRE 39 27 69.2% 

MAINE


OREGON


MICHIGAN


ARIZONA


DELAWARE


INDIANA


COLORADO


RHODE ISLAND


OHIO


CALIFORNIA


WASHINGTON


NEW YORK


MARYLAND


D.C.


NEW JERSEY


U.S. TOTAL


STATE MEAN


STATE MEDIAN


41 28 68.3% 

68 46 \ 67.7% II 

192 128 66.7% 

I I I I


102 68 66.7% I


15 10 66.7%


1 I 1 I I


165 109 66.1% 

I 1 I I 

90 59 65.6%
 I I I 1


20 13 65.0%


212 136 64.2% 

I 557 I 355 63.7% II 

97 61 62.9% 

294 184 62.6% 

I 81 I 50 I 61.7% II 

16 9 56.3% I 

120 62 51.7% 

I I I I I 6588 I 4917 I NA II 

I 127 I 95 I 74.6% II 

I 117 I 90.5 I 76.4% II 

Source:AdverseActions by State, 1990-1993, HealthResources& ServicesAdministration,U.S. Public 

HealthService. II


A-2

TABLE 2 

HOSPITAL ADVERSE ACTION REPORTS PER 1000 HOSPITAL BEDS, 

BY STATE, SEPTEMBER 1, 1990- DECEMBER 31, 1993 

Numberof 

STATE HospitalBeds 

NEVADA 4,144 

D.C. 7,527 

ARIZONA 13,629 

COLORADO 13,691 

WASHINGTON 15,735 

VIRGINIA 29,349 

DELAWARE 2,808 

MAINE 6,083 

OREGON 10,153 

CALIFORNIA 105,270 

UTAH 5,641 

NEW HAMPSHIRE 4,831 

MARYLAND 19,982 

INDIANA 26,143 

KANSAS 15,477 

OKLAHOMA 15,100 

ALASKA 1,909 

NEW JERSEY 37,796 

NEBRASKA 10,292 

MICHIGAN 39,913 

OHIO 51,701 

FLORIDA 63,415 

WYOMING 3,026 

VERMONT 2,290 

GEORGIA 36,334 

NEW MEXICO 6,867 .— — 

TEXAS 79,982 

KENTUCKY 19,052 

N. DAKOTA 5,213 

MONTANA 4,742 

Numberof Reports ReportsPer 1000 

Madeby Hospitals HospitalBeds 

35 8.5 

61 8.1 

94 6.9 

90 6.6 

88 5.6 

124 4.2 

11 3.9 

23 3.8 

38 3.7 

390 3.7 

20 3.6 

17 3.5 

70 3.5 

90 3.4 

52 3.4 

50 3.3 

6 3.1 

117 3.1 

30 2.9 

116 2.9 

149 2.9 

174 2.7 

8 2.6 

6 2.6 

91 2.5 

17 2.5 

190 2.4 

43 2.3 

11 2.1 

10 2.1 

A-3

RHODE ISLAND 4,301 9 2.1 

WISCONSIN 23,971 50 2.1 

NEW YORK 102,036 210 2.1 

S. CAROLINA 15,166 29 1.9 

MISSOURI 29,455 56 1.9 

ARKANSAS 13,328 24 1.8 

IOWA 17,009 30 1.8 

CONNECTICUT 14,238 25 1.8 

PENNSYLVANIA 66,298 116 1.8 

N. CAROLINA 30,151 52 1.7 

MASSACHUSETTS 31,973 55 1.7 

W. VIRGINIA 10,590 18 1.7 

IDAHO 4,045 6 1.5 

ILLINOIS 57,343 84 1.5 

LOUISIANA 23,980 35 1.5 

MINNESOTA 24,019 35 1.5 

HAWAII 4,274 6 1.4 

ALABAMA 23,574 33 1.4 

TENNESSEE 29,420 37 1.3 

MISSISSIPPI 17,577 19 1.1 

S. DAKOTA 5,450 4 0.7 

U.S. TOTAL 1,206,293 3,154 NA 

STATE MEAN 23,198 61 2.6 

STATE MEDIAN 15,606 37.5 2.5 

Sources: Adverse Actions by State, 1990-1993, Health Resources & Services Administration, U.S. Public Health 

Service; and State Sumry of Hospital Beds, Quality Resource Systems, Inc. (from data provided by the 

American Hospital Association’s 1991 MM Annual Survey). 

A-4

APPENDIX B 

COMMENTS ON THE DRAFT REPORT 

In this appendix, we present in full the comments from the Assistant Secretary for Health 

and the Health Care Financing Administration, We also present the comments from the 

Joint Commission on Accreditation of Healthcare Organizations, the American Hospital 

Association, the Public Citizens Health Resource Group, and the American Medical 

Association. 

B-1

,f”- ‘ 

DEP-M~ OF EIEALfM& HUW SEUVICES F@GC+kdlllsmic9

‘%4 

4 Memorandum . 

JAI’11919S Dam 

ROm Assistant Secretary fox Heaith 

was


OffLCO of Inspectar General (OXG) Draft Repoti “Rospital Reporting to the NationaL PractLtfoner Data Bank,” 

OE1-01-94-00050 

Attached are the Public Heaith Senice comments on the subject 

draft report. we concur fully or in part with the report’s 

recommendations. The attached Comments delineate thq Actions


we plan to tm.ke to i.m,pJementthese recommendations.


Attachment

J’m LIC HEALTH SERVICE (PHSI COMMENTS ON OFFICE OF 

lNSPECTOR GENERAL (OIGI DRAFT REPORT “HOSPIT~ REPORTING TO 

~ 

@nerul Cmnm ents


The UIG report focuses on the issue of hospital compliance 

with NatSonai Practitioner Data Bank (Data Bank) repo-lng 

requirements. The period studied encompasae8 3 1/3 yeaz=, 

from the opening of the Data EMnk on September 1, 1990 through 

December 31, 1993. -ing this period, 3,1S4 di8clos*le 

adverse clinical privileges reports were submitted to the Data 

Bank by hospitals. During this same period, State llcensure 

boards reported almost 9,000 adverse licensure actions, and


malpractice insurers reported over 60,000 malpractice


payments. ,..


The (YIG report raises concerns about hospital compliance with


reporting requirements based on the relatively low number of


clinical privileges reports from hospitals in comparison to


PM’s pre-Data Bank opening planning estimate of 5,000


cllnical privileges reports per year ~rom hospitals. The fact


that the rate of hospital reporting varies widely from State


to State also raises concerns, as does the number of clinical 

privileges reports in relation to the laxger numbers of 

reports of other types. 

We note that the issue is not one of the efficiency of Data 

Bank operations themselves. Hospitals use the same reporting 

form6 and procedures that are successfully used by malpractice 

insurers, State licensing boards, and others to report to the


Data Bank. During the study period, the Data Bank processed


over 73,000 disclosable malpractice payment and adverse action


reports and over 3 million queries from authorized entities.


In addition, the Data Bank provided over 122,000 responses


concerning malpractice payments anciior adverse actions to


queriers. Data from other CYIG reports indicate that Data Hank


information provided co queriers may have resulted in


decisions not to provide privileges to about 2,000


practitioners with poor zecords, who otherwise would have been


granted privileges.


The Data Bank relies on voluntary compliance by hospitals with


reporting requirements. The Data Bank uses several means tO


make the required reporting as easy as possible. For example,


the Data Bank provfdes guidance materials on what is to be


reported and how it should be reported. A new (third) edition


of the Llata Bank Guidebook is scheduled fcr mailing to ail


hospitals in late JanUarY 1995. In addition, a free telephone


“help line” for questions about reporting requirements is


available to hospitals. 
,-

2. 

Reporting forms and methods are also being improved. Paper 

reporting forms ware revised in 1994 to simplify their 

completion c During 1995, the Data Bank’s cUrrent system foz 

electronic querying will be expanded to also provide a 

capability for electronic reporting. ‘rhIs w~ll eMainatO the 

necessity to fill out paper fox. The Data Bank will pxcnr$do 

free reporting software to hospitals and other reporters and 

will provide tollfree modem connections for submitting reports 

electronically. 

Despite these efforts to facilitate voluntary compi$azace with


xeporting requirements the OIG report identifies &o specific


types of potential problems in hospital reporting to the Data 

Bank. Although PI-IS’Health Resouzces and Services 

Administration (HIWA) was aware of the possible problems 

identified in the repo= (in fact, HRSA requested that the OZG 

conduct this study)z we believe the report is valuable beuause 

it highlights the problems. By documenting these problems, 

the report will serve as a basis for discussion and as a means


to gain cooperation of others, including hospitals, the Jofnt


Commission on Accreditation of Healthcare Organizations


(JCAHO), and the Health Ca= Financing Administration {HCFA), 

in resolving them. 

There axe two types of under-reporting. The first is


noncompliance with the law by failing to report disciplinary


actions which are required to be reported to the Data Bank. 

The second type involves a change in the manner in which 

hospitals impose penalties in professional disciplinary canes 

to minimize the imposition of penalties which would “require 

reporting to the Data Bank. For example, clinical privileges 

suspensions of more than 30 days must be reported; shorter 

suspensions are not reportable. By reducing the length of 

suspensions to les6 than 30 days, hospitals could avoid 

reporting to the Data Bank. 

The first type of und=-reporting is illegal. The second type 

is legal, but contrary to the intent of the law and 

detrimental to the general utility of the Data 13ank program. 

Although the OIG report primarily focuses on the first type; 

the second type may actxxally be of much greater significance 

to the Data Bank, depending on the extent of each type. The 

OIG report identifies the second type as an issue warranting 

further analysis and suggests that WSA conduct some intensive 

case studies on the issue. HRSA is focusing attention on this 

issue in a major survey of hospitais and other erititfe8 which 

interact with the Data Bank. 
3


designed to-e~ ‘‘e, among other issues? the s-end t--of 

Unde=-reportfngs Walcoff and Associates s~ a sampie of 

~,MO entftfs=, f=c~u@w 600 hospitals~ tO d@t*s ~OW ~W 

f.nteract with the Data Bank, use Ilata Bank tifomtlori (if * 

entitie= are asking for data)~ and how Oata Sank reportfng and 

querying p~ocedures can be improved. Results are due in-t!xa 

early spring of 1995. If the s~y remxlts inticat~t hat 

changes in hospital behavior are being made to avoid Data Bank 

repofilng, we may want to conduct case studies as recommended 

in the OIG report. 

The OZG report also contributes new information in relation to 

the first type of under-reportfng. M one unnamed Stats, 16 

act~ons by hospitals which should hava been reported to the 

Data Rank were found to have not been reported. Since the (YIG 

only examined incidents from hospitals which had reported to


the State Licensing boati, but had made no reports to the Data 

Bank, We cannot dete~ine~ (1) the extent of under-reportiIZg 

by hospitals which did make at least one report to the Dat8


~an.k; (2) the extent of under-re~ofiing M hospitals which did 

not :eport some or all incidents which should have been 

reported ta the State ~lcensing board; or (3) the overall 

extent of under-reporting in the unnamed State. We Qniy know 

for certain that there was some under-reporting in this one 

State, but “~e cannot d=temine either the true extent or the 

significance of the under-reporting. The cucwnented fact of 

this wxier-reporting~ ~ow@ver. indicates the possibility that 

sj.milar under-reporting may take piace in other States and maY 

be a significant problem. 

The report’s other argument that there may be under-reporting 

by hospitals seems less explanatory. The report cites the


fact that rates Of reporting of adverse clinicai privileges 

actions .~ary considerably from State to State. It should also 

be noted, however, that there is no evidence that the 

variation results from under-reporting (or a greater degree of 

under-reporting) in some States. !ialpraccice payment 

reporting also varies considerably from State to State, There 

is on~y a Weak correlation between a State’s malpractice 

report =ate and its clinical privileges report :ate. TO date, 

the state-t~-s~ate var~ations are unexplained, hut we have no 

particular xeason to believe that some States have higher 

under-reporting rates than others fur clinicai privileges 

actions =nd that under-reporting explains the differences in


clinical privileges r@porting rates ubserved among the states.

OIG Recommendation 

1.	 The PHS~ Eh=ough the -A, should suPE$ort further 

inquiry to foster a bettez understanding of the 

factors influencing hospital reporting to the Da%a 

Oank . 

We concur. We are currently undeztakirig one such study (one 

portion of the Walcuff and Associates study discussed under 

the general comments above examines hospital reporting), In 

addition, we received some relevant information from the WAMI 

(Washington, Alaska, Moxacana, and Idaho) study of the 

experience of rural hospitals with the llata Bank. liowever, we 

note that data are Mnited on which to assese the issues 

specifically identified by the QIG as warranting further 

analysis. rn particular, further examination may be required 

concerning the proportion of hospitals that either do not take 

actions against practitioners or take actions which are not


reportable. The extent of failure by hospitals to make 

required reports also may require further examination, 

Intensive case studies invoiving review of peer review 

records, as recommended by the OIG, may be the best way to 

examine these issues even though it may be difficult to get 

hospitals to participate. It is important to note that HHSA 

does not have the staff or financial xesouxces to perform the 

type of detailed examinations envisioned by the OIG. If


resources became available, any studies would have to be


performed by contractors.


OXG Recommendation


2.	 The PHS should sponsor a conference to focus 

attention on issues influencing reporting to the 

Data Bank. 

FHS Comment 

We concur with the thrust of this zecc.mmenciation, but believe 

that ‘Ne can achieve the desired resul:s by taking a different 

approach. In order to establish strcnger direct communication


with hospitals, the HRSA’S LIivision of Quality Assurance, 

which manages the operation of the Data Bank, will be engaged


in a series of & ~ work group meetings and presentations at


various professional society meetings. These work group 

meetings and presentations should reach a broader audience 

ehan would a one-time cmference. In addition, these types Of 

fora will allow for more one-on-one interaction between the 

relevant parties and Shouid be more effective at focusing

s 

~ttm~on, g= both ~hg hospital and Data Bank points of 

viewr on issues affectfng report~ng. However, if tlzese 

meetings and presentatf~- do not P=- tO be @ffectl~ fi 

idezmffyhzg issues influencing repar%~ng to the Data Bank, we 

will g~ve further consfdezatfon tu the conference approach 

reooaunended by the OIG. 

9= rzecomm endatfon 

3.	 The PHS and the JfCF’Ashouid work together to ensure 

that the JCAMO more ftzlly assess hospitals’ 

compliance with the intent and parzicuiars of the


Data ~ank law.


s Resvo nse 

we concur. The OZG proposed three optfonss (1) sending a 

jofnt Letter f.-m PHS and HCFA urging that it incorporate 

compliance with Data Bank requirements into its standards and 

identify hospitals which do not comply during its reviews; 

(2) amending the Medicare Conditions of Participation 

(regulatory change) to rewixe Compliance with Data Bank 

requ~x=~ents, which would in turn lead to better JCA.HO 

oversight in this area; and (3) proposing legislation 

requiring amendment of the Medicare Conditions of


Parcic:pation, as proposed in (2] above. “#e support


impiemencation Oi the first option.


Data ~ank s~aif .Ni~l work with HCFA an this ~ette~. Initial


discussions have already been held. .%meeting wi.Ll be


scfi.eciuled
soon between Data Bank and ENA staff tu discus6


this issue ana begin drafting ths necessary correspondence.


It ~h= ~o~n~ ~~~~er to J~O apprcac~ does ~OC :esu~t ~~ the 

needed change, :hen we wouid support afforts ta change the 

Me~icare Conditions of PartlClp?itfO~, :hrough legislation if 

necessary (options 2 anti 3), 
*,,,.,C,, ,/, 

/ , Health Care 

.+ DEPARTMENT OF HEALTH & HUhl Ah’SERVICES Financing Adm(nis[ra[ion ~ 

; k 

DATE 

FROM 

SUBJECT 

TO 

Memorandum 

DEC I 2 1994 

Bruce C. V1adeck+-v 

Administrator 

Office of Inspector General Draft Repoxt: ‘fHospital Reporting to the 

NationalPractitioner


June Gibbs Brown


hspector General


We reviewed the subject draft report which looks at how hospitals are responding to 

their legal obligation to report to the National Practitioner Data Bank adverse actions 

they take against heahh care practitioners. 

The EIealth Care Financing Adrninistration concurs with the report recommendations. 

Our comments are attached for your consideration. 

Thank you for the opportunity to review and comment on this report. PIease advise us 

~~j--&fidLn& ‘ffid’~~~wadd like to discuss our position on the report’s 

(requlato~ chanqe) ta requixe compliance WA ~.A . . . . 

requirements, .~hich would in turn lead to better JCAHC) 

avers ight in this area; and (3) proposing legislation 

reauir=ng amendment of the Medicare Candi tiuns of 

?arciczpaci~n, as proposed in (2) above. ‘i?esupport 

impiemenratiun of the fixsc option. 

-~ .wi~~ work •~ith HCFA an thiS ~ette~ c Initial
 Data Eank stax.


discussions have already been heid. .%meeting will be


scfi.
 eauled soon ketween Data Bank and EP3A szaff to discuss 

tiis issue anti begin drafting the necessary correspondence. 

If the joint letter to JUUKl apprcac.h does not :esu Lt in the 

needed change, :hen we would supporz afforts ta champ the 

Meaicare Conditions of ~articipacfsn, :hrouqh legislation if 

nece5saq (options 2 ana 3), 
Comments of the EIeaIthCare FinancingAdministration(HCFA) on


OfficeofImsuectorGeneral (OIG) Draft Report


“l?Iosnital Reportingto thePJational Practitioner
 Data 13ank.”


[oEI-ol-94-ooo50\ 

OIG Recommendation 

The Public HeaM Service (PHS), through the Health Resources Services 

Administration, should support further inquiry to foster a better understanding of the 

factors influencing hospital reporting to the Data Bank. 

HCFA Response 

We defer to PI-IS. 

OIG Recommendation 

The PHS should sponsor a conference to focus attention on issues influencing reporting 

to the Data Bank. 

HCFA Response 

We defer to PHS. 

OIG Recommendation 

The PHS and the J3CFA should work together to ensure that the Joint Commission on 

Accreditation of HeaIthcare Organizations assesses more fully hospitaIs’ compliance with 

the intent and particulars of the Data Bank law. Toward this end, they might consider 

thefollowing
options:A Letter, Regulatory Change, and/or Legislation.

HCFA Response 

We concurand recommend the “letter”
 approach as opposed to regulatoryor statutory 

change, \Ve alsorecommend includingtheAmerican OsteopathicAssociation,which 

accredits 150 hospitals for Medicare purposes, in the communication. 
JointCommission 

wAcueat@lan o! tkwmcare Llmami:,ons December 19, 1994 

June Gibbs Brown 

Inspector General 

Department of Health and Human Services 

Wilbur J. Cohen Building - Room 5250 

330 Independence Avenue S.W. 

Washington, DC 20201


Dear Ms. Brown:


I am writing in response to your letter of November 1S, 1994 which 

invites the comments of the Joint Commission on Accreditation of 

Healthcare Organizations on your draft inspection report, “Xospital 

Reporting to the National Praccicioner Data Bank.” Our cormnencs are


limited to the recommendations that appear in your draft report.


More in-depth Public Health Service (PHS) inquiry to achieve a better 

understanding of the factors influencing hospital reporting to the Data 

Bank should, we believe, be the first priority. Such an understanding is 

an essential prerequisite to any informed action concerning che issue of 

National Practitioner Data Bank (NPDB) reporting. We are persuaded that


there are a host of factors influencing hospital reporting to the Data


Bank. If a decision is made to expiore these more fully, che Joint


Commission would be pleased to cooperate in such an endeavor before new


seeps are taken CO reined-ythe perceived pro’blem with hospital reporting.


.-i
PHS-sponsored conference focusim on issues which may in~luence DZCZ 

Bank reporting sounds like a soiid ‘f:rsc step coward defining the 

reporting problem. We certainly su?porc this approach, znd would suggest 

chac such a conference be limited in size and be structured in a manner


designed to facilitate participation of appropriate experts. .+


conference designed in this fashion .Gould be most likely to yield the


concrete information and recommendations we all seek.


The third recommendation, that :he PHS and che Health Care Financing


Administration (HCFA) work together zo ensure that che Joint Commission


assesses more fully hospitals’ compliance with che intent and particulars


of the Data Bank law, seems somewnac premature when contrasted with che


previous recommendations aimed z: .d~fining che problem. .Absenc z better


unaerscancing of this problem, ..-zs’:ggest there is a substantial risk


:hac nore costly and burdensome feaerai requirements may be piacea on 

providers without a clear sense of :he likelv outcomes chat may result. 

It is Worthy of note chat this recommendation ignores the face chat XCFA


direccly certifies approximate;; 2.000 unaccredited hospitals for


Medicare participation.

June Gibbs Brown


December 19, 1994


Page Two


We believe it is appropriate to expect the Joint Commission to


collaborate with PHS and HCFA to “assess more fully hospitals’ compliance


with the intent and particulars of the Data Bank law. “ However, we


suggest it is premature to draw conclusions about the most appropriate


remedy for disparate reporting at this time.


Thank you for providing us the opportunity to comment on this important 

matter. 

Sincerely,


Dennis S[.O’Leary! Y.D.


President

Cl&go. Rfii 60604 

Tdqdmu 3124WOOO 

hnuary 26.1995 

June Gibbs Brown 

InspectorGencrd 

Oflke of InspezmrGenemi 

Depamnentof Heaith & Human Services 

Washington, D.C 20201 

Re: DraftReport - Hospitai Reporting to the Nationai Practitioner Data Bank 

I)car Ms. Brown 

7%e American Hospitai Association
 (AHA), on behalfofits 5,000 hospi~i m~bcrs. wclcomea 

thisopportunitym comment on theOfficeof Inspector Gcncmi’s ~~t EPOR on hospital 

qorring to the Nationai PtaccicioncrData Btmk Because our rrtcrnbers am pficipa.i contributors 

to and u.scrs of hta Bank infoxrnation. the AHA hasa significant interest inreportingpatterns 

and thefactors KM Mucrtce them. Althoughwc salute your office’s continuing cfforIsto


monitorandcvduatecoxrtplhncc
 withData Bank requirements. we have .tious concerns with 

some ofthereport’s findings,omissions. and interpretations. 

Mcthoduloticd Cortccrns: .Asthe report acknowkdges, the PHS tXh7X~R that them would be 

5,000 hospi~ adverse action reports peryearwas justthat:an cstimam~vichoutanycmpiricai


evidence. theDepartment’s “bestguess” m to what it wouid findonce repottingrequirements€

were inqdemented. To theextent[hateswnate In factmis..cs the mark. xiktbie conclusions 

~bouctk mwmableness of hosp:mi reporting arc irnpossibic. \loreovcr. = the OIG suggests. 

lmprovcmettts incretfentiahng wmiquality assurance practices Sincethecsumatewas formulated

can be expected to improve practitioner performance. To the extent they have doneso.the5,000 

per yesr estimate becomes an even less reliance basis foreva.iuatirtg [hedata.


C)thcr indicatom used in the reponalsoareproblematic. There is Iitdem nxommcnd reporting

~atcs per 1000 hospitalhcdsasa rciiabic measure of hospital rcpurting. Sirnii+, tic ~xv~~ 

Medical Pl~ studyhtil.whileinteresting, fad to provide a basis for comparison: incidents of 

ncgii:encc wc not inmmhwge~bje ~~i~ adverse acti~~$ for Dam B@ WIJo*s” 

Indeed. omong the data presented. only the .wace-m-sci.ttereporting vuiatiuns. presented in Table 

1 of Appendix A- suggest thatfunher analysis might bc fruitfuI. [II the discussion of issues it 

believes warrant further maiy.sis. however. [hcOIG foilsco focus on tk insufficiency of the 

I{tiilth CiIR Quality lmorovernenc .4CC’S (HCQIA) immunity provisions and the powerful 

Jisinccntivc (hey cfta~c r’t’r h(~spltai cecr rewew activity. 
Analytical Concern: When HCQIA was enacted, itwas recognized that maadatoty qxmittg 

mquircnxntswould lead to an inctmsc in litigation as physicians faced with discipiimtry action 

challenged adverse peer review aah?ns. In m effort tomducc the chiiling effectsuchlitigation

wotdd have on cfftivc peer review. Congress provided qwdifkd immwi[y topw’c@ncs in~ 

peer review prtmss. 

HCQIA’Speer review immunity, however. has been oniy panially effectivebecausemany courts 

ttavenot required physicians COrcbucthestatutnry presumption of immunity with credible

evidencepxiurco&M. Earlymsoiuaon in these cases is impossible. even where thtxc is no 

objective evidence of improper peer review activity. Although by no means W the cases have 

misimcrpnmd the immunity provisio~ some mum have substantially ignomi tlmm denying 

moaons for suznmazyjudgment and forcing triais. Unless the avaiiabifit y of these provisiork is 

detmnined objective&yand early in the {itigation,they cannot hcip bat fall short of theirstatuttxy 

purpose. The specter of baseicss. time-cunsuming and expensive iicigation serves as a powcrfid 

disincentive to effective peerreviewactivity.Any study of reporting behavior needa to take this 

disincentive into ixcount inorder10accwafeiy interpret adverse actions that fall below the 

r.h.msholdfor Data Bank reporting. 

The AHA appreciates the opportunity 10 provide our comments on the OIG’s draft reporton 

hospital reporting to the National practitioner Data Ebnk. We hope our comments am Mpftzi 

and wili await xmciving die finai rcpom 

Sinccreiy, 

2L?L..’& 

Fnxlric
J.Entin 

Senior Vice Resident 

md Gencrai Counsci 
@@&!2
 h

u ~! 

1 

Buyers Up . Congress Watch � critical Mass. Health RcsemCh Grwup� Liti~alion
 Group

JoanC@bmok.President 

January 9, 1!395 

June Gibbs Brown


Inspector General


Department ofl-lealth andt-iuman Sewices


Washington, DC 20201


Dear Ms. Brown: 

Please find enclosed our comments on OIG’S draft repofi: “Hospital Repofiing 

to the National Practitioner Data Bank.” We appreciate the opportunity to review and 

comment on this repoft. Please let us know if we can be of fudher assistance to you 

or your staff in your studies regarding the I’4ationai Practitioner Data Bank. 

Sincerely, 

*O - * ef’~ 

Sidney 

d 

M. Wolfe, t!-D Joan Stleber, JD, MSW

Director Staff Attorney 

Public Citizen’s Health Research Group 

Enc!osure 

Ralph Nader, Founder 

2000 P %ce[ NW � Wkhin~ton, D.C. 20036 � (202) 833-3000 

9“ @ wmw0. medal Pam 
--

� 

� 

� 

COMMENTS ON “HOSPITAL REPORTING TO THE NATIONAL 

PF?ACTITiONEF? DATA BANK” [OEJ-01-94-00050) 

Submitted by Public Citiien’s Heaith Research Group 

January 9, 1995 

We appreciate the oppodunity to comment on this report by the OIWe of 

Inspeotor General (01(3} of the Department of tieatth and Human SerVioes (12HHS). 

The report represents an important first step Ioward understanding the faotors 

irtfiuencing hospitais’ reporting -or faiiure to report - to the Natlc?naiPraotithxwr Data 

Bank, as mandated by the !-ieatth Care Quality Improvement Act of 1986 (HCQIA). 

However, the repod raises more questions than it answers, and follow up study on this 

issue is imperative. 

As noted by the OIG, hospitals’ cooperation is especially criticai to the Data 

Bank’s effective operation, since: 

the nation’s approximately 6,500 hospitals represent a major source of 

information for the Data Bank; 

a loss or reduction of hospitai privileges raises serious questions about a 

physician’s competence and/or professionalism; and 

hospitals have considerable data on the practice patterns of individual doctors, 

and are in a good position to identify those who may be placing their patients at 

risk. 

We share the OIG’S concern about the suspiciously low rate at which hospitals 

are repotilng adverse actions to the Data Bank, A shocking 75 percent of all hospitals 

never reported a single adverse action during the 3-1/3 year period covered by the 

OiG’s report, While the OIG offers several possible hypotheses for thh deficiency, We 

find the first -- thatthere may be few practitioners with serious performance problems 

to be highly improbable. 

In fact, published estimates of negligence in hospitals strongly discredit this idea. 

The 199~ Harvard Medical Practice Study (as noted by the 01(3) found that one percent 

of hospitaiizaticm in New York state in one year involved adverse events caused by 

negligence, inGiUdinfjalmost 7,000 cieaths~Thisresult prujected to b@talS nati~n~i~~ 

suggests that 80,(??0patients a year are kiiied by negligence, mostly by physicians, in 

hospital settings alone. At this rate, there would have been 266,400 patient deaths due 

to negligence in hwpital$ cwer the 3-1/3 year period in which hospitals reported only 

3,154 adverse atitons to the Data Bank, 

For this reason as well as others noted by the OIG, we suspect that hospitais are 

either failing to take serious disciplinary actions against doctors as needed, or they are 

taking such actions but grcms{yunderreporting them to the Data 5ank, Therefore, we 
Comments by Public Citizen’s Heaith Research Group 

Page Two 

strongly support the OIG”S recommendation for further study, both to team more about 

factors influencing hospitals’ reporting practices, and as a basis for enforcement aotions 

against hospitals found out of compliance with the law. We also support the OIG’Sother 

recommendations, with particular attention to the option of revising the Medioare 

Conditions of Participation to speci~ hospitais’ responsibilities under the l-iCQtA. 

t%aily, we note that the current penaity provided by the HCQiA for 

noncompliance by hospitals maybe insufficient to deter violations of the law. Hospitals 

that faii to repofl adverse actions to the Data Bank as required risk Io$lngthe IICQIA’6 

liability prokticm for three years. That protection exempts peer reviewem from 

monetary damages in private iawsuits over professional review aotions that meet 

certain standards, However, the law appears to provide only immunity from damages, 

not from suit, leaving peer reviewers still at risk of having to defend against claims for 

injunctive or declaratory reiief, Even suits seeking damages may still go to trial to 

decide whether discipline was imposed in bad faith. Thus, some view the HGQIA’s 

liability protection as relatively weak, and its loss may not appear k?pose ~UGh cif a 

threat. 

The penalty for noncompliance by hospitais is aiso inconsistent with most other 

penaity provisions in the iaw. The t-iCQIA authorizes monetary penaities upto$10,000 

per inoident for faiiing to repoti payments on malpractice claims, as weil as for 

violations of the confidentiality provision. 

We urge the Pubiic Heaith Service to propose legislation strengthening penaities 

for noncompliance by hospitais. That legislation should authorize (in adcfltlon to loss of 

the law’s limited liability protection) monetary penajties up to $10,000 per incident for 

hospitals that faii to report to the Data Bank as mandated by law, This would make 

hospitai penaities at ie$st comparable t~ those applied to malpractice insurers who fail 

to submit payment reports. 

Of course, even stronger penalties wiii be ineffective unless enforced by DHHS. 

We are unaware of any instance since the Data Bank’s inception in which a hospitai 

was penaiized for faiiing to submit reports. VVe recommend that the OIG, in its foiiow 

up studies, consider whether DHHS is appropriately exercising its enforcement powers 

under the tiCQIA. 
American Medicai Association 

Ptt@cIwMdedicated10th?healthIIf.Wermi 

JamesS.W. MD 516NorthSW4!-WI’= 312464.5000 

hSCUUW5 vh hrSMeM -. i~OU 60610 312464-4184 Fex

February 1, 1995 

T& Honorable June Gibbs Brown


Inspeetor General


Office of InspectorGcnend


Departmentof Heakh& HumanSexvices


330 IndependenceAvenue. SW - Room5246


Cohenlhtiiding 

Washington. D.C. 20201 

“HospItaiRepmting to the National Practitioner Data ~s” 

The American Medical As=iah (~) ww=ia~s your solic@I ow co-em .OSI 

the OffIce of Ioapector General*sdraft inspection report. “Hospital kporting to the 

National
 PraccitiomrData Bati. ” Ocmf= iw (O~G Rep). ~ O~G ~CPOfiW= 

writun for the purpose of helping tie Public Health Service (lVIS) determine whether 

hospitals am reporting adverse actiow to the National Practitioner Data Bank (NPDB). as 

requiredby the HealthCam Quality Improvement Act (HCQIA). TM AMA’s review, 

however, conciudes that the Report fails far short of its purported goai. Even given the 

“preliminary”statusof the Report, our review has revealed important gaps in both 

accuracy and completeness of data, creating a rnisieading pietttre. We offer the foflowing 

comments and suggestions for your consideration. 

The dam presemed on the extent of hospwti repordng isflawed and incomplete. For 

example, Tsble 1 of Appendix A does not take utto account any adjusnncnt for the size 

of the non-mpming hospitals or the number of physicianstcktltis~ on their medicalstaffs. 

And although Table 2 does provide information on the number of reports per 1.000 

hospid beds. the number ofreports per 1.000 practicingphysicians mustalsobe

pnxemed inorderrodemonstrate significance sr.a(cvariation.


Becauseof the irsxmpIete nature of the Reporr’s data, tie OIG’S co=iusion+ based on 

this data. that the number of hospitals reporting adverse actions is “uMMwnddy IOW” 

seems unfounded. The AMA’s concernis heightenedby he Report’smlkuxe on chc 

following three items to support its case: (1) the 19i39planning cfoettmentsubmitted to the 

Oflice of Management and Budget; (2) the disparity between the number of lieemum 

actions against physicians and the number of adverse actions taken against hospital-bphysiciam only: and (3) the 1991 Hamrd Medical Practice study of hospitalized pasients 
POgc2 

FCbNaL-Y1, 1995 

The Honorable June Gibbs Brown 

in New York state. .None of t~ese rkee items credibly supports rhe OIG’S coneiusiona. 

The i989 estimate that hospitals may report 5.000 adverse actionrqxm per year is 

invalid. In OIG’S WOdS the esdrnate was “based on iittle emptica~ evidence’ and was 

“widely acknowledged to be iittle more than informed guesses. ” 

To determine if therehas been 8 change in the frequency of RPOf@l hospiti ahrse 

actions as a result of the implementationfHCQIA’Sreporting mqttifmem to the 

,NPDB,the OIG Shouk!conracchemedicallkensingboarda.which-* hospirala
 to

report adverseactions. lfthedarashowsno changeinthereporting
 ratesinceSeptember


1.1990.itwouldconfhm thattheearlycsdxnates
 weresimplyway offticmark.


Comparison of the Number of Actions &po rrcd by Liccnsirw Boards and HThere is a difference between tie number of actions reported by licensing boards and 

hospitals. This diffcmnce in and ofitself doesnotindicate
 anypanicuhtrpxwblctn;

nevertheless,
 theOIG uses this difference to suggest that Imspitak are not taking 

~ssazy actiom to ensure the qudiry of their medicai staff. The AMA dispures this 

conclusion. 

Tbe OIG should have analyzed tic reasons these numbers may be different. in concert 

with information avadab]e on the 7,675 “prejudicial actions” taken by Iieensing boards 

against physicians. The diffmtmees couid be basedon a varietyof factorsnot considered 

h-t
heReport. Most sunifxanti y, how many of the phys~ciansreported ate on a hospital 

.medicai sraff. and how many are office-baaed/ambulatory care-based physicians? How 

many of that number are multiple iicensurc actions against a single physician.perhaps 

even regardingthe same evenras sanctionedby rnuitiple jurisdictions? What are the 

degreesof sanction imolved and do they vary by state? 

Evahuttion of questions such as rhese maYhelp 10explain quantitative disparities and 

resot~e concernabout hospiralUnder-mponing.The broadening of the OIG’Sevaluation 

[o include ~alitative data wilI Iead uscoa more complete and crediblcportrayalof whet 

[s actually happening. For exampie, the (XG might consider raking a random munpk of 

reported liccnsurc
 actions to determine if a hospitai shouid have initiated an adverse

action atior reported an adverseaction
cotheNPDB. 
Page 3


February1, 1995


TheHonorableJune Gibbs Brown


1991 Harvard Medical Practice Studv of New York State 

T&ereference co this study does not SUWXMa concern about w “UIUC~OIIMY low ievei 

of bospiudrepotting.” Cleady, adversecvems do occur. In a msjofiw of immmces. 

though.the event is not the responsibiIiV of a “bad physicti. ” Mr. adverse events 

am fmqumttly attribu@bleto flawed systems or processes. It is u~vefidly t=ognized 

that punitive !neasm= against physicians do noc prevent adverse evenu from occurring 

and overail is not an effectwe patient safcty~quaiiwimprovement me=um. It is more 

cfkctive to improve the process or system by wfich health care is delivered than ro 

penalize a physician who practices in a bad system. 

In conclusion. we urge tie OIG to ~on.wdcr m data and h cowhsions drawn from 

that data to either cotirm or refute tie charge that hospitals are not fully compiying with 

chairkgaI obligation to report adverse acuons to the Natiomd Practitio= Data Bank. 

Without further analysis. it is pmmaturc to recommend that the PHS sponsora 

conferenceon issues irdluencing reporthg to IJXNPDB, or to take steps to have che Joint 

Commission on Accreditation of Heaithcare Organizations increase its focus on assessing 

the hospitai’s Compliance witi the H~QIA- we offer our asskf=e to obtain the best 

available information and understanding of the facto=influencing hospital reportingto 

theNPDB. 

~ James S. Todd. MD 
APPENDIX C


1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

NOTES 

Information, under certain conditions, could also be made available to 

plaintiffs’ attorneys. 

45 CFR Part 60 (1989). 

See Department of Health and Human Services, Office of Inspector General, 

National Practitioner Data Bank: Use@lness and Impact of Repotis to 

Hospitals, 0E1-01-90-O0520, February 1993 and Department of Health and 

Human Services, Office of Inspector General, National Practitioner Data 

Bank: Use&lness and Impact of Repotis to State Licensing Boards, OEI-Ol90-00523, March 1993. 

At the time of our inquiry, December 31, 1993 was the latest date for which data 

were available to us. 

Across the United States we are reporting on a total of 6,588 hospitals, 

based on data provided by the Health Resources and Services 

Administration. The total represents hospitals which were in existence 

sometime during the September 1, 1990 to December 31, 1993 period and 

which, therefore, could have submitted adverse action reports sometime 

during that period. The total is not a count of the number of hospitals in 

existence on December 31, 1993. 

54 Fed. Reg. 52,853, Dec. 22, 1989. 

For calendar years 1991, 1992, and 1993, the Federation of State Medical 

Boards reports 7,675 “prejudicial actions” against physicians. These 

include license revocation, suspension, or surrender; probation or licensure 

restrictions of some kind; and other formal actions such as penalties or 

reprimands. We arrived at a 3 1/3 years estimated total of 8,000 

prejudicial actions by assuming that at least 325 were taken in the last 4 

months of 1990. Given that 2,361 were taken in all of 1993, the 325 

estimate appears to be reasonable. 

All physicians disciplined by boards are not necessarily on hospital staffs. On the 

other hand, some could be on the staff of more than one hospital. 

Troyen A. Brennan, et al., “Incidence of Adverse Events and Negligence in 

Hospitalized Patients: Results of the Harvard Medical Practice Study 1,” The New 

England Journal of Medicine 324, no.6 (February 7, 1991): 370-76. 

c-1 
10.	 Improving the overall performance of the medical staff and assuring that 

certain minimum standards of performance are maintained are not 

necessarily incompatible objectives. Indeed, the director of one wellrespected quality insurance program told us that in his program involving 

multiple hospitals both objectives coexist. At the same time that the overall 

standard of care has been improved, a number of physicians have been 

disciplined and/or reported to the risk management program. 

Yet, in the quest to maintain a “safe” environment for physicians to 

participate in reviewing data on practice variations, it certainly is plausible 

that a hospital may choose to reemphasize or even avoid disciplinary 

activities, perhaps by allowing physicians whose performance is 

questionable over a substantial period of time to leave the staff and find 

other practice settings. 

11.	 To obtain some information on the extent to which reportable hospital actions may 

not in fact be reported to the Data Bank, we sought the cooperation of medical 

licensure boards in eight States. Our intention had been to give them a list of all 

hospitals in their States that had not reported a single practitioner to the Data Bank 

in the 1990- 1993 period and then to have asked them to identify any referrals 

they received and disciplinary actions they took involving physicians from those 

hospitals. With that information, we would then have checked to see if any of 

those cases involved hospital actions that should have been reported to the Data 

Bank. 

Unfortunately, during the brief period of our inquiry, only one State was 

able to provide us with sufficient information. Other States either were not 

readily able to identify referrals or disciplinary actions by source or to free 

up sufficient resources to review hospital referrals to determine if they 

should have been reported to the Data Bank. In the participating State, 

officials were able to provide such information and afforded us the 

opportunity to review hospital reports ourselves. 

12.	 These actions included reductions, surrenders, suspensions, and 

terminations of physicians’ clinical privileges. Information was obtained 

from case files. 

13.	 Through the Health Care Financing Administration, the Department conducts 

validation surveys of a sample of hospitals to assure that they comply with the 

Medicare Conditions of Participation. 

14. The more precise explanations that the Joint Commission inserted in the scoring 

guidelines	 respond to suggestions made by the Health Resources and Services 

Administration of the Public Health Service. The amendment concerning timely 

querying responds in part to a recommendation we made in a February 1993 

report. In that report, National Practitioner Data Bank: Usefi.dness and Impact of 

Reports to Hospitals (OEI-01-90-O0520), we called for the Joint Commission to 

c-2 
“establish guidelines on how quickly hospital should query the Data Bank after 

receiving applications for privileges. ” 

c-3