I 

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

FEBRUARY 1993 

I 
OFFICE OF INSPECI’OR 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 OIG’S 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 OIG’S 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. ‘l’he 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECI’IONS 

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., 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 

about how they use it. Some observers 

readily available through other sources. 

have argued that reports of malpractice 

utility of this information to hospitals and 

note that much of the information was already 

Critics of the current reporting requirements 

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 Bank’s 

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 

� The Data 

18 month 

Bank has delivered accurate reports to hospitals. 

Bank’s average response time has been improving steadily. Over an 

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 Bank’s 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 

FINDINGS . . . . . 

..-

. . . 

Usefulness to Hospitals 

Impact on Decisions . . 

. . . . . . . . . . . . . . . . . . . . . -

. . . . . . . . . . . . . . . . . . . . . -

. . . ...0 . . . . . . . . . . . . . . 

. . . . . . . � . . . . . . . . . . . . . . 

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

COMMENTS ONq’HEDRAIV REPORT . . . . . . 

APPENDICES 

A. Methodology . ,. ..,.. . . . . . . . � -O..*. ,00 

B. Summary of Hospitals’ Responses to OIG Mail 

c. Detailed Comments on the Draft 

OIG Response to the Comments 

D. Notes . . . . . . . . . . . . . . . . . . . 

Report and 

.* ..*.. ..* 

. . . ...0 � . . 

. . . . . . . 

. . . . . . . 

.* *.*,* 

.* *.*.* 

. . . . . . . 

. . . . . . . 

.* ..*.. 

Survey . 

. . . . . . . 

. . . . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . 

. ..0.0. .0 ..0.. . . 

1 

3 

3 

7 

. . . . . . . . . . . . . . . 12 

. . . . . . . . . . . . . . . 14 

.. 0.,.. . . . . . . 

. . . . . . . . . . . . . 

,. .0... . . . . . . 

. . . . . . . ., ...0. � 0.... 

A-1 

B-1 

c-1 

D-1 

. 

. 

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 Bank’s


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 President’s 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 practitioner’s 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 Bank’s 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 Bank’s 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 Bank’s 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 Bank’s 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 Bank’s 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 week’s delay. 

� Hospital officials found 58 percent of Data Bank reports to be useful. As the 

Data Bank’s 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 report’s 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 

1301 Data Bank Reports Increased r100 

-$0 

llo -

1oo- -80 

90- -70 

80-

-60 

70-

60- -50 

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 Typ of adverse action I I 

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). , 

� 

There 

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. 

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 physician’s 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 physician’s 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 physician’s 

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. 

� 

9 

Some 

to the 

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 

privileging decisions. 

hospitals explain that the Data Bank reports, even when they are received prior 

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 doctor’s 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 

time. f2 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 qu”ckly hospitak shotdii query the Data Bank a@r receiving 

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 ASMB’S suggestions, and direct PHS’S 

attention to them. Nevertheless, as we explain in appendix C, we chose not to 

incorporate ASMB’S 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 ASPE’S 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 ASPE’S 

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 Bank’s 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 Association’s 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 to”the 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 

TOTAL 

PHYSICIANS 

General Surgery


Family Medicine


Internal Medicine


Orthopedic Surgery


Emergency Medicine


Pediatrics


Neurological Surgery


Obstetrics and Gynecology


Urology


General Medicine


Anesthesiology


Ophthalmology


Radiology


Other or Missing


Cardiac Surgery


Cardiology


Gynecology (Osteopathic)


Gastroenterology


Eye, Ear, Nose, and Throat


Plastic Surgery


Psychiatry


Thoracic Surgery


Oncology


Allergy


DENTISTS and ORAL 

SURGEONS 

PODIATRISTS 

SOURCE: OIG Suxvey of Hospitals, 

Number of Percentage of 

matches matches 

142 100.0 

137 96.5 

23 16.2 

21 14.8 

12 8.5 

11 7.8 

9 6.3 

7 4.9 

7 4.9 

7 4.9 

5 3.5 

4 2.8 

4 2.8 

3 2.1 

3 2.1 

3 2.1 

2 1.4 

2 1.4 

2 1.4 

2 1.4 

2 1.4 

2 1.4 

2 1.4 

2 1.4 

1 0.7 

1 0.7 

4 2.8 

1 0.7 

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% 

hospital’s 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 A’s 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 A’s 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 board’s 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 A’s 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 ij’you answered YES to 8) Ya: 7 9 

Were Practitioner A’s 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 A’s 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 A’s 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 A’s 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 A’s No: 5 

privileges in place prior to the application? oh I 

No answer 134 . 

B-3 
13 (Skip i’fyou answered YES108 or 9 or NO to IO) (Check one) 13 

Which of the following best describes the 

restrictions applied to Practitioner A’s 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 A’s history) 

14	 Were any other actions taken with regard to Ya: 18 14 

Practitioner A’s 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


From which of the following sources were you aware of the adverse


action or malpractice payment?


a Practitioner A (self-report) Ya:67 

No: 17


other I


No answm 57


b Licensing board in your state Ya:31 

No: 54


No anmwm 57


c Licensing board in another state Ya:3 

No: 82


No answer 57


d Malpractice insurer in your state Y=: 7 

No: 77


other I


No answer 57


Malpractice insurer in another state No:85


No answez 57


Other hospital in your state Y=: 16 

No: 69


No answm 57


Hospital in another state	 Y=: 3


No: 82


No armwm 57


Professional society in your state Y6: 3 

No: 82


No answm 57


Professional society in another state No: 85 

No answer 57


Other source in your state Y=: 12


(IF YES, SPECIFY: No: 73


) No answer 57


k Other source in another state Y~: 1 

(IF YES, SPECIFY: No: w 

16 

a 

b 

c 

d 

e 

f 

g 

h 

i 

j 

k 

) 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 

a 

b 

c 

d 

e 

f 

g 

h 

i 

j 

k 

(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? 

Practitioner A (self-report) Y=.= 7 

Licensing board in your state Y~: O 

Licensing board in another state Ya: O 

Malpractice insurer in your state Ya: O 

Malpractice insurer in another state Y=: 1 

Other hospital in your state Ya: O 

Hospital in another state Ya: 1 

Professional society in your state Ya: O 

Professional society in another state Ya: O 

Other source in your state Ya: 2 

(IF YES, SPECIFY: 

Other source in another state” Ya: 1 

(IF YES, SPECIFY: 

B-7 
CONSIDERATION OF INFORMATION 

24 Based on the notes in Practitioner A’s file and your personal 

knowledge of Practitioner A’s 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 A’s 

a Department chair 

b Chief of medical staff 

c Hospital administration (CEO, Vice President, etc.) 

d Credentials committee 

. e Medical staff executive committee 

f . Hospital board subcommittee 

t! Full hospital board 

implication? 

Y=: 80 

No: 46 

Not app.: 8 

other 2 

No answer 6 

Ya: 71 

No: 58 

Not app.: 5 

Othec2 

No amwen 6 

Ya: 67 

No: 62 

Not app.: 5 

other 2 

No amver 6 

Ya: 80 

No: 45 

Not app.: 9 

other 2 

No answm 6 

Ya: 66 

No: 62 

Not app.: 6 

other 2 

No anmw 6 

Ya: 28 

No: 90 

Not app.: 15 

other 2 

No answez 7 

Ya: 59 

24 

a 

b 

c 

d 

e 

f 

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 “1”to 25) 

Overall, was the information contained in the . complete Data Bank response (i.e., all reports 

combined) useful to you? 

IF YES, WHY? 

a Information was unavailable elsewhere 

b Information confirmed other reports that were 

available elsewhere 

c Information helped us to judge practitioner’s 

competency 

d Information helped us to judge practitioner’s 

professionalism 

‘ Other (EXPLAIN: ) 

IF NO, WHY NOT? 

f Information was available elsewhere 

g Information was inaccurate 

h Information did not help us to judge practitioner’s 

competency or professionalism 

i Information was not provided in a timely manner 

J Other (EXPLAIN: ) 

Ya: 24 26 

No: 14 

other 1 

No answer 103 

(Check all that 

appty) 

5 a 

16 b 

10 c 

10 c1 

2 e 

(Check alI that 

apply) 

10 f 

o i? 

7 h 

7 i 

3 j 

B-9 
27	 (Sk(p ~you answered “1”to 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: )

) 1

T 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) 

28 

b Information confirmed other reports that were 45 

available elsewhere 

c Information helped us to judge practitioner’s 26 

competency 

d Information helped us to judge practitioner’s 17 

a Information was unavailable elsewhere 

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 practitioner’s 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 A’s 

privileges have been different if you had @ 

received the report on the last page from the Data 

Bank? (IF YES, HOW?) 

a Would have granted requested privileges 

b Would not have granted requested privileges 

c “Would have restricted privileges 

d Would not have restricted privileges 

Ya: 3 29 

No: 120 

Not app.: 2 

other 11 

No amwer 6 

(~ YES, check one.) 

2 a 

o b 

o c 

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#thMemorandum 

OEC 8 !992 

D8te 

From Assistant Secretary for Health 

Subject	 Office of Inspector General (OIG) Draft Report “National 

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 report’s 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 copy of the final OIG 

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. 

P

/7


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 PHS should seek to further reduce the time between query 

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 “online” 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 Bank’s 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.AHO’Sefforts 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 PHS’S actions to date toward minimizing response times and its 

pledge to publish related performance indicators. We direct PHS’S 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 

‘~bv,la 7 Washington, D.C. 20201 

0CT231$IW 

MEMOWWDT,JM TO: 

FROM 

SUBJECT � 

� 

Bryan B. Mitchell n 

Principal Deputy Ins e tor G er 

� 

Arnold R. Tompkins Wh+ 

Assistant Secretary for anagexnentand” u get 

OIG Draft Report: v 

@ 

ltNaional Practit’o r Data “ 

Bank: Usefulness and Ihpact of Repor to 

Hospitalssl0EI-01-90-O0520 

Thank you for the opportunity to review yOUr draft report, 

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 

system expires However, 

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. 

current contract in December, 1993. PHS 

- 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 way because the reports did not help them to 

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 ASMB’S 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 PHS’S 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 

7J*V4, 7 Q 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 NPDB’s 

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 OIG’S 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 NPDB reports provided at 

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 

NPDB report confirmed information secured elsewhere. 

In sum, conclusions of the OIG report -- U the data on 

is based are statistically valid -- seem to support are 

fold : 

tha< the 

which it 

three1. 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 inforxnation about 

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 

grant 

If you have any 

contact Elise D. 

has had littl& impact in deciding whether to 

privileges. 

questions regarding 

Smith at 690-6870. 

these comments, please 

( 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 ASPE’S 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 Bank’s information on their own terms. 

We question ASPE’S 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 ASPE’S 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~ 

Data Bank: 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 

chat therebe medicalstaff,and gwernlng body bylawsand that these 

corn~lemencarydocuments specifythe timef~~s withinwhich requests foz 

medical scaf~ rnebership ~md prt~~leges be actedupQn. We would be 

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 for the 

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 L”l)ll\L l,) ..111\\lll L’1,lL’lL’@)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: NationalPractitioner Data 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. 

Withrespectto“Usefulness toHospitals, ”theOfficeofInspectorGeneral(OIG)makesthe 

followingfindingsthatheAHA 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 13ank’s average time has been improving ste~dily. 

� Hospital officials found 58 percent of Data Bank reports to be useful (e.g., they 

confirmedinformation, etc.) 

MM Comments: One ofthepurposesoftheDataBankk tobecomea nationalrepository 

foradverseactionand malpracticeinformation.Sinceindividual stateshavedifferent 

reporting criteria,thasbeendifficult, ifnotimpossible, forhospitals inonestatetoreceive 

practitioner information fromhospitals in a second state. We are pleased that the Data Bank 

is meeting this challenge and is filling this information gap. 

Since hospitals simplydo nothavethecapacityoverifyallinformation thatcomestothem 

fromnumeroussources,we arepleasedthathesystemsetupbytheData Bank is providing 

hospitals withaccuratereportsandconfirminginformation hospitals hadreceivedfromother 

sources. 

C-15 
OIG RESPONSE TO JCAHO COMMENTS 

We thank JCAHO for considering a specification related to timely querying of the 

Data Bank. We directJCAHO’S attentiontoPHS’Scomments,whichdetailPHS’S 

intenttoworkwithJCAHO on thismatter. 

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 Bank’s utility. Another study looking at this direct effect should be 

instituted by the OIG within the next two years. 

If you shouldhaveany questionsregardingourcomments,feelfreeto contactIlaS. 

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 backup 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 

l’tl~slci:in>dedicated[0 the health Of.Wericu 

JiiIIW S, T~dd,MI) 515Iiorth MiteStreet 

Exwutiyc \’iccI’middnt Chicago,Illinois (XM1O 

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 

General’s (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 important .
 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 draft’s


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 

assess adequately the utility to hospitals of the information 

the NPDB.. 

to 

in 

Jehes S . Todd , MD 

C-21 
OIG RESPONSE TO AMA COMMENTS 

We drawan importantdktinctionbetween“theutility oftheDataBank tohospitals” 

and“theutility tohospitals ofthe 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 

Bank’s 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 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

. 

10. 

11. 

NOTES 

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. 

OIG Final Inspection Report, “National Practitioner Data Bank: Profile of 

Matches,” OEI-01-90-00522. 

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. 

Ninety percent confidence internal: 8 percent to 32 percent. 

Ninety percent confidence interval: 1 percent to 19 percent. 

Ninety percent confidence intexval: 35 percent to 65 percent. 

Ninety percent confidence internal: 69 percent to 100 percent. 

This difference is statistically significant (Pearson’s 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 hospital’s State. 

Because many physicians use out-of-State insurance companies, malpractice 

payment reports were defined as coming from out of State if the hospital’s 

State was different from the practitioner’s work state. 

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. 

M. Holoweiko, “The malpractice data bank is turning into a Frankenstein,” 

Medical Economics, May 6, 1991, pp. 120-133. 

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. 

13. 

14. 

15.’ 

16. 

17. 

18. 

19. 

20. 

21. 

22. 

23. 

24. 

25. 

This hospital said it knew of four malpractice payments made on one 

practitioner’s 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. 

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. 

This proportion is calculated from only 4.06 weighted observations. The margin 

of error is 41 percent. 

Ninety percent confidence interval: 49 percent to 83 percent. 

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 query’s 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. 

For example, they might match on name and date of birth, but not on license 

number or other unique identifier fields. 

Human operators can examine information such as address and medical school. 

Partial matches are only considered true matches if two operatom reach that 

conclusionidependently. 

Ninetypercentconfidence 

Ninetypercentconfidence 

Ninetypercentconfidence 

Ninetypercentconfidence 

interval: 58 percent to 90 percent. 

interval: 51 percent to 69 percent. 

interval: 28 percent to 46 percent. 

internal: 22 percent to 38 percent. 

Totals do not add to 100 percent because respondents could give multiple 

answers. 

Ninety percent confidence interval: 41 percent to 63 percent. 

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 
26. 

27. 

28. 

29. 

30. 

31. 

32. 

33. 

34* 

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. 

Ninety percent confidence interval: 4 percent to 12 percent. 

Ninety percent confidence interval: 4 percent to 12 percent. 

Ninety percent confidence interval: O percent to 2 percent. 

In one case, the practitioner’s requested credentials were restricted somewhat 

because the hospital did not perform certain procedures. 

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. 

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 

rates each hospital on the rigor of the hospital’s reporting requirements. It 

expects hospitals to require physicians to fully disclose disciplina~ actions, 

voluntary surrenders of licenses or privileges, and malpractice judgments and 

settlements. 

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. : 

This figure differs from the 18 percent cited on page 10 because pending 

decisions were not included in the analysis on page 10. 

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” 

report,whichgavethecorrect 

universeof19,122ratherthan 

figure, we refer in this report to the true 

the sample pool of 19,111. 

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