Noting that it is literally inconceivable that so few disciplinary actions had occurred in U.S. hospitals during the duration of the study, Sidney Wolfe, the founder and director of the Health Research Group and acting president of Public Citizen, declared, They are obviously playing games.
The Public Citizen study cites a 1994 report that alleged hospitals had purposely imposed disciplinary periods shorter than 31 days in an effort to sidestep the reporting requirements.
In a letter to HHS Secretary Kathleen Sebelius, Wolfe and the studys author, Alan Levine, of Public Citizen, linked this dangerously low number of hospital-based disciplinary reports to lax hospital peer review.
To make hospitals more accountable to the public, Public Citizen recommends civil penalties be imposed on hospitals who fail to file reports, that CMS be given statutory authority to impose sanctions on hospitals that fail to perform peer review, and that the HHS inspector general investigate hospital peer review practices related to the granting and renewing of hospital admitting privileges.
Peer review is an incredibly important function when it works well, said Nancy Foster, vice president for policy with the American Hospital Association, though she noted that state laws governing peer review vary widely from state to state and this can serve to limit its effectiveness.
While not commenting directly on the Public Citizen report or its recommendations, Foster suggested a different course for improving peer review and the National Practitioner Data Bank.
If this tool is not being used in the way that it should be used, then the first thing that weve learned is that you go back to the end userin this case, hospitalsand ask whats working right and whats not working right. And then ask what can we, meaning HRSA, do to make it better? Foster said, referring to HHS Health Resources and Services Administration.
Foster said she couldnt speculate on how many hospitals may be issuing sanctions of under 30 days in order to bypass the database reporting requirement.
I have no way of knowing how common a practice that would be, she said. Nor would Dr. Wolfe.
Foster also questioned whether the decline in reports filed was necessarily a negative trend.
What I dont know is how many hospitals should have filed a reportPublic Citizen has reached a conclusion that too few have, she said. To get to the magnitude that a report should have been filed is a rare thing.
Foster said hospitals are learning to better identify potential competency or conduct problems and are beginning to intervene earlier before sanctions have to be issued. Physicians who are not using new technology effectively, for example, can now receive extra training, she said, while correcting behavioral problems or the identification and remediation of impaired individuals of all professions has become something of an industry in itself among business consultants.
Safety really is a team sport, Foster said. If a physician has an issue of behaving badly, you try to intervene early before a significant sanction would have to be levied.
Public Citizen had praise for states with a high rate of reporting, such as Connecticut, where 30 of the states 40 hospitals with active NPDB registration have filed reports. Connecticut Hospital Association Director of Communications Leslie Gianelli said its higher filing rate hasnt created an adversarial environment.
We havent sensed any friction and dont believe it has created any tension between the hospitals and the doctors, Gianelli said. We think it adds to a safer and higher quality of care for patients ultimately. In Connecticut, we have a focus on safety and quality of care, and hospitals are going to intervene when they see something being done thats not up to standard.
In Louisiana, 144 out of 209 hospitals, or 69%, have not submitted a single report to the NPDB, and it was cited by Public Citizen as a state with a poor reporting record. A representative from the Louisiana Hospital Association was not available for comment.
While information on how many hospitals within a state have filed reports is publicly available, statistics from individual hospitals are not. At a news conference, Wolfe tried to goad the Obama administration into changing this policy.
An administration that prides itself on transparency should lead the way, Wolfe said. Later he added that something ought to be done in this transparency-oriented administration.
HHS declined to comment for this article.
Wolfe said there was no excuse for keeping information on which individual hospitals were or werent generating reports private. He blamed the policy on the patronizing attitude of the American Medical Association, arguing that its the AMAs position that patients wouldnt understand why a doctor was removed from a hospitals staff.
The AMA declined to comment for this article, and instead referred to a Sept. 20, 2000 congressional hearing, at which its then-president-elect, Richard Corlin, appeared. Corlin was testifying against a proposal by then-Rep. Thomas Bliley Jr. (R-Va.) to allow patients access to the information stored within the NPDB.
"Since the establishment of the NPDB, Congress has consistently recognized that only medical credentialing and licensing entities have the resources and expertise needed to evaluate NPDB reports and analyze how the reports reflect the competency of healthcare professionals, Corlin told the U.S. House Commerce Committee, then chaired by Bliley. After citing previous congressional debates on the issue in 1986 and 1995, Corlin added, After extensive deliberation in each debate, greater dissemination of the NPDBs data was rejected."
Foster also spoke against opening up the NPDB for public scrutiny.
What would be the purpose? she asked. Were all for public reporting of meaningful measures, but it isnt clear if that would be an accurate assessment of a hospitals quality or a gauge of its safety.
Ilene Corina, president of the patient-safety organization PULSE of New York, disagreed. She argued for greater public disclosure.
Its a very serious patient-safety problem and its a very serious transparency and lack-of-accountability problem, Corina said. Instead of disciplining doctors, everyone wants to treat them with kid gloves. They only discipline doctors when the media gets to them and their hands are tied.
That said, she realizes that public disclosure alone wont solve everything.
Its not a win-win, Corina acknowledged, adding that full access would only lead to even fewer reports being filed. Instead, she said a better solution may be to open the peer review process to lay or public members.
Corina, who became a patient-safety advocate when her son died after a tonsillectomy, has been on the board of the Joint Commission since January 2005, and said she participates in the hearings in which it is decided whether hospitals maintain their accreditation or not. If shes able to do that, Corina argued, then she and others like her can participate in peer reviewlike settings after undergoing some training and education.
The AMA believes in health literacy and education, so if theyre so brilliant, they can make me understand, Corina said. If a doctor has been sued or disciplined, Im the first to say that thats not the only thing to judge them onbut let us make our own judgment.
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