One side says hospitals have “dropped the ball” when it comes to physician oversight, while another argues that the lack of disciplinary actions being reported to the National Practitioner Data Bank could be evidence that methods for early identification and intervention of potential problems are working.
In a new study that states that the “failure of hospitals to discipline and report doctors endangers patients,” the Health Research Group of the consumer advocacy organization Public Citizen reports that nearly half of all U.S. hospitals have failed to file a single report to the federal database that collects information on incidents in which a doctor’s hospital-admitting privileges were revoked or restricted for more than 30 days because of issues of competency or conduct.
The NPDB was launched in 1990 and, as of December 2007, only 11,221 incidents had been reported—which is one-eighth of what the government estimated would be collected when the database was created under the Health Care Quality Improvement Act of 1986, the report said. According to Public Citizen, 2,845 out of 5,823 U.S. hospitals, or 49%, had never submitted a privilege sanction report in the 17 years covered by the study.
Although a slight increase in the number of reports filed was seen in 2007 (551 compared with 531 in 2006), there has been a general downward trend since a record 830 reports were filed in 1991 and the recent high of 687 reports in 2002.
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, M.D., the founder and director of the Health Research Group and acting president of Public Citizen, declares, “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 study’s author, Alan Levine, of Public Citizen, link “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 the 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,” says Nancy Foster, vice president for policy with the American Hospital Association, though she notes 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 suggests 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 we’ve learned is that you go back to the end-user—in this case, hospitals—and ask what’s working right and what’s not working right. And then ask what can we, meaning HRSA, do to make it better?” Foster says, referring to HHS’ Health Resources and Services Administration.
Foster says she wouldn’t 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 says. “Nor would Dr. Wolfe.”
Foster also questions whether the decline in reports filed was necessarily a negative trend.
“What I don’t know is how many hospitals should have filed a report—Public Citizen has reached a conclusion that too few have,” she says. “To get to the magnitude that a report should have been filed is a rare thing.”
Foster says that 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 says, 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 says. “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 has praise for states with a high rate of reporting, such as Connecticut, where 30 of the state’s 40 hospitals with active NPDB registration have filed reports. Leslie Gianelli, Connecticut Hospital Association director of communications, says its higher filing rate hasn’t created an adversarial environment.
“We haven’t sensed any friction and don’t believe it has created any tension between the hospitals and the doctors,” Gianelli says. “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 that’s 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.
In Colorado, Public Citizen reports that 42 of 78 hospitals, or 53.8%, have not filed a single report. Surgeon Robert McIntyre, M.D., says that he is not sure of the exact number or reports his institution, the University of Colorado Hospital in Aurora, has filed, but he says “it’s in double digits.”
But McIntyre, who is president-elect of the hospital medical staff and chair of its credentials committee, says the nature of the institution sets it apart from other hospitals. First, a doctor has to have a medical school appointment to have admitting privileges; and second, the hospital is self-insured, and this helps promote vigorous self-policing, he says.
“The fact that we’re a self-insured institution has made our peer review as robust as it is because we have to manage our own risk,” McIntyre says. “At other institutions, a physician’s malpractice is the physician’s problem and not the hospital’s problem, so one of the reasons our peer review is so good is that we’re all in the same boat together.”
McIntyre, however, questions whether a 31-day suspension of privileges is the proper trigger for filing a report. He explains that the length of a suspension may be more administrative than punitive as privileges may be suspended for the time it takes to conduct an investigation, hold a hearing or process an appeal. All in all, McIntyre says that the database fulfills a useful function for his credentialing committee.
“Whenever we have someone apply for medical staff privileges at the hospital, one of the first steps is a query to the National Practitioner Data Bank so we would be aware of any reports,” he says. “We often ask the physician to provide information about anything that would be in the database, so it’s extremely rare that there’s something there we didn’t know about. The database keeps people pretty open and honest during the application process.”
McIntyre agrees with Foster that measures are taken to identify and address potential conduct and competency issues early before they escalate. He adds that there is also self-identification as the hospital’s physician-wellness program notes how stress can lead to unprofessional behavior and offers ways of preventing that from occurring.
In terms of competency issues, McIntyre says that self-policing efforts are enhanced with a patient-safety intranet site where staff can discuss issues they are witnessing and by internal reporting systems, which are used when physicians go through the reappointment process every two years.
“Our peer review is so robust, we don’t have a problem with people trying to get privileges they wouldn’t be qualified to have,” he explains. “Everyone sees that the ultimate goal is to improve care and safety of patients and not to have a culture of blame—saying this is this person’s fault and that is that person’s fault—but it’s more about how can we do it better.”
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 says. Later he adds that “something ought to be done in this transparency-oriented administration.”
HHS declined to comment for this article.
Wolfe says that there is no excuse for keeping information on which individual hospitals were or weren’t generating reports private. He blames the policy on the “patronizing” attitude of the American Medical Association, arguing that it’s the AMA’s position that patients wouldn’t understand why a doctor was removed from a hospital’s 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 NPDB’s data was rejected."
Foster is also against opening up the NPDB for public scrutiny.
“What would be the purpose?” she asks. “We’re all for public reporting of meaningful measures, but it isn’t clear if that would be an accurate assessment of a hospital’s quality or a gauge of its safety.”
Ilene Corina, president of the patient-safety organization PULSE of New York, disagrees. She argues for greater public disclosure.
“It’s a very serious patient-safety problem, and it’s a very serious transparency and lack-of-accountability problem,” Corina says. “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 says, she realizes that public disclosure alone won’t solve everything.
“It’s not a win-win,” Corina acknowledges, adding that full access would only lead to even fewer reports being filed. Instead, she says 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 says that she participates in the hearings in which it is decided whether hospitals maintain their accreditation or not. If she’s able to do that, Corina argues, 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 they’re so brilliant, they can make me understand,” Corina says. “If a doctor has been sued or disciplined, I’m the first to say that that’s not the only thing to judge them on—but let us make our own judgment.”
McIntyre says that he has no strong opinion on opening up the NPDB files, but he adds that the reports are usually just an outline and offer few details, so he is unsure of how useful they would be to anyone. On the other hand, he strongly believes peer-review proceedings should be kept confidential.
“Knowing that the peer-review processes are private and confidential by statute encourages people to participate and be open and honest about what’s going on—and if you change that, you may have a problem,” he says. “If you change the rules, it could alter peer review in a way that could be very damaging.”Submit a letter to the Modern Physician Reader Blog. Please include your name, title, company and hometown. Modern Physician reserves the right to edit all submissions.