HB0003 EngrossedLRB101 03006 CPF 48014 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Hospital Report Card Act is amended by
5changing Section 25 as follows:
 
6    (210 ILCS 86/25)
7    Sec. 25. Hospital reports.
8    (a) Individual hospitals shall prepare a quarterly report
9including all of the following:
10        (1) Nursing hours per patient day, average daily
11    census, and average daily hours worked for each clinical
12    service area.
13        (2) Infection-related measures for the facility for
14    the specific clinical procedures and devices determined by
15    the Department by rule under 2 or more of the following
16    categories:
17            (A) Surgical procedure outcome measures.
18            (B) Surgical procedure infection control process
19        measures.
20            (C) Outcome or process measures related to
21        ventilator-associated pneumonia.
22            (D) Central vascular catheter-related bloodstream
23        infection rates in designated critical care units.

 

 

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1        (3) Information required under paragraph (4) of
2    Section 2310-312 of the Department of Public Health Powers
3    and Duties Law of the Civil Administrative Code of
4    Illinois.
5        (4) Additional infection measures mandated by the
6    Centers for Medicare and Medicaid Services that are
7    reported by hospitals to the Centers for Disease Control
8    and Prevention's National Healthcare Safety Network
9    surveillance system, or its successor, and deemed relevant
10    to patient safety by the Department.
11        (5) Each instance of preterm birth and infant mortality
12    within the reporting period, including the racial and
13    ethnic information of the mothers of those infants, and the
14    disparity of such occurrences across different racial and
15    ethnic groups.
16        (6) Each instance of maternal mortality within the
17    reporting period, including the racial and ethnic
18    information of those mothers, and the disparity of such
19    occurrences across different racial and ethnic groups.
20    The infection-related measures developed by the Department
21shall be based upon measures and methods developed by the
22Centers for Disease Control and Prevention, the Centers for
23Medicare and Medicaid Services, the Agency for Healthcare
24Research and Quality, the Joint Commission on Accreditation of
25Healthcare Organizations, or the National Quality Forum. The
26Department may align the infection-related measures with the

 

 

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1measures and methods developed by the Centers for Disease
2Control and Prevention, the Centers for Medicare and Medicaid
3Services, the Agency for Healthcare Research and Quality, the
4Joint Commission on Accreditation of Healthcare Organizations,
5and the National Quality Forum by adding reporting measures
6based on national health care strategies and measures deemed
7scientifically reliable and valid for public reporting. The
8Department shall receive approval from the State Board of
9Health to retire measures deemed no longer scientifically valid
10or valuable for informing quality improvement or infection
11prevention efforts. The Department shall notify the Chairs and
12Minority Spokespersons of the House Human Services Committee
13and the Senate Public Health Committee of its intent to have
14the State Board of Health take action to retire measures no
15later than 7 business days before the meeting of the State
16Board of Health.
17    The Department shall include interpretive guidelines for
18infection-related indicators and, when available, shall
19include relevant benchmark information published by national
20organizations.
21    (b) Individual hospitals shall prepare annual reports
22including vacancy and turnover rates for licensed nurses per
23clinical service area.
24    (c) None of the information the Department discloses to the
25public may be made available in any form or fashion unless the
26information has been reviewed, adjusted, and validated

 

 

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1according to the following process:
2        (1) The Department shall organize an advisory
3    committee, including representatives from the Department,
4    public and private hospitals, direct care nursing staff,
5    physicians, academic researchers, consumers, health
6    insurance companies, organized labor, and organizations
7    representing hospitals and physicians. The advisory
8    committee must be meaningfully involved in the development
9    of all aspects of the Department's methodology for
10    collecting, analyzing, and disclosing the information
11    collected under this Act, including collection methods,
12    formatting, and methods and means for release and
13    dissemination.
14        (2) The entire methodology for collecting and
15    analyzing the data shall be disclosed to all relevant
16    organizations and to all hospitals that are the subject of
17    any information to be made available to the public before
18    any public disclosure of such information.
19        (3) Data collection and analytical methodologies shall
20    be used that meet accepted standards of validity and
21    reliability before any information is made available to the
22    public.
23        (4) The limitations of the data sources and analytic
24    methodologies used to develop comparative hospital
25    information shall be clearly identified and acknowledged,
26    including but not limited to the appropriate and

 

 

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1    inappropriate uses of the data.
2        (5) To the greatest extent possible, comparative
3    hospital information initiatives shall use standard-based
4    norms derived from widely accepted provider-developed
5    practice guidelines.
6        (6) Comparative hospital information and other
7    information that the Department has compiled regarding
8    hospitals shall be shared with the hospitals under review
9    prior to public dissemination of such information and these
10    hospitals have 30 days to make corrections and to add
11    helpful explanatory comments about the information before
12    the publication.
13        (7) Comparisons among hospitals shall adjust for
14    patient case mix and other relevant risk factors and
15    control for provider peer groups, when appropriate.
16        (8) Effective safeguards to protect against the
17    unauthorized use or disclosure of hospital information
18    shall be developed and implemented.
19        (9) Effective safeguards to protect against the
20    dissemination of inconsistent, incomplete, invalid,
21    inaccurate, or subjective hospital data shall be developed
22    and implemented.
23        (10) The quality and accuracy of hospital information
24    reported under this Act and its data collection, analysis,
25    and dissemination methodologies shall be evaluated
26    regularly.

 

 

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1        (11) Only the most basic identifying information from
2    mandatory reports shall be used, and information
3    identifying a patient, employee, or licensed professional
4    shall not be released. None of the information the
5    Department discloses to the public under this Act may be
6    used to establish a standard of care in a private civil
7    action.
8    (d) Quarterly reports shall be submitted, in a format set
9forth in rules adopted by the Department, to the Department by
10April 30, July 31, October 31, and January 31 each year for the
11previous quarter. Data in quarterly reports must cover a period
12ending not earlier than one month prior to submission of the
13report. Annual reports shall be submitted by December 31 in a
14format set forth in rules adopted by the Department to the
15Department. All reports shall be made available to the public
16on-site and through the Department.
17    (e) If the hospital is a division or subsidiary of another
18entity that owns or operates other hospitals or related
19organizations, the annual public disclosure report shall be for
20the specific division or subsidiary and not for the other
21entity.
22    (f) The Department shall disclose information under this
23Section in accordance with provisions for inspection and
24copying of public records required by the Freedom of
25Information Act provided that such information satisfies the
26provisions of subsection (c) of this Section.

 

 

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1    (g) Notwithstanding any other provision of law, under no
2circumstances shall the Department disclose information
3obtained from a hospital that is confidential under Part 21 of
4Article VIII of the Code of Civil Procedure.
5    (h) No hospital report or Department disclosure may contain
6information identifying a patient, employee, or licensed
7professional.
8(Source: P.A. 98-463, eff. 8-16-13; 99-326, eff. 8-10-15.)
 
9    Section 99. Effective date. This Act takes effect upon
10becoming law.