Section 255.250  Hospital Reports

a)         Individual hospitals shall prepare a quarterly report including all of the following (Section 25(a) of the Act):

1)         Direct care hours, by reporting individually all of the following:

A)        Total inpatient days, which is the sum of each daily census for the time period.

B)        Total direct care RN hours, which equals the sum of the paid productive hours for direct care RN employees, including agency, per diem and registry RNs.

C)        Total direct care LPN hours, which equals the sum of the paid productive hours for direct care LPN employees, including agency, per diem and registry LPNs.

D)        Total direct care hours for assistive nursing personnel, which is the sum of the paid productive hours for direct care assistive nursing personnel, including agency, per diem and registry assistive nursing personnel.

E)        Nursing hours per patient day for direct care, which is the sum of total direct care RN hours and total direct care LPN hours and total direct care assistive nursing personnel hours divided by total inpatient days.  (Section 25(a)(1) of the Act)

F)         Licensed nursing hours per patient day − by RNs and LPNs (RN hours per patient day, LPN hours per patient day), which is:

i)          the total direct care hospital employed RN hours divided by the total inpatient days for the quarter;

ii)         the total direct care commercial agency contracted RN hours divided by the total inpatient days for the quarter;

iii)        the total direct care hospital employed LPN hours divided by the total inpatient days for the quarter; and

iv)        the total direct care commercial agency contracted LPN hours divided by the total inpatient days for the quarter.

G)        Average daily hours worked (Section 25(a)(1) of the Act) − by RNs and LPNs (average daily RN hours worked, average daily LPN hours worked), which is:

i)          the total direct care hospital employed RN hours divided by the number of calendar days for the quarter,

ii)         the total direct care commercial agency contracted RN hours divided by the number of calendar days for the quarter,

iii)        the total direct care hospital employed LPN hours divided by the number of calendar days for the quarter, and

iv)        the total direct care commercial agency contracted LPN hours divided by the number of calendar days for the quarter.

H)        Average daily census per clinical service area, which is the total inpatient days divided by the days in the quarter.  (Section 25(a)(1) of the Act)

2)         Infection-related measures for the facility for the following clinical procedures (Section 25(a)(2) of the Act) for patients ages 18 and over in hospitals providing services where these treatments are clinically appropriate.

A)        Surgical outcome measures by reporting postoperative wound infection diagnosed during index hopitalization.

B)        Central vascular catheter-related bloodstream infection rates in designated critical care units.

C)        Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization.

b)         Individual hospitals may also, but are not required to, submit the following optional reports:  (Agency, per-diem and registry RNs must be included in the number of productive hours for the optional report.  The optional report may not include licensed nursing orientees in the number of productive hours.)

1)         Total number of nursing hours per patient day and licensed nursing hours per patient day for those licensed nursing personnel with indirect patient care responsibilities. The licensed nursing hours per patient day will be reported separately for registered professional nurses and licensed practical nurses. Hospitals may also submit the number of licensed nursing hours per patient day that are associated with caring for outpatient and observation patients.

2)         Average daily hours worked and average daily census for the quarter per clinical service area.

c)         Individual hospitals shall prepare annual reports including vacancy and turnover rates for licensed nurses per clinical service area for direct care nurses as follows: (Section 25(b) of the Act) 

1)         Vacancy Rate:

The vacancy rate submitted for licensed nurses per clinical service area must equal the number of full-time equivalent openings for licensed nursing personnel on January 1 of each year, divided by the number of full-time equivalents for licensed nursing personnel budgeted as of January 1. Budgeted positions include both filled positions and vacant positions for which the hospital is recruiting on January 1.  The vacancy rate does not include those licensed nursing employees who are on family, medical or disability leave or who provide per diem services to the hospital.  The vacancy rate shall be reported separately for registered nurses and licensed practical nurses.

2)         Turnover Rate:

The turnover rate submitted for licensed nurses per clinical service area must equal the number of separated employees for licensed nursing personnel for the calendar year preceding January 1, divided by the number of employees for licensed nursing personnel on the hospital's payroll for the same clinical service area as of the preceding January 1.  The turnover rate does not include those licensed nursing employees who are on family, medical or disability leave or who provide per diem services to the hospital.  The turnover rate shall be reported separately for registered nurses and licensed practical nurses.

(Source:  Amended at 40 Ill. Reg. 1833, effective January 5, 2016)