Public Act 099-0326
 
HB2706 EnrolledLRB099 09933 RPS 30149 b


  
    AN ACT concerning regulation.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  


 
    Section 5. The Hospital Report Card Act is amended  by 
changing Sections 25 and 30 as follows:
 



    (210 ILCS 86/25)


    Sec. 25. Hospital reports. 

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


        (1) Nursing hours per patient day, average daily 
    census, and average daily
hours worked
for each clinical 
    service area.


        (2) Infection-related measures for the facility for 
    the specific clinical
procedures
and devices determined by 
    the Department by rule under 2 or more of the following 
    categories:


            (A) Surgical procedure outcome measures.

            (B) Surgical procedure infection control process 
        measures.



            (C)

Outcome or process measures related to 
        ventilator-associated pneumonia.


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

        (3) Information required under paragraph (4) of 
    Section 2310-312 of the Department of Public Health Powers 
    and Duties Law of the
Civil Administrative Code of 
    Illinois.

        (4) Additional infection measures mandated by the 
    Centers for Medicare and Medicaid Services that are 
    reported by hospitals to the Centers for Disease Control 
    and Prevention's National Healthcare Safety Network 
    surveillance system, or its successor, and deemed relevant 
    to patient safety by the Department. 
    The infection-related measures developed by the Department 
shall be based upon measures and methods developed by the 
Centers for Disease Control and Prevention, the Centers for 
Medicare and Medicaid Services, the Agency for Healthcare 
Research and Quality, the Joint Commission on Accreditation of 
Healthcare Organizations, or the National Quality Forum. The 
Department may align the infection-related measures with the 
measures and methods developed by the Centers for Disease 
Control and Prevention, the Centers for Medicare and Medicaid 
Services, the Agency for Healthcare Research and Quality, the 
Joint Commission on Accreditation of Healthcare Organizations, 
and the National Quality Forum by adding reporting measures 
based on national health care strategies and measures deemed 
scientifically reliable and valid for public reporting. The 
Department shall receive approval from the State Board of 
Health to retire measures deemed no longer scientifically valid 
or valuable for informing quality improvement or infection 
prevention efforts. The Department shall notify the Chairs and 
Minority Spokespersons of the House Human Services Committee 
and the Senate Public Health Committee of its intent to have 
the State Board of Health take action to retire measures no 
later than 7 business days before the meeting of the State 
Board of Health.
    The Department shall include interpretive guidelines for 
infection-related indicators and, when available, shall 
include relevant benchmark information published by national 
organizations.

    (b) Individual hospitals shall prepare annual reports 
including vacancy and
turnover rates
for licensed nurses per 
clinical service area.

    (c) None of the information the Department discloses to the 
public may be
made
available
in any form or fashion unless the 
information has been reviewed, adjusted, and
validated

according to the following process:


        (1) The Department shall organize an advisory 
    committee, including
representatives
from the Department, 
    public and private hospitals, direct care nursing staff,

    physicians,
academic researchers, consumers, health 
    insurance companies, organized labor,
and
organizations 
    representing hospitals and physicians. The advisory 
    committee
must be
meaningfully involved in the development 
    of all aspects of the Department's
methodology
for 
    collecting, analyzing, and disclosing the information 
    collected under this
Act, including
collection methods, 
    formatting, and methods and means for release and

    dissemination.


        (2) The entire methodology for collecting and 
    analyzing the data shall be
disclosed
to all
relevant 
    organizations and to all hospitals that are the subject of 
    any
information to be made
available to the public before 
    any public disclosure of such information.


        (3) Data collection and analytical methodologies shall 
    be used that meet
accepted
standards of validity and 
    reliability before any information is made available
to the 
    public.


        (4) The limitations of the data sources and analytic 
    methodologies used to
develop
comparative hospital 
    information shall be  clearly identified and acknowledged,

    including but not
limited to the appropriate and 
    inappropriate uses of the data.


        (5) To the greatest extent possible, comparative 
    hospital information
initiatives shall
use standard-based 
    norms derived from widely accepted provider-developed

    practice
guidelines.


        (6) Comparative hospital information and other 
    information that the
Department
has
compiled regarding 
    hospitals shall be shared with the hospitals under review

    prior to
public
dissemination of such information and these 
    hospitals have 30 days to make
corrections and
to add 
    helpful explanatory comments about the information before 
    the
publication.


        (7) Comparisons among hospitals shall adjust for 
    patient case mix and
other
relevant
risk factors and 
    control for provider peer groups, when appropriate.


        (8) Effective safeguards to protect against the 
    unauthorized use or
disclosure
of
hospital information 
    shall be developed and implemented.


        (9) Effective safeguards to protect against the 
    dissemination of
inconsistent,
incomplete, invalid, 
    inaccurate, or subjective hospital data shall be developed

    and
implemented.


        (10) The quality and accuracy of hospital information 
    reported under this
Act
and its
data collection, analysis, 
    and dissemination methodologies shall be evaluated

    regularly.


        (11) Only the most basic identifying information from 
    mandatory reports
shall be
used, and
information 
    identifying a patient, employee, or licensed professional

    shall not be released.
None of the information the 
    Department discloses to the public under this Act
may be 
    used to
establish a standard of care in a private civil 
    action.

    (d) Quarterly reports shall be submitted, in a format set 
forth in rules
adopted
by the
Department, to the Department by 
April 30, July 31, October 31, and January 31
each year
for the 
previous quarter. Data in quarterly reports must cover a period 
ending
not earlier than
one month prior to submission of the 
report. Annual reports shall be submitted
by December
31 in a 
format set forth in rules adopted by the Department to the 
Department.
All reports
shall be made available to the public 
on-site and through the Department.

    (e) If the hospital is a division or subsidiary of another 
entity that owns
or
operates other
hospitals or related 
organizations, the annual public disclosure report shall
be for 
the specific
division or subsidiary and not for the other 
entity.

    (f) The Department shall disclose information under this 
Section in
accordance with provisions for inspection and 
copying of public records
required by the Freedom of

Information Act provided that such information satisfies the 
provisions of
subsection (c) of this Section.

    (g) Notwithstanding any other provision of law, under no 
circumstances shall
the
Department disclose information 
obtained from a hospital that is confidential
under Part 21
of 
Article VIII of the Code of Civil Procedure.

    (h) No hospital report or Department disclosure may contain 
information
identifying a patient, employee, or licensed 
professional.

(Source: P.A. 98-463, eff. 8-16-13.)

 



    (210 ILCS 86/30)



    Sec. 30. Department reports. The Department of Public 
Health shall
annually submit
to the General Assembly a report 
summarizing the quarterly reports by health
service area
and 
shall publish that report on its website. The Department of 
Public Health
may issue
quarterly informational bulletins at 
its discretion, summarizing all or part of
the information

submitted in these quarterly reports. The Department shall 
publish quality and safety measures on major public health 
problems, such as cardiovascular disease and diabetes, that 
have been vetted by the National Quality Forum, the Agency for 
Healthcare Research and Quality, the Centers for Disease 
Control and Prevention, or the Centers for Medicare and 
Medicaid Services. The Department shall also publish

risk-adjusted mortality
rates for each hospital based upon 
information hospitals have already submitted
to the
Department 
pursuant to their obligations to report health care information

under other public
health reporting laws and regulations 
outside of this Act. The published
mortality rates must
comply 
with the hospital data publication process contained in 
subsection (c)
of Section 25 of this Act.

(Source: P.A. 93-563, eff. 1-1-04.)


 
    Section 99. Effective date. This Act takes effect upon 
becoming law.