102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB0068

 

Introduced 1/14/2021, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
110 ILCS 330/11 new
210 ILCS 85/10.12 new
210 ILCS 86/25

     Amends the University of Illinois Hospital Act and the Hospital Licensing Act. Requires hospitals to require an intern, resident, or physician who provides medical services at the hospital to have proper credentials and any required certificates for ongoing training at the time the intern, resident, or physician renews his or her license. Amends the Hospital Report Card Act. Requires hospitals to include in their quarterly reports the number of female patients who have died within the reporting period, the number of female patients who have died of a preventable cause within the reporting period and the number of those preventable deaths that the hospital has otherwise reported within the reporting period, and the number of physicians who were required by the hospital to undergo any amount or type of retraining during the reporting period.


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A BILL FOR

 

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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 University of Illinois Hospital Act is
5amended by adding Section 11 as follows:
 
6    (110 ILCS 330/11 new)
7    Sec. 11. Credentials and certificates. The University of
8Illinois Hospital shall require an intern, resident, or
9physician who provides medical services at the University of
10Illinois Hospital to have proper credentials and any required
11certificates for ongoing training at the time the intern,
12resident, or physician renews his or her license.
 
13    Section 10. The Hospital Licensing Act is amended by
14adding Section 10.12 as follows:
 
15    (210 ILCS 85/10.12 new)
16    Sec. 10.12. Credentials and certificates. A hospital
17licensed under this Act shall require an intern, resident, or
18physician who provides medical services at the hospital to
19have proper credentials and any required certificates for
20ongoing training at the time the intern, resident, or
21physician renews his or her license.
 

 

 

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1    Section 15. The Hospital Report Card Act is amended by
2changing Section 25 as follows:
 
3    (210 ILCS 86/25)
4    Sec. 25. Hospital reports.
5    (a) Individual hospitals shall prepare a quarterly report
6including all of the following:
7        (1) Nursing hours per patient day, average daily
8    census, and average daily hours worked for each clinical
9    service area.
10        (2) Infection-related measures for the facility for
11    the specific clinical procedures and devices determined by
12    the Department by rule under 2 or more of the following
13    categories:
14            (A) Surgical procedure outcome measures.
15            (B) Surgical procedure infection control process
16        measures.
17            (C) Outcome or process measures related to
18        ventilator-associated pneumonia.
19            (D) Central vascular catheter-related bloodstream
20        infection rates in designated critical care units.
21        (3) Information required under paragraph (4) of
22    Section 2310-312 of the Department of Public Health Powers
23    and Duties Law of the Civil Administrative Code of
24    Illinois.

 

 

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1        (4) Additional infection measures mandated by the
2    Centers for Medicare and Medicaid Services that are
3    reported by hospitals to the Centers for Disease Control
4    and Prevention's National Healthcare Safety Network
5    surveillance system, or its successor, and deemed relevant
6    to patient safety by the Department.
7        (5) Each instance of preterm birth and infant
8    mortality within the reporting period, including the
9    racial and ethnic information of the mothers of those
10    infants.
11        (6) Each instance of maternal mortality within the
12    reporting period, including the racial and ethnic
13    information of those mothers.
14        (7) The number of female patients who have died within
15    the reporting period.
16        (8) The number of female patients who have died of a
17    preventable cause within the reporting period and the
18    number of those preventable deaths that the hospital has
19    otherwise reported within the reporting period.
20        (9) The number of physicians, as that term is defined
21    in the Medical Practice Act of 1987, required by the
22    hospital to undergo any amount or type of retraining
23    during the reporting period.
24    The infection-related measures developed by the Department
25shall be based upon measures and methods developed by the
26Centers for Disease Control and Prevention, the Centers for

 

 

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1Medicare and Medicaid Services, the Agency for Healthcare
2Research and Quality, the Joint Commission on Accreditation of
3Healthcare Organizations, or the National Quality Forum. The
4Department may align the infection-related measures with the
5measures and methods developed by the Centers for Disease
6Control and Prevention, the Centers for Medicare and Medicaid
7Services, the Agency for Healthcare Research and Quality, the
8Joint Commission on Accreditation of Healthcare Organizations,
9and the National Quality Forum by adding reporting measures
10based on national health care strategies and measures deemed
11scientifically reliable and valid for public reporting. The
12Department shall receive approval from the State Board of
13Health to retire measures deemed no longer scientifically
14valid or valuable for informing quality improvement or
15infection prevention efforts. The Department shall notify the
16Chairs and Minority Spokespersons of the House Human Services
17Committee and the Senate Public Health Committee of its intent
18to have the State Board of Health take action to retire
19measures no later than 7 business days before the meeting of
20the State Board of Health.
21    The Department shall include interpretive guidelines for
22infection-related indicators and, when available, shall
23include relevant benchmark information published by national
24organizations.
25    The Department shall collect the information reported
26under paragraphs (5) and (6) and shall use it to illustrate the

 

 

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1disparity of those occurrences across different racial and
2ethnic groups.
3    (b) Individual hospitals shall prepare annual reports
4including vacancy and turnover rates for licensed nurses per
5clinical service area.
6    (c) None of the information the Department discloses to
7the public may be made available in any form or fashion unless
8the information has been reviewed, adjusted, and validated
9according to the following process:
10        (1) The Department shall organize an advisory
11    committee, including representatives from the Department,
12    public and private hospitals, direct care nursing staff,
13    physicians, academic researchers, consumers, health
14    insurance companies, organized labor, and organizations
15    representing hospitals and physicians. The advisory
16    committee must be meaningfully involved in the development
17    of all aspects of the Department's methodology for
18    collecting, analyzing, and disclosing the information
19    collected under this Act, including collection methods,
20    formatting, and methods and means for release and
21    dissemination.
22        (2) The entire methodology for collecting and
23    analyzing the data shall be disclosed to all relevant
24    organizations and to all hospitals that are the subject of
25    any information to be made available to the public before
26    any public disclosure of such information.

 

 

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1        (3) Data collection and analytical methodologies shall
2    be used that meet accepted standards of validity and
3    reliability before any information is made available to
4    the public.
5        (4) The limitations of the data sources and analytic
6    methodologies used to develop comparative hospital
7    information shall be clearly identified and acknowledged,
8    including but not limited to the appropriate and
9    inappropriate uses of the data.
10        (5) To the greatest extent possible, comparative
11    hospital information initiatives shall use standard-based
12    norms derived from widely accepted provider-developed
13    practice guidelines.
14        (6) Comparative hospital information and other
15    information that the Department has compiled regarding
16    hospitals shall be shared with the hospitals under review
17    prior to public dissemination of such information and
18    these hospitals have 30 days to make corrections and to
19    add helpful explanatory comments about the information
20    before the publication.
21        (7) Comparisons among hospitals shall adjust for
22    patient case mix and other relevant risk factors and
23    control for provider peer groups, when appropriate.
24        (8) Effective safeguards to protect against the
25    unauthorized use or disclosure of hospital information
26    shall be developed and implemented.

 

 

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1        (9) Effective safeguards to protect against the
2    dissemination of inconsistent, incomplete, invalid,
3    inaccurate, or subjective hospital data shall be developed
4    and implemented.
5        (10) The quality and accuracy of hospital information
6    reported under this Act and its data collection, analysis,
7    and dissemination methodologies shall be evaluated
8    regularly.
9        (11) Only the most basic identifying information from
10    mandatory reports shall be used, and information
11    identifying a patient, employee, or licensed professional
12    shall not be released. None of the information the
13    Department discloses to the public under this Act may be
14    used to establish a standard of care in a private civil
15    action.
16    (d) Quarterly reports shall be submitted, in a format set
17forth in rules adopted by the Department, to the Department by
18April 30, July 31, October 31, and January 31 each year for the
19previous quarter. Data in quarterly reports must cover a
20period ending not earlier than one month prior to submission
21of the report. Annual reports shall be submitted by December
2231 in a format set forth in rules adopted by the Department to
23the Department. All reports shall be made available to the
24public on-site and through the Department.
25    (e) If the hospital is a division or subsidiary of another
26entity that owns or operates other hospitals or related

 

 

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1organizations, the annual public disclosure report shall be
2for the specific division or subsidiary and not for the other
3entity.
4    (f) The Department shall disclose information under this
5Section in accordance with provisions for inspection and
6copying of public records required by the Freedom of
7Information Act provided that such information satisfies the
8provisions of subsection (c) of this Section.
9    (g) Notwithstanding any other provision of law, under no
10circumstances shall the Department disclose information
11obtained from a hospital that is confidential under Part 21 of
12Article VIII of the Code of Civil Procedure.
13    (h) No hospital report or Department disclosure may
14contain information identifying a patient, employee, or
15licensed professional.
16(Source: P.A. 101-446, eff. 8-23-19.)