093_SB0059eng
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1 AN ACT concerning hospitals.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Hospital Report Card Act.
6 Section 5. Findings. The General Assembly finds that
7 Illinois consumers have a right to access information about
8 the quality of health care provided in Illinois hospitals in
9 order to make better decisions about their choice of health
10 care provider.
11 Section 10. Definitions. For the purpose of this Act:
12 "Average daily census" means the average number of
13 inpatients receiving service on any given 24-hour period
14 beginning at midnight in each clinical service area of the
15 hospital.
16 "Clinical service area" means a grouping of clinical
17 services by a generic class of various types or levels of
18 support functions, equipment, care, or treatment provided to
19 inpatients. Hospitals may have, but are not required to have,
20 the following categories of service: behavioral health,
21 critical care, maternal-child care, medical-surgical,
22 pediatrics, perioperative services, and telemetry.
23 "Department" means the Department of Public Health.
24 "Direct-care nurse" and "direct-care nursing staff"
25 includes any registered nurse, licensed practical nurse, or
26 assistive nursing personnel with direct responsibility to
27 oversee or carry out medical regimens or nursing care for one
28 or more patient.
29 "Hospital" means a health care facility licensed under
30 the Hospital Licensing Act.
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1 "Nursing care" means care that falls within the scope of
2 practice set forth in the Nursing and Advanced Practice
3 Nursing Act or is otherwise encompassed within recognized
4 professional standards of nursing practice, including
5 assessment, nursing diagnosis, planning, intervention,
6 evaluation, and patient advocacy.
7 "Retaliate" means to discipline, discharge, suspend,
8 demote, harass, deny employment or promotion, lay off, or
9 take any other adverse action against direct-care nursing
10 staff as a result of that nursing staff taking any action
11 described in this Act.
12 "Skill mix" means the differences in licensing,
13 specialty, and experiences among direct-care nurses.
14 "Staffing levels" means the numerical nurse to patient
15 ratio by licensed nurse classification within a nursing
16 department or unit.
17 "Unit" means a functional division or area of a hospital
18 in which nursing care is provided.
19 Section 15. Staffing levels.
20 (a) The number of registered professional nurses,
21 licensed practical nurses, and other nursing personnel
22 assigned to each patient care unit shall be consistent with
23 the types of nursing care needed by the patients and the
24 capabilities of the staff. Patients on each unit shall be
25 evaluated near the end of each change of shift by criteria
26 developed by the nursing service. There shall be staffing
27 schedules reflecting actual nursing personnel required for
28 the hospital and for each patient unit. Staffing patterns
29 shall reflect consideration of nursing goals, standards of
30 nursing practice, and the needs of the patients.
31 (b) Current nursing staff schedules shall be available
32 upon request at each patient care unit. Each schedule shall
33 list the daily assigned nursing personnel and average daily
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1 census for the unit. The actual nurse staffing assignment
2 roster for each patient care unit shall be available upon
3 request at the patient care unit for the effective date of
4 that roster. Upon the roster's expiration, the hospital shall
5 retain the roster for 5 years from the date of its
6 expiration.
7 (c) All records required under this Section, including
8 anticipated staffing schedules and the methods to determine
9 and adjust staffing levels shall be made available to the
10 public upon request.
11 (d) All records required under this Section shall be
12 maintained by the facility for no less than 5 years.
13 Section 20. Orientation and training.
14 (a) All health care facilities shall have established an
15 orientation process that provides initial job training and
16 information and assesses the direct care nursing staff's
17 ability to fulfill specified responsibilities.
18 (b) Personnel not competent for a given unit shall not
19 be assigned to work there without direct supervision until
20 appropriately trained.
21 (c) Staff training information will be available upon
22 request at the hospital.
23 Section 25. Hospital reports.
24 (a) Individual hospitals shall prepare a quarterly
25 report including all of the following:
26 (1) Nursing hours per patient day, average daily
27 census, and average daily hours worked for each clinical
28 service area.
29 (2) Nosocomial infection rates for the facility for
30 the specific clinical procedures determined by the
31 Department by rule under the following categories:
32 (A) Class I surgical site infection.
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1 (B) Ventilator-associated pneumonia.
2 (C) Central line-related bloodstream
3 infections.
4 The Department shall only disclose Illinois hospital
5 infection rate data according to the current benchmarks of
6 the Centers for Disease Control's National Nosocomial
7 Infection Surveillance Program.
8 (b) Individual hospitals shall prepare annual reports
9 including vacancy and turnover rates for licensed nurses per
10 clinical service area.
11 (c) None of the information the Department discloses to
12 the public may be made available in any form or fashion
13 unless the information has been reviewed, adjusted, and
14 validated according to the following process:
15 (1) The Department shall organize an advisory
16 committee, including representatives from the Department,
17 public and private hospitals, direct care nursing staff,
18 physicians, academic researchers, consumers, health
19 insurance companies, organized labor, and organizations
20 representing hospitals and physicians. The advisory
21 committee must be meaningfully involved in the
22 development of all aspects of the Department's
23 methodology for collecting, analyzing, and disclosing the
24 information collected under this Act, including
25 collection methods, formatting, and methods and means for
26 release and dissemination.
27 (2) The entire methodology for collecting and
28 analyzing the data shall be disclosed to all relevant
29 organizations and to all hospitals that are the subject
30 of any information to be made available to the public
31 before any public disclosure of such information.
32 (3) Data collection and analytical methodologies
33 shall be used that meet accepted standards of validity
34 and reliability before any information is made available
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1 to the public.
2 (4) The limitations of the data sources and
3 analytic methodologies used to develop comparative
4 hospital information shall be clearly identified and
5 acknowledged, including but not limited to the
6 appropriate and inappropriate uses of the data.
7 (5) To the greatest extent possible, comparative
8 hospital information initiatives shall use standard-based
9 norms derived from widely accepted provider-developed
10 practice guidelines.
11 (6) Comparative hospital information and other
12 information that the Department has compiled regarding
13 hospitals shall be shared with the hospitals under review
14 prior to public dissemination of such information and
15 these hospitals have 30 days to make corrections and to
16 add helpful explanatory comments about the information
17 before the publication.
18 (7) Comparisons among hospitals shall adjust for
19 patient case mix and other relevant risk factors and
20 control for provider peer groups, when appropriate.
21 (8) Effective safeguards to protect against the
22 unauthorized use or disclosure of hospital information
23 shall be developed and implemented.
24 (9) Effective safeguards to protect against the
25 dissemination of inconsistent, incomplete, invalid,
26 inaccurate, or subjective hospital data shall be
27 developed and implemented.
28 (10) The quality and accuracy of hospital
29 information reported under this Act and its data
30 collection, analysis, and dissemination methodologies
31 shall be evaluated regularly.
32 (11) Only the most basic identifying information
33 from mandatory reports shall be used, and
34 patient-identifiable information shall not be released.
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1 None of the information the Department discloses to the
2 public under this Act may be used to establish a standard
3 of care in a private civil action.
4 (d) Quarterly reports shall be submitted, in a format
5 set forth in rules adopted by the Department, to the
6 Department by April 30, July 31, October 31, and January 31
7 each year for the previous quarter. Data in quarterly reports
8 must cover a period ending not earlier than one month prior
9 to submission of the report. Annual reports shall be
10 submitted by December 31 in a format set forth in rules
11 adopted by the Department to the Department. All reports
12 shall be made available to the public on-site and through the
13 Department.
14 (e) If the hospital is a division or subsidiary of
15 another entity that owns or operates other hospitals or
16 related organizations, the annual public disclosure report
17 shall be for the specific division or subsidiary and not for
18 the other entity.
19 (f) The Department shall disclose information under this
20 Section in accordance with provisions for inspection and
21 copying of public records required by the Freedom of
22 Information Act provided that such information satisfies the
23 provisions of subsection (c) of this Section.
24 (g) Notwithstanding any other provision of law, under no
25 circumstances shall the Department disclose information
26 obtained from a hospital that is confidential under Part 21
27 of Article 8 of the Code of Civil Procedure.
28 Section 30. Department reports. The Department of Public
29 Health shall annually submit to the General Assembly a report
30 summarizing the quarterly reports by health service area and
31 shall publish that report on its website. The Department of
32 Public Health may issue quarterly informational bulletins at
33 its discretion, summarizing all or part of the information
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1 submitted in these quarterly reports. The Department shall
2 also publish risk-adjusted mortality rates for each hospital
3 based upon information hospitals have already submitted to
4 the Department pursuant to their obligations to report health
5 care information under other public health reporting laws and
6 regulations outside of this Act. The published mortality
7 rates must comply with the hospital data publication process
8 contained in subsection (c) of Section 25 of this Act.
9 Section 35. Whistleblower protections.
10 (a) A hospital covered by this Act shall not penalize,
11 discriminate, or retaliate in any manner against an employee
12 with respect to compensation or the terms, conditions, or
13 privileges of employment who in good faith, individually or
14 in conjunction with another person or persons, does any of
15 the following or intimidate, threaten, or punish an employee
16 to prevent him or her from doing any of the following:
17 (1) Discloses to the nursing staff supervisor or
18 manager, a private accreditation organization, the
19 nurse's collective bargaining agent, or a regulatory
20 agency any activity, policy, or practice of a hospital
21 that violates this Act or any other law or rule or that
22 the employee reasonably believes poses a risk to the
23 health, safety, or welfare of a patient or the public.
24 (2) Initiates, cooperates, or otherwise
25 participates in an investigation or proceeding brought by
26 a regulatory agency or private accreditation body
27 concerning matters covered by this Act or any other law
28 or rule or that the employee reasonably believes poses a
29 risk to the health, safety, or welfare of a patient or
30 the public.
31 (3) Objects to or refuses to participate in any
32 activity, policy, or practice of a hospital that violates
33 this Act or any law or rule of the Department or that a
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1 reasonable person would believe poses a risk to the
2 health, safety, or welfare of a patient or the public.
3 (4) Participates in a committee or peer review
4 process or files a report or complaint that discusses
5 allegation of unsafe, dangerous, or potentially dangerous
6 care within the hospital.
7 (b) For the purposes of this Section, an employee is
8 presumed to act in good faith if the employee reasonably
9 believes that (i) the information reported or disclosed is
10 true and (ii) a violation has occurred or may occur. An
11 employee is not acting in good faith under this Section if
12 the employee's report or action was based on information that
13 the employee should reasonably know is false or misleading.
14 The protection of this Section shall also not apply to an
15 employee unless the employee gives written notice to a
16 hospital manager of the activity, policy, practice, or
17 violation that the employee believes poses a risk to the
18 health of a patient or the public and provides the manager a
19 reasonable opportunity to correct the problem. The manager
20 shall respond in writing to the employee within 7 days
21 acknowledging that the notice was received and provide
22 written notice of any action taken within a reasonable time
23 of receiving the employee's notice. This notice requirement
24 shall not apply if the employee is reasonably certain that
25 the activity, policy, practice, or violation: (i) is known by
26 one or more hospital managers who have had an opportunity to
27 correct the problem and have not done so; (ii) involves the
28 commission of a crime; or (iii) places patient health or
29 safety in severe and immediate danger. The notice requirement
30 shall not apply if the employee is participating in a survey,
31 investigation, or other activity of a regulatory agency, law
32 enforcement agency, or private accreditation body that was
33 not initiated by the employee. Nothing in this Section
34 prohibits a hospital from training, educating, correcting, or
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1 otherwise taking action to improve the performance of
2 employees who report that they are unable or unwilling to
3 perform an assigned task.
4 Section 40. Private right of action. Any health care
5 facility that violates the provisions of Section 35 may be
6 held liable to the employee affected in an action brought in
7 a court of competent jurisdiction for such legal or equitable
8 relief as may be appropriate to effectuate the purposes of
9 this Act.
10 Section 45. Regulatory oversight. The Department shall
11 be responsible for ensuring compliance with this Act as a
12 condition of licensure under the Hospital Licensing Act and
13 shall enforce such compliance according to the provisions of
14 the Hospital Licensing Act.
15 Section 90. The Hospital Licensing Act is amended by
16 changing Section 7 as follows:
17 (210 ILCS 85/7) (from Ch. 111 1/2, par. 148)
18 Sec. 7. (a) The Director after notice and opportunity for
19 hearing to the applicant or licensee may deny, suspend, or
20 revoke a permit to establish a hospital or deny, suspend, or
21 revoke a license to open, conduct, operate, and maintain a
22 hospital in any case in which he finds that there has been a
23 substantial failure to comply with the provisions of this Act
24 or the Hospital Report Card Act or the standards, rules, and
25 regulations established by virtue of either of those Acts
26 thereof.
27 (b) Such notice shall be effected by registered mail or
28 by personal service setting forth the particular reasons for
29 the proposed action and fixing a date, not less than 15 days
30 from the date of such mailing or service, at which time the
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1 applicant or licensee shall be given an opportunity for a
2 hearing. Such hearing shall be conducted by the Director or
3 by an employee of the Department designated in writing by the
4 Director as Hearing Officer to conduct the hearing. On the
5 basis of any such hearing, or upon default of the applicant
6 or licensee, the Director shall make a determination
7 specifying his findings and conclusions. In case of a denial
8 to an applicant of a permit to establish a hospital, such
9 determination shall specify the subsection of Section 6 under
10 which the permit was denied and shall contain findings of
11 fact forming the basis of such denial. A copy of such
12 determination shall be sent by registered mail or served
13 personally upon the applicant or licensee. The decision
14 denying, suspending, or revoking a permit or a license shall
15 become final 35 days after it is so mailed or served, unless
16 the applicant or licensee, within such 35 day period,
17 petitions for review pursuant to Section 13.
18 (c) The procedure governing hearings authorized by this
19 Section shall be in accordance with rules promulgated by the
20 Department and approved by the Hospital Licensing Board. A
21 full and complete record shall be kept of all proceedings,
22 including the notice of hearing, complaint, and all other
23 documents in the nature of pleadings, written motions filed
24 in the proceedings, and the report and orders of the Director
25 and Hearing Officer. All testimony shall be reported but need
26 not be transcribed unless the decision is appealed pursuant
27 to Section 13. A copy or copies of the transcript may be
28 obtained by any interested party on payment of the cost of
29 preparing such copy or copies.
30 (d) The Director or Hearing Officer shall upon his own
31 motion, or on the written request of any party to the
32 proceeding, issue subpoenas requiring the attendance and the
33 giving of testimony by witnesses, and subpoenas duces tecum
34 requiring the production of books, papers, records, or
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1 memoranda. All subpoenas and subpoenas duces tecum issued
2 under the terms of this Act may be served by any person of
3 full age. The fees of witnesses for attendance and travel
4 shall be the same as the fees of witnesses before the Circuit
5 Court of this State, such fees to be paid when the witness is
6 excused from further attendance. When the witness is
7 subpoenaed at the instance of the Director, or Hearing
8 Officer, such fees shall be paid in the same manner as other
9 expenses of the Department, and when the witness is
10 subpoenaed at the instance of any other party to any such
11 proceeding the Department may require that the cost of
12 service of the subpoena or subpoena duces tecum and the fee
13 of the witness be borne by the party at whose instance the
14 witness is summoned. In such case, the Department in its
15 discretion, may require a deposit to cover the cost of such
16 service and witness fees. A subpoena or subpoena duces tecum
17 issued as aforesaid shall be served in the same manner as a
18 subpoena issued out of a court.
19 (e) Any Circuit Court of this State upon the application
20 of the Director, or upon the application of any other party
21 to the proceeding, may, in its discretion, compel the
22 attendance of witnesses, the production of books, papers,
23 records, or memoranda and the giving of testimony before the
24 Director or Hearing Officer conducting an investigation or
25 holding a hearing authorized by this Act, by an attachment
26 for contempt, or otherwise, in the same manner as production
27 of evidence may be compelled before the court.
28 (f) The Director or Hearing Officer, or any party in an
29 investigation or hearing before the Department, may cause the
30 depositions of witnesses within the State to be taken in the
31 manner prescribed by law for like depositions in civil
32 actions in courts of this State, and to that end compel the
33 attendance of witnesses and the production of books, papers,
34 records, or memoranda.
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1 (Source: Laws 1967, p. 3969.)
2 Section 99. Effective date. This Act takes effect on
3 January 1, 2004.