093_SB0059sam001

 










                                     LRB093 03368 AMC 12325 a

 1                     AMENDMENT TO SENATE BILL 59

 2        AMENDMENT NO.     .  Amend Senate Bill  59  by  replacing
 3    everything after the enacting clause with the following:

 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,
 
                            -2-      LRB093 03368 AMC 12325 a
 1    pediatrics, perioperative services, and telemetry.
 2        "Department" means the Department of Public Health.
 3        "Direct-care   nurse"  and  "direct-care  nursing  staff"
 4    includes any registered nurse, licensed practical  nurse,  or
 5    assistive  nursing  personnel  with  direct responsibility to
 6    oversee or carry out medical regimens or nursing care for one
 7    or more patient.
 8        "Hospital" means a health care  facility  licensed  under
 9    the Hospital Licensing Act.
10        "Nursing  care" means care that falls within the scope of
11    practice set forth  in  the  Nursing  and  Advanced  Practice
12    Nursing  Act  or  is  otherwise encompassed within recognized
13    professional  standards  of   nursing   practice,   including
14    assessment,   nursing   diagnosis,   planning,  intervention,
15    evaluation, and patient advocacy.
16        "Retaliate"  means  to  discipline,  discharge,  suspend,
17    demote, harass, deny employment or  promotion,  lay  off,  or
18    take  any  other  adverse  action against direct-care nursing
19    staff as a result of that nursing  staff  taking  any  action
20    described in this Act.
21        "Skill   mix"   means   the   differences  in  licensing,
22    specialty, and experiences among direct-care nurses.
23        "Staffing levels" means the numerical  nurse  to  patient
24    ratio  by  licensed  nurse  classification  within  a nursing
25    department or unit.
26        "Unit" means a functional division or area of a  hospital
27    in which nursing care is provided.

28        Section 15.  Staffing levels.
29        (a)  The   number   of  registered  professional  nurses,
30    licensed  practical  nurses,  and  other  nursing   personnel
31    assigned  to  each patient care unit shall be consistent with
32    the types of nursing care needed  by  the  patients  and  the
33    capabilities  of  the  staff.  Patients on each unit shall be
 
                            -3-      LRB093 03368 AMC 12325 a
 1    evaluated near the end of each change of  shift  by  criteria
 2    developed  by  the  nursing  service. There shall be staffing
 3    schedules reflecting actual nursing  personnel  required  for
 4    the  hospital  and  for  each patient unit. Staffing patterns
 5    shall reflect consideration of nursing  goals,  standards  of
 6    nursing practice, and the needs of the patients.
 7        (b)  Current  nursing  staff schedules shall be available
 8    upon request at each patient care unit. Each  schedule  shall
 9    list  the  daily assigned nursing personnel and average daily
10    census for the unit. The  actual  nurse  staffing  assignment
11    roster  for  each  patient  care unit shall be available upon
12    request at the patient care unit for the  effective  date  of
13    that roster. Upon the roster's expiration, the hospital shall
14    retain   the  roster  for  5  years  from  the  date  of  its
15    expiration.
16        (c)  All records required under this  Section,  including
17    anticipated  staffing  schedules and the methods to determine
18    and adjust staffing levels shall be  made  available  to  the
19    public upon request.
20        (d)  All  records  required  under  this Section shall be
21    maintained by the facility for no less than 5 years.

22        Section 20.  Orientation and training.
23        (a)  All health care facilities shall have established an
24    orientation process that provides initial  job  training  and
25    information  and  assesses  the  direct  care nursing staff's
26    ability to fulfill specified responsibilities.
27        (b)  Personnel not competent for a given unit  shall  not
28    be  assigned  to  work there without direct supervision until
29    appropriately trained.
30        (c)  Staff training information will  be  available  upon
31    request at the hospital.

32        Section 25.  Hospital reports.
 
                            -4-      LRB093 03368 AMC 12325 a
 1        (a)  Individual   hospitals  shall  prepare  a  quarterly
 2    report including all of the following:
 3             (1)  Nursing hours per patient  day,  average  daily
 4        census,  and average daily hours worked for each clinical
 5        service area.
 6             (2)  Nosocomial infection rates for the facility for
 7        the  specific  clinical  procedures  determined  by   the
 8        Department by rule under the following categories:
 9                  (A)  Class I surgical site infection.
10                  (B)  Ventilator-associated pneumonia.
11                  (C)  Central      line-related      bloodstream
12             infections.
13        The  Department  shall  only  disclose  Illinois hospital
14    infection rate data according to the  current  benchmarks  of
15    the   Centers   for  Disease  Control's  National  Nosocomial
16    Infection Surveillance Program.
17        (b)  Individual hospitals shall  prepare  annual  reports
18    including  vacancy and turnover rates for licensed nurses per
19    clinical service area.
20        (c)  None of the information the Department discloses  to
21    the  public  may  be  made  available  in any form or fashion
22    unless the  information  has  been  reviewed,  adjusted,  and
23    validated according to the following process:
24             (1)  The   Department  shall  organize  an  advisory
25        committee, including representatives from the Department,
26        public and private hospitals, direct care nursing  staff,
27        physicians,   academic   researchers,  consumers,  health
28        insurance companies, organized labor,  and  organizations
29        representing   hospitals  and  physicians.  The  advisory
30        committee  must   be   meaningfully   involved   in   the
31        development   of   all   aspects   of   the  Department's
32        methodology for collecting, analyzing, and disclosing the
33        information   collected   under   this   Act,   including
34        collection methods, formatting, and methods and means for
 
                            -5-      LRB093 03368 AMC 12325 a
 1        release and dissemination.
 2             (2)  The  entire  methodology  for  collecting   and
 3        analyzing  the  data  shall  be disclosed to all relevant
 4        organizations and to all hospitals that are  the  subject
 5        of  any  information  to  be made available to the public
 6        before any public disclosure of such information.
 7             (3)  Data collection  and  analytical  methodologies
 8        shall  be  used  that meet accepted standards of validity
 9        and reliability before any information is made  available
10        to the public.
11             (4)  The   limitations   of  the  data  sources  and
12        analytic  methodologies  used  to   develop   comparative
13        hospital  information  shall  be   clearly identified and
14        acknowledged,  including   but   not   limited   to   the
15        appropriate and inappropriate uses of the data.
16             (5)  To  the  greatest  extent possible, comparative
17        hospital information initiatives shall use standard-based
18        norms derived  from  widely  accepted  provider-developed
19        practice guidelines.
20             (6)  Comparative   hospital  information  and  other
21        information that the Department  has  compiled  regarding
22        hospitals shall be shared with the hospitals under review
23        prior  to  public  dissemination  of such information and
24        these hospitals have 30 days to make corrections  and  to
25        add  helpful  explanatory  comments about the information
26        before the publication.
27             (7)  Comparisons among hospitals  shall  adjust  for
28        patient  case  mix  and  other  relevant risk factors and
29        control for provider peer groups, when appropriate.
30             (8)  Effective safeguards  to  protect  against  the
31        unauthorized  use  or  disclosure of hospital information
32        shall be developed and implemented.
33             (9)  Effective safeguards  to  protect  against  the
34        dissemination   of   inconsistent,  incomplete,  invalid,
 
                            -6-      LRB093 03368 AMC 12325 a
 1        inaccurate,  or  subjective  hospital   data   shall   be
 2        developed and implemented.
 3             (10)  The   quality   and   accuracy   of   hospital
 4        information   reported   under  this  Act  and  its  data
 5        collection,  analysis,  and  dissemination  methodologies
 6        shall be evaluated regularly.
 7             (11)  Only the most  basic  identifying  information
 8        from    mandatory    reports    shall    be   used,   and
 9        patient-identifiable information shall not  be  released.
10        None  of  the information the Department discloses to the
11        public under this Act may be used to establish a standard
12        of care in a private civil action.
13        (d)  Quarterly reports shall be submitted,  in  a  format
14    set  forth  in  rules  adopted  by  the  Department,  to  the
15    Department  by  April 30, July 31, October 31, and January 31
16    each year for the previous quarter. Data in quarterly reports
17    must cover a period ending not earlier than one  month  prior
18    to   submission  of  the  report.  Annual  reports  shall  be
19    submitted by December 31 in  a  format  set  forth  in  rules
20    adopted  by  the  Department  to  the Department. All reports
21    shall be made available to the public on-site and through the
22    Department.
23        (e)  If the hospital  is  a  division  or  subsidiary  of
24    another  entity  that  owns  or  operates  other hospitals or
25    related organizations, the annual  public  disclosure  report
26    shall  be for the specific division or subsidiary and not for
27    the other entity.
28        (f)  The Department shall disclose information under this
29    Section in accordance  with  provisions  for  inspection  and
30    copying   of  public  records  required  by  the  Freedom  of
31    Information Act provided that such information satisfies  the
32    provisions of subsection (c) of this Section.
33        (g)  Notwithstanding any other provision of law, under no
34    circumstances   shall  the  Department  disclose  information
 
                            -7-      LRB093 03368 AMC 12325 a
 1    obtained from a hospital that is confidential under  Part  21
 2    of Article 8 of the Code of Civil Procedure.

 3        Section 30.  Department reports. The Department of Public
 4    Health shall annually submit to the General Assembly a report
 5    summarizing  the quarterly reports by health service area and
 6    shall publish that report on its website. The  Department  of
 7    Public  Health may issue quarterly informational bulletins at
 8    its discretion, summarizing all or part  of  the  information
 9    submitted  in  these  quarterly reports. The Department shall
10    also publish risk-adjusted mortality rates for each  hospital
11    based  upon  information  hospitals have already submitted to
12    the Department pursuant to their obligations to report health
13    care information under other public health reporting laws and
14    regulations outside of  this  Act.  The  published  mortality
15    rates  must comply with the hospital data publication process
16    contained in subsection (c) of Section 25 of this Act.

17        Section 35.  Whistleblower protections.
18        (a)  A hospital covered by this Act shall  not  penalize,
19    discriminate,  or retaliate in any manner against an employee
20    with respect to compensation or  the  terms,  conditions,  or
21    privileges  of  employment who in good faith, individually or
22    in conjunction with another person or persons,  does  any  of
23    the  following or intimidate, threaten, or punish an employee
24    to prevent him or her from doing any of the following:
25             (1)  Discloses to the nursing  staff  supervisor  or
26        manager,   a   private  accreditation  organization,  the
27        nurse's collective  bargaining  agent,  or  a  regulatory
28        agency  any  activity,  policy, or practice of a hospital
29        that violates this Act or any other law or rule  or  that
30        the  employee  reasonably  believes  poses  a risk to the
31        health, safety, or welfare of a patient or the public.
32             (2)  Initiates,     cooperates,     or     otherwise
 
                            -8-      LRB093 03368 AMC 12325 a
 1        participates in an investigation or proceeding bought  by
 2        a   regulatory   agency  or  private  accreditation  body
 3        concerning matters covered by this Act or any  other  law
 4        or  rule or that the employee reasonably believes poses a
 5        risk to the health, safety, or welfare of  a  patient  or
 6        the public.
 7             (3)  Objects  to  or  refuses  to participate in any
 8        activity, policy, or practice of a hospital that violates
 9        this Act or any law or rule of the Department or  that  a
10        reasonable  person  would  believe  poses  a  risk to the
11        health, safety, or welfare of a patient or the public.
12             (4)  Participates in  a  committee  or  peer  review
13        process  or  files  a  report or complaint that discusses
14        allegation of unsafe, dangerous, or potentially dangerous
15        care within the hospital.
16        (b)  For the purposes of this  Section,  an  employee  is
17    presumed  to  act  in  good  faith if the employee reasonably
18    believes that (i) the information reported  or  disclosed  is
19    true  and  (ii)  a  violation  has  occurred or may occur. An
20    employee is not acting in good faith under  this  Section  if
21    the employee's report or action was based on information that
22    the  employee  should reasonably know is false or misleading.
23    The protection of this Section shall also  not  apply  to  an
24    employee  unless  the  employee  gives  written  notice  to a
25    hospital  manager  of  the  activity,  policy,  practice,  or
26    violation that the employee believes  poses  a  risk  to  the
27    health  of a patient or the public and provides the manager a
28    reasonable opportunity to correct the  problem.  The  manager
29    shall  respond  in  writing  to  the  employee  within 7 days
30    acknowledging  that  the  notice  was  received  and  provide
31    written notice of any action taken within a  reasonable  time
32    of  receiving  the employee's notice. This notice requirement
33    shall not apply if the employee is  reasonably  certain  that
34    the activity, policy, practice, or violation: (i) is known by
 
                            -9-      LRB093 03368 AMC 12325 a
 1    one  or more hospital managers who have had an opportunity to
 2    correct the problem and have not done so; (ii)  involves  the
 3    commission  of  a  crime;  or  (iii) places patient health or
 4    safety in severe and immediate danger. The notice requirement
 5    shall not apply if the employee is participating in a survey,
 6    investigation, or other activity of a regulatory agency,  law
 7    enforcement  agency,  or  private accreditation body that was
 8    not initiated  by  the  employee.  Nothing  in  this  Section
 9    prohibits a hospital from training, educating, correcting, or
10    otherwise   taking  action  to  improve  the  performance  of
11    employees who report that they are  unable  or  unwilling  to
12    perform an assigned task.

13        Section  40.  Private  right  of  action. Any health care
14    facility that violates the provisions of Section  35  may  be
15    held  liable to the employee affected in an action brought in
16    a court of competent jurisdiction for such legal or equitable
17    relief as may be appropriate to effectuate  the  purposes  of
18    this Act.

19        Section  45.  Regulatory  oversight. The Department shall
20    be responsible for ensuring compliance with  this  Act  as  a
21    condition  of  licensure under the Hospital Licensing Act and
22    shall enforce such compliance according to the provisions  of
23    the Hospital Licensing Act.

24        Section  90.   The  Hospital  Licensing Act is amended by
25    changing Section 7 as follows:

26        (210 ILCS 85/7) (from Ch. 111 1/2, par. 148)
27        Sec. 7. (a) The Director after notice and opportunity for
28    hearing to the applicant or licensee may  deny,  suspend,  or
29    revoke  a permit to establish a hospital or deny, suspend, or
30    revoke a license to open, conduct, operate,  and  maintain  a
 
                            -10-     LRB093 03368 AMC 12325 a
 1    hospital  in any case in which he finds that there has been a
 2    substantial failure to comply with the provisions of this Act
 3    or the Hospital Report Card Act or the standards, rules,  and
 4    regulations  established  by  virtue  of either of those Acts
 5    thereof.
 6        (b)  Such notice shall be effected by registered mail  or
 7    by  personal service setting forth the particular reasons for
 8    the proposed action and fixing a date, not less than 15  days
 9    from  the  date of such mailing or service, at which time the
10    applicant or licensee shall be given  an  opportunity  for  a
11    hearing.  Such  hearing shall be conducted by the Director or
12    by an employee of the Department designated in writing by the
13    Director as Hearing Officer to conduct the  hearing.  On  the
14    basis  of  any such hearing, or upon default of the applicant
15    or  licensee,  the  Director  shall  make   a   determination
16    specifying  his findings and conclusions. In case of a denial
17    to an applicant of a permit to  establish  a  hospital,  such
18    determination shall specify the subsection of Section 6 under
19    which  the  permit  was  denied and shall contain findings of
20    fact forming the  basis  of  such  denial.  A  copy  of  such
21    determination  shall  be  sent  by  registered mail or served
22    personally upon  the  applicant  or  licensee.  The  decision
23    denying,  suspending, or revoking a permit or a license shall
24    become final 35 days after it is so mailed or served,  unless
25    the  applicant  or  licensee,  within  such  35  day  period,
26    petitions for review pursuant to Section 13.
27        (c)  The  procedure governing hearings authorized by this
28    Section shall be in accordance with rules promulgated by  the
29    Department  and  approved  by the Hospital Licensing Board. A
30    full and complete record shall be kept  of  all  proceedings,
31    including  the  notice  of  hearing, complaint, and all other
32    documents in the nature of pleadings, written  motions  filed
33    in the proceedings, and the report and orders of the Director
34    and Hearing Officer. All testimony shall be reported but need
 
                            -11-     LRB093 03368 AMC 12325 a
 1    not  be  transcribed unless the decision is appealed pursuant
 2    to Section 13. A copy or copies  of  the  transcript  may  be
 3    obtained  by  any  interested party on payment of the cost of
 4    preparing such copy or copies.
 5        (d)  The Director or Hearing Officer shall upon  his  own
 6    motion,  or  on  the  written  request  of  any  party to the
 7    proceeding, issue subpoenas requiring the attendance and  the
 8    giving  of  testimony by witnesses, and subpoenas duces tecum
 9    requiring  the  production  of  books,  papers,  records,  or
10    memoranda. All subpoenas and  subpoenas  duces  tecum  issued
11    under  the  terms  of this Act may be served by any person of
12    full age. The fees of witnesses  for  attendance  and  travel
13    shall be the same as the fees of witnesses before the Circuit
14    Court of this State, such fees to be paid when the witness is
15    excused   from   further  attendance.  When  the  witness  is
16    subpoenaed at  the  instance  of  the  Director,  or  Hearing
17    Officer,  such fees shall be paid in the same manner as other
18    expenses  of  the  Department,  and  when  the   witness   is
19    subpoenaed  at  the  instance  of any other party to any such
20    proceeding the  Department  may  require  that  the  cost  of
21    service  of  the subpoena or subpoena duces tecum and the fee
22    of the witness be borne by the party at  whose  instance  the
23    witness  is  summoned.  In  such  case, the Department in its
24    discretion, may require a deposit to cover the cost  of  such
25    service  and witness fees. A subpoena or subpoena duces tecum
26    issued as aforesaid shall be served in the same manner  as  a
27    subpoena issued out of a court.
28        (e)  Any Circuit Court of this State upon the application
29    of  the  Director, or upon the application of any other party
30    to  the  proceeding,  may,  in  its  discretion,  compel  the
31    attendance of witnesses, the  production  of  books,  papers,
32    records,  or memoranda and the giving of testimony before the
33    Director or Hearing Officer conducting  an  investigation  or
34    holding  a  hearing  authorized by this Act, by an attachment
 
                            -12-     LRB093 03368 AMC 12325 a
 1    for contempt, or otherwise, in the same manner as  production
 2    of evidence may be compelled before the court.
 3        (f)  The  Director or Hearing Officer, or any party in an
 4    investigation or hearing before the Department, may cause the
 5    depositions of witnesses within the State to be taken in  the
 6    manner  prescribed  by  law  for  like  depositions  in civil
 7    actions in courts of this State, and to that end  compel  the
 8    attendance  of witnesses and the production of books, papers,
 9    records, or memoranda.
10    (Source: Laws 1967, p. 3969.)

11        Section 99. Effective date.  This  Act  takes  effect  on
12    January 1, 2004.".