SB1862 Enrolled LRB094 11494 RSP 42443 b

1     AN ACT concerning State government.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Hospital Report Card Act is amended by
5 changing Section 25 as follows:
 
6     (210 ILCS 86/25)
7     Sec. 25. Hospital reports.
8     (a) Individual hospitals shall prepare a quarterly report
9 including all of the following:
10         (1) Nursing hours per patient day, average daily
11     census, and average daily hours worked for each clinical
12     service area.
13         (2) Infection-related measures Nosocomial infection
14     rates for the facility for the specific clinical procedures
15     and devices determined by the Department by rule under 2 or
16     more of the following categories:
17             (A) Surgical procedure outcome measures Class I
18         surgical site infection.
19             (B) Surgical procedure infection control process
20         measures.
21             (C) (B) Outcome or process measures related to
22         ventilator-associated Ventilator-associated pneumonia.
23             (D) (C) Central vascular catheter-related
24         line-related bloodstream infection rates in designated
25         critical care units infections.
26     The infection-related measures developed by the Department
27 shall be based upon measures and methods developed by the
28 Centers for Disease Control and Prevention, the Centers for
29 Medicare and Medicaid Services, the Agency for Healthcare
30 Research and Quality, the Joint Commission on Accreditation of
31 Healthcare Organizations, or the National Quality Forum.
32     The Department shall include interpretive guidelines for

 

 

SB1862 Enrolled - 2 - LRB094 11494 RSP 42443 b

1 infection-related indicators and, when available, shall
2 include relevant benchmark information published by national
3 organizations. The Department shall only disclose Illinois
4 hospital infection rate data according to the current
5 benchmarks of the Centers for Disease Control's National
6 Nosocomial Infection Surveillance Program.
7     (b) Individual hospitals shall prepare annual reports
8 including vacancy and turnover rates for licensed nurses per
9 clinical service area.
10     (c) None of the information the Department discloses to the
11 public may be made available in any form or fashion unless the
12 information has been reviewed, adjusted, and validated
13 according to the following process:
14         (1) The Department shall organize an advisory
15     committee, including representatives from the Department,
16     public and private hospitals, direct care nursing staff,
17     physicians, academic researchers, consumers, health
18     insurance companies, organized labor, and organizations
19     representing hospitals and physicians. The advisory
20     committee must be meaningfully involved in the development
21     of all aspects of the Department's methodology for
22     collecting, analyzing, and disclosing the information
23     collected under this Act, including collection methods,
24     formatting, and methods and means for release and
25     dissemination.
26         (2) The entire methodology for collecting and
27     analyzing the data shall be disclosed to all relevant
28     organizations and to all hospitals that are the subject of
29     any information to be made available to the public before
30     any public disclosure of such information.
31         (3) Data collection and analytical methodologies shall
32     be used that meet accepted standards of validity and
33     reliability before any information is made available to the
34     public.
35         (4) The limitations of the data sources and analytic
36     methodologies used to develop comparative hospital

 

 

SB1862 Enrolled - 3 - LRB094 11494 RSP 42443 b

1     information shall be clearly identified and acknowledged,
2     including but not limited to the appropriate and
3     inappropriate uses of the data.
4         (5) To the greatest extent possible, comparative
5     hospital information initiatives shall use standard-based
6     norms derived from widely accepted provider-developed
7     practice guidelines.
8         (6) Comparative hospital information and other
9     information that the Department has compiled regarding
10     hospitals shall be shared with the hospitals under review
11     prior to public dissemination of such information and these
12     hospitals have 30 days to make corrections and to add
13     helpful explanatory comments about the information before
14     the publication.
15         (7) Comparisons among hospitals shall adjust for
16     patient case mix and other relevant risk factors and
17     control for provider peer groups, when appropriate.
18         (8) Effective safeguards to protect against the
19     unauthorized use or disclosure of hospital information
20     shall be developed and implemented.
21         (9) Effective safeguards to protect against the
22     dissemination of inconsistent, incomplete, invalid,
23     inaccurate, or subjective hospital data shall be developed
24     and implemented.
25         (10) The quality and accuracy of hospital information
26     reported under this Act and its data collection, analysis,
27     and dissemination methodologies shall be evaluated
28     regularly.
29         (11) Only the most basic identifying information from
30     mandatory reports shall be used, and information
31     identifying a patient, employee, or licensed professional
32     shall not be released. None of the information the
33     Department discloses to the public under this Act may be
34     used to establish a standard of care in a private civil
35     action.
36     (d) Quarterly reports shall be submitted, in a format set

 

 

SB1862 Enrolled - 4 - LRB094 11494 RSP 42443 b

1 forth in rules adopted by the Department, to the Department by
2 April 30, July 31, October 31, and January 31 each year for the
3 previous quarter. Data in quarterly reports must cover a period
4 ending not earlier than one month prior to submission of the
5 report. Annual reports shall be submitted by December 31 in a
6 format set forth in rules adopted by the Department to the
7 Department. All reports shall be made available to the public
8 on-site and through the Department.
9     (e) If the hospital is a division or subsidiary of another
10 entity that owns or operates other hospitals or related
11 organizations, the annual public disclosure report shall be for
12 the specific division or subsidiary and not for the other
13 entity.
14     (f) The Department shall disclose information under this
15 Section in accordance with provisions for inspection and
16 copying of public records required by the Freedom of
17 Information Act provided that such information satisfies the
18 provisions of subsection (c) of this Section.
19     (g) Notwithstanding any other provision of law, under no
20 circumstances shall the Department disclose information
21 obtained from a hospital that is confidential under Part 21 of
22 Article 8 of the Code of Civil Procedure.
23     (h) No hospital report or Department disclosure may contain
24 information identifying a patient, employee, or licensed
25 professional.
26 (Source: P.A. 93-563, eff. 1-1-04.)
 
27     Section 99. Effective date. This Act takes effect upon
28 becoming law.