HB0192 Engrossed LRB095 03991 DRJ 24024 b

1     AN ACT concerning health.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Mental Health and Developmental
5 Disabilities Administrative Act is amended by adding Section
6 10.5 as follows:
 
7     (20 ILCS 1705/10.5 new)
8     Sec. 10.5. Prevention and control of Multidrug-Resistant
9 Organisms. The Department, in consultation with the Department
10 of Public Health, shall adopt rules that may require one or
11 more of the facilities described in Section 4 of this Act to
12 implement comprehensive interventions to prevent and control
13 multidrug-resistant organisms (MDROs), including
14 methicillin-resistant Staphylococcus aureus (MRSA),
15 vancomycin-resistant enterococci (VRE), and certain
16 gram-negative bacilli (GNB), pursuant to updated prevention
17 and control interventions recommended by the U.S. Centers for
18 Disease Control and Prevention. The Department shall also
19 require facilities to submit reports to the Department that
20 contain substantially the same information contained in the
21 related infection reports required to be submitted by hospitals
22 to the Department of Public Health under Section 25 of the
23 Hospital Report Card Act. The Department shall provide that

 

 

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1 information to the Department of Public Health upon the
2 Department of Public Health's request.
 
3     Section 10. The Department of Public Health Powers and
4 Duties Law of the Civil Administrative Code of Illinois is
5 amended by adding Section 2310-312 as follows:
 
6     (20 ILCS 2310/2310-312 new)
7     Sec. 2310-312. Multidrug-Resistant Organisms. The
8 Department shall perform the following functions in relation to
9 the prevention and control of Multidrug-Resistant Organisms
10 (MDROs), including methicillin-resistant Staphylococcus aureus
11 (MRSA), vancomycin-resistant (VRE) and certain gram-negative
12 bacilli (GNB), as these terms are referenced by the United
13 States Centers for Disease Control and Prevention:
14         (1) Except with regard to hospitals, for which
15     administrative rules shall be adopted in accordance with
16     Section 6.23 of the Hospital Licensing Act and Section 7 of
17     the University of Illinois Hospital Act, the Department
18     shall adopt administrative rules for health care
19     facilities subject to licensure, certification,
20     registration, or other regulation by the Department that
21     may require one or more types of those facilities to (i)
22     perform an annual infection control risk assessment, (ii)
23     develop infection control policies for MDROs that are based
24     on this assessment and incorporate, as appropriate,

 

 

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1     updated recommendations of the U.S. Centers for Disease
2     Control and Prevention for the prevention and control of
3     MDROs, and (iii) enforce hand hygiene requirements.
4         (2) The Department shall:
5             (A) publicize guidelines for reducing the
6         incidence of MDROs to health care providers, health
7         care facilities, public health departments, prisons,
8         jails, and the general public; and
9             (B) provide periodic reports and updates to public
10         officials, health professionals, and the general
11         public statewide regarding new developments or
12         procedures concerning prevention and management of
13         infections due to MDROs.
14         (3) The Department shall publish a yearly report
15     regarding MRSA and Clostridium difficile infections based
16     on the Hospital Discharge Dataset. The Department is
17     authorized to require hospitals, based on guidelines
18     developed by the National Center for Health Statistics,
19     after October 1, 2007, to submit data to the Department
20     that is coded as "present on admission" and "occurred
21     during the stay".
22         (4) Reporting to the Department under the Hospital
23     Report Card Act shall include organisms, including but not
24     limited to MRSA, that are responsible for central venous
25     catheter-associated bloodstream infections and
26     ventilator-associated pneumonia in designated hospital

 

 

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1     units.
2         (5) The Department shall implement surveillance for
3     designated cases of community associated MRSA infections
4     for a period of at least 3 years, beginning on or before
5     January 1, 2008.
 
6     Section 15. The University of Illinois Hospital Act is
7 amended by adding Section 7 as follows:
 
8     (110 ILCS 330/7 new)
9     Sec. 7. Prevention and control for Multidrug-Resistant
10 Organisms. The University of Illinois Hospital shall develop
11 and implement comprehensive interventions to prevent and
12 control multidrug-resistant organisms (MDROs), including
13 methicillin-resistant Staphylococcus aureus (MRSA),
14 vancomycin-resistant enterococci (VRE), and certain
15 gram-negative bacilli (GNB), that take into consideration
16 guidelines of the U.S. Centers for Disease Control and
17 Prevention for the management of MDROs in healthcare settings.
18 The Department of Public Health shall adopt administrative
19 rules that require the University of Illinois Hospital to
20 perform an annual facility-wide infection control risk
21 assessment and enforce hand hygiene and contact precaution
22 requirements.
 
23     Section 20. The Hospital Licensing Act is amended by adding

 

 

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1 Section 6.23 as follows:
 
2     (210 ILCS 85/6.23 new)
3     Sec. 6.23. Prevention and control of Multidrug-Resistant
4 Organisms. Each hospital shall develop and implement
5 comprehensive interventions to prevent and control
6 multidrug-resistant organisms (MDROs), including
7 methicillin-resistant Staphylococcus aureus (MRSA),
8 vancomycin-resistant enterococci (VRE), and certain
9 gram-negative bacilli (GNB), that take into consideration
10 guidelines of the U.S. Centers for Disease Control and
11 Prevention for the management of MDROs in healthcare settings.
12 The Department shall adopt administrative rules that require
13 hospitals to perform an annual facility-wide infection control
14 risk assessment and enforce hand hygiene and contact precaution
15 requirements.
 
16     Section 25. The Hospital Report Card Act is amended by
17 changing Section 25 as follows:
 
18     (210 ILCS 86/25)
19     Sec. 25. Hospital reports.
20     (a) Individual hospitals shall prepare a quarterly report
21 including all of the following:
22         (1) Nursing hours per patient day, average daily
23     census, and average daily hours worked for each clinical

 

 

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1     service area.
2         (2) Infection-related measures for the facility for
3     the specific clinical procedures and devices determined by
4     the Department by rule under 2 or more of the following
5     categories:
6             (A) Surgical procedure outcome measures.
7             (B) Surgical procedure infection control process
8         measures.
9             (C) Outcome or process measures related to
10         ventilator-associated pneumonia.
11             (D) Central vascular catheter-related bloodstream
12         infection rates in designated critical care units.
13         (3) Information required under paragraph (4) of
14     Section 2310-312 of the Department of Public Health Powers
15     and Duties Law of the Civil Administrative Code of
16     Illinois.
17     The infection-related measures developed by the Department
18 shall be based upon measures and methods developed by the
19 Centers for Disease Control and Prevention, the Centers for
20 Medicare and Medicaid Services, the Agency for Healthcare
21 Research and Quality, the Joint Commission on Accreditation of
22 Healthcare Organizations, or the National Quality Forum.
23     The Department shall include interpretive guidelines for
24 infection-related indicators and, when available, shall
25 include relevant benchmark information published by national
26 organizations.

 

 

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

 

 

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

 

 

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

 

 

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1 entity.
2     (f) The Department shall disclose information under this
3 Section in accordance with provisions for inspection and
4 copying of public records required by the Freedom of
5 Information Act provided that such information satisfies the
6 provisions of subsection (c) of this Section.
7     (g) Notwithstanding any other provision of law, under no
8 circumstances shall the Department disclose information
9 obtained from a hospital that is confidential under Part 21 of
10 Article 8 of the Code of Civil Procedure.
11     (h) No hospital report or Department disclosure may contain
12 information identifying a patient, employee, or licensed
13 professional.
14 (Source: P.A. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)
 
15     Section 99. Effective date. This Act takes effect upon
16 becoming law.