Rep. Mary E. Flowers

Filed: 3/19/2007

 

 


 

 


 
09500HB0192ham003 LRB095 03991 DRJ 33701 a

1
AMENDMENT TO HOUSE BILL 192

2     AMENDMENT NO. ______. Amend House Bill 192, AS AMENDED, by
3 replacing everything after the enacting clause with the
4 following:
 
5     "Section 5. The Mental Health and Developmental
6 Disabilities Administrative Act is amended by adding Section
7 10.5 as follows:
 
8     (20 ILCS 1705/10.5 new)
9     Sec. 10.5. Prevention and control of Multidrug-Resistant
10 Organisms. The Department, in consultation with the Department
11 of Public Health, shall adopt rules that may require one or
12 more of the facilities described in Section 4 of this Act to
13 implement comprehensive interventions to prevent and control
14 multidrug-resistant organisms (MDROs), including
15 methicillin-resistant Staphylococcus aureus (MRSA),
16 vancomycin-resistant enterococci (VRE), and certain

 

 

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1 gram-negative bacilli (GNB), pursuant to updated prevention
2 and control interventions recommended by the U.S. Centers for
3 Disease Control and Prevention. The Department shall also
4 require facilities to submit reports to the Department that
5 contain substantially the same information contained in the
6 related infection reports required to be submitted by hospitals
7 to the Department of Public Health under Section 25 of the
8 Hospital Report Card Act. The Department shall provide that
9 information to the Department of Public Health upon the
10 Department of Public Health's request.
 
11     Section 10. The Department of Public Health Powers and
12 Duties Law of the Civil Administrative Code of Illinois is
13 amended by adding Section 2310-312 as follows:
 
14     (20 ILCS 2310/2310-312 new)
15     Sec. 2310-312. Multidrug-Resistant Organisms. The
16 Department shall perform the following functions in relation to
17 the prevention and control of Multidrug-Resistant Organisms
18 (MDROs), including methicillin-resistant Staphylococcus aureus
19 (MRSA), vancomycin-resistant (VRE) and certain gram-negative
20 bacilli (GNB), as these terms are referenced by the United
21 States Centers for Disease Control and Prevention:
22         (1) Except with regard to hospitals, for which
23     administrative rules shall be adopted in accordance with
24     Section 6.23 of the Hospital Licensing Act and Section 7 of

 

 

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1     the University of Illinois Hospital Act, the Department
2     shall adopt administrative rules for health care
3     facilities subject to licensure, certification,
4     registration, or other regulation by the Department that
5     may require one or more types of those facilities to (i)
6     perform an annual infection control risk assessment, (ii)
7     develop infection control policies for MDROs that are based
8     on this assessment and incorporate, as appropriate,
9     updated recommendations of the U.S. Centers for Disease
10     Control and Prevention for the prevention and control of
11     MDROs, and (iii) enforce hand hygiene requirements.
12         (2) The Department shall:
13             (A) publicize guidelines for reducing the
14         incidence of MDROs to health care providers, health
15         care facilities, public health departments, prisons,
16         jails, and the general public; and
17             (B) provide periodic reports and updates to public
18         officials, health professionals, and the general
19         public statewide regarding new developments or
20         procedures concerning prevention and management of
21         infections due to MDROs.
22         (3) The Department shall publish a yearly report
23     regarding MRSA and Clostridium difficile infections based
24     on the Hospital Discharge Dataset. The Department is
25     authorized to require hospitals, based on guidelines
26     developed by the National Center for Health Statistics,

 

 

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1     after October 1, 2007, to submit data to the Department
2     that is coded as "present on admission" and "occurred
3     during the stay".
4         (4) Reporting to the Department under the Hospital
5     Report Card Act shall include organisms, including but not
6     limited to MRSA, that are responsible for central venous
7     catheter-associated bloodstream infections and
8     ventilator-associated pneumonia in designated hospital
9     units.
10         (5) The Department shall implement surveillance for
11     designated cases of community associated MRSA infections
12     for a period of at least 3 years, beginning on or before
13     January 1, 2008.
 
14     Section 15. The University of Illinois Hospital Act is
15 amended by adding Section 7 as follows:
 
16     (110 ILCS 330/7 new)
17     Sec. 7. Prevention and control for Multidrug-Resistant
18 Organisms. The University of Illinois Hospital shall develop
19 and implement comprehensive interventions to prevent and
20 control multidrug-resistant organisms (MDROs), including
21 methicillin-resistant Staphylococcus aureus (MRSA),
22 vancomycin-resistant enterococci (VRE), and certain
23 gram-negative bacilli (GNB), that take into consideration
24 guidelines of the U.S. Centers for Disease Control and

 

 

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1 Prevention for the management of MDROs in healthcare settings.
2 The Department of Public Health shall adopt administrative
3 rules that require the University of Illinois Hospital to
4 perform an annual facility-wide infection control risk
5 assessment and enforce hand hygiene and contact precaution
6 requirements.
 
7     Section 20. The Hospital Licensing Act is amended by adding
8 Section 6.23 as follows:
 
9     (210 ILCS 85/6.23 new)
10     Sec. 6.23. Prevention and control of Multidrug-Resistant
11 Organisms. Each hospital shall develop and implement
12 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), that take into consideration
17 guidelines of the U.S. Centers for Disease Control and
18 Prevention for the management of MDROs in healthcare settings.
19 The Department shall adopt administrative rules that require
20 hospitals to perform an annual facility-wide infection control
21 risk assessment and enforce hand hygiene and contact precaution
22 requirements.
 
23     Section 25. The Hospital Report Card Act is amended by

 

 

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

 

 

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1 Centers for Disease Control and Prevention, the Centers for
2 Medicare and Medicaid Services, the Agency for Healthcare
3 Research and Quality, the Joint Commission on Accreditation of
4 Healthcare Organizations, or the National Quality Forum.
5     The Department shall include interpretive guidelines for
6 infection-related indicators and, when available, shall
7 include relevant benchmark information published by national
8 organizations.
9     (b) Individual hospitals shall prepare annual reports
10 including vacancy and turnover rates for licensed nurses per
11 clinical service area.
12     (c) None of the information the Department discloses to the
13 public may be made available in any form or fashion unless the
14 information has been reviewed, adjusted, and validated
15 according to the following process:
16         (1) The Department shall organize an advisory
17     committee, including representatives from the Department,
18     public and private hospitals, direct care nursing staff,
19     physicians, academic researchers, consumers, health
20     insurance companies, organized labor, and organizations
21     representing hospitals and physicians. The advisory
22     committee must be meaningfully involved in the development
23     of all aspects of the Department's methodology for
24     collecting, analyzing, and disclosing the information
25     collected under this Act, including collection methods,
26     formatting, and methods and means for release and

 

 

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1     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 of
5     any information to be made available to the public before
6     any public disclosure of such information.
7         (3) Data collection and analytical methodologies shall
8     be used that meet accepted standards of validity and
9     reliability before any information is made available to the
10     public.
11         (4) The limitations of the data sources and analytic
12     methodologies used to develop comparative hospital
13     information shall be clearly identified and acknowledged,
14     including but not limited to the appropriate and
15     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 these
24     hospitals have 30 days to make corrections and to add
25     helpful explanatory comments about the information before
26     the publication.

 

 

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1         (7) Comparisons among hospitals shall adjust for
2     patient case mix and other relevant risk factors and
3     control for provider peer groups, when appropriate.
4         (8) Effective safeguards to protect against the
5     unauthorized use or disclosure of hospital information
6     shall be developed and implemented.
7         (9) Effective safeguards to protect against the
8     dissemination of inconsistent, incomplete, invalid,
9     inaccurate, or subjective hospital data shall be developed
10     and implemented.
11         (10) The quality and accuracy of hospital information
12     reported under this Act and its data collection, analysis,
13     and dissemination methodologies shall be evaluated
14     regularly.
15         (11) Only the most basic identifying information from
16     mandatory reports shall be used, and information
17     identifying a patient, employee, or licensed professional
18     shall not be released. None of the information the
19     Department discloses to the public under this Act may be
20     used to establish a standard of care in a private civil
21     action.
22     (d) Quarterly reports shall be submitted, in a format set
23 forth in rules adopted by the Department, to the Department by
24 April 30, July 31, October 31, and January 31 each year for the
25 previous quarter. Data in quarterly reports must cover a period
26 ending not earlier than one month prior to submission of the

 

 

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1 report. Annual reports shall be submitted by December 31 in a
2 format set forth in rules adopted by the Department to the
3 Department. All reports shall be made available to the public
4 on-site and through the Department.
5     (e) If the hospital is a division or subsidiary of another
6 entity that owns or operates other hospitals or related
7 organizations, the annual public disclosure report shall be for
8 the specific division or subsidiary and not for the other
9 entity.
10     (f) The Department shall disclose information under this
11 Section in accordance with provisions for inspection and
12 copying of public records required by the Freedom of
13 Information Act provided that such information satisfies the
14 provisions of subsection (c) of this Section.
15     (g) Notwithstanding any other provision of law, under no
16 circumstances shall the Department disclose information
17 obtained from a hospital that is confidential under Part 21 of
18 Article 8 of the Code of Civil Procedure.
19     (h) No hospital report or Department disclosure may contain
20 information identifying a patient, employee, or licensed
21 professional.
22 (Source: P.A. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)
 
23     Section 99. Effective date. This Act takes effect upon
24 becoming law.".