Illinois General Assembly - Full Text of HB0068
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Full Text of HB0068  102nd General Assembly




HB0068 EnrolledLRB102 03824 CPF 13838 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Hospital Report Card Act is amended by
5changing Section 25 as follows:
6    (210 ILCS 86/25)
7    Sec. 25. Hospital reports.
8    (a) Individual hospitals shall prepare a quarterly report
9including 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 for the facility for
14    the specific clinical procedures and devices determined by
15    the Department by rule under 2 or more of the following
16    categories:
17            (A) Surgical procedure outcome measures.
18            (B) Surgical procedure infection control process
19        measures.
20            (C) Outcome or process measures related to
21        ventilator-associated pneumonia.
22            (D) Central vascular catheter-related bloodstream
23        infection rates in designated critical care units.



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1        (3) Information required under paragraph (4) of
2    Section 2310-312 of the Department of Public Health Powers
3    and Duties Law of the Civil Administrative Code of
4    Illinois.
5        (4) Additional infection measures mandated by the
6    Centers for Medicare and Medicaid Services that are
7    reported by hospitals to the Centers for Disease Control
8    and Prevention's National Healthcare Safety Network
9    surveillance system, or its successor, and deemed relevant
10    to patient safety by the Department.
11        (5) Each instance of preterm birth and infant
12    mortality within the reporting period, including the
13    racial and ethnic information of the mothers of those
14    infants.
15        (6) Each instance of maternal mortality within the
16    reporting period, including the racial and ethnic
17    information of those mothers.
18        (7) The number of female patients who have died within
19    the reporting period.
20        (8) The number of female patients admitted to the
21    hospital with a diagnosis of COVID-19 and at least one
22    known underlying condition identified by the United States
23    Centers for Disease Control and Prevention as a condition
24    that increases the risk of mortality from COVID-19 who
25    subsequently died at the hospital within the reporting
26    period.



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1    The infection-related measures developed by the Department
2shall be based upon measures and methods developed by the
3Centers for Disease Control and Prevention, the Centers for
4Medicare and Medicaid Services, the Agency for Healthcare
5Research and Quality, the Joint Commission on Accreditation of
6Healthcare Organizations, or the National Quality Forum. The
7Department may align the infection-related measures with the
8measures and methods developed by the Centers for Disease
9Control and Prevention, the Centers for Medicare and Medicaid
10Services, the Agency for Healthcare Research and Quality, the
11Joint Commission on Accreditation of Healthcare Organizations,
12and the National Quality Forum by adding reporting measures
13based on national health care strategies and measures deemed
14scientifically reliable and valid for public reporting. The
15Department shall receive approval from the State Board of
16Health to retire measures deemed no longer scientifically
17valid or valuable for informing quality improvement or
18infection prevention efforts. The Department shall notify the
19Chairs and Minority Spokespersons of the House Human Services
20Committee and the Senate Public Health Committee of its intent
21to have the State Board of Health take action to retire
22measures no later than 7 business days before the meeting of
23the State Board of Health.
24    The Department shall include interpretive guidelines for
25infection-related indicators and, when available, shall
26include relevant benchmark information published by national



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



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



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1        (8) Effective safeguards to protect against the
2    unauthorized use or disclosure of hospital information
3    shall be developed and implemented.
4        (9) Effective safeguards to protect against the
5    dissemination of inconsistent, incomplete, invalid,
6    inaccurate, or subjective hospital data shall be developed
7    and implemented.
8        (10) The quality and accuracy of hospital information
9    reported under this Act and its data collection, analysis,
10    and dissemination methodologies shall be evaluated
11    regularly.
12        (11) Only the most basic identifying information from
13    mandatory reports shall be used, and information
14    identifying a patient, employee, or licensed professional
15    shall not be released. None of the information the
16    Department discloses to the public under this Act may be
17    used to establish a standard of care in a private civil
18    action.
19    (d) Quarterly reports shall be submitted, in a format set
20forth in rules adopted by the Department, to the Department by
21April 30, July 31, October 31, and January 31 each year for the
22previous quarter. Data in quarterly reports must cover a
23period ending not earlier than one month prior to submission
24of the report. Annual reports shall be submitted by December
2531 in a format set forth in rules adopted by the Department to
26the Department. All reports shall be made available to the



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1public on-site and through the Department.
2    (e) If the hospital is a division or subsidiary of another
3entity that owns or operates other hospitals or related
4organizations, the annual public disclosure report shall be
5for the specific division or subsidiary and not for the other
7    (f) The Department shall disclose information under this
8Section in accordance with provisions for inspection and
9copying of public records required by the Freedom of
10Information Act provided that such information satisfies the
11provisions of subsection (c) of this Section.
12    (g) Notwithstanding any other provision of law, under no
13circumstances shall the Department disclose information
14obtained from a hospital that is confidential under Part 21 of
15Article VIII of the Code of Civil Procedure.
16    (h) No hospital report or Department disclosure may
17contain information identifying a patient, employee, or
18licensed professional.
19(Source: P.A. 101-446, eff. 8-23-19.)