093_SB0059enr

 
SB59 Enrolled                        LRB093 03368 AMC 03386 b

 1        AN ACT concerning hospitals.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

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

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

13        Section 20.  Orientation and training.
14        (a)  All health care facilities shall have established an
15    orientation process that provides initial  job  training  and
16    information  and  assesses  the  direct  care nursing staff's
17    ability to fulfill specified responsibilities.
18        (b)  Personnel not competent for a given unit  shall  not
19    be  assigned  to  work there without direct supervision until
20    appropriately trained.
21        (c)  Staff training information will  be  available  upon
22    request,  without  any  information  identifying  a  patient,
23    employee, or licensed professional  at the hospital.

24        Section 25.  Hospital reports.
25        (a)  Individual   hospitals  shall  prepare  a  quarterly
26    report including all of the following:
27             (1)  Nursing hours per patient  day,  average  daily
28        census,  and average daily hours worked for each clinical
29        service area.
30             (2)  Nosocomial infection rates for the facility for
31        the  specific  clinical  procedures  determined  by   the
32        Department by rule under the following categories:
 
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 1                  (A)  Class I surgical site infection.
 2                  (B)  Ventilator-associated pneumonia.
 3                  (C)  Central      line-related      bloodstream
 4             infections.
 5        The  Department  shall  only  disclose  Illinois hospital
 6    infection rate data according to the  current  benchmarks  of
 7    the   Centers   for  Disease  Control's  National  Nosocomial
 8    Infection Surveillance Program.
 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
13    the  public  may  be  made  available  in any form or fashion
14    unless the  information  has  been  reviewed,  adjusted,  and
15    validated 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
23        development   of   all   aspects   of   the  Department's
24        methodology for collecting, analyzing, and disclosing the
25        information   collected   under   this   Act,   including
26        collection methods, formatting, and methods and means for
27        release and dissemination.
28             (2)  The  entire  methodology  for  collecting   and
29        analyzing  the  data  shall  be disclosed to all relevant
30        organizations and to all hospitals that are  the  subject
31        of  any  information  to  be made available to the public
32        before any public disclosure of such information.
33             (3)  Data collection  and  analytical  methodologies
34        shall  be  used  that meet accepted standards of validity
 
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 1        and reliability before any information is made  available
 2        to the public.
 3             (4)  The   limitations   of  the  data  sources  and
 4        analytic  methodologies  used  to   develop   comparative
 5        hospital  information  shall  be   clearly identified and
 6        acknowledged,  including   but   not   limited   to   the
 7        appropriate and 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
16        these hospitals have 30 days to make corrections  and  to
17        add  helpful  explanatory  comments about the information
18        before 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,
27        inaccurate,  or  subjective  hospital   data   shall   be
28        developed and implemented.
29             (10)  The   quality   and   accuracy   of   hospital
30        information   reported   under  this  Act  and  its  data
31        collection,  analysis,  and  dissemination  methodologies
32        shall be evaluated regularly.
33             (11)  Only the most  basic  identifying  information
34        from  mandatory  reports  shall  be used, and information
 
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 1        identifying a patient, employee, or licensed professional
 2        shall not  be  released.  None  of  the  information  the
 3        Department  discloses to the public under this Act may be
 4        used to establish a standard of care in a  private  civil
 5        action.
 6        (d)  Quarterly  reports  shall  be submitted, in a format
 7    set  forth  in  rules  adopted  by  the  Department,  to  the
 8    Department by April 30, July 31, October 31, and  January  31
 9    each year for the previous quarter. Data in quarterly reports
10    must  cover  a period ending not earlier than one month prior
11    to  submission  of  the  report.  Annual  reports  shall   be
12    submitted  by  December  31  in  a  format set forth in rules
13    adopted by the Department  to  the  Department.  All  reports
14    shall be made available to the public on-site and through the
15    Department.
16        (e)  If  the  hospital  is  a  division  or subsidiary of
17    another entity that  owns  or  operates  other  hospitals  or
18    related  organizations,  the  annual public disclosure report
19    shall be for the specific division or subsidiary and not  for
20    the other entity.
21        (f)  The Department shall disclose information under this
22    Section  in  accordance  with  provisions  for inspection and
23    copying  of  public  records  required  by  the  Freedom   of
24    Information  Act provided that such information satisfies the
25    provisions of subsection (c) of this Section.
26        (g)  Notwithstanding any other provision of law, under no
27    circumstances  shall  the  Department  disclose   information
28    obtained  from  a hospital that is confidential under Part 21
29    of Article 8 of the Code of Civil Procedure.
30        (h)  No hospital  report  or  Department  disclosure  may
31    contain  information  identifying  a  patient,  employee,  or
32    licensed professional.

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

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

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

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

20        Section 90.  The Hospital Licensing  Act  is  amended  by
21    changing Section 7 as follows:

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

 7        Section  99.  Effective  date.  This  Act takes effect on
 8    January 1, 2004.