State of Illinois
2019 and 2020


Introduced , by Rep. Mary E. Flowers - LaToya Greenwood


110 ILCS 330/11 new
210 ILCS 85/10.12 new
210 ILCS 86/25

     Amends the University of Illinois Hospital Act and the Hospital Licensing Act. Requires hospitals to require an intern, resident, or physician who provides medical services at the hospital to have proper credentials and any required certificates for ongoing training at the time the intern, resident, or physician renews his or her license. Amends the Hospital Report Card Act. Requires hospitals to include in their quarterly reports the number of female patients who have died within the reporting period, the number of female patients who have died of a preventable cause within the reporting period and the number of those preventable deaths that the hospital has otherwise reported within the reporting period, and the number of physicians who were required by the hospital to undergo any amount or type of retraining during the reporting period.

LRB101 02848 CPF 47856 b





HB2431LRB101 02848 CPF 47856 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 University of Illinois Hospital Act is
5amended by adding Section 11 as follows:
6    (110 ILCS 330/11 new)
7    Sec. 11. Credentials and certificates. The University of
8Illinois Hospital shall require an intern, resident, or
9physician who provides medical services at the University of
10Illinois Hospital to have proper credentials and any required
11certificates for ongoing training at the time the intern,
12resident, or physician renews his or her license.
13    Section 10. The Hospital Licensing Act is amended by adding
14Section 10.12 as follows:
15    (210 ILCS 85/10.12 new)
16    Sec. 10.12. Credentials and certificates. A hospital
17licensed under this Act shall require an intern, resident, or
18physician who provides medical services at the hospital to have
19proper credentials and any required certificates for ongoing
20training at the time the intern, resident, or physician renews
21his or her license.



HB2431- 2 -LRB101 02848 CPF 47856 b

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



HB2431- 3 -LRB101 02848 CPF 47856 b

1        (4) Additional infection measures mandated by the
2    Centers for Medicare and Medicaid Services that are
3    reported by hospitals to the Centers for Disease Control
4    and Prevention's National Healthcare Safety Network
5    surveillance system, or its successor, and deemed relevant
6    to patient safety by the Department.
7        (5) The number of female patients who have died within
8    the reporting period.
9        (6) The number of female patients who have died of a
10    preventable cause within the reporting period and the
11    number of those preventable deaths that the hospital has
12    otherwise reported within the reporting period.
13        (7) The number of physicians, as that term is defined
14    in the Medical Practice Act of 1987, required by the
15    hospital to undergo any amount or type of retraining during
16    the reporting period.
17    The infection-related measures developed by the Department
18shall be based upon measures and methods developed by the
19Centers for Disease Control and Prevention, the Centers for
20Medicare and Medicaid Services, the Agency for Healthcare
21Research and Quality, the Joint Commission on Accreditation of
22Healthcare Organizations, or the National Quality Forum. The
23Department may align the infection-related measures with the
24measures and methods developed by the Centers for Disease
25Control and Prevention, the Centers for Medicare and Medicaid
26Services, the Agency for Healthcare Research and Quality, the



HB2431- 4 -LRB101 02848 CPF 47856 b

1Joint Commission on Accreditation of Healthcare Organizations,
2and the National Quality Forum by adding reporting measures
3based on national health care strategies and measures deemed
4scientifically reliable and valid for public reporting. The
5Department shall receive approval from the State Board of
6Health to retire measures deemed no longer scientifically valid
7or valuable for informing quality improvement or infection
8prevention efforts. The Department shall notify the Chairs and
9Minority Spokespersons of the House Human Services Committee
10and the Senate Public Health Committee of its intent to have
11the State Board of Health take action to retire measures no
12later than 7 business days before the meeting of the State
13Board of Health.
14    The Department shall include interpretive guidelines for
15infection-related indicators and, when available, shall
16include relevant benchmark information published by national
18    (b) Individual hospitals shall prepare annual reports
19including vacancy and turnover rates for licensed nurses per
20clinical service area.
21    (c) None of the information the Department discloses to the
22public may be made available in any form or fashion unless the
23information has been reviewed, adjusted, and validated
24according to the following process:
25        (1) The Department shall organize an advisory
26    committee, including representatives from the Department,



HB2431- 5 -LRB101 02848 CPF 47856 b

1    public and private hospitals, direct care nursing staff,
2    physicians, academic researchers, consumers, health
3    insurance companies, organized labor, and organizations
4    representing hospitals and physicians. The advisory
5    committee must be meaningfully involved in the development
6    of all aspects of the Department's methodology for
7    collecting, analyzing, and disclosing the information
8    collected under this Act, including collection methods,
9    formatting, and methods and means for release and
10    dissemination.
11        (2) The entire methodology for collecting and
12    analyzing the data shall be disclosed to all relevant
13    organizations and to all hospitals that are the subject of
14    any information to be made available to the public before
15    any public disclosure of such information.
16        (3) Data collection and analytical methodologies shall
17    be used that meet accepted standards of validity and
18    reliability before any information is made available to the
19    public.
20        (4) The limitations of the data sources and analytic
21    methodologies used to develop comparative hospital
22    information shall be clearly identified and acknowledged,
23    including but not limited to the appropriate and
24    inappropriate uses of the data.
25        (5) To the greatest extent possible, comparative
26    hospital information initiatives shall use standard-based



HB2431- 6 -LRB101 02848 CPF 47856 b

1    norms derived from widely accepted provider-developed
2    practice guidelines.
3        (6) Comparative hospital information and other
4    information that the Department has compiled regarding
5    hospitals shall be shared with the hospitals under review
6    prior to public dissemination of such information and these
7    hospitals have 30 days to make corrections and to add
8    helpful explanatory comments about the information before
9    the publication.
10        (7) Comparisons among hospitals shall adjust for
11    patient case mix and other relevant risk factors and
12    control for provider peer groups, when appropriate.
13        (8) Effective safeguards to protect against the
14    unauthorized use or disclosure of hospital information
15    shall be developed and implemented.
16        (9) Effective safeguards to protect against the
17    dissemination of inconsistent, incomplete, invalid,
18    inaccurate, or subjective hospital data shall be developed
19    and implemented.
20        (10) The quality and accuracy of hospital information
21    reported under this Act and its data collection, analysis,
22    and dissemination methodologies shall be evaluated
23    regularly.
24        (11) Only the most basic identifying information from
25    mandatory reports shall be used, and information
26    identifying a patient, employee, or licensed professional



HB2431- 7 -LRB101 02848 CPF 47856 b

1    shall not be released. None of the information the
2    Department discloses to the public under this Act may be
3    used to establish a standard of care in a private civil
4    action.
5    (d) Quarterly reports shall be submitted, in a format set
6forth in rules adopted by the Department, to the Department by
7April 30, July 31, October 31, and January 31 each year for the
8previous quarter. Data in quarterly reports must cover a period
9ending not earlier than one month prior to submission of the
10report. Annual reports shall be submitted by December 31 in a
11format set forth in rules adopted by the Department to the
12Department. All reports shall be made available to the public
13on-site and through the Department.
14    (e) If the hospital is a division or subsidiary of another
15entity that owns or operates other hospitals or related
16organizations, the annual public disclosure report shall be for
17the specific division or subsidiary and not for the other
19    (f) The Department shall disclose information under this
20Section in accordance with provisions for inspection and
21copying of public records required by the Freedom of
22Information Act provided that such information satisfies the
23provisions of subsection (c) of this Section.
24    (g) Notwithstanding any other provision of law, under no
25circumstances shall the Department disclose information
26obtained from a hospital that is confidential under Part 21 of



HB2431- 8 -LRB101 02848 CPF 47856 b

1Article VIII of the Code of Civil Procedure.
2    (h) No hospital report or Department disclosure may contain
3information identifying a patient, employee, or licensed
5(Source: P.A. 98-463, eff. 8-16-13; 99-326, eff. 8-10-15.)