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Public Act 095-0282


 

Public Act 0282 95TH GENERAL ASSEMBLY



 


 
Public Act 095-0282
 
HB0192 Enrolled LRB095 03991 DRJ 24024 b

    AN ACT concerning health.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Mental Health and Developmental
Disabilities Administrative Act is amended by adding Section
10.5 as follows:
 
    (20 ILCS 1705/10.5 new)
    Sec. 10.5. Prevention and control of Multidrug-Resistant
Organisms. The Department, in consultation with the Department
of Public Health, shall adopt rules that may require one or
more of the facilities described in Section 4 of this Act to
implement comprehensive interventions to prevent and control
multidrug-resistant organisms (MDROs), including
methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococci (VRE), and certain
gram-negative bacilli (GNB), pursuant to updated prevention
and control interventions recommended by the U.S. Centers for
Disease Control and Prevention. The Department shall also
require facilities to submit reports to the Department that
contain substantially the same information contained in the
related infection reports required to be submitted by hospitals
to the Department of Public Health under Section 25 of the
Hospital Report Card Act. The Department shall provide that
information to the Department of Public Health upon the
Department of Public Health's request.
 
    Section 10. The Department of Public Health Powers and
Duties Law of the Civil Administrative Code of Illinois is
amended by adding Section 2310-312 as follows:
 
    (20 ILCS 2310/2310-312 new)
    Sec. 2310-312. Multidrug-Resistant Organisms. The
Department shall perform the following functions in relation to
the prevention and control of Multidrug-Resistant Organisms
(MDROs), including methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant (VRE) and certain gram-negative
bacilli (GNB), as these terms are referenced by the United
States Centers for Disease Control and Prevention:
        (1) Except with regard to hospitals, for which
    administrative rules shall be adopted in accordance with
    Section 6.23 of the Hospital Licensing Act and Section 7 of
    the University of Illinois Hospital Act, the Department
    shall adopt administrative rules for health care
    facilities subject to licensure, certification,
    registration, or other regulation by the Department that
    may require one or more types of those facilities to (i)
    perform an annual infection control risk assessment, (ii)
    develop infection control policies for MDROs that are based
    on this assessment and incorporate, as appropriate,
    updated recommendations of the U.S. Centers for Disease
    Control and Prevention for the prevention and control of
    MDROs, and (iii) enforce hand hygiene requirements.
        (2) The Department shall:
            (A) publicize guidelines for reducing the
        incidence of MDROs to health care providers, health
        care facilities, public health departments, prisons,
        jails, and the general public; and
            (B) provide periodic reports and updates to public
        officials, health professionals, and the general
        public statewide regarding new developments or
        procedures concerning prevention and management of
        infections due to MDROs.
        (3) The Department shall publish a yearly report
    regarding MRSA and Clostridium difficile infections based
    on the Hospital Discharge Dataset. The Department is
    authorized to require hospitals, based on guidelines
    developed by the National Center for Health Statistics,
    after October 1, 2007, to submit data to the Department
    that is coded as "present on admission" and "occurred
    during the stay".
        (4) Reporting to the Department under the Hospital
    Report Card Act shall include organisms, including but not
    limited to MRSA, that are responsible for central venous
    catheter-associated bloodstream infections and
    ventilator-associated pneumonia in designated hospital
    units.
        (5) The Department shall implement surveillance for
    designated cases of community associated MRSA infections
    for a period of at least 3 years, beginning on or before
    January 1, 2008.
 
    Section 15. The University of Illinois Hospital Act is
amended by adding Section 7 as follows:
 
    (110 ILCS 330/7 new)
    Sec. 7. Prevention and control for Multidrug-Resistant
Organisms. The University of Illinois Hospital shall develop
and implement comprehensive interventions to prevent and
control multidrug-resistant organisms (MDROs), including
methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococci (VRE), and certain
gram-negative bacilli (GNB), that take into consideration
guidelines of the U.S. Centers for Disease Control and
Prevention for the management of MDROs in healthcare settings.
The Department of Public Health shall adopt administrative
rules that require the University of Illinois Hospital to
perform an annual facility-wide infection control risk
assessment and enforce hand hygiene and contact precaution
requirements.
 
    Section 20. The Hospital Licensing Act is amended by adding
Section 6.23 as follows:
 
    (210 ILCS 85/6.23 new)
    Sec. 6.23. Prevention and control of Multidrug-Resistant
Organisms. Each hospital shall develop and implement
comprehensive interventions to prevent and control
multidrug-resistant organisms (MDROs), including
methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococci (VRE), and certain
gram-negative bacilli (GNB), that take into consideration
guidelines of the U.S. Centers for Disease Control and
Prevention for the management of MDROs in healthcare settings.
The Department shall adopt administrative rules that require
hospitals to perform an annual facility-wide infection control
risk assessment and enforce hand hygiene and contact precaution
requirements.
 
    Section 25. The Hospital Report Card Act is amended by
changing Section 25 as follows:
 
    (210 ILCS 86/25)
    Sec. 25. Hospital reports.
    (a) Individual hospitals shall prepare a quarterly report
including all of the following:
        (1) Nursing hours per patient day, average daily
    census, and average daily hours worked for each clinical
    service area.
        (2) Infection-related measures for the facility for
    the specific clinical procedures and devices determined by
    the Department by rule under 2 or more of the following
    categories:
            (A) Surgical procedure outcome measures.
            (B) Surgical procedure infection control process
        measures.
            (C) Outcome or process measures related to
        ventilator-associated pneumonia.
            (D) Central vascular catheter-related bloodstream
        infection rates in designated critical care units.
        (3) Information required under paragraph (4) of
    Section 2310-312 of the Department of Public Health Powers
    and Duties Law of the Civil Administrative Code of
    Illinois.
    The infection-related measures developed by the Department
shall be based upon measures and methods developed by the
Centers for Disease Control and Prevention, the Centers for
Medicare and Medicaid Services, the Agency for Healthcare
Research and Quality, the Joint Commission on Accreditation of
Healthcare Organizations, or the National Quality Forum.
    The Department shall include interpretive guidelines for
infection-related indicators and, when available, shall
include relevant benchmark information published by national
organizations.
    (b) Individual hospitals shall prepare annual reports
including vacancy and turnover rates for licensed nurses per
clinical service area.
    (c) None of the information the Department discloses to the
public may be made available in any form or fashion unless the
information has been reviewed, adjusted, and validated
according to the following process:
        (1) The Department shall organize an advisory
    committee, including representatives from the Department,
    public and private hospitals, direct care nursing staff,
    physicians, academic researchers, consumers, health
    insurance companies, organized labor, and organizations
    representing hospitals and physicians. The advisory
    committee must be meaningfully involved in the development
    of all aspects of the Department's methodology for
    collecting, analyzing, and disclosing the information
    collected under this Act, including collection methods,
    formatting, and methods and means for release and
    dissemination.
        (2) The entire methodology for collecting and
    analyzing the data shall be disclosed to all relevant
    organizations and to all hospitals that are the subject of
    any information to be made available to the public before
    any public disclosure of such information.
        (3) Data collection and analytical methodologies shall
    be used that meet accepted standards of validity and
    reliability before any information is made available to the
    public.
        (4) The limitations of the data sources and analytic
    methodologies used to develop comparative hospital
    information shall be clearly identified and acknowledged,
    including but not limited to the appropriate and
    inappropriate uses of the data.
        (5) To the greatest extent possible, comparative
    hospital information initiatives shall use standard-based
    norms derived from widely accepted provider-developed
    practice guidelines.
        (6) Comparative hospital information and other
    information that the Department has compiled regarding
    hospitals shall be shared with the hospitals under review
    prior to public dissemination of such information and these
    hospitals have 30 days to make corrections and to add
    helpful explanatory comments about the information before
    the publication.
        (7) Comparisons among hospitals shall adjust for
    patient case mix and other relevant risk factors and
    control for provider peer groups, when appropriate.
        (8) Effective safeguards to protect against the
    unauthorized use or disclosure of hospital information
    shall be developed and implemented.
        (9) Effective safeguards to protect against the
    dissemination of inconsistent, incomplete, invalid,
    inaccurate, or subjective hospital data shall be developed
    and implemented.
        (10) The quality and accuracy of hospital information
    reported under this Act and its data collection, analysis,
    and dissemination methodologies shall be evaluated
    regularly.
        (11) Only the most basic identifying information from
    mandatory reports shall be used, and information
    identifying a patient, employee, or licensed professional
    shall not be released. None of the information the
    Department discloses to the public under this Act may be
    used to establish a standard of care in a private civil
    action.
    (d) Quarterly reports shall be submitted, in a format set
forth in rules adopted by the Department, to the Department by
April 30, July 31, October 31, and January 31 each year for the
previous quarter. Data in quarterly reports must cover a period
ending not earlier than one month prior to submission of the
report. Annual reports shall be submitted by December 31 in a
format set forth in rules adopted by the Department to the
Department. All reports shall be made available to the public
on-site and through the Department.
    (e) If the hospital is a division or subsidiary of another
entity that owns or operates other hospitals or related
organizations, the annual public disclosure report shall be for
the specific division or subsidiary and not for the other
entity.
    (f) The Department shall disclose information under this
Section in accordance with provisions for inspection and
copying of public records required by the Freedom of
Information Act provided that such information satisfies the
provisions of subsection (c) of this Section.
    (g) Notwithstanding any other provision of law, under no
circumstances shall the Department disclose information
obtained from a hospital that is confidential under Part 21 of
Article 8 of the Code of Civil Procedure.
    (h) No hospital report or Department disclosure may contain
information identifying a patient, employee, or licensed
professional.
(Source: P.A. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 8/20/2007