Public Act 093-0563
Public Act 93-0563 of the 93rd General Assembly
Public Act 93-0563
SB59 Enrolled LRB093 03368 AMC 03386 b
AN ACT concerning hospitals.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the
Hospital Report Card Act.
Section 5. Findings. The General Assembly finds that
Illinois consumers have a right to access information about
the quality of health care provided in Illinois hospitals in
order to make better decisions about their choice of health
Section 10. Definitions. For the purpose of this Act:
"Average daily census" means the average number of
inpatients receiving service on any given 24-hour period
beginning at midnight in each clinical service area of the
"Clinical service area" means a grouping of clinical
services by a generic class of various types or levels of
support functions, equipment, care, or treatment provided to
inpatients. Hospitals may have, but are not required to have,
the following categories of service: behavioral health,
critical care, maternal-child care, medical-surgical,
pediatrics, perioperative services, and telemetry.
"Department" means the Department of Public Health.
"Direct-care nurse" and "direct-care nursing staff"
includes any registered nurse, licensed practical nurse, or
assistive nursing personnel with direct responsibility to
oversee or carry out medical regimens or nursing care for one
or more patient.
"Hospital" means a health care facility licensed under
the Hospital Licensing Act.
"Nursing care" means care that falls within the scope of
practice set forth in the Nursing and Advanced Practice
Nursing Act or is otherwise encompassed within recognized
professional standards of nursing practice, including
assessment, nursing diagnosis, planning, intervention,
evaluation, and patient advocacy.
"Retaliate" means to discipline, discharge, suspend,
demote, harass, deny employment or promotion, lay off, or
take any other adverse action against direct-care nursing
staff as a result of that nursing staff taking any action
described in this Act.
"Skill mix" means the differences in licensing,
specialty, and experiences among direct-care nurses.
"Staffing levels" means the numerical nurse to patient
ratio by licensed nurse classification within a nursing
department or unit.
"Unit" means a functional division or area of a hospital
in which nursing care is provided.
Section 15. Staffing levels.
(a) The number of registered professional nurses,
licensed practical nurses, and other nursing personnel
assigned to each patient care unit shall be consistent with
the types of nursing care needed by the patients and the
capabilities of the staff. Patients on each unit shall be
evaluated near the end of each change of shift by criteria
developed by the nursing service. There shall be staffing
schedules reflecting actual nursing personnel required for
the hospital and for each patient unit. Staffing patterns
shall reflect consideration of nursing goals, standards of
nursing practice, and the needs of the patients.
(b) Current nursing staff schedules shall be available
upon request at each patient care unit. Each schedule shall
list the daily assigned nursing personnel and average daily
census for the unit. The actual nurse staffing assignment
roster for each patient care unit shall be available upon
request at the patient care unit for the effective date of
that roster. Upon the roster's expiration, the hospital shall
retain the roster for 5 years from the date of its
(c) All records required under this Section, including
anticipated staffing schedules and the methods to determine
and adjust staffing levels shall be made available to the
public upon request.
(d) All records required under this Section shall be
maintained by the facility for no less than 5 years.
Section 20. Orientation and training.
(a) All health care facilities shall have established an
orientation process that provides initial job training and
information and assesses the direct care nursing staff's
ability to fulfill specified responsibilities.
(b) Personnel not competent for a given unit shall not
be assigned to work there without direct supervision until
(c) Staff training information will be available upon
request, without any information identifying a patient,
employee, or licensed professional at the hospital.
Section 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
(2) Nosocomial infection rates for the facility for
the specific clinical procedures determined by the
Department by rule under the following categories:
(A) Class I surgical site infection.
(B) Ventilator-associated pneumonia.
(C) Central line-related bloodstream
The Department shall only disclose Illinois hospital
infection rate data according to the current benchmarks of
the Centers for Disease Control's National Nosocomial
Infection Surveillance Program.
(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
(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
(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
(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
Section 30. Department reports. The Department of Public
Health shall annually submit to the General Assembly a report
summarizing the quarterly reports by health service area and
shall publish that report on its website. The Department of
Public Health may issue quarterly informational bulletins at
its discretion, summarizing all or part of the information
submitted in these quarterly reports. The Department shall
also publish risk-adjusted mortality rates for each hospital
based upon information hospitals have already submitted to
the Department pursuant to their obligations to report health
care information under other public health reporting laws and
regulations outside of this Act. The published mortality
rates must comply with the hospital data publication process
contained in subsection (c) of Section 25 of this Act.
Section 35. Whistleblower protections.
(a) A hospital covered by this Act shall not penalize,
discriminate, or retaliate in any manner against an employee
with respect to compensation or the terms, conditions, or
privileges of employment who in good faith, individually or
in conjunction with another person or persons, does any of
the following or intimidate, threaten, or punish an employee
to prevent him or her from doing any of the following:
(1) Discloses to the nursing staff supervisor or
manager, a private accreditation organization, the
nurse's collective bargaining agent, or a regulatory
agency any activity, policy, or practice of a hospital
that violates this Act or any other law or rule or that
the employee reasonably believes poses a risk to the
health, safety, or welfare of a patient or the public.
(2) Initiates, cooperates, or otherwise
participates in an investigation or proceeding brought by
a regulatory agency or private accreditation body
concerning matters covered by this Act or any other law
or rule or that the employee reasonably believes poses a
risk to the health, safety, or welfare of a patient or
(3) Objects to or refuses to participate in any
activity, policy, or practice of a hospital that violates
this Act or any law or rule of the Department or that a
reasonable person would believe poses a risk to the
health, safety, or welfare of a patient or the public.
(4) Participates in a committee or peer review
process or files a report or complaint that discusses
allegation of unsafe, dangerous, or potentially dangerous
care within the hospital.
(b) For the purposes of this Section, an employee is
presumed to act in good faith if the employee reasonably
believes that (i) the information reported or disclosed is
true and (ii) a violation has occurred or may occur. An
employee is not acting in good faith under this Section if
the employee's report or action was based on information that
the employee should reasonably know is false or misleading.
The protection of this Section shall also not apply to an
employee unless the employee gives written notice to a
hospital manager of the activity, policy, practice, or
violation that the employee believes poses a risk to the
health of a patient or the public and provides the manager a
reasonable opportunity to correct the problem. The manager
shall respond in writing to the employee within 7 days
acknowledging that the notice was received and provide
written notice of any action taken within a reasonable time
of receiving the employee's notice. This notice requirement
shall not apply if the employee is reasonably certain that
the activity, policy, practice, or violation: (i) is known by
one or more hospital managers who have had an opportunity to
correct the problem and have not done so; (ii) involves the
commission of a crime; or (iii) places patient health or
safety in severe and immediate danger. The notice requirement
shall not apply if the employee is participating in a survey,
investigation, or other activity of a regulatory agency, law
enforcement agency, or private accreditation body that was
not initiated by the employee. Nothing in this Section
prohibits a hospital from training, educating, correcting, or
otherwise taking action to improve the performance of
employees who report that they are unable or unwilling to
perform an assigned task.
Section 40. Private right of action. Any health care
facility that violates the provisions of Section 35 may be
held liable to the employee affected in an action brought in
a court of competent jurisdiction for such legal or equitable
relief as may be appropriate to effectuate the purposes of
Section 45. Regulatory oversight. The Department shall
be responsible for ensuring compliance with this Act as a
condition of licensure under the Hospital Licensing Act and
shall enforce such compliance according to the provisions of
the Hospital Licensing Act.
Section 90. The Hospital Licensing Act is amended by
changing Section 7 as follows:
(210 ILCS 85/7) (from Ch. 111 1/2, par. 148)
Sec. 7. (a) The Director after notice and opportunity for
hearing to the applicant or licensee may deny, suspend, or
revoke a permit to establish a hospital or deny, suspend, or
revoke a license to open, conduct, operate, and maintain a
hospital in any case in which he finds that there has been a
substantial failure to comply with the provisions of this Act
or the Hospital Report Card Act or the standards, rules, and
regulations established by virtue of either of those Acts
(b) Such notice shall be effected by registered mail or
by personal service setting forth the particular reasons for
the proposed action and fixing a date, not less than 15 days
from the date of such mailing or service, at which time the
applicant or licensee shall be given an opportunity for a
hearing. Such hearing shall be conducted by the Director or
by an employee of the Department designated in writing by the
Director as Hearing Officer to conduct the hearing. On the
basis of any such hearing, or upon default of the applicant
or licensee, the Director shall make a determination
specifying his findings and conclusions. In case of a denial
to an applicant of a permit to establish a hospital, such
determination shall specify the subsection of Section 6 under
which the permit was denied and shall contain findings of
fact forming the basis of such denial. A copy of such
determination shall be sent by registered mail or served
personally upon the applicant or licensee. The decision
denying, suspending, or revoking a permit or a license shall
become final 35 days after it is so mailed or served, unless
the applicant or licensee, within such 35 day period,
petitions for review pursuant to Section 13.
(c) The procedure governing hearings authorized by this
Section shall be in accordance with rules promulgated by the
Department and approved by the Hospital Licensing Board. A
full and complete record shall be kept of all proceedings,
including the notice of hearing, complaint, and all other
documents in the nature of pleadings, written motions filed
in the proceedings, and the report and orders of the Director
and Hearing Officer. All testimony shall be reported but need
not be transcribed unless the decision is appealed pursuant
to Section 13. A copy or copies of the transcript may be
obtained by any interested party on payment of the cost of
preparing such copy or copies.
(d) The Director or Hearing Officer shall upon his own
motion, or on the written request of any party to the
proceeding, issue subpoenas requiring the attendance and the
giving of testimony by witnesses, and subpoenas duces tecum
requiring the production of books, papers, records, or
memoranda. All subpoenas and subpoenas duces tecum issued
under the terms of this Act may be served by any person of
full age. The fees of witnesses for attendance and travel
shall be the same as the fees of witnesses before the Circuit
Court of this State, such fees to be paid when the witness is
excused from further attendance. When the witness is
subpoenaed at the instance of the Director, or Hearing
Officer, such fees shall be paid in the same manner as other
expenses of the Department, and when the witness is
subpoenaed at the instance of any other party to any such
proceeding the Department may require that the cost of
service of the subpoena or subpoena duces tecum and the fee
of the witness be borne by the party at whose instance the
witness is summoned. In such case, the Department in its
discretion, may require a deposit to cover the cost of such
service and witness fees. A subpoena or subpoena duces tecum
issued as aforesaid shall be served in the same manner as a
subpoena issued out of a court.
(e) Any Circuit Court of this State upon the application
of the Director, or upon the application of any other party
to the proceeding, may, in its discretion, compel the
attendance of witnesses, the production of books, papers,
records, or memoranda and the giving of testimony before the
Director or Hearing Officer conducting an investigation or
holding a hearing authorized by this Act, by an attachment
for contempt, or otherwise, in the same manner as production
of evidence may be compelled before the court.
(f) The Director or Hearing Officer, or any party in an
investigation or hearing before the Department, may cause the
depositions of witnesses within the State to be taken in the
manner prescribed by law for like depositions in civil
actions in courts of this State, and to that end compel the
attendance of witnesses and the production of books, papers,
records, or memoranda.
(Source: Laws 1967, p. 3969.)
Section 99. Effective date. This Act takes effect on
January 1, 2004.