Human Services Committee

Adopted in House Comm. on Apr 27, 2005

 

 


 

 


 
09400SB1862ham001 LRB094 11494 RSP 45537 a

1
AMENDMENT TO SENATE BILL 1862

2     AMENDMENT NO. ______. Amend Senate Bill 1862 on page 1,
3 immediately below line 24, by inserting the following:
 
4     "Section 10. The Hospital Report Card Act is amended by
5 changing Section 25 as follows:
 
6     (210 ILCS 86/25)
7     Sec. 25. Hospital reports.
8     (a) Individual hospitals shall prepare a quarterly report
9 including 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 Nosocomial infection
14     rates for the facility for the specific clinical procedures
15     and devices determined by the Department by rule under 2 or
16     more of the following categories:
17             (A) Surgical procedure outcome measures Class I
18         surgical site infection.
19             (B) Surgical procedure infection control process
20         measures.
21             (C) (B) Outcome or process measures related to
22         ventilator-associated Ventilator-associated pneumonia.
23             (D) (C) Central vascular catheter-related
24         line-related bloodstream infection rates in designated

 

 

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1         critical care units infections.
2     The infection-related measures developed by the Department
3 shall be based upon measures and methods developed by the
4 Centers for Disease Control and Prevention, the Centers for
5 Medicare and Medicaid Services, the Agency for Healthcare
6 Research and Quality, the Joint Commission on Accreditation of
7 Healthcare Organizations, or the National Quality Forum.
8     The Department shall include interpretive guidelines for
9 infection-related indicators and, when available, shall
10 include relevant benchmark information published by national
11 organizations. The Department shall only disclose Illinois
12 hospital infection rate data according to the current
13 benchmarks of the Centers for Disease Control's National
14 Nosocomial Infection Surveillance Program.
15     (b) Individual hospitals shall prepare annual reports
16 including vacancy and turnover rates for licensed nurses per
17 clinical service area.
18     (c) None of the information the Department discloses to the
19 public may be made available in any form or fashion unless the
20 information has been reviewed, adjusted, and validated
21 according to the following process:
22         (1) The Department shall organize an advisory
23     committee, including representatives from the Department,
24     public and private hospitals, direct care nursing staff,
25     physicians, academic researchers, consumers, health
26     insurance companies, organized labor, and organizations
27     representing hospitals and physicians. The advisory
28     committee must be meaningfully involved in the development
29     of all aspects of the Department's methodology for
30     collecting, analyzing, and disclosing the information
31     collected under this Act, including collection methods,
32     formatting, and methods and means for release and
33     dissemination.
34         (2) The entire methodology for collecting and

 

 

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

 

 

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

 

 

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1     (h) No hospital report or Department disclosure may contain
2 information identifying a patient, employee, or licensed
3 professional.
4 (Source: P.A. 93-563, eff. 1-1-04.)".