Illinois General Assembly - Full Text of HB0003
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Full Text of HB0003  101st General Assembly




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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 Hospital Report Card Act is amended by
5changing Section 25 as follows:
6    (210 ILCS 86/25)
7    Sec. 25. Hospital reports.
8    (a) Individual hospitals shall prepare a quarterly report
9including 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 for the facility for
14    the specific clinical procedures and devices determined by
15    the Department by rule under 2 or more of the following
16    categories:
17            (A) Surgical procedure outcome measures.
18            (B) Surgical procedure infection control process
19        measures.
20            (C) Outcome or process measures related to
21        ventilator-associated pneumonia.
22            (D) Central vascular catheter-related bloodstream
23        infection rates in designated critical care units.



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1        (3) Information required under paragraph (4) of
2    Section 2310-312 of the Department of Public Health Powers
3    and Duties Law of the Civil Administrative Code of
4    Illinois.
5        (4) Additional infection measures mandated by the
6    Centers for Medicare and Medicaid Services that are
7    reported by hospitals to the Centers for Disease Control
8    and Prevention's National Healthcare Safety Network
9    surveillance system, or its successor, and deemed relevant
10    to patient safety by the Department.
11        (5) Each instance of preterm birth and infant mortality
12    within the reporting period, including the racial and
13    ethnic information of the mothers of those infants.
14        (6) Each instance of maternal mortality within the
15    reporting period, including the racial and ethnic
16    information of those mothers.
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



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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    The Department shall collect the information reported
19under paragraphs (5) and (6) and shall use it to illustrate the
20disparity of those occurrences across different racial and
21ethnic groups.
22    (b) Individual hospitals shall prepare annual reports
23including vacancy and turnover rates for licensed nurses per
24clinical service area.
25    (c) None of the information the Department discloses to the
26public may be made available in any form or fashion unless the



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1information has been reviewed, adjusted, and validated
2according to the following process:
3        (1) The Department shall organize an advisory
4    committee, including representatives from the Department,
5    public and private hospitals, direct care nursing staff,
6    physicians, academic researchers, consumers, health
7    insurance companies, organized labor, and organizations
8    representing hospitals and physicians. The advisory
9    committee must be meaningfully involved in the development
10    of all aspects of the Department's methodology for
11    collecting, analyzing, and disclosing the information
12    collected under this Act, including collection methods,
13    formatting, and methods and means for release and
14    dissemination.
15        (2) The entire methodology for collecting and
16    analyzing the data shall be disclosed to all relevant
17    organizations and to all hospitals that are the subject of
18    any information to be made available to the public before
19    any public disclosure of such information.
20        (3) Data collection and analytical methodologies shall
21    be used that meet accepted standards of validity and
22    reliability before any information is made available to the
23    public.
24        (4) The limitations of the data sources and analytic
25    methodologies used to develop comparative hospital
26    information shall be clearly identified and acknowledged,



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1    including but not limited to the appropriate and
2    inappropriate uses of the data.
3        (5) To the greatest extent possible, comparative
4    hospital information initiatives shall use standard-based
5    norms derived from widely accepted provider-developed
6    practice guidelines.
7        (6) Comparative hospital information and other
8    information that the Department has compiled regarding
9    hospitals shall be shared with the hospitals under review
10    prior to public dissemination of such information and these
11    hospitals have 30 days to make corrections and to add
12    helpful explanatory comments about the information before
13    the publication.
14        (7) Comparisons among hospitals shall adjust for
15    patient case mix and other relevant risk factors and
16    control for provider peer groups, when appropriate.
17        (8) Effective safeguards to protect against the
18    unauthorized use or disclosure of hospital information
19    shall be developed and implemented.
20        (9) Effective safeguards to protect against the
21    dissemination of inconsistent, incomplete, invalid,
22    inaccurate, or subjective hospital data shall be developed
23    and implemented.
24        (10) The quality and accuracy of hospital information
25    reported under this Act and its data collection, analysis,
26    and dissemination methodologies shall be evaluated



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1    regularly.
2        (11) Only the most basic identifying information from
3    mandatory reports shall be used, and information
4    identifying a patient, employee, or licensed professional
5    shall not be released. None of the information the
6    Department discloses to the public under this Act may be
7    used to establish a standard of care in a private civil
8    action.
9    (d) Quarterly reports shall be submitted, in a format set
10forth in rules adopted by the Department, to the Department by
11April 30, July 31, October 31, and January 31 each year for the
12previous quarter. Data in quarterly reports must cover a period
13ending not earlier than one month prior to submission of the
14report. Annual reports shall be submitted by December 31 in a
15format set forth in rules adopted by the Department to the
16Department. All reports shall be made available to the public
17on-site and through the Department.
18    (e) If the hospital is a division or subsidiary of another
19entity that owns or operates other hospitals or related
20organizations, the annual public disclosure report shall be for
21the specific division or subsidiary and not for the other
23    (f) The Department shall disclose information under this
24Section in accordance with provisions for inspection and
25copying of public records required by the Freedom of
26Information Act provided that such information satisfies the



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1provisions of subsection (c) of this Section.
2    (g) Notwithstanding any other provision of law, under no
3circumstances shall the Department disclose information
4obtained from a hospital that is confidential under Part 21 of
5Article VIII of the Code of Civil Procedure.
6    (h) No hospital report or Department disclosure may contain
7information identifying a patient, employee, or licensed
9(Source: P.A. 98-463, eff. 8-16-13; 99-326, eff. 8-10-15.)
10    Section 99. Effective date. This Act takes effect upon
11becoming law.