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


Sen. Jacqueline Y. Collins

Filed: 5/15/2019





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2    AMENDMENT NO. ______. Amend House Bill 3 by replacing
3everything after the enacting clause with the following:
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:



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1            (A) Surgical procedure outcome measures.
2            (B) Surgical procedure infection control process
3        measures.
4            (C) Outcome or process measures related to
5        ventilator-associated pneumonia.
6            (D) Central vascular catheter-related bloodstream
7        infection rates in designated critical care units.
8        (3) Information required under paragraph (4) of
9    Section 2310-312 of the Department of Public Health Powers
10    and Duties Law of the Civil Administrative Code of
11    Illinois.
12        (4) Additional infection measures mandated by the
13    Centers for Medicare and Medicaid Services that are
14    reported by hospitals to the Centers for Disease Control
15    and Prevention's National Healthcare Safety Network
16    surveillance system, or its successor, and deemed relevant
17    to patient safety by the Department.
18        (5) Each instance of preterm birth and infant mortality
19    within the reporting period, including the racial and
20    ethnic information of the mothers of those infants.
21        (6) Each instance of maternal mortality within the
22    reporting period, including the racial and ethnic
23    information of those mothers.
24    The infection-related measures developed by the Department
25shall be based upon measures and methods developed by the
26Centers for Disease Control and Prevention, the Centers for



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1Medicare and Medicaid Services, the Agency for Healthcare
2Research and Quality, the Joint Commission on Accreditation of
3Healthcare Organizations, or the National Quality Forum. The
4Department may align the infection-related measures with the
5measures and methods developed by the Centers for Disease
6Control and Prevention, the Centers for Medicare and Medicaid
7Services, the Agency for Healthcare Research and Quality, the
8Joint Commission on Accreditation of Healthcare Organizations,
9and the National Quality Forum by adding reporting measures
10based on national health care strategies and measures deemed
11scientifically reliable and valid for public reporting. The
12Department shall receive approval from the State Board of
13Health to retire measures deemed no longer scientifically valid
14or valuable for informing quality improvement or infection
15prevention efforts. The Department shall notify the Chairs and
16Minority Spokespersons of the House Human Services Committee
17and the Senate Public Health Committee of its intent to have
18the State Board of Health take action to retire measures no
19later than 7 business days before the meeting of the State
20Board of Health.
21    The Department shall include interpretive guidelines for
22infection-related indicators and, when available, shall
23include relevant benchmark information published by national
25    The Department shall collect the information reported
26under paragraphs (5) and (6) and shall use it to illustrate the



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1disparity of those occurrences across different racial and
2ethnic groups.
3    (b) Individual hospitals shall prepare annual reports
4including vacancy and turnover rates for licensed nurses per
5clinical service area.
6    (c) None of the information the Department discloses to the
7public may be made available in any form or fashion unless the
8information has been reviewed, adjusted, and validated
9according to the following process:
10        (1) The Department shall organize an advisory
11    committee, including representatives from the Department,
12    public and private hospitals, direct care nursing staff,
13    physicians, academic researchers, consumers, health
14    insurance companies, organized labor, and organizations
15    representing hospitals and physicians. The advisory
16    committee must be meaningfully involved in the development
17    of all aspects of the Department's methodology for
18    collecting, analyzing, and disclosing the information
19    collected under this Act, including collection methods,
20    formatting, and methods and means for release and
21    dissemination.
22        (2) The entire methodology for collecting and
23    analyzing the data shall be disclosed to all relevant
24    organizations and to all hospitals that are the subject of
25    any information to be made available to the public before
26    any public disclosure of such information.



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



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1        (9) Effective safeguards to protect against the
2    dissemination of inconsistent, incomplete, invalid,
3    inaccurate, or subjective hospital data shall be developed
4    and implemented.
5        (10) The quality and accuracy of hospital information
6    reported under this Act and its data collection, analysis,
7    and dissemination methodologies shall be evaluated
8    regularly.
9        (11) Only the most basic identifying information from
10    mandatory reports shall be used, and information
11    identifying a patient, employee, or licensed professional
12    shall not be released. None of the information the
13    Department discloses to the public under this Act may be
14    used to establish a standard of care in a private civil
15    action.
16    (d) Quarterly reports shall be submitted, in a format set
17forth in rules adopted by the Department, to the Department by
18April 30, July 31, October 31, and January 31 each year for the
19previous quarter. Data in quarterly reports must cover a period
20ending not earlier than one month prior to submission of the
21report. Annual reports shall be submitted by December 31 in a
22format set forth in rules adopted by the Department to the
23Department. All reports shall be made available to the public
24on-site and through the Department.
25    (e) If the hospital is a division or subsidiary of another
26entity that owns or operates other hospitals or related



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1organizations, the annual public disclosure report shall be for
2the specific division or subsidiary and not for the other
4    (f) The Department shall disclose information under this
5Section in accordance with provisions for inspection and
6copying of public records required by the Freedom of
7Information Act provided that such information satisfies the
8provisions of subsection (c) of this Section.
9    (g) Notwithstanding any other provision of law, under no
10circumstances shall the Department disclose information
11obtained from a hospital that is confidential under Part 21 of
12Article VIII of the Code of Civil Procedure.
13    (h) No hospital report or Department disclosure may contain
14information identifying a patient, employee, or licensed
16(Source: P.A. 98-463, eff. 8-16-13; 99-326, eff. 8-10-15.)
17    Section 99. Effective date. This Act takes effect upon
18becoming law.".