(210 ILCS 86/25)
(a) Individual hospitals shall prepare a quarterly report including all of
(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
(C) Outcome or process measures related to
(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.
(4) Additional infection measures mandated by the
Centers for Medicare and Medicaid Services that are reported by hospitals to the Centers for Disease Control and Prevention's National Healthcare Safety Network surveillance system, or its successor, and deemed relevant to patient safety by the Department.
(5) Each instance of preterm birth and infant
mortality within the reporting period, including the racial and ethnic information of the mothers of those infants.
(6) Each instance of maternal mortality within the
reporting period, including the racial and ethnic information of those mothers.
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 may align the infection-related measures with the 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, and the National Quality Forum by adding reporting measures based on national health care strategies and measures deemed scientifically reliable and valid for public reporting. The Department shall receive approval from the State Board of Health to retire measures deemed no longer scientifically valid or valuable for informing quality improvement or infection prevention efforts. The Department shall notify the Chairs and Minority Spokespersons of the House Human Services Committee and the Senate Public Health Committee of its intent to have the State Board of Health take action to retire measures no later than 7 business days before the meeting of the State Board of Health.
The Department shall include interpretive guidelines for infection-related indicators and, when available, shall include relevant benchmark information published by national organizations.
The Department shall collect the information reported under paragraphs (5) and (6) and shall use it to illustrate the disparity of those occurrences across different racial and ethnic groups.
(b) Individual hospitals shall prepare annual reports including vacancy and
for licensed nurses per clinical service area.
(c) None of the information the Department discloses to the public may be
in any form or fashion unless the information has been reviewed, adjusted, and
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
Department, to the Department by April 30, July 31, October 31, and January 31
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
31 in a format set forth in rules adopted by the Department to the Department.
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
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
Department disclose information obtained from a hospital that is confidential
under Part 21
of Article VIII 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. 101-446, eff. 8-23-19.)
(210 ILCS 86/35)
(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,
privileges of employment who in good faith, individually or in conjunction with
person or persons, does any of the following or intimidate, threaten, or
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 the public.
(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
(ii) a violation has occurred or may occur. An employee is not acting in good
under this Section if the employee's report or action was based on information
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
to a hospital manager of the activity, policy, practice, or violation that the
believes poses a risk to the health of a patient or the public and provides the
reasonable opportunity to correct the problem. The manager shall respond in
to the employee within 7 days acknowledging that the notice was received and
notice of any action taken within a reasonable time of receiving the employee's
This notice requirement shall not apply if the employee is reasonably certain
activity, policy, practice, or violation: (i) is known by one or more hospital
who have had an opportunity to correct the problem and have not done so; (ii)
the commission of a crime; or (iii) places patient health or safety in severe
immediate danger. The notice requirement shall not apply if the employee is
participating in a survey, investigation, or other activity of a regulatory
enforcement agency, or private accreditation body that was not initiated by the
employee. Nothing in this Section prohibits a hospital from training,
correcting, or otherwise taking action to improve the performance of employees
report that they are unable or unwilling to perform an assigned task.
(Source: P.A. 93-563, eff. 1-1-04.)