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
care provider.

    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
appropriately trained.
    (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
    service area.
         (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
    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
    (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
licensed professional.

    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
    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
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
this Act.

    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.

Effective Date: 1/1/2004