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Public Act 102-0256


Public Act 0256 102ND GENERAL ASSEMBLY



Public Act 102-0256
HB0068 EnrolledLRB102 03824 CPF 13838 b

    AN ACT concerning regulation.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Hospital Report Card Act is amended by
changing Section 25 as follows:
    (210 ILCS 86/25)
    Sec. 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) 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
            (A) Surgical procedure outcome measures.
            (B) Surgical procedure infection control process
            (C) Outcome or process measures related to
        ventilator-associated pneumonia.
            (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
        (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
        (6) Each instance of maternal mortality within the
    reporting period, including the racial and ethnic
    information of those mothers.
        (7) The number of female patients who have died within
    the reporting period.
        (8) The number of female patients admitted to the
    hospital with a diagnosis of COVID-19 and at least one
    known underlying condition identified by the United States
    Centers for Disease Control and Prevention as a condition
    that increases the risk of mortality from COVID-19 who
    subsequently died at the hospital within the reporting
    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
    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 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
        (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
        (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 Department.
    (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
    (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 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.)

Effective Date: 1/1/2022