(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 categories:

(A) Surgical procedure outcome measures.

(B) Surgical procedure infection control process measures.

(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 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.

(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 period.

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 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 action.

(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 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 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; 102-256, eff. 1-1-22.)