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| Public Act 102-0256 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Hospital Report Card Act is amended by | ||||
changing Section 25 as follows:
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(210 ILCS 86/25)
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Sec. 25. Hospital reports.
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(a) Individual hospitals shall prepare a quarterly report | ||||
including all of
the
following:
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(1) Nursing hours per patient day, average daily | ||||
census, and average daily
hours worked
for each clinical | ||||
service area.
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(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:
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(A) Surgical procedure outcome measures. | ||||
(B) Surgical procedure infection control process | ||||
measures.
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(C)
Outcome or process measures related to | ||||
ventilator-associated pneumonia.
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(D) Central vascular catheter-related bloodstream | ||||
infection rates in designated critical care units.
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(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.
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(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.
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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.
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(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
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according to the following process:
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(1) The Department shall organize an advisory | ||
committee, including
representatives
from the Department, | ||
public and private hospitals, direct care nursing staff,
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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
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dissemination.
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(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.
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(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.
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(4) The limitations of the data sources and analytic | ||
methodologies used to
develop
comparative hospital | ||
information shall be clearly identified and acknowledged,
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including but not
limited to the appropriate and | ||
inappropriate uses of the data.
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(5) To the greatest extent possible, comparative | ||
hospital information
initiatives shall
use standard-based | ||
norms derived from widely accepted provider-developed
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practice
guidelines.
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(6) Comparative hospital information and other | ||
information that the
Department
has
compiled regarding | ||
hospitals shall be shared with the hospitals under review
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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.
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(7) Comparisons among hospitals shall adjust for | ||
patient case mix and
other
relevant
risk factors and | ||
control for provider peer groups, when appropriate.
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(8) Effective safeguards to protect against the | ||
unauthorized use or
disclosure
of
hospital information | ||
shall be developed and implemented.
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(9) Effective safeguards to protect against the | ||
dissemination of
inconsistent,
incomplete, invalid, | ||
inaccurate, or subjective hospital data shall be developed
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and
implemented.
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(10) The quality and accuracy of hospital information | ||
reported under this
Act
and its
data collection, analysis, | ||
and dissemination methodologies shall be evaluated
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regularly.
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(11) Only the most basic identifying information from | ||
mandatory reports
shall be
used, and
information | ||
identifying a patient, employee, or licensed professional
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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.
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(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
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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.
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(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.
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(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
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Information Act provided that such information satisfies the | ||
provisions of
subsection (c) of this Section.
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(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.
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(h) No hospital report or Department disclosure may | ||
contain information
identifying a patient, employee, or | ||
licensed professional.
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(Source: P.A. 101-446, eff. 8-23-19.)
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