Public Act 095-0282
 		





HB0192 Enrolled
LRB095 03991 DRJ 24024 b






    AN ACT concerning health.

 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:

 
    Section 5. The Mental Health and Developmental 
Disabilities Administrative Act is amended  by adding Section 
10.5 as follows:
 
    (20 ILCS 1705/10.5  new)
    Sec. 10.5. Prevention and control of Multidrug-Resistant 
Organisms. The Department, in consultation with the Department 
of Public Health, shall adopt rules that may require one or 
more of the facilities described in Section 4 of this Act to 
implement comprehensive interventions to prevent and control 
multidrug-resistant organisms (MDROs), including 
methicillin-resistant Staphylococcus aureus (MRSA), 
vancomycin-resistant enterococci (VRE), and certain 
gram-negative bacilli (GNB), pursuant to updated prevention 
and control interventions recommended by the U.S. Centers for 
Disease Control and Prevention.  The Department shall also 
require facilities to submit reports to the Department that 
contain substantially the same information contained in the 
related infection reports required to be submitted by hospitals 
to the Department of Public Health under Section 25 of the 
Hospital Report Card Act. The Department shall provide that 
information to the Department of Public Health upon the 
Department of Public Health's request.
 
    Section 10. The Department of Public Health Powers and 
Duties Law of the
Civil Administrative Code of Illinois is 
amended  by adding Section 2310-312 as follows:
 
    (20 ILCS 2310/2310-312  new)
    Sec. 2310-312. Multidrug-Resistant Organisms. The 
Department shall perform the following functions in relation to 
the prevention and control of Multidrug-Resistant Organisms 
(MDROs), including methicillin-resistant Staphylococcus aureus 
(MRSA), vancomycin-resistant (VRE) and certain gram-negative 
bacilli (GNB), as these terms are referenced by the United 
States Centers for Disease Control and Prevention:
        (1) Except with regard to hospitals, for which  
    administrative rules  shall be adopted in accordance with 
    Section 6.23 of the Hospital Licensing Act and Section 7 of 
    the University of Illinois Hospital Act, the Department 
    shall adopt administrative rules for health care 
    facilities subject to licensure, certification, 
    registration, or other regulation by the Department that 
    may require one or more types of those facilities to (i) 
    perform an annual infection control risk assessment, (ii) 
    develop  infection control policies for MDROs that are based 
    on this assessment and incorporate, as appropriate, 
    updated recommendations of the U.S. Centers for Disease 
    Control and Prevention for the prevention and control of 
    MDROs, and (iii) enforce hand hygiene requirements.
        (2) The Department shall:
            (A) publicize guidelines for reducing the 
        incidence of MDROs to health care providers, health 
        care facilities, public health departments, prisons, 
        jails, and the general public; and
            (B) provide periodic reports and updates to public 
        officials, health professionals, and the general 
        public statewide regarding new developments or 
        procedures concerning prevention and management of 
        infections due to MDROs.
        (3) The Department shall publish a yearly report 
    regarding MRSA and Clostridium difficile infections based 
    on the Hospital Discharge Dataset. The Department is 
    authorized to require hospitals, based on guidelines 
    developed by the National Center for Health Statistics, 
    after October 1, 2007, to submit data to the Department 
    that is coded as "present on admission" and "occurred 
    during the stay".
        (4) Reporting to the Department under the Hospital 
    Report Card Act shall include organisms, including but not 
    limited to MRSA, that are responsible for central venous 
    catheter-associated bloodstream infections and 
    ventilator-associated pneumonia in designated hospital 
    units.
        (5) The Department shall implement surveillance for 
    designated cases of community associated MRSA infections 
    for a period of at least 3 years, beginning on or before 
    January 1, 2008.
 
    Section 15. The University of Illinois Hospital Act is 
amended  by adding Section 7 as follows:
 
    (110 ILCS 330/7  new)
    Sec. 7. Prevention and control for Multidrug-Resistant 
Organisms. The University of Illinois Hospital shall develop  
and implement comprehensive interventions to prevent and 
control multidrug-resistant organisms (MDROs), including 
methicillin-resistant Staphylococcus aureus (MRSA), 
vancomycin-resistant enterococci (VRE), and certain 
gram-negative bacilli (GNB), that take into consideration 
guidelines of the U.S. Centers for Disease Control and 
Prevention for the management of MDROs in healthcare settings.  
The Department of Public Health shall adopt administrative 
rules that require the University of Illinois Hospital to 
perform an annual facility-wide infection control risk 
assessment and enforce hand hygiene and contact precaution 
requirements.
 
    Section 20. The Hospital Licensing Act is amended  by adding 
Section 6.23 as follows:
 
    (210 ILCS 85/6.23  new)
    Sec. 6.23. Prevention and control of Multidrug-Resistant 
Organisms. Each hospital shall develop  and implement 
comprehensive interventions to prevent and control 
multidrug-resistant organisms (MDROs), including 
methicillin-resistant Staphylococcus aureus (MRSA), 
vancomycin-resistant enterococci (VRE), and certain 
gram-negative bacilli (GNB), that take into consideration 
guidelines of the U.S. Centers for Disease Control and 
Prevention for the management of MDROs in healthcare settings.  
The Department shall adopt administrative rules that require 
hospitals to  perform an annual facility-wide infection control 
risk assessment and enforce hand hygiene and contact precaution 
requirements.
 
    Section 25. 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 
    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.

    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 shall include interpretive guidelines for 
infection-related indicators and, when available, shall 
include relevant benchmark information published by national 
organizations.

    (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 8 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. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)

 

    Section 99. Effective date. This Act takes effect upon 
becoming law.