093_SB0059enr
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1 AN ACT concerning hospitals.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Hospital Report Card Act.
6 Section 5. Findings. The General Assembly finds that
7 Illinois consumers have a right to access information about
8 the quality of health care provided in Illinois hospitals in
9 order to make better decisions about their choice of health
10 care provider.
11 Section 10. Definitions. For the purpose of this Act:
12 "Average daily census" means the average number of
13 inpatients receiving service on any given 24-hour period
14 beginning at midnight in each clinical service area of the
15 hospital.
16 "Clinical service area" means a grouping of clinical
17 services by a generic class of various types or levels of
18 support functions, equipment, care, or treatment provided to
19 inpatients. Hospitals may have, but are not required to have,
20 the following categories of service: behavioral health,
21 critical care, maternal-child care, medical-surgical,
22 pediatrics, perioperative services, and telemetry.
23 "Department" means the Department of Public Health.
24 "Direct-care nurse" and "direct-care nursing staff"
25 includes any registered nurse, licensed practical nurse, or
26 assistive nursing personnel with direct responsibility to
27 oversee or carry out medical regimens or nursing care for one
28 or more patient.
29 "Hospital" means a health care facility licensed under
30 the Hospital Licensing Act.
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1 "Nursing care" means care that falls within the scope of
2 practice set forth in the Nursing and Advanced Practice
3 Nursing Act or is otherwise encompassed within recognized
4 professional standards of nursing practice, including
5 assessment, nursing diagnosis, planning, intervention,
6 evaluation, and patient advocacy.
7 "Retaliate" means to discipline, discharge, suspend,
8 demote, harass, deny employment or promotion, lay off, or
9 take any other adverse action against direct-care nursing
10 staff as a result of that nursing staff taking any action
11 described in this Act.
12 "Skill mix" means the differences in licensing,
13 specialty, and experiences among direct-care nurses.
14 "Staffing levels" means the numerical nurse to patient
15 ratio by licensed nurse classification within a nursing
16 department or unit.
17 "Unit" means a functional division or area of a hospital
18 in which nursing care is provided.
19 Section 15. Staffing levels.
20 (a) The number of registered professional nurses,
21 licensed practical nurses, and other nursing personnel
22 assigned to each patient care unit shall be consistent with
23 the types of nursing care needed by the patients and the
24 capabilities of the staff. Patients on each unit shall be
25 evaluated near the end of each change of shift by criteria
26 developed by the nursing service. There shall be staffing
27 schedules reflecting actual nursing personnel required for
28 the hospital and for each patient unit. Staffing patterns
29 shall reflect consideration of nursing goals, standards of
30 nursing practice, and the needs of the patients.
31 (b) Current nursing staff schedules shall be available
32 upon request at each patient care unit. Each schedule shall
33 list the daily assigned nursing personnel and average daily
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1 census for the unit. The actual nurse staffing assignment
2 roster for each patient care unit shall be available upon
3 request at the patient care unit for the effective date of
4 that roster. Upon the roster's expiration, the hospital shall
5 retain the roster for 5 years from the date of its
6 expiration.
7 (c) All records required under this Section, including
8 anticipated staffing schedules and the methods to determine
9 and adjust staffing levels shall be made available to the
10 public upon request.
11 (d) All records required under this Section shall be
12 maintained by the facility for no less than 5 years.
13 Section 20. Orientation and training.
14 (a) All health care facilities shall have established an
15 orientation process that provides initial job training and
16 information and assesses the direct care nursing staff's
17 ability to fulfill specified responsibilities.
18 (b) Personnel not competent for a given unit shall not
19 be assigned to work there without direct supervision until
20 appropriately trained.
21 (c) Staff training information will be available upon
22 request, without any information identifying a patient,
23 employee, or licensed professional at the hospital.
24 Section 25. Hospital reports.
25 (a) Individual hospitals shall prepare a quarterly
26 report including all of the following:
27 (1) Nursing hours per patient day, average daily
28 census, and average daily hours worked for each clinical
29 service area.
30 (2) Nosocomial infection rates for the facility for
31 the specific clinical procedures determined by the
32 Department by rule under the following categories:
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1 (A) Class I surgical site infection.
2 (B) Ventilator-associated pneumonia.
3 (C) Central line-related bloodstream
4 infections.
5 The Department shall only disclose Illinois hospital
6 infection rate data according to the current benchmarks of
7 the Centers for Disease Control's National Nosocomial
8 Infection Surveillance Program.
9 (b) Individual hospitals shall prepare annual reports
10 including vacancy and turnover rates for licensed nurses per
11 clinical service area.
12 (c) None of the information the Department discloses to
13 the public may be made available in any form or fashion
14 unless the information has been reviewed, adjusted, and
15 validated according to the following process:
16 (1) The Department shall organize an advisory
17 committee, including representatives from the Department,
18 public and private hospitals, direct care nursing staff,
19 physicians, academic researchers, consumers, health
20 insurance companies, organized labor, and organizations
21 representing hospitals and physicians. The advisory
22 committee must be meaningfully involved in the
23 development of all aspects of the Department's
24 methodology for collecting, analyzing, and disclosing the
25 information collected under this Act, including
26 collection methods, formatting, and methods and means for
27 release and dissemination.
28 (2) The entire methodology for collecting and
29 analyzing the data shall be disclosed to all relevant
30 organizations and to all hospitals that are the subject
31 of any information to be made available to the public
32 before any public disclosure of such information.
33 (3) Data collection and analytical methodologies
34 shall be used that meet accepted standards of validity
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1 and reliability before any information is made available
2 to the public.
3 (4) The limitations of the data sources and
4 analytic methodologies used to develop comparative
5 hospital information shall be clearly identified and
6 acknowledged, including but not limited to the
7 appropriate and inappropriate uses of the data.
8 (5) To the greatest extent possible, comparative
9 hospital information initiatives shall use standard-based
10 norms derived from widely accepted provider-developed
11 practice guidelines.
12 (6) Comparative hospital information and other
13 information that the Department has compiled regarding
14 hospitals shall be shared with the hospitals under review
15 prior to public dissemination of such information and
16 these hospitals have 30 days to make corrections and to
17 add helpful explanatory comments about the information
18 before the publication.
19 (7) Comparisons among hospitals shall adjust for
20 patient case mix and other relevant risk factors and
21 control for provider peer groups, when appropriate.
22 (8) Effective safeguards to protect against the
23 unauthorized use or disclosure of hospital information
24 shall be developed and implemented.
25 (9) Effective safeguards to protect against the
26 dissemination of inconsistent, incomplete, invalid,
27 inaccurate, or subjective hospital data shall be
28 developed and implemented.
29 (10) The quality and accuracy of hospital
30 information reported under this Act and its data
31 collection, analysis, and dissemination methodologies
32 shall be evaluated regularly.
33 (11) Only the most basic identifying information
34 from mandatory reports shall be used, and information
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1 identifying a patient, employee, or licensed professional
2 shall not be released. None of the information the
3 Department discloses to the public under this Act may be
4 used to establish a standard of care in a private civil
5 action.
6 (d) Quarterly reports shall be submitted, in a format
7 set forth in rules adopted by the Department, to the
8 Department by April 30, July 31, October 31, and January 31
9 each year for the previous quarter. Data in quarterly reports
10 must cover a period ending not earlier than one month prior
11 to submission of the report. Annual reports shall be
12 submitted by December 31 in a format set forth in rules
13 adopted by the Department to the Department. All reports
14 shall be made available to the public on-site and through the
15 Department.
16 (e) If the hospital is a division or subsidiary of
17 another entity that owns or operates other hospitals or
18 related organizations, the annual public disclosure report
19 shall be for the specific division or subsidiary and not for
20 the other entity.
21 (f) The Department shall disclose information under this
22 Section in accordance with provisions for inspection and
23 copying of public records required by the Freedom of
24 Information Act provided that such information satisfies the
25 provisions of subsection (c) of this Section.
26 (g) Notwithstanding any other provision of law, under no
27 circumstances shall the Department disclose information
28 obtained from a hospital that is confidential under Part 21
29 of Article 8 of the Code of Civil Procedure.
30 (h) No hospital report or Department disclosure may
31 contain information identifying a patient, employee, or
32 licensed professional.
33 Section 30. Department reports. The Department of Public
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1 Health shall annually submit to the General Assembly a report
2 summarizing the quarterly reports by health service area and
3 shall publish that report on its website. The Department of
4 Public Health may issue quarterly informational bulletins at
5 its discretion, summarizing all or part of the information
6 submitted in these quarterly reports. The Department shall
7 also publish risk-adjusted mortality rates for each hospital
8 based upon information hospitals have already submitted to
9 the Department pursuant to their obligations to report health
10 care information under other public health reporting laws and
11 regulations outside of this Act. The published mortality
12 rates must comply with the hospital data publication process
13 contained in subsection (c) of Section 25 of this Act.
14 Section 35. Whistleblower protections.
15 (a) A hospital covered by this Act shall not penalize,
16 discriminate, or retaliate in any manner against an employee
17 with respect to compensation or the terms, conditions, or
18 privileges of employment who in good faith, individually or
19 in conjunction with another person or persons, does any of
20 the following or intimidate, threaten, or punish an employee
21 to prevent him or her from doing any of the following:
22 (1) Discloses to the nursing staff supervisor or
23 manager, a private accreditation organization, the
24 nurse's collective bargaining agent, or a regulatory
25 agency any activity, policy, or practice of a hospital
26 that violates this Act or any other law or rule or that
27 the employee reasonably believes poses a risk to the
28 health, safety, or welfare of a patient or the public.
29 (2) Initiates, cooperates, or otherwise
30 participates in an investigation or proceeding brought by
31 a regulatory agency or private accreditation body
32 concerning matters covered by this Act or any other law
33 or rule or that the employee reasonably believes poses a
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1 risk to the health, safety, or welfare of a patient or
2 the public.
3 (3) Objects to or refuses to participate in any
4 activity, policy, or practice of a hospital that violates
5 this Act or any law or rule of the Department or that a
6 reasonable person would believe poses a risk to the
7 health, safety, or welfare of a patient or the public.
8 (4) Participates in a committee or peer review
9 process or files a report or complaint that discusses
10 allegation of unsafe, dangerous, or potentially dangerous
11 care within the hospital.
12 (b) For the purposes of this Section, an employee is
13 presumed to act in good faith if the employee reasonably
14 believes that (i) the information reported or disclosed is
15 true and (ii) a violation has occurred or may occur. An
16 employee is not acting in good faith under this Section if
17 the employee's report or action was based on information that
18 the employee should reasonably know is false or misleading.
19 The protection of this Section shall also not apply to an
20 employee unless the employee gives written notice to a
21 hospital manager of the activity, policy, practice, or
22 violation that the employee believes poses a risk to the
23 health of a patient or the public and provides the manager a
24 reasonable opportunity to correct the problem. The manager
25 shall respond in writing to the employee within 7 days
26 acknowledging that the notice was received and provide
27 written notice of any action taken within a reasonable time
28 of receiving the employee's notice. This notice requirement
29 shall not apply if the employee is reasonably certain that
30 the activity, policy, practice, or violation: (i) is known by
31 one or more hospital managers who have had an opportunity to
32 correct the problem and have not done so; (ii) involves the
33 commission of a crime; or (iii) places patient health or
34 safety in severe and immediate danger. The notice requirement
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1 shall not apply if the employee is participating in a survey,
2 investigation, or other activity of a regulatory agency, law
3 enforcement agency, or private accreditation body that was
4 not initiated by the employee. Nothing in this Section
5 prohibits a hospital from training, educating, correcting, or
6 otherwise taking action to improve the performance of
7 employees who report that they are unable or unwilling to
8 perform an assigned task.
9 Section 40. Private right of action. Any health care
10 facility that violates the provisions of Section 35 may be
11 held liable to the employee affected in an action brought in
12 a court of competent jurisdiction for such legal or equitable
13 relief as may be appropriate to effectuate the purposes of
14 this Act.
15 Section 45. Regulatory oversight. The Department shall
16 be responsible for ensuring compliance with this Act as a
17 condition of licensure under the Hospital Licensing Act and
18 shall enforce such compliance according to the provisions of
19 the Hospital Licensing Act.
20 Section 90. The Hospital Licensing Act is amended by
21 changing Section 7 as follows:
22 (210 ILCS 85/7) (from Ch. 111 1/2, par. 148)
23 Sec. 7. (a) The Director after notice and opportunity for
24 hearing to the applicant or licensee may deny, suspend, or
25 revoke a permit to establish a hospital or deny, suspend, or
26 revoke a license to open, conduct, operate, and maintain a
27 hospital in any case in which he finds that there has been a
28 substantial failure to comply with the provisions of this Act
29 or the Hospital Report Card Act or the standards, rules, and
30 regulations established by virtue of either of those Acts
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1 thereof.
2 (b) Such notice shall be effected by registered mail or
3 by personal service setting forth the particular reasons for
4 the proposed action and fixing a date, not less than 15 days
5 from the date of such mailing or service, at which time the
6 applicant or licensee shall be given an opportunity for a
7 hearing. Such hearing shall be conducted by the Director or
8 by an employee of the Department designated in writing by the
9 Director as Hearing Officer to conduct the hearing. On the
10 basis of any such hearing, or upon default of the applicant
11 or licensee, the Director shall make a determination
12 specifying his findings and conclusions. In case of a denial
13 to an applicant of a permit to establish a hospital, such
14 determination shall specify the subsection of Section 6 under
15 which the permit was denied and shall contain findings of
16 fact forming the basis of such denial. A copy of such
17 determination shall be sent by registered mail or served
18 personally upon the applicant or licensee. The decision
19 denying, suspending, or revoking a permit or a license shall
20 become final 35 days after it is so mailed or served, unless
21 the applicant or licensee, within such 35 day period,
22 petitions for review pursuant to Section 13.
23 (c) The procedure governing hearings authorized by this
24 Section shall be in accordance with rules promulgated by the
25 Department and approved by the Hospital Licensing Board. A
26 full and complete record shall be kept of all proceedings,
27 including the notice of hearing, complaint, and all other
28 documents in the nature of pleadings, written motions filed
29 in the proceedings, and the report and orders of the Director
30 and Hearing Officer. All testimony shall be reported but need
31 not be transcribed unless the decision is appealed pursuant
32 to Section 13. A copy or copies of the transcript may be
33 obtained by any interested party on payment of the cost of
34 preparing such copy or copies.
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1 (d) The Director or Hearing Officer shall upon his own
2 motion, or on the written request of any party to the
3 proceeding, issue subpoenas requiring the attendance and the
4 giving of testimony by witnesses, and subpoenas duces tecum
5 requiring the production of books, papers, records, or
6 memoranda. All subpoenas and subpoenas duces tecum issued
7 under the terms of this Act may be served by any person of
8 full age. The fees of witnesses for attendance and travel
9 shall be the same as the fees of witnesses before the Circuit
10 Court of this State, such fees to be paid when the witness is
11 excused from further attendance. When the witness is
12 subpoenaed at the instance of the Director, or Hearing
13 Officer, such fees shall be paid in the same manner as other
14 expenses of the Department, and when the witness is
15 subpoenaed at the instance of any other party to any such
16 proceeding the Department may require that the cost of
17 service of the subpoena or subpoena duces tecum and the fee
18 of the witness be borne by the party at whose instance the
19 witness is summoned. In such case, the Department in its
20 discretion, may require a deposit to cover the cost of such
21 service and witness fees. A subpoena or subpoena duces tecum
22 issued as aforesaid shall be served in the same manner as a
23 subpoena issued out of a court.
24 (e) Any Circuit Court of this State upon the application
25 of the Director, or upon the application of any other party
26 to the proceeding, may, in its discretion, compel the
27 attendance of witnesses, the production of books, papers,
28 records, or memoranda and the giving of testimony before the
29 Director or Hearing Officer conducting an investigation or
30 holding a hearing authorized by this Act, by an attachment
31 for contempt, or otherwise, in the same manner as production
32 of evidence may be compelled before the court.
33 (f) The Director or Hearing Officer, or any party in an
34 investigation or hearing before the Department, may cause the
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1 depositions of witnesses within the State to be taken in the
2 manner prescribed by law for like depositions in civil
3 actions in courts of this State, and to that end compel the
4 attendance of witnesses and the production of books, papers,
5 records, or memoranda.
6 (Source: Laws 1967, p. 3969.)
7 Section 99. Effective date. This Act takes effect on
8 January 1, 2004.