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1 | AN ACT concerning health.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Mental Health and Developmental | ||||||
5 | Disabilities Administrative Act is amended by adding Section | ||||||
6 | 10.5 as follows: | ||||||
7 | (20 ILCS 1705/10.5 new) | ||||||
8 | Sec. 10.5. Prevention and control of Multidrug-Resistant | ||||||
9 | Organisms. The Department, in consultation with the Department | ||||||
10 | of Public Health, shall adopt rules that may require one or | ||||||
11 | more of the facilities described in Section 4 of this Act to | ||||||
12 | implement comprehensive interventions to prevent and control | ||||||
13 | multidrug-resistant organisms (MDROs), including | ||||||
14 | methicillin-resistant Staphylococcus aureus (MRSA), | ||||||
15 | vancomycin-resistant enterococci (VRE), and certain | ||||||
16 | gram-negative bacilli (GNB), pursuant to updated prevention | ||||||
17 | and control interventions recommended by the U.S. Centers for | ||||||
18 | Disease Control and Prevention. The Department shall also | ||||||
19 | require facilities to submit reports to the Department that | ||||||
20 | contain substantially the same information contained in the | ||||||
21 | related infection reports required to be submitted by hospitals | ||||||
22 | to the Department of Public Health under Section 25 of the | ||||||
23 | Hospital Report Card Act. The Department shall provide that |
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1 | information to the Department of Public Health upon the | ||||||
2 | Department of Public Health's request. | ||||||
3 | Section 10. The Department of Public Health Powers and | ||||||
4 | Duties Law of the
Civil Administrative Code of Illinois is | ||||||
5 | amended by adding Section 2310-312 as follows: | ||||||
6 | (20 ILCS 2310/2310-312 new) | ||||||
7 | Sec. 2310-312. Multidrug-Resistant Organisms. The | ||||||
8 | Department shall perform the following functions in relation to | ||||||
9 | the prevention and control of Multidrug-Resistant Organisms | ||||||
10 | (MDROs), including methicillin-resistant Staphylococcus aureus | ||||||
11 | (MRSA), vancomycin-resistant (VRE) and certain gram-negative | ||||||
12 | bacilli (GNB), as these terms are referenced by the United | ||||||
13 | States Centers for Disease Control and Prevention: | ||||||
14 | (1) Except with regard to hospitals, for which | ||||||
15 | administrative rules shall be adopted in accordance with | ||||||
16 | Section 6.23 of the Hospital Licensing Act and Section 7 of | ||||||
17 | the University of Illinois Hospital Act, the Department | ||||||
18 | shall adopt administrative rules for health care | ||||||
19 | facilities subject to licensure, certification, | ||||||
20 | registration, or other regulation by the Department that | ||||||
21 | may require one or more types of those facilities to (i) | ||||||
22 | perform an annual infection control risk assessment, (ii) | ||||||
23 | develop infection control policies for MDROs that are based | ||||||
24 | on this assessment and incorporate, as appropriate, |
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1 | updated recommendations of the U.S. Centers for Disease | ||||||
2 | Control and Prevention for the prevention and control of | ||||||
3 | MDROs, and (iii) enforce hand hygiene requirements. | ||||||
4 | (2) The Department shall: | ||||||
5 | (A) publicize guidelines for reducing the | ||||||
6 | incidence of MDROs to health care providers, health | ||||||
7 | care facilities, public health departments, prisons, | ||||||
8 | jails, and the general public; and | ||||||
9 | (B) provide periodic reports and updates to public | ||||||
10 | officials, health professionals, and the general | ||||||
11 | public statewide regarding new developments or | ||||||
12 | procedures concerning prevention and management of | ||||||
13 | infections due to MDROs. | ||||||
14 | (3) The Department shall publish a yearly report | ||||||
15 | regarding MRSA and Clostridium difficile infections based | ||||||
16 | on the Hospital Discharge Dataset. The Department is | ||||||
17 | authorized to require hospitals, based on guidelines | ||||||
18 | developed by the National Center for Health Statistics, | ||||||
19 | after October 1, 2007, to submit data to the Department | ||||||
20 | that is coded as "present on admission" and "occurred | ||||||
21 | during the stay". | ||||||
22 | (4) Reporting to the Department under the Hospital | ||||||
23 | Report Card Act shall include organisms, including but not | ||||||
24 | limited to MRSA, that are responsible for central venous | ||||||
25 | catheter-associated bloodstream infections and | ||||||
26 | ventilator-associated pneumonia in designated hospital |
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1 | units. | ||||||
2 | (5) The Department shall implement surveillance for | ||||||
3 | designated cases of community associated MRSA infections | ||||||
4 | for a period of at least 3 years, beginning on or before | ||||||
5 | January 1, 2008. | ||||||
6 | Section 15. The University of Illinois Hospital Act is | ||||||
7 | amended by adding Section 7 as follows: | ||||||
8 | (110 ILCS 330/7 new) | ||||||
9 | Sec. 7. Prevention and control for Multidrug-Resistant | ||||||
10 | Organisms. The University of Illinois Hospital shall develop | ||||||
11 | and implement comprehensive interventions to prevent and | ||||||
12 | control multidrug-resistant organisms (MDROs), including | ||||||
13 | methicillin-resistant Staphylococcus aureus (MRSA), | ||||||
14 | vancomycin-resistant enterococci (VRE), and certain | ||||||
15 | gram-negative bacilli (GNB), that take into consideration | ||||||
16 | guidelines of the U.S. Centers for Disease Control and | ||||||
17 | Prevention for the management of MDROs in healthcare settings. | ||||||
18 | The Department of Public Health shall adopt administrative | ||||||
19 | rules that require the University of Illinois Hospital to | ||||||
20 | perform an annual facility-wide infection control risk | ||||||
21 | assessment and enforce hand hygiene and contact precaution | ||||||
22 | requirements. | ||||||
23 | Section 20. The Hospital Licensing Act is amended by adding |
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1 | Section 6.23 as follows: | ||||||
2 | (210 ILCS 85/6.23 new) | ||||||
3 | Sec. 6.23. Prevention and control of Multidrug-Resistant | ||||||
4 | Organisms. Each hospital shall develop and implement | ||||||
5 | comprehensive interventions to prevent and control | ||||||
6 | multidrug-resistant organisms (MDROs), including | ||||||
7 | methicillin-resistant Staphylococcus aureus (MRSA), | ||||||
8 | vancomycin-resistant enterococci (VRE), and certain | ||||||
9 | gram-negative bacilli (GNB), that take into consideration | ||||||
10 | guidelines of the U.S. Centers for Disease Control and | ||||||
11 | Prevention for the management of MDROs in healthcare settings. | ||||||
12 | The Department shall adopt administrative rules that require | ||||||
13 | hospitals to perform an annual facility-wide infection control | ||||||
14 | risk assessment and enforce hand hygiene and contact precaution | ||||||
15 | requirements. | ||||||
16 | Section 25. The Hospital Report Card Act is amended by | ||||||
17 | changing Section 25 as follows:
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18 | (210 ILCS 86/25)
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19 | Sec. 25. Hospital reports.
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20 | (a) Individual hospitals shall prepare a quarterly report | ||||||
21 | including all of
the
following:
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22 | (1) Nursing hours per patient day, average daily | ||||||
23 | census, and average daily
hours worked
for each clinical |
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1 | service area.
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2 | (2) Infection-related measures for the facility for | ||||||
3 | the specific clinical
procedures
and devices determined by | ||||||
4 | the Department by rule under 2 or more of the following | ||||||
5 | categories:
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6 | (A) Surgical procedure outcome measures.
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7 | (B) Surgical procedure infection control process | ||||||
8 | measures.
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9 | (C)
Outcome or process measures related to | ||||||
10 | ventilator-associated pneumonia.
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11 | (D) Central vascular catheter-related bloodstream | ||||||
12 | infection rates in designated critical care units.
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13 | (3) Information required under paragraph (4) of | ||||||
14 | Section 2310-312 of the Department of Public Health Powers | ||||||
15 | and Duties Law of the
Civil Administrative Code of | ||||||
16 | Illinois.
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17 | The infection-related measures developed by the Department | ||||||
18 | shall be based upon measures and methods developed by the | ||||||
19 | Centers for Disease Control and Prevention, the Centers for | ||||||
20 | Medicare and Medicaid Services, the Agency for Healthcare | ||||||
21 | Research and Quality, the Joint Commission on Accreditation of | ||||||
22 | Healthcare Organizations, or the National Quality Forum. | ||||||
23 | The Department shall include interpretive guidelines for | ||||||
24 | infection-related indicators and, when available, shall | ||||||
25 | include relevant benchmark information published by national | ||||||
26 | organizations.
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1 | (b) Individual hospitals shall prepare annual reports | ||||||
2 | including vacancy and
turnover rates
for licensed nurses per | ||||||
3 | clinical service area.
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4 | (c) None of the information the Department discloses to the | ||||||
5 | public may be
made
available
in any form or fashion unless the | ||||||
6 | information has been reviewed, adjusted, and
validated
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7 | according to the following process:
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8 | (1) The Department shall organize an advisory | ||||||
9 | committee, including
representatives
from the Department, | ||||||
10 | public and private hospitals, direct care nursing staff,
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11 | physicians,
academic researchers, consumers, health | ||||||
12 | insurance companies, organized labor,
and
organizations | ||||||
13 | representing hospitals and physicians. The advisory | ||||||
14 | committee
must be
meaningfully involved in the development | ||||||
15 | of all aspects of the Department's
methodology
for | ||||||
16 | collecting, analyzing, and disclosing the information | ||||||
17 | collected under this
Act, including
collection methods, | ||||||
18 | formatting, and methods and means for release and
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19 | dissemination.
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20 | (2) The entire methodology for collecting and | ||||||
21 | analyzing the data shall be
disclosed
to all
relevant | ||||||
22 | organizations and to all hospitals that are the subject of | ||||||
23 | any
information to be made
available to the public before | ||||||
24 | any public disclosure of such information.
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25 | (3) Data collection and analytical methodologies shall | ||||||
26 | be used that meet
accepted
standards of validity and |
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1 | reliability before any information is made available
to the | ||||||
2 | public.
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3 | (4) The limitations of the data sources and analytic | ||||||
4 | methodologies used to
develop
comparative hospital | ||||||
5 | information shall be clearly identified and acknowledged,
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6 | including but not
limited to the appropriate and | ||||||
7 | inappropriate uses of the data.
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8 | (5) To the greatest extent possible, comparative | ||||||
9 | hospital information
initiatives shall
use standard-based | ||||||
10 | norms derived from widely accepted provider-developed
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11 | practice
guidelines.
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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
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15 | prior to
public
dissemination of such information and these | ||||||
16 | hospitals have 30 days to make
corrections and
to add | ||||||
17 | helpful explanatory comments about the information before | ||||||
18 | the
publication.
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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.
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22 | (8) Effective safeguards to protect against the | ||||||
23 | unauthorized use or
disclosure
of
hospital information | ||||||
24 | shall be developed and implemented.
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25 | (9) Effective safeguards to protect against the | ||||||
26 | dissemination of
inconsistent,
incomplete, invalid, |
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1 | inaccurate, or subjective hospital data shall be developed
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2 | and
implemented.
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3 | (10) The quality and accuracy of hospital information | ||||||
4 | reported under this
Act
and its
data collection, analysis, | ||||||
5 | and dissemination methodologies shall be evaluated
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6 | regularly.
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7 | (11) Only the most basic identifying information from | ||||||
8 | mandatory reports
shall be
used, and
information | ||||||
9 | identifying a patient, employee, or licensed professional
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10 | shall not be released.
None of the information the | ||||||
11 | Department discloses to the public under this Act
may be | ||||||
12 | used to
establish a standard of care in a private civil | ||||||
13 | action.
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14 | (d) Quarterly reports shall be submitted, in a format set | ||||||
15 | forth in rules
adopted
by the
Department, to the Department by | ||||||
16 | April 30, July 31, October 31, and January 31
each year
for the | ||||||
17 | previous quarter. Data in quarterly reports must cover a period | ||||||
18 | ending
not earlier than
one month prior to submission of the | ||||||
19 | report. Annual reports shall be submitted
by December
31 in a | ||||||
20 | format set forth in rules adopted by the Department to the | ||||||
21 | Department.
All reports
shall be made available to the public | ||||||
22 | on-site and through the Department.
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23 | (e) If the hospital is a division or subsidiary of another | ||||||
24 | entity that owns
or
operates other
hospitals or related | ||||||
25 | organizations, the annual public disclosure report shall
be for | ||||||
26 | the specific
division or subsidiary and not for the other |
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1 | entity.
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2 | (f) The Department shall disclose information under this | ||||||
3 | Section in
accordance with provisions for inspection and | ||||||
4 | copying of public records
required by the Freedom of
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5 | Information Act provided that such information satisfies the | ||||||
6 | provisions of
subsection (c) of this Section.
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7 | (g) Notwithstanding any other provision of law, under no | ||||||
8 | circumstances shall
the
Department disclose information | ||||||
9 | obtained from a hospital that is confidential
under Part 21
of | ||||||
10 | Article 8 of the Code of Civil Procedure.
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11 | (h) No hospital report or Department disclosure may contain | ||||||
12 | information
identifying a patient, employee, or licensed | ||||||
13 | professional.
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14 | (Source: P.A. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)
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15 | Section 99. Effective date. This Act takes effect upon | ||||||
16 | becoming law.
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