Sen. Karina Villa

Filed: 5/14/2021

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 68

2    AMENDMENT NO. ______. Amend House Bill 68 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Hospital Report Card Act is amended by
5changing Section 25 as follows:
 
6    (210 ILCS 86/25)
7    Sec. 25. Hospital reports.
8    (a) Individual hospitals shall prepare a quarterly report
9including all of the following:
10        (1) Nursing hours per patient day, average daily
11    census, and average daily hours worked for each clinical
12    service area.
13        (2) Infection-related measures for the facility for
14    the specific clinical procedures and devices determined by
15    the Department by rule under 2 or more of the following
16    categories:

 

 

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1            (A) Surgical procedure outcome measures.
2            (B) Surgical procedure infection control process
3        measures.
4            (C) Outcome or process measures related to
5        ventilator-associated pneumonia.
6            (D) Central vascular catheter-related bloodstream
7        infection rates in designated critical care units.
8        (3) Information required under paragraph (4) of
9    Section 2310-312 of the Department of Public Health Powers
10    and Duties Law of the Civil Administrative Code of
11    Illinois.
12        (4) Additional infection measures mandated by the
13    Centers for Medicare and Medicaid Services that are
14    reported by hospitals to the Centers for Disease Control
15    and Prevention's National Healthcare Safety Network
16    surveillance system, or its successor, and deemed relevant
17    to patient safety by the Department.
18        (5) Each instance of preterm birth and infant
19    mortality within the reporting period, including the
20    racial and ethnic information of the mothers of those
21    infants.
22        (6) Each instance of maternal mortality within the
23    reporting period, including the racial and ethnic
24    information of those mothers.
25        (7) The number of female patients who have died within
26    the reporting period.

 

 

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1        (8) The number of female patients admitted to the
2    hospital with a diagnosis of COVID-19 and at least one
3    known underlying condition identified by the United States
4    Centers for Disease Control and Prevention as a condition
5    that increases the risk of mortality from COVID-19 who
6    subsequently died at the hospital within the reporting
7    period.
8    The infection-related measures developed by the Department
9shall be based upon measures and methods developed by the
10Centers for Disease Control and Prevention, the Centers for
11Medicare and Medicaid Services, the Agency for Healthcare
12Research and Quality, the Joint Commission on Accreditation of
13Healthcare Organizations, or the National Quality Forum. The
14Department may align the infection-related measures with the
15measures and methods developed by the Centers for Disease
16Control and Prevention, the Centers for Medicare and Medicaid
17Services, the Agency for Healthcare Research and Quality, the
18Joint Commission on Accreditation of Healthcare Organizations,
19and the National Quality Forum by adding reporting measures
20based on national health care strategies and measures deemed
21scientifically reliable and valid for public reporting. The
22Department shall receive approval from the State Board of
23Health to retire measures deemed no longer scientifically
24valid or valuable for informing quality improvement or
25infection prevention efforts. The Department shall notify the
26Chairs and Minority Spokespersons of the House Human Services

 

 

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1Committee and the Senate Public Health Committee of its intent
2to have the State Board of Health take action to retire
3measures no later than 7 business days before the meeting of
4the State Board of Health.
5    The Department shall include interpretive guidelines for
6infection-related indicators and, when available, shall
7include relevant benchmark information published by national
8organizations.
9    The Department shall collect the information reported
10under paragraphs (5) and (6) and shall use it to illustrate the
11disparity of those occurrences across different racial and
12ethnic groups.
13    (b) Individual hospitals shall prepare annual reports
14including vacancy and turnover rates for licensed nurses per
15clinical service area.
16    (c) None of the information the Department discloses to
17the public may be made available in any form or fashion unless
18the information has been reviewed, adjusted, and validated
19according to the following process:
20        (1) The Department shall organize an advisory
21    committee, including representatives from the Department,
22    public and private hospitals, direct care nursing staff,
23    physicians, academic researchers, consumers, health
24    insurance companies, organized labor, and organizations
25    representing hospitals and physicians. The advisory
26    committee must be meaningfully involved in the development

 

 

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1    of all aspects of the Department's methodology for
2    collecting, analyzing, and disclosing the information
3    collected under this Act, including collection methods,
4    formatting, and methods and means for release and
5    dissemination.
6        (2) The entire methodology for collecting and
7    analyzing the data shall be disclosed to all relevant
8    organizations and to all hospitals that are the subject of
9    any information to be made available to the public before
10    any public disclosure of such information.
11        (3) Data collection and analytical methodologies shall
12    be used that meet accepted standards of validity and
13    reliability before any information is made available to
14    the public.
15        (4) The limitations of the data sources and analytic
16    methodologies used to develop comparative hospital
17    information shall be clearly identified and acknowledged,
18    including but not limited to the appropriate and
19    inappropriate uses of the data.
20        (5) To the greatest extent possible, comparative
21    hospital information initiatives shall use standard-based
22    norms derived from widely accepted provider-developed
23    practice guidelines.
24        (6) Comparative hospital information and other
25    information that the Department has compiled regarding
26    hospitals shall be shared with the hospitals under review

 

 

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1    prior to public dissemination of such information and
2    these hospitals have 30 days to make corrections and to
3    add helpful explanatory comments about the information
4    before the publication.
5        (7) Comparisons among hospitals shall adjust for
6    patient case mix and other relevant risk factors and
7    control for provider peer groups, when appropriate.
8        (8) Effective safeguards to protect against the
9    unauthorized use or disclosure of hospital information
10    shall be developed and implemented.
11        (9) Effective safeguards to protect against the
12    dissemination of inconsistent, incomplete, invalid,
13    inaccurate, or subjective hospital data shall be developed
14    and implemented.
15        (10) The quality and accuracy of hospital information
16    reported under this Act and its data collection, analysis,
17    and dissemination methodologies shall be evaluated
18    regularly.
19        (11) Only the most basic identifying information from
20    mandatory reports shall be used, and information
21    identifying a patient, employee, or licensed professional
22    shall not be released. None of the information the
23    Department discloses to the public under this Act may be
24    used to establish a standard of care in a private civil
25    action.
26    (d) Quarterly reports shall be submitted, in a format set

 

 

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1forth in rules adopted by the Department, to the Department by
2April 30, July 31, October 31, and January 31 each year for the
3previous quarter. Data in quarterly reports must cover a
4period ending not earlier than one month prior to submission
5of the report. Annual reports shall be submitted by December
631 in a format set forth in rules adopted by the Department to
7the Department. All reports shall be made available to the
8public on-site and through the Department.
9    (e) If the hospital is a division or subsidiary of another
10entity that owns or operates other hospitals or related
11organizations, the annual public disclosure report shall be
12for the specific division or subsidiary and not for the other
13entity.
14    (f) The Department shall disclose information under this
15Section in accordance with provisions for inspection and
16copying of public records required by the Freedom of
17Information Act provided that such information satisfies the
18provisions of subsection (c) of this Section.
19    (g) Notwithstanding any other provision of law, under no
20circumstances shall the Department disclose information
21obtained from a hospital that is confidential under Part 21 of
22Article VIII of the Code of Civil Procedure.
23    (h) No hospital report or Department disclosure may
24contain information identifying a patient, employee, or
25licensed professional.
26(Source: P.A. 101-446, eff. 8-23-19.)".