Illinois General Assembly - Full Text of HB2706
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Full Text of HB2706  99th General Assembly




HB2706 EnrolledLRB099 09933 RPS 30149 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Hospital Report Card Act is amended by
5changing Sections 25 and 30 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:
17            (A) Surgical procedure outcome measures.
18            (B) Surgical procedure infection control process
19        measures.
20            (C) Outcome or process measures related to
21        ventilator-associated pneumonia.
22            (D) Central vascular catheter-related bloodstream
23        infection rates in designated critical care units.



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1        (3) Information required under paragraph (4) of
2    Section 2310-312 of the Department of Public Health Powers
3    and Duties Law of the Civil Administrative Code of
4    Illinois.
5        (4) Additional infection measures mandated by the
6    Centers for Medicare and Medicaid Services that are
7    reported by hospitals to the Centers for Disease Control
8    and Prevention's National Healthcare Safety Network
9    surveillance system, or its successor, and deemed relevant
10    to patient safety by the Department.
11    The infection-related measures developed by the Department
12shall be based upon measures and methods developed by the
13Centers for Disease Control and Prevention, the Centers for
14Medicare and Medicaid Services, the Agency for Healthcare
15Research and Quality, the Joint Commission on Accreditation of
16Healthcare Organizations, or the National Quality Forum. The
17Department may align the infection-related measures with the
18measures and methods developed by the Centers for Disease
19Control and Prevention, the Centers for Medicare and Medicaid
20Services, the Agency for Healthcare Research and Quality, the
21Joint Commission on Accreditation of Healthcare Organizations,
22and the National Quality Forum by adding reporting measures
23based on national health care strategies and measures deemed
24scientifically reliable and valid for public reporting. The
25Department shall receive approval from the State Board of
26Health to retire measures deemed no longer scientifically valid



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



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



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



HB2706 Enrolled- 6 -LRB099 09933 RPS 30149 b

1April 30, July 31, October 31, and January 31 each year for the
2previous quarter. Data in quarterly reports must cover a period
3ending not earlier than one month prior to submission of the
4report. Annual reports shall be submitted by December 31 in a
5format set forth in rules adopted by the Department to the
6Department. All reports shall be made available to the public
7on-site and through the Department.
8    (e) If the hospital is a division or subsidiary of another
9entity that owns or operates other hospitals or related
10organizations, the annual public disclosure report shall be for
11the specific division or subsidiary and not for the other
13    (f) The Department shall disclose information under this
14Section in accordance with provisions for inspection and
15copying of public records required by the Freedom of
16Information Act provided that such information satisfies the
17provisions of subsection (c) of this Section.
18    (g) Notwithstanding any other provision of law, under no
19circumstances shall the Department disclose information
20obtained from a hospital that is confidential under Part 21 of
21Article VIII of the Code of Civil Procedure.
22    (h) No hospital report or Department disclosure may contain
23information identifying a patient, employee, or licensed
25(Source: P.A. 98-463, eff. 8-16-13.)



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1    (210 ILCS 86/30)
2    Sec. 30. Department reports. The Department of Public
3Health shall annually submit to the General Assembly a report
4summarizing the quarterly reports by health service area and
5shall publish that report on its website. The Department of
6Public Health may issue quarterly informational bulletins at
7its discretion, summarizing all or part of the information
8submitted in these quarterly reports. The Department shall
9publish quality and safety measures on major public health
10problems, such as cardiovascular disease and diabetes, that
11have been vetted by the National Quality Forum, the Agency for
12Healthcare Research and Quality, the Centers for Disease
13Control and Prevention, or the Centers for Medicare and
14Medicaid Services. The Department shall also publish
15risk-adjusted mortality rates for each hospital based upon
16information hospitals have already submitted to the Department
17pursuant to their obligations to report health care information
18under other public health reporting laws and regulations
19outside of this Act. The published mortality rates must comply
20with the hospital data publication process contained in
21subsection (c) of Section 25 of this Act.
22(Source: P.A. 93-563, eff. 1-1-04.)
23    Section 99. Effective date. This Act takes effect upon
24becoming law.