Illinois General Assembly - Full Text of Public Act 094-0275
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Public Act 094-0275




Public Act 094-0275
SB1862 Enrolled LRB094 11494 RSP 42443 b

    AN ACT concerning State government.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. 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 Nosocomial infection
    rates 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 Class I
        surgical site infection.
            (B) Surgical procedure infection control process
            (C) (B) Outcome or process measures related to
        ventilator-associated Ventilator-associated pneumonia.
            (D) (C) Central vascular catheter-related
        line-related bloodstream infection rates in designated
        critical care units infections.
    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. The Department shall only disclose Illinois
hospital infection rate data according to the current
benchmarks of the Centers for Disease Control's National
Nosocomial Infection Surveillance Program.
    (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
        (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
        (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
        (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
    (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
    (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
(Source: P.A. 93-563, eff. 1-1-04.)
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 7/19/2005