Illinois General Assembly - Full Text of Public Act 099-0326
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Public Act 099-0326





Public Act 099-0326
HB2706 EnrolledLRB099 09933 RPS 30149 b

    AN ACT concerning regulation.
    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 Sections 25 and 30 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 for the facility for
    the specific clinical procedures and devices determined by
    the Department by rule under 2 or more of the following
            (A) Surgical procedure outcome measures.
            (B) Surgical procedure infection control process
            (C) Outcome or process measures related to
        ventilator-associated pneumonia.
            (D) Central vascular catheter-related bloodstream
        infection rates in designated critical care units.
        (3) Information required under paragraph (4) of
    Section 2310-312 of the Department of Public Health Powers
    and Duties Law of the Civil Administrative Code of
        (4) Additional infection measures mandated by the
    Centers for Medicare and Medicaid Services that are
    reported by hospitals to the Centers for Disease Control
    and Prevention's National Healthcare Safety Network
    surveillance system, or its successor, and deemed relevant
    to patient safety by the Department.
    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 may align the infection-related measures with the
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,
and the National Quality Forum by adding reporting measures
based on national health care strategies and measures deemed
scientifically reliable and valid for public reporting. The
Department shall receive approval from the State Board of
Health to retire measures deemed no longer scientifically valid
or valuable for informing quality improvement or infection
prevention efforts. The Department shall notify the Chairs and
Minority Spokespersons of the House Human Services Committee
and the Senate Public Health Committee of its intent to have
the State Board of Health take action to retire measures no
later than 7 business days before the meeting of the State
Board of Health.
    The Department shall include interpretive guidelines for
infection-related indicators and, when available, shall
include relevant benchmark information published by national
    (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 VIII 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. 98-463, eff. 8-16-13.)
    (210 ILCS 86/30)
    Sec. 30. Department reports. The Department of Public
Health shall annually submit to the General Assembly a report
summarizing the quarterly reports by health service area and
shall publish that report on its website. The Department of
Public Health may issue quarterly informational bulletins at
its discretion, summarizing all or part of the information
submitted in these quarterly reports. The Department shall
publish quality and safety measures on major public health
problems, such as cardiovascular disease and diabetes, that
have been vetted by the National Quality Forum, the Agency for
Healthcare Research and Quality, the Centers for Disease
Control and Prevention, or the Centers for Medicare and
Medicaid Services. The Department shall also publish
risk-adjusted mortality rates for each hospital based upon
information hospitals have already submitted to the Department
pursuant to their obligations to report health care information
under other public health reporting laws and regulations
outside of this Act. The published mortality rates must comply
with the hospital data publication process contained in
subsection (c) of Section 25 of this Act.
(Source: P.A. 93-563, eff. 1-1-04.)
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 8/10/2015