2023 Illinois Compiled Statutes › Chapter 210 - HEALTH FACILITIES AND REGULATION › 210 ILCS 86/ - Hospital Report Card Act.

(210 ILCS 86/1)
Sec. 1. 
		Short title. 
		This Act may be cited as the Hospital Report Card
Act.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/5)
Sec. 5. 
		Findings. 
		The General Assembly finds that Illinois consumers have
a
right to
access information about the quality of health care provided in Illinois
hospitals in order to
make better decisions about their choice of health care provider.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/10)
Sec. 10. Definitions. For the purpose of this Act:
"Average daily census" means the average number of inpatients
receiving
service on any given 24-hour period beginning at midnight in each clinical
service area of the
hospital.
"Clinical service area" means a grouping of clinical services by a generic
class of
various types or levels of support functions, equipment, care, or treatment
provided to
inpatients. Hospitals may have, but are not required to have, the following
categories of
service: behavioral health, critical care, maternal-child care,
medical-surgical, pediatrics,
perioperative services, and telemetry.
"Department" means the Department of Public Health.
"Direct-care nurse" and "direct-care nursing staff" includes any registered
nurse,
licensed practical nurse, or assistive nursing personnel with direct
responsibility to oversee or
carry out medical regimens or nursing care for one or more patient.
"Hospital" means a health care facility licensed under the Hospital Licensing
Act.
"Nursing care" means care that falls within the scope of practice set
forth in the
Nurse Practice Act or is otherwise encompassed within
recognized
professional standards of nursing practice, including assessment, nursing
diagnosis, planning,
intervention, evaluation, and patient advocacy.
"Retaliate" means to discipline, discharge, suspend, demote,
harass, deny
employment or promotion, lay off, or take any other adverse action against
direct-care
nursing staff as a result of that nursing staff taking any action described in
this
Act.
"Skill mix" means the differences in licensing, specialty, and experiences
among direct-care nurses.
"Staffing levels" means the numerical nurse to patient ratio by licensed
nurse
classification within a nursing department or unit.
"Unit" means a functional division or area of a hospital in which nursing
care is
provided.
(Source: P.A. 95-639, eff. 10-5-07.)
(210 ILCS 86/15)
Sec. 15. 
		Staffing levels.
(a) The number of registered professional nurses, licensed practical nurses,
and other
nursing personnel assigned to each patient care unit shall be consistent with
the types of
nursing care needed by the patients and the capabilities of the staff. Patients
on each unit
shall be evaluated near the end of each change of shift by criteria developed
by the nursing
service. There shall be staffing schedules reflecting actual nursing personnel
required for the
hospital and for each patient unit. Staffing patterns shall reflect
consideration of nursing
goals, standards of nursing practice, and the needs of the patients.
(b) Current nursing staff schedules shall be available upon request at each
patient care
unit. Each schedule shall list the daily assigned nursing personnel and average
daily census
for the unit. The actual nurse staffing assignment roster for each patient care
unit shall be
available upon request at the patient care unit for the effective date of that
roster. Upon the
roster's expiration, the hospital shall retain the roster for 5 years from the
date of its
expiration.
(c) All records required under this Section, including anticipated staffing
schedules
and the methods to determine and adjust staffing levels shall be made available
to the public
upon request.
(d) All records required under this Section shall be maintained by the
facility for no
less than 5 years.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/20)
Sec. 20. 
		Orientation and training.
(a) All health care facilities shall have established an orientation process
that
provides initial job training and information and assesses the direct care
nursing staff's
ability to fulfill specified responsibilities.
(b) Personnel not competent for a given unit shall not be assigned to work
there
without direct supervision until appropriately trained.
(c) Staff training information will be available upon
request, without any information identifying a
patient, employee, or licensed professional
 at the hospital.
(Source: P.A. 93-563, eff. 1-1-04.)
(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 categories:
(A) Surgical procedure outcome measures.
(B) Surgical procedure infection control process         measures.
(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 Illinois.
(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.
(5) Each instance of preterm birth and infant     mortality within the reporting period, including the racial and ethnic information of the mothers of those infants.
(6) Each instance of maternal mortality within the     reporting period, including the racial and ethnic information of those mothers.
(7)  The number of female patients who have died     within the reporting period.
(8)  The number of female patients admitted to the     hospital with a diagnosis of COVID-19 and at least one known underlying condition identified by the United States Centers for Disease Control and Prevention as a condition that increases the risk of mortality from COVID-19 who subsequently died at the hospital within the reporting period.
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 organizations.
The Department shall collect the information reported under paragraphs (5) and (6) and shall use it to illustrate the disparity of those occurrences across different racial and ethnic groups.
(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 dissemination.
(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 public.
(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 regularly.
(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 action.
(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 entity.
(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 professional.
(Source: P.A. 101-446, eff. 8-23-19; 102-256, eff. 1-1-22.)
(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. 99-326, eff. 8-10-15.)
(210 ILCS 86/35)
Sec. 35. 
		Whistleblower protections.
(a) A hospital covered by this Act shall not penalize, discriminate, or
retaliate in any
manner against an employee with respect to compensation or the terms,
conditions, or
privileges of employment who in good faith, individually or in conjunction with
another
person or persons, does any of the following or intimidate, threaten, or
punish an
employee to prevent him or her from doing any of the following:
(1) Discloses to the nursing staff supervisor or     manager, a private accreditation organization, the nurse's collective bargaining agent, or a regulatory agency any activity, policy, or practice of a hospital that violates this Act or any other law or rule or that the employee reasonably believes poses a risk to the health, safety, or welfare of a patient or the public.
(2) Initiates, cooperates, or otherwise participates     in an investigation or proceeding brought by a regulatory agency or private accreditation body concerning matters covered by this Act or any other law or rule or that the employee reasonably believes poses a risk to the health, safety, or welfare of a patient or the public.
(3) Objects to or refuses to participate in any     activity, policy, or practice of a hospital that violates this Act or any law or rule of the Department or that a reasonable person would believe poses a risk to the health, safety, or welfare of a patient or the public.
(4) Participates in a committee or peer review     process or files a report or complaint that discusses allegation of unsafe, dangerous, or potentially dangerous care within the hospital.
(b) For the purposes of this Section, an employee is presumed to act in good
faith if the
employee reasonably believes that (i) the information reported or disclosed is
true and
(ii) a violation has occurred or may occur. An employee is not acting in good
faith
under this Section if the employee's report or action was based on information
that the
employee should reasonably know is false or misleading. The protection of this
Section shall also not apply to an employee unless the employee gives written
notice
to a hospital manager of the activity, policy, practice, or violation that the
employee
believes poses a risk to the health of a patient or the public and provides the
manager a
reasonable opportunity to correct the problem. The manager shall respond in
writing
to the employee within 7 days acknowledging that the notice was received and
provide
written
notice of any action taken within a reasonable time of receiving the employee's
notice.
This notice requirement shall not apply if the employee is reasonably certain
that the
activity, policy, practice, or violation: (i) is known by one or more hospital
managers
who have had an opportunity to correct the problem and have not done so; (ii)
involves
the commission of a crime; or (iii) places patient health or safety in severe
and
immediate danger. The notice requirement shall not apply if the employee is
participating in a survey, investigation, or other activity of a regulatory
agency, law
enforcement agency, or private accreditation body that was not initiated by the
employee. Nothing in this Section prohibits a hospital from training,
educating,
correcting, or otherwise taking action to improve the performance of employees
who
report that they are unable or unwilling to perform an assigned task.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/40)
Sec. 40. 
		Private right of action. 
		Any health care facility that violates
the
provisions of
Section 35 may be held liable to the employee affected in an action brought
in a court of
competent jurisdiction for such legal or equitable relief as may be appropriate
to effectuate
the purposes of this Act.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/45)
Sec. 45. 
		Regulatory oversight. 
		The Department shall be responsible for
ensuring
compliance with this Act as a condition of licensure under the Hospital
Licensing Act and
shall enforce such compliance according to the provisions of the Hospital
Licensing Act.
(Source: P.A. 93-563, eff. 1-1-04.)
(210 ILCS 86/90)
Sec. 90. 
		(Amendatory provisions; text omitted).
(Source: P.A. 93-563, eff. 1-1-04; text omitted.)
(210 ILCS 86/99)
Sec. 99. 
		Effective date. 
		This Act takes effect on January 1, 2004.
(Source: P.A. 93-563, eff. 1-1-04.)