|
(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. |
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.
|
(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. 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.)
|
