77 Ill. Adm. Code 255.250
Hospital Reports
Section 255.250 Â Hospital Reports
a)
Individual
hospitals shall prepare a quarterly report including all of the following
(Section 25(a) of the Act)
:
1)Â Â Â Â Â Â Â Â Direct
care hours, by reporting individually all of the following:
A)Â Â Â Â Â Â Â Total
inpatient days, which is the sum of each daily census for the time period.
B)Â Â Â Â Â Â Â Total
direct care RN hours, which equals the sum of the paid productive hours for
direct care RN employees, including agency, per diem and registry RNs.
C)Â Â Â Â Â Â Â Total
direct care LPN hours, which equals the sum of the paid productive hours for
direct care LPN employees, including agency, per diem and registry LPNs.
D)Â Â Â Â Â Â Â Total
direct care hours for assistive nursing personnel, which is the sum of the paid
productive hours for direct care assistive nursing personnel, including agency,
per diem and registry assistive nursing personnel.
E)
Nursing
hours per patient day
for direct care, which is the sum of total direct
care RN hours and total direct care LPN hours and total direct care assistive
nursing personnel hours divided by total inpatient days. (Section 25(a)(1) of
the Act)
F)Â Â Â Â Â Â Â Â Licensed
nursing hours per patient day − by RNs and LPNs (RN hours per patient
day, LPN hours per patient day), which is:
i) Â Â Â Â Â Â Â Â the
total direct care hospital employed RN hours divided by the total inpatient
days for the quarter;
ii)Â Â Â Â Â Â Â Â the
total direct care commercial agency contracted RN hours divided by the total
inpatient days for the quarter;
iii)Â Â Â Â Â Â Â the
total direct care hospital employed LPN hours divided by the total inpatient
days for the quarter; and
iv)Â Â Â Â Â Â Â the
total direct care commercial agency contracted LPN hours divided by the total
inpatient days for the quarter.
G)
Average
daily hours worked
(Section 25(a)(1) of the Act) − by RNs and LPNs
(average daily RN hours worked, average daily LPN hours worked), which is:
i)Â Â Â Â Â Â Â Â Â the
total direct care hospital employed RN hours divided by the number of calendar
days for the quarter,
ii)Â Â Â Â Â Â Â Â the
total direct care commercial agency contracted RN hours divided by the number
of calendar days for the quarter,
iii)Â Â Â Â Â Â Â the
total direct care hospital employed LPN hours divided by the number of calendar
days for the quarter, and
iv)Â Â Â Â Â Â Â the
total direct care commercial agency contracted LPN hours divided by the number
of calendar days for the quarter.
H)
Average
daily census per clinical service area
, which is the total inpatient days
divided by the days in the quarter. (Section 25(a)(1) of the Act)
2)
Infection-related
measures for the facility for the following clinical procedures
(Section
25(a)(2) of the Act) for patients ages 18 and over in hospitals providing
services where these treatments are clinically appropriate.
A)Â Â Â Â Â Â Â Surgical
outcome measures by reporting postoperative wound infection diagnosed during
index hopitalization.
B)Â Â Â Â Â Â Â Central
vascular catheter-related bloodstream infection rates in designated critical
care units.
C)Â Â Â Â Â Â Â Patients
diagnosed with postoperative ventilator-associated pneumonia (VAP) during index
hospitalization.
b)Â Â Â Â Â Â Â Â Individual
hospitals may also, but are not required to, submit the following optional
reports: Â (Agency, per-diem and registry RNs must be included in the number of
productive hours for the optional report. The optional report may not include
licensed nursing orientees in the number of productive hours.)
1)Â Â Â Â Â Â Â Â Total
number of nursing hours per patient day and licensed nursing hours per patient
day for those licensed nursing personnel with indirect patient care
responsibilities. The licensed nursing hours per patient day will be reported
separately for registered professional nurses and licensed practical nurses.
Hospitals may also submit the number of licensed nursing hours per patient day
that are associated with caring for outpatient and observation patients.
2)Â Â Â Â Â Â Â Â Average
daily hours worked and average daily census for the quarter per clinical
service area.
c)
Individual
hospitals shall prepare annual reports including vacancy and turnover rates for
licensed nurses per clinical service area
for direct care nurses as
follows:
(Section 25(b) of the Act)
1)Â Â Â Â Â Â Â Â Vacancy
Rate:
The vacancy rate submitted for
licensed nurses per clinical service area must equal the number of full-time
equivalent openings for licensed nursing personnel on January 1 of each year,
divided by the number of full-time equivalents for licensed nursing personnel
budgeted as of January 1. Budgeted positions include both filled positions and
vacant positions for which the hospital is recruiting on January 1. The
vacancy rate does not include those licensed nursing employees who are on
family, medical or disability leave or who provide per diem services to the
hospital. The vacancy rate shall be reported separately for registered nurses
and licensed practical nurses.
2)Â Â Â Â Â Â Â Â Turnover
Rate:
The turnover rate submitted for
licensed nurses per clinical service area must equal the number of separated
employees for licensed nursing personnel for the calendar year preceding
January 1, divided by the number of employees for licensed nursing personnel on
the hospital's payroll for the same clinical service area as of the preceding
January 1. The turnover rate does not include those licensed nursing employees
who are on family, medical or disability leave or who provide per diem services
to the hospital. The turnover rate shall be reported separately for registered
nurses and licensed practical nurses.