Illinois Department of Public HealthBruce Rauner, Governor

Where the data comes from

Illinois Hospital Report Card and Consumer Guide to Health Care




Illinois Public Health Community Map

Quality - Recommended Care

The composite score represents how well a hospital cares for patients with specific conditions.  The data comes from the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services. Each set of recommended care measures pertains to a specific condition (heart attack, heart failure and pneumonia).  Read about the composite score methodology.

Readmission rates

Readmission rates includes patients readmitted to a hospital within 30 days of discharge from a previous hospital stay for heart attack, heart failure, or pneumonia. Readmission rates are reported for Medicare patients only. IDPH obtains this data from the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services.

Thirty Day Mortality

Thirty day mortality rates take into account deaths within 30 days from all causes after an initial hospitalization with a principal diagnosis of heart attack, heart failure, or pneumonia. Mortality rates are reported for Medicare patients only. IDPH obtains this data from the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services.

Surgical Care Improvement Project (SCIP)

These data come from core measure data submitted by participating Illinois hospitals to the Illinois Department of Public Health quarterly. These measures are a result of combined efforts of the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) and the Joint Commission to develop a set of common national hospital performance measures with a shared set of common documentation. Data are abstracted from hospitals' treatment charts and records for patients treated with selected surgical procedures. SCIP process measures are utilized to illustrate how often hospitals use recommended treatments that are known to get the best results for patients undergoing surgical procedures.

Patient Satisfaction

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized survey of hospital patients. HCAHPS was created to publicly report the patient's perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experiences. IDPH obtains this data from the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services.


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The information on hospital stays is derived from Illinois Department of Public Health's Hospital Discharge Data Set. This data is collected on a quarterly processing schedule from Illinois acute care hospitals and ambulatory surgical treatment centers (ASTCs) to meet the requirements of the Illinois Health Finance Reform Act (Public Act 83-1243 originally signed into law in 1984 and last amended by Public Act 94-27 in 2005). Industry standard edits for content and context (see the CMS Medicare Code Edits for details) are applied to each data element when appropriate. The data are checked for duplicates and completeness prior to storage in the Department's databases. After each submission, the submitting facility is given access to statistical reports showing individual cases in error and a summary of clean data accepted by the Department to that point in time.

 

Volume

Volume data refer to the number of times a certain procedure was performed. This data is obtained from the Illinois Department of Public Health Hospital Discharge Data Set. See discussion of Administrative data for processes involved in obtaining this data.


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Infection Data

Hospital-associated infection data are collected by each hospital using the National Healthcare Safety Network (NHSN). NHSN is the Centers for Disease Control and Prevention's nationally recognized surveillance system and database. It is used by hospitals throughout the country to collect valid measurements to generate reports of health care associated adverse events; particularly health care-associated infections. Illinois Hospitals are mandated to collect information about central-line associated blood stream infections (CLABIs) using NHSN.

 

Facility Information

Facility data, including number of beds and services are gathered from both the Annual Hospital Profile and the Annual Ambulatory Surgical Treatment Center Profile. The data in these reports are collected through questionnaires administered by the Division of Health Systems Development, Office of Policy, Planning and Statistics, of the Illinois Department of Public Health under the authority of the Illinois Health Facilities Planning Act (20 ILCS 3960/). These questionnaires are distributed on an annual basis and results are posted on the IDPH Web site.


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Nurse Staffing Data

The Illinois Hospital Report Act (210 ILCS 86), requires all Illinois hospitals to submit reports to the Office of Policy, Planning and Statistics of the Illinois Department of Public Health documenting nurse staffing levels. Quarterly reports must follow documentation guidelines that delineate direct care nurse staffing hours and average daily patient census per clinical service area. Annual reports must follow documentation guidelines that delineate annual vacancy and turnover rates of nursing staff.

 

Revenue

Revenue is collected through administrative data submitted by hospitals to the Illinois Department of Public Health.

 

 

 

Methicillin-Resistant Staphylococcus aureus (MRSA) Data

Data on Methicillin-resistant staphylococcus aureus or MRSA are obtained from administrative data submitted by hospitals to the Illinois Department of Public Health.

Clostridium Difficile Data

Data on Clostridium difficile are obtained from administrative data submitted by hospitals to the Illinois Department of Public Health.

Breast Feeding Data

The breast feeding measures are calculated from birth certificate data submitted to the Vital Records program of the Illinois Department of Public health. Illinois birth certificates were revised to include whether a newborn is breast fed at discharge from the hospital, with possible answers yes, no and unknown. Each response is shown as a percentage of all births in a hospital.

The breastfeeding data by hospital are from a newly-revised birth certificate that was implemented in Illinois beginning in January 2010. The item was added as part of the incorporation of the 2003 US Standard Certificate Revisions recommended by the National Center for Health Statistics (NCHS). These counts are based on self-reporting of the mothers and hospital staff. The numbers and corresponding percentages have no birth certificate precedent for comparison. In addition, these are preliminary counts and subject to ongoing and annual data clean-up. As such, these counts may vary for the same period based on final counts produced annually.

The question, as originally presented on the US Standard Birth Certificate reads: "Is Infant Being Breastfed at the time of Discharge?" The original intent by NCHS was to collect data on infants being breastfed at discharge from the hospital. In the latter part of 2010, NCHS revised their definition of this field. The question now asks if an infant was breastfed at any time between delivery and discharge, and not just at discharge. The field label in the Illinois Vital Records System Birth application that is in use in all Illinois birthing hospitals is being reworded and future data will reflect this change.

Infection Prevention Control Staffing

The number of infection prevention and control staff, both total and those certified in infection control, is gathered from data submitted by hospitals to the Illinois Department of Public Health through the Annual Hospital Profile survey.

Patient Insurance Mix

Data on the percentage of types of major healthcare insurance providers is gathered from the Annual Hospital Profile. The data in these reports are collected through the Annual Hospital Questionnaire administered by the Division of Health Systems Development, Office of Policy, Planning and Statistics, of the Illinois Department of Public Health under the authority of the Illinois Health Facilities Planning Act (20 ILCS 3960/). This questionnaire for the preceding year is distributed annually early in the year and results posted on the Department's web site each fall. The Hospital Profiles and Bed Reports can be viewed at http://www.hfsrb.illinois.gov/HospProf_ABR.htm

 

 

 

Administrative Data (Illinois Public Health Community Map)

The information on preventable hospitalizations and emergency room visits is derived from Illinois Department of Public Health's (IDPH) Hospital Discharge Data Set. The IDPH Hospital Discharge Data Set includes many elements such as procedure codes, diagnosis codes, facility charges and patient demographic information for each inpatient hospital stay and emergency room visit. This data is collected on a quarterly processing schedule from Illinois acute care hospitals and ambulatory surgical treatment centers (ASTCs) to meet the requirements of the Illinois Health Finance Reform Act (Public Act 83-1243 originally signed into law in 1984 and last amended by Public Act 94-27 in 2005). Industry standard edits for content and context (see the CMS Medicare Code Edits for details) are applied to each data element when appropriate. The data are checked for duplicates and completeness prior to storage in the Department's databases. After each submission, the submitting facility is given access to statistical reports showing individual cases in error and a summary of clean data accepted by the Department to that point in time.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses and procedures received during hospital and emergency room visits. The system is maintained by the World Health Organization and the U.S. National Center for Health Statistics and updated periodically. There are about 12,000 ICD-9-CM diagnosis codes.

The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.

 

Behavioral Risk Factor Surveillance System Data (Illinois Public Health Community Map)

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based program that gathers information on risk factors among Illinois adults 18 years of age and older through monthly telephone surveys.  Established in 1984 as a collaboration between the U.S. Centers for Disease Control and Prevention (CDC) and state health departments, the BRFSS has grown to be the primary source of information on health risk behaviors and conditions related to the leading causes of death for adults in the general population. 
 
The Illinois County Behavioral Risk Factor Surveys (ICBRFS) are conducted for individual counties employing the same procedures and questions as the BRFSS.  A random digit dial telephone survey is used to conduct telephone interviews using specific questionnaires.  Data obtained from the BRFSS are representative of the non-institutionalized population over 18 years of age.  All data from the BRFSS are weighted by population.
 
For more information about the BRFSS program at CDC, visit that agency's website at www.cdc.gov/brfss.  More information specific to the Illinois BRFSS, is available at http://app.idph.state.il.us/brfss/faqs.asp.

 

 

 

Population Data

Information about county and county sub-region population with respect to age, income and race/ethnicity is derived from the U.S. Census Bureau, American Community Survey 2007 update.

Comprehensive nationwide Census surveys are conducted every ten years with frequent updates to the national population data. Further details regarding rolling updates and their frequency are provided at: http://www.census.gov/population/www/cen2010/glance/.

Information provided on insurance status (payer category) is based on Illinois Hospital Discharge data.

 

 

 

Payer

Payer categories are calculated from hospital discharge data. Payer is the expected primary payer for the hospital stay combining detailed categories into more general groups:

  • Medicare (All programs, including fee-for-service and managed care Medicare patients).
  • Medicaid (All programs, including fee-for-service, managed care Medicaid patients and patients covered by the State Children's Health Insurance Program (SCHIP).
  • Private insurance includes all identifiable carriers: commercial carriers (including Worker's Compensation) and private HMOs and PPOs.
  • Self pay includes bills for charges made to the patient, having no identifiable private or public insurance coverage or eligibility.
  • "Other" includes declared but un-identifiable carriers (including Worker's Compensation), TRICARE/CHAMPUS, Black Lung, Title V, and other government programs.

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

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