Section 205.230  Standards of Professional Work

Management and/or the owner of the ambulatory surgical treatment center shall maintain proper standards of professional work in the licensed facility.

a)         A qualified consulting committee shall be appointed in writing by the management and/or owner of the ambulatory surgical treatment center and shall establish and enforce standards for professional work in the facility and standards of competency for physicians.  The consulting committee shall meet not less than quarterly and shall document all meetings with written minutes.  These written minutes shall be maintained at the facility and shall be available for inspection by the Department.

1)         The membership of the consulting committee shall reflect the types of procedures performed.  If the facility performs more than 50 procedures per month or more than 10% of the total procedures performed are in a specific specialty area then there shall be a consulting physician of that specialty on the consulting committee.

2)         The consulting committee shall review development and content of the written policies and procedures of the center, the procedures for granting privileges, and the quality of the surgical procedures performed.  Evidence of such review shall be recorded in the minutes.

3)         Credentials shall be provided by those physicians seeking practice privileges.  These credentials shall be reviewed by the credentials committee and specific practice privileges identified and recorded.  Record of such accepted practice privileges shall be available for facility staff use and public information within the facility.

4)         Each member of the medical staff granted specific surgical practice privileges shall provide a notarized statement or documentation indicating the name of the Illinois' licensed hospital(s) where they have  skilled-equivalent practice privileges.  Such statements or documentation shall be available for inspection by the Department.  A list of privileges granted each medical staff member of the ambulatory surgical treatment center shall be available at all times for use by the staff of the center and for inspection by Department staff. As used in this subsection, "skilled-equivalent" means the ability to perform similar procedures requiring the same level of training and expertise.

5)         The consulting committee shall act as a tissue committee and shall review at least quarterly pathological reports from procedures performed by each physician on the staff.  Evidence of such review shall be recorded in the minutes.

b)         A qualified physician shall be designated "Medical Director."

1)         The Medical Director shall secure compliance with the policies and procedures pertaining to medical and surgical procedures, approved by the consulting committee.

2)         The Medical Director shall be responsible for the implementation of medical policies and procedures contained in the facility's policies and procedures manual (Section 205.240) governing the professional personnel involved directly in the care of patients undergoing surgical procedures, including their preoperative and postoperative care and follow-up.

3)         The Medical Director shall establish and secure compliance of standards for the observation of patients by nursing personnel during the postoperative period.

(Source:  Amended at 10 Ill. Reg. 21906, effective January 15, 1987)