Section 250.310  Organization

 

a)         The medical staff shall be organized in accordance with written bylaws, rules and regulations approved by the governing board.  The bylaws, rules and regulations shall specifically provide but not be limited to:

 

1)         establishing written procedures relating to the acceptance and processing of initial applications for medical staff membership, granting and denying of medical staff reappointment, and medical staff membership or clinical privileges disciplinary matters in accordance with subsection (b) of this Section for county hospitals as defined in Section 15-1(c) of the Illinois Public Aid Code [305 ILCS 5/15-1], or subsection (c) of this Section for all other hospitals.  The procedures for initial applicants at any particular hospital may differ from those for current medical staff members.  However, the procedures at any particular hospital shall be applied equally to each practitioner eligible for medical staff membership as defined in Section 250.150 of this Part.  The procedures shall provide that, prior to the granting of any medical staff privileges to an applicant, or renewing a current medical staff member's privileges, the hospital shall request of the Director of the Department of Financial and Professional Regulation information concerning the licensure status and any disciplinary action taken against the applicant's or medical staff member's license.  This provision shall not apply to medical personnel who enter a hospital to obtain organs and tissues for transplant from a deceased donor in accordance with the Illinois Anatomical Gift Act [755 ILCS 50].  This provision shall not apply to medical personnel who have been granted disaster privileges pursuant to the procedures and requirements established in this Section.  (Section 10.4 of the Act);

 

2)         identifying divisions and departments as are warranted (as a minimum, active and consulting divisions are required);

 

3)         identifying officers as are warranted;

 

4)         establishing committees as are warranted to assure the responsibility for such functions as pharmacy and therapeutics, infection control, utilization review, patient care evaluation, and the maintenance of complete medical records;

 

5)         assuring that active medical staff meetings are held regularly, and that written minutes of all meetings are kept;

 

6)         reviewing and analyzing the clinical experience of the hospital at regular intervals − the medical records of patients to be the basis for such review and analysis;

 

7)         identifying conditions or situations that require consultation, including consultation between medical staff members in complicated cases;

 

8)         examining tissue removed during operations by a qualified pathologist and requiring that the findings are made a part of the patient's medical record;

 

9)         keeping completed medical records;

 

10)         maintaining a Utilization Review Plan, which shall be in accordance with the Conditions of Participation for Hospitals in the Medicare Program;

 

11)         establishing Medical Care Evaluation Studies;

 

12)         establishing policies requiring a physician as first assistant to major and/or hazardous surgery, including written criteria to determine when an assistant is necessary;

 

13)         assuring, through credentialing by the medical staff, that a qualified surgical assistant, whether a physician or non-physician, assists the operating surgeon in the operating room;

 

14)         determining additional privileges that may be granted a staff member for the use of his/her employed allied health personnel in the hospital in accordance with policies and procedures recommended by the medical staff and approved by the governing authority.  The policies and procedures shall include, at least, requirements that the staff member requesting this additional privilege shall submit for review and approval by the medical staff and the governing authority of the hospital:

 

A)        a curriculum vitae of the identified allied health personnel, and

 

B)        a written protocol with a description of the duties, assignments and/or functions, including a description of the manner of performance within the hospital by the allied health personnel in relationship with other hospital staff;

 

15)         establishing a mechanism for assisting medical staff members in addressing physical and mental health problems;

 

16)         implementing a procedure for preserving medical staff credentialing files in the event of the closure of the hospital; and

 

17)         establishing a procedure for granting disaster privileges.

 

A)        When the emergency management plan has been activated and the hospital is unable to handle patients' immediate needs, it shall:

 

i)          identify in writing the individuals responsible for granting disaster privileges;

 

ii)         describe in writing the responsibilities of the individuals granting disaster privileges.  The responsible individual is not required to grant privileges to any individual and is expected to make such decisions on a case-by-case basis at his or her discretion;

 

iii)         describe in writing a mechanism to manage individuals who receive disaster privileges;

 

iv)        include a mechanism to allow staff to readily identify individuals who receive disaster privileges;

 

v)         require that medical staff address the verification process as a high priority and begin the verification process of the credentials and privileges of individuals who receive disaster privileges as soon as the immediate situation is under control.

 

B)        The individual responsible for granting disaster privileges may grant disaster privileges upon presentation of any of the following:

 

i)          a current picture hospital ID card;

 

ii)         a current license to practice and a valid picture ID issued by a state, federal or regulatory agency;

 

iii)         identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT) or an Illinois Medical Emergency Response Team (IMERT);

 

iv)        identification indicating that the individual has been granted authority to render patient care, treatment and services in disaster circumstances (such authority having been granted by a federal, state or municipal entity); or

 

v)         presentation by current hospital or medical staff members with personal knowledge regarding practitioner's identity.

 

C)        Any hospital and any employees of the hospital or others involved in granting privileges that, in good faith, grants disaster privileges pursuant to Section 10.4 of the Act to respond to an emergency shall not, as a result of his, her, or its acts or omissions, be liable for civil damages for granting or denying disaster privileges except in the event of willful and wanton misconduct, as that term is defined in Section 10.2 of the Act.

 

D)        Individuals granted privileges who provide care in an emergency situation, in good faith and without direct compensation, shall not, as a result of his or her acts or omissions, except for acts or omissions involving willful and wanton misconduct, as that term is defined in Section 10.2 of the Act, on the part of the person, be liable for civil damages.  (Section 10.4 of the Act)

 

b)         The medical staff bylaws for county hospitals as defined in Section 15-1(c) of the Illinois Public Aid Code shall include at least the following:

 

1)         The procedures relating to evaluating individuals for staff membership, whether the practitioners are or are not currently members of the medical staff, shall include procedures for determination of qualifications and privileges, criteria for evaluation of qualifications, and procedures requiring information about current health status, current license status in Illinois, and biennial review of renewed license.

 

2)         The procedure shall grant to current medical staff members at least: written notice of an adverse decision by the Governing Board; an explanation and reasons for an adverse decision; the right to examine and/or present copies of relevant information, if any, related to an adverse decision; an opportunity to appeal an adverse decision; and written notice of the decision resulting from the appeal.  The procedures for providing written notice shall include timeframes for giving such notice.

 

c)         The medical staff bylaws for all hospitals except county hospitals shall include at least the following provisions for granting, limiting, renewing, or denying medical staff membership and clinical staff privileges:

 

1)         Minimum procedures for initial applicants for medical staff membership shall include the following:

 

A)        Written procedures relating to the acceptance and processing of initial applicants for medical staff membership.

 

B)        Written procedures to be followed in determining an applicant's qualifications for being granted medical staff membership and privileges.

 

C)        Written criteria to be followed in evaluating an applicant's qualifications.

 

D)        An evaluation of an applicant's current health status and current license status in Illinois.

 

E)         A written response to each applicant that explains the reason or reasons for any adverse decision (including all reasons based in whole or in part on the applicant's medical qualifications or any other basis, including economic factors).

 

2)         Minimum procedures with respect to medical staff and clinical privilege determinations concerning current members of the medical staff shall include the following:

 

A)        A written explanation of the reasons for an adverse decision including all reasons based on the quality of medical care or any other basis, including economic factors.

 

B)        A statement of the medical staff member's right to request a fair hearing on the adverse decision before a hearing panel whose membership is mutually agreed upon by the medical staff and the hospital governing board. The hearing panel shall have independent authority to recommend action to the hospital governing board.  Upon the request of the medical staff member or the hospital governing board, the hearing panel shall make findings concerning the nature of each basis for any adverse decision recommended to and accepted by the hospital governing board.

 

i)          Nothing in subsection (c)(2)(B) of this Section limits a hospital's or medical staff's right to summarily suspend, without a prior hearing, a person's medical staff membership or clinical privileges if the continuation of practice of a medical staff member constitutes an immediate danger to the public, including patients, visitors, and hospital employees and staff.

 

ii)         In the event that a hospital or the medical staff imposes a summary suspension, the Medical Executive Committee, or other comparable governance committee of the medical staff as specified in the bylaws, must meet as soon as is reasonably possible to review the suspension and to recommend whether  it should be affirmed, lifted, expunged, or modified if the suspended physician requests such review.

 

iii)         A summary suspension may not be implemented unless there is actual documentation or other reliable information that an immediate danger exists.  This documentation or information must be available at the time the summary suspension decision is made and when the decision is reviewed by the Medical Executive Committee.

 

iv)        If the Medical Executive Committee recommends that the summary suspension should be lifted, expunged, or modified, this recommendation must be reviewed and considered by the hospital governing board, or a committee of the board, on an expedited basis.

 

v)         Nothing in this subsection (c)(2)(B) shall affect the requirement that any requested hearing must be commenced within 15 days after the summary suspension and completed without delay unless otherwise agreed to by the parties.

 

vi)        A fair hearing shall be commenced within 15 days after the suspension and completed without delay, except that, when the medical staff member's license to practice has been suspended or revoked by the Department of Financial and Professional Regulation, no hearing shall be necessary.

 

vii)        Nothing in subsection (c)(2)(B) of this Section limits a medical staff's right to permit, in the medical staff bylaws, summary suspension of membership or clinical privileges in designated administrative circumstances as specifically approved by the medical staff.  This bylaw provision must specifically describe both the administrative circumstance that can result in a summary suspension and the length of the summary suspension. The opportunity for a fair hearing is required for any administrative summary suspension.  Any requested hearing must be commenced within 15 days after the summary suspension and completed without delay.  Adverse decisions other than suspension or other restrictions on the treatment or admission of patients may be imposed summarily and without a hearing under designated administrative circumstances as specifically provided for in the medical staff bylaws as approved by the medical staff.

 

viii)       If a hospital exercises its option to enter into an exclusive contract and that contract results in the total or partial termination or reduction of medical staff membership or clinical privileges of a current medical staff member, the hospital shall provide the affected medical staff member 60 days prior notice of the effect on his or her medical staff membership or privileges.  An affected medical staff member desiring a hearing under subsection (c)(2)(B) of this Section must request the hearing within 14 days after the date he or she is so notified.  The requested hearing shall be commenced and completed (with a report and recommendation to the affected medical staff member, hospital governing board, and medical staff) within 30 days after the date of the medical staff member's request.  If agreed upon by both the medical staff and the hospital governing board, the medical staff bylaws may provide for longer time periods.

 

C)        All peer review used for the purpose of credentialing, privileging, disciplinary action, or other recommendations affecting medical staff membership or exercise of clinical privileges, whether relying in whole or in part on internal or external reviews, shall be conducted in accordance with the medical staff bylaws and applicable rules, regulations, or policies of the medical staff.  If external review is obtained, any adverse report utilized shall be in writing and shall be made part of the internal peer review process under the bylaws.  The report shall also be shared with a medical staff peer review committee and the individual under review.  If the medical staff peer review committee or the individual under review prepares a written response to the report of the external peer review within 30 days after receiving such report, the governing board shall consider the response prior to the implementation of any final actions by the governing board which may affect the individual's medical staff membership or clinical privileges.  Any peer review that involves willful or wanton misconduct shall be subject to civil damages as provided for under Section 10.2 of the Act.

 

D)        A statement of the member's right to inspect all pertinent information in the hospital's possession with respect to the decision.

 

E)         A statement of the member's right to present witnesses and other evidence at the hearing on the decision.

 

F)         A written notice and written explanation of the decision resulting from the hearings.

 

G)        A written notice of a final adverse decision by the Hospital Governing Board.

 

H)        Notice given 15 days before implementation of an adverse medical staff membership or clinical privileges decision based substantially on economic factors.  This notice shall be given after the medical staff member exhausts all applicable procedures under subsection (c)(2)(B)(viii) of this Section, and under the medical staff bylaws in order to allow sufficient time for the orderly provision of patient care.

 

I)          Nothing in subsection (c)(2) of this Section limits a medical staff member's right to waive, in writing, the rights provided in subsection (c)(2)(A)-(H) of this Section upon being granted the written exclusive right to provide particular services at a hospital, either individually or as a member of a group.  If an exclusive contract is signed by a representative of a group of physicians, a waiver contained in the contract shall apply to all members of the group unless stated otherwise in the contract.  (Section 10.4(b) of the Act)

 

3)         Every adverse medical staff membership and clinical privilege decision based substantially on economic factors shall be reported to the Hospital Licensing Board before the decision takes effect.  The reports shall not be disclosed in any form that reveals the identity of any hospital or physician.  These reports shall be utilized to study the effects that hospital medical staff membership and clinical privilege decisions based upon economic factors have on access to care and the availability of physician services. (Section 10.4(b) of the Act)

 

d)         Regardless of any other categories (divisions of the medical staff) having privileges in the hospital, there shall be an active staff, which shall include physicians and may also include podiatrists and dentists, properly organized, who perform all the organizational duties pertaining to the medical staff.  These duties include:

 

1)         Maintenance of the proper quality of all medical care and treatment of inpatients and outpatients in the hospital.  Proper quality of medical care and treatment includes:

 

A)        availability and use of accurate diagnostic testing for the types of patients admitted;

 

B)        availability and use of medical, surgical, and psychiatric treatment for patients admitted;

 

C)        availability and use of consultation, diagnostic tools and treatment modalities for the care of patients admitted including the care needed for complications that may be expected to occur; and

 

D)        availability and performance of auxiliary and associate staff with documented training and experience in diagnostic and treatment modalities in use by the medical staff and documented training and experience in managing complications that may be expected to occur.

 

2)         Organization of the medical staff, including adoption of rules and regulations for its government (which require the approval of the governing body), election of its officers or recommendations to the governing body for appointment of the officers, and recommendations to the governing body upon all appointments to the staff and grants of hospital privileges.

 

3)         Other recommendations to the governing body regarding matters within the purview of the medical staff.

 

e)         The medical staff may include one or more divisions in addition to the active staff, but this in no way modifies the duties and responsibilities of the active staff.

 

f)          For the purpose of this Section only:

 

1)         Adverse decision means a decision reducing, restricting, suspending, revoking, denying, or not renewing medical staff membership or clinical privileges. 

 

2)         Economic factor means any information or reasons for decisions unrelated to quality of care or professional competency. 

 

3)         Privilege means permission to provide medical or other patient care services and permission to use hospital resources, including equipment, facilities and personnel that are necessary to effectively provide medical or other patient care services.  This definition shall not be construed to require a hospital to acquire additional equipment, facilities, or personnel to accommodate the granting of privileges. (Section 10.4(b) of the Act)

 

(Source:  Amended at 34 Ill. Reg. 19158, effective November 23, 2010)