100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB2769

 

Introduced , by Rep. Ann M. Williams

 

SYNOPSIS AS INTRODUCED:
 
110 ILCS 330/3.5 new
210 ILCS 85/10.4  from Ch. 111 1/2, par. 151.4

    Amends the University of Illinois Hospital Act and the Hospital Licensing Act. Provides that if agreeing to a medical staff member's resignation, surrender, restriction, or limitation of his or her medical staff membership or clinical privileges; determining a medical staff member's leave of absence of greater than 30 days has begun; or determining a medical staff member's medical staff membership or clinical privileges have expired due to failure of the medical staff member to reapply requires a hospital to file a report with the National Practitioner Data Bank, then, upon request or prior to such agreement or determination, the hospital must provide the medical staff member with specified notice and opportunities to postpone such adverse action. Provides that medical staff members shall be given at least 14 days after the date of notice to exercise their right to postpone.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB2769LRB100 05558 MJP 15572 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The University of Illinois Hospital Act is
5amended by adding Section 3.5 as follows:
 
6    (110 ILCS 330/3.5 new)
7    Sec. 3.5. Notice required prior to filing a report with the
8National Practitioner Data Bank. Upon request or prior to (1)
9agreeing to the resignation, surrender, restriction, or
10limitation of a medical staff member's medical staff membership
11or clinical privileges, (2) determining a medical staff
12member's leave of absence of greater than 30 days has begun, or
13(3) determining a medical staff member's medical staff
14membership or clinical privileges has expired due to failure of
15the medical staff member to reapply, the University of Illinois
16Hospital must, if such agreement or determination requires the
17University of Illinois Hospital to file a report with the
18National Practitioner Data Bank:    
19        (A) give notice to the medical staff member that such
20    agreement or determination triggers a report to the
21    National Practitioner Data Bank if not postponed; and
22        (B) afford the medical staff member the opportunity to
23    postpone the resignation, surrender, restriction,

 

 

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1    limitation, leave, or expiration in order to participate in
2    the investigation until the hospital formally closes the
3    matter or, if the investigation results in an adverse
4    action recommendation or if an adverse action has already
5    been proposed, then until exhaustion of the substantive and
6    procedural rights afforded medical staff members under
7    federal and State law and the University of Illinois
8    Hospital's medical staff bylaws.
9    Medical staff members shall be given a minimum of 14 days
10after the date of the notice from the University of Illinois
11Hospital to exercise their right to postpone. The purpose and
12intent of this Section is to preserve the right of medical
13staff members to defend themselves against allegations and
14adverse actions related to professional competence or conduct
15before a report is required to be filed with the National
16Practitioner Data Bank under the federal Health Care Quality
17Improvement Act of 1986, including any amendments thereto.
 
18    Section 10. The Hospital Licensing Act is amended by
19changing Section 10.4 as follows:
 
20    (210 ILCS 85/10.4)  (from Ch. 111 1/2, par. 151.4)
21    Sec. 10.4. Medical staff privileges.
22    (a) Any hospital licensed under this Act or any hospital
23organized under the University of Illinois Hospital Act shall,
24prior to the granting of any medical staff privileges to an

 

 

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1applicant, or renewing a current medical staff member's
2privileges, request of the Director of Professional Regulation
3information concerning the licensure status and any
4disciplinary action taken against the applicant's or medical
5staff member's license, except: (1) for medical personnel who
6enter a hospital to obtain organs and tissues for transplant
7from a donor in accordance with the Illinois Anatomical Gift
8Act; or (2) for medical personnel who have been granted
9disaster privileges pursuant to the procedures and
10requirements established by rules adopted by the Department.
11Any hospital and any employees of the hospital or others
12involved in granting privileges who, in good faith, grant
13disaster privileges pursuant to this Section to respond to an
14emergency shall not, as a result of their acts or omissions, be
15liable for civil damages for granting or denying disaster
16privileges except in the event of willful and wanton
17misconduct, as that term is defined in Section 10.2 of this
18Act. Individuals granted privileges who provide care in an
19emergency situation, in good faith and without direct
20compensation, shall not, as a result of their acts or
21omissions, except for acts or omissions involving willful and
22wanton misconduct, as that term is defined in Section 10.2 of
23this Act, on the part of the person, be liable for civil
24damages. The Director of Professional Regulation shall
25transmit, in writing and in a timely fashion, such information
26regarding the license of the applicant or the medical staff

 

 

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1member, including the record of imposition of any periods of
2supervision or monitoring as a result of alcohol or substance
3abuse, as provided by Section 23 of the Medical Practice Act of
41987, and such information as may have been submitted to the
5Department indicating that the application or medical staff
6member has been denied, or has surrendered, medical staff
7privileges at a hospital licensed under this Act, or any
8equivalent facility in another state or territory of the United
9States. The Director of Professional Regulation shall define by
10rule the period for timely response to such requests.
11    No transmittal of information by the Director of
12Professional Regulation, under this Section shall be to other
13than the president, chief operating officer, chief
14administrative officer, or chief of the medical staff of a
15hospital licensed under this Act, a hospital organized under
16the University of Illinois Hospital Act, or a hospital operated
17by the United States, or any of its instrumentalities. The
18information so transmitted shall be afforded the same status as
19is information concerning medical studies by Part 21 of Article
20VIII of the Code of Civil Procedure, as now or hereafter
21amended.
22    (b) All hospitals licensed under this Act, except county
23hospitals as defined in subsection (c) of Section 15-1 of the
24Illinois Public Aid Code, shall comply with, and the medical
25staff bylaws of these hospitals shall include rules consistent
26with, the provisions of this Section in granting, limiting,

 

 

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1renewing, or denying medical staff membership and clinical
2staff privileges. Hospitals that require medical staff members
3to possess faculty status with a specific institution of higher
4education are not required to comply with subsection (1) below
5when the physician does not possess faculty status.
6        (1) Minimum procedures for pre-applicants and
7    applicants for medical staff membership shall include the
8    following:
9            (A) Written procedures relating to the acceptance
10        and processing of pre-applicants or applicants for
11        medical staff membership, which should be contained in
12        medical staff bylaws.
13            (B) Written procedures to be followed in
14        determining a pre-applicant's or an applicant's
15        qualifications for being granted medical staff
16        membership and privileges.
17            (C) Written criteria to be followed in evaluating a
18        pre-applicant's or an applicant's qualifications.
19            (D) An evaluation of a pre-applicant's or an
20        applicant's current health status and current license
21        status in Illinois.
22            (E) A written response to each pre-applicant or
23        applicant that explains the reason or reasons for any
24        adverse decision (including all reasons based in whole
25        or in part on the applicant's medical qualifications or
26        any other basis, including economic factors).

 

 

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1        (2) Minimum procedures with respect to medical staff
2    and clinical privilege determinations concerning current
3    members of the medical staff shall include the following:
4            (A) A written notice of an adverse decision.
5            (B) An explanation of the reasons for an adverse
6        decision including all reasons based on the quality of
7        medical care or any other basis, including economic
8        factors.
9            (C) A statement of the medical staff member's right
10        to request a fair hearing on the adverse decision
11        before a hearing panel whose membership is mutually
12        agreed upon by the medical staff and the hospital
13        governing board. The hearing panel shall have
14        independent authority to recommend action to the
15        hospital governing board. Upon the request of the
16        medical staff member or the hospital governing board,
17        the hearing panel shall make findings concerning the
18        nature of each basis for any adverse decision
19        recommended to and accepted by the hospital governing
20        board.
21                (i) Nothing in this subparagraph (C) limits a
22            hospital's or medical staff's right to summarily
23            suspend, without a prior hearing, a person's
24            medical staff membership or clinical privileges if
25            the continuation of practice of a medical staff
26            member constitutes an immediate danger to the

 

 

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1            public, including patients, visitors, and hospital
2            employees and staff. In the event that a hospital
3            or the medical staff imposes a summary suspension,
4            the Medical Executive Committee, or other
5            comparable governance committee of the medical
6            staff as specified in the bylaws, must meet as soon
7            as is reasonably possible to review the suspension
8            and to recommend whether it should be affirmed,
9            lifted, expunged, or modified if the suspended
10            physician requests such review. A summary
11            suspension may not be implemented unless there is
12            actual documentation or other reliable information
13            that an immediate danger exists. This
14            documentation or information must be available at
15            the time the summary suspension decision is made
16            and when the decision is reviewed by the Medical
17            Executive Committee. If the Medical Executive
18            Committee recommends that the summary suspension
19            should be lifted, expunged, or modified, this
20            recommendation must be reviewed and considered by
21            the hospital governing board, or a committee of the
22            board, on an expedited basis. Nothing in this
23            subparagraph (C) shall affect the requirement that
24            any requested hearing must be commenced within 15
25            days after the summary suspension and completed
26            without delay unless otherwise agreed to by the

 

 

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1            parties. A fair hearing shall be commenced within
2            15 days after the suspension and completed without
3            delay, except that when the medical staff member's
4            license to practice has been suspended or revoked
5            by the State's licensing authority, no hearing
6            shall be necessary.
7                (ii) Nothing in this subparagraph (C) limits a
8            medical staff's right to permit, in the medical
9            staff bylaws, summary suspension of membership or
10            clinical privileges in designated administrative
11            circumstances as specifically approved by the
12            medical staff. This bylaw provision must
13            specifically describe both the administrative
14            circumstance that can result in a summary
15            suspension and the length of the summary
16            suspension. The opportunity for a fair hearing is
17            required for any administrative summary
18            suspension. Any requested hearing must be
19            commenced within 15 days after the summary
20            suspension and completed without delay. Adverse
21            decisions other than suspension or other
22            restrictions on the treatment or admission of
23            patients may be imposed summarily and without a
24            hearing under designated administrative
25            circumstances as specifically provided for in the
26            medical staff bylaws as approved by the medical

 

 

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1            staff.
2                (iii) If a hospital exercises its option to
3            enter into an exclusive contract and that contract
4            results in the total or partial termination or
5            reduction of medical staff membership or clinical
6            privileges of a current medical staff member, the
7            hospital shall provide the affected medical staff
8            member 60 days prior notice of the effect on his or
9            her medical staff membership or privileges. An
10            affected medical staff member desiring a hearing
11            under subparagraph (C) of this paragraph (2) must
12            request the hearing within 14 days after the date
13            he or she is so notified. The requested hearing
14            shall be commenced and completed (with a report and
15            recommendation to the affected medical staff
16            member, hospital governing board, and medical
17            staff) within 30 days after the date of the medical
18            staff member's request. If agreed upon by both the
19            medical staff and the hospital governing board,
20            the medical staff bylaws may provide for longer
21            time periods.
22            (C-5) All peer review used for the purpose of
23        credentialing, privileging, disciplinary action, or
24        other recommendations affecting medical staff
25        membership or exercise of clinical privileges, whether
26        relying in whole or in part on internal or external

 

 

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1        reviews, shall be conducted in accordance with the
2        medical staff bylaws and applicable rules,
3        regulations, or policies of the medical staff. If
4        external review is obtained, any adverse report
5        utilized shall be in writing and shall be made part of
6        the internal peer review process under the bylaws. The
7        report shall also be shared with a medical staff peer
8        review committee and the individual under review. If
9        the medical staff peer review committee or the
10        individual under review prepares a written response to
11        the report of the external peer review within 30 days
12        after receiving such report, the governing board shall
13        consider the response prior to the implementation of
14        any final actions by the governing board which may
15        affect the individual's medical staff membership or
16        clinical privileges. Any peer review that involves
17        willful or wanton misconduct shall be subject to civil
18        damages as provided for under Section 10.2 of this Act.
19            (D) A statement of the member's right to inspect
20        all pertinent information in the hospital's possession
21        with respect to the decision.
22            (E) A statement of the member's right to present
23        witnesses and other evidence at the hearing on the
24        decision.
25            (E-5) The right to be represented by a personal
26        attorney.

 

 

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1            (F) A written notice and written explanation of the
2        decision resulting from the hearing.
3            (F-5) A written notice of a final adverse decision
4        by a hospital governing board.
5            (G) Notice given 15 days before implementation of
6        an adverse medical staff membership or clinical
7        privileges decision based substantially on economic
8        factors. This notice shall be given after the medical
9        staff member exhausts all applicable procedures under
10        this Section, including item (iii) of subparagraph (C)
11        of this paragraph (2), and under the medical staff
12        bylaws in order to allow sufficient time for the
13        orderly provision of patient care.
14            (H) Nothing in this paragraph (2) of this
15        subsection (b) limits a medical staff member's right to
16        waive, in writing, the rights provided in
17        subparagraphs (A) through (G) of this paragraph (2) of
18        this subsection (b) upon being granted the written
19        exclusive right to provide particular services at a
20        hospital, either individually or as a member of a
21        group. If an exclusive contract is signed by a
22        representative of a group of physicians, a waiver
23        contained in the contract shall apply to all members of
24        the group unless stated otherwise in the contract.
25        (3) Every adverse medical staff membership and
26    clinical privilege decision based substantially on

 

 

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1    economic factors shall be reported to the Hospital
2    Licensing Board before the decision takes effect. These
3    reports shall not be disclosed in any form that reveals the
4    identity of any hospital or physician. These reports shall
5    be utilized to study the effects that hospital medical
6    staff membership and clinical privilege decisions based
7    upon economic factors have on access to care and the
8    availability of physician services. The Hospital Licensing
9    Board shall submit an initial study to the Governor and the
10    General Assembly by January 1, 1996, and subsequent reports
11    shall be submitted periodically thereafter.
12        (4) As used in this Section:
13        "Adverse decision" means a decision reducing,
14    restricting, suspending, revoking, denying, or not
15    renewing medical staff membership or clinical privileges.
16        "Economic factor" means any information or reasons for
17    decisions unrelated to quality of care or professional
18    competency.
19        "Pre-applicant" means a physician licensed to practice
20    medicine in all its branches who requests an application
21    for medical staff membership or privileges.
22        "Privilege" means permission to provide medical or
23    other patient care services and permission to use hospital
24    resources, including equipment, facilities and personnel
25    that are necessary to effectively provide medical or other
26    patient care services. This definition shall not be

 

 

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1    construed to require a hospital to acquire additional
2    equipment, facilities, or personnel to accommodate the
3    granting of privileges.
4        (5) Any amendment to medical staff bylaws required
5    because of this amendatory Act of the 91st General Assembly
6    shall be adopted on or before July 1, 2001.
7    (c) All hospitals shall consult with the medical staff
8prior to closing membership in the entire or any portion of the
9medical staff or a department. If the hospital closes
10membership in the medical staff, any portion of the medical
11staff, or the department over the objections of the medical
12staff, then the hospital shall provide a detailed written
13explanation for the decision to the medical staff 10 days prior
14to the effective date of any closure. No applications need to
15be provided when membership in the medical staff or any
16relevant portion of the medical staff is closed.
17    (d) Upon request or prior to (1) agreeing to the
18resignation, surrender, restriction, or limitation of a
19medical staff member's medical staff membership or clinical
20privileges, (2) determining a medical staff member's leave of
21absence of greater than 30 days has begun, or (3) determining a
22medical staff member's medical staff membership or clinical
23privileges has expired due to failure of the medical staff
24member to reapply, a hospital must, if such agreement or
25determination requires the hospital to file a report with the
26National Practitioner Data Bank:

 

 

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1        (A) give notice to the medical staff member that such
2    agreement or determination triggers a report to the
3    National Practitioner Data Bank if not postponed; and
4        (B) afford the medical staff member the opportunity to
5    postpone the resignation, surrender, restriction,
6    limitation, leave, or expiration in order to participate in
7    the investigation until the hospital formally closes the
8    matter or, if the investigation results in an adverse
9    action recommendation or if an adverse action has already
10    been proposed, then until exhaustion of the substantive and
11    procedural rights afforded medical staff members under
12    federal and State law and the hospital's medical staff
13    bylaws.
14    Medical staff members shall be given a minimum of 14 days
15after the date of the notice from the hospital to exercise
16their right to postpone. The purpose and intent of this Section
17is to preserve the right of medical staff members to defend
18themselves against allegations and adverse actions related to
19professional competence or conduct before a report is required
20to be filed with the National Practitioner Data Bank under the
21federal Health Care Quality Improvement Act of 1986, including
22any amendments thereto.
23(Source: P.A. 96-445, eff. 8-14-09; 97-1006, eff. 8-17-12.)