(210 ILCS 85/3)
As used in this Act:
(A) "Hospital" means any institution, place, building, buildings on a campus, or agency, public
or private, whether organized for profit or not, devoted primarily to the
maintenance and operation of facilities for the diagnosis and treatment or
care of 2 or more unrelated persons admitted for overnight stay or longer
in order to obtain medical, including obstetric, psychiatric and nursing,
care of illness, disease, injury, infirmity, or deformity.
The term "hospital", without regard to length of stay, shall also
(a) any facility which is devoted primarily to
providing psychiatric and related services and programs for the diagnosis and treatment or care of 2 or more unrelated persons suffering from emotional or nervous diseases;
(b) all places where pregnant females are received,
cared for, or treated during delivery irrespective of the number of patients received.
The term "hospital" includes general and specialized hospitals,
tuberculosis sanitaria, mental or psychiatric hospitals and sanitaria, and
includes maternity homes, lying-in homes, and homes for unwed mothers in
which care is given during delivery.
The term "hospital" does not include:
(1) any person or institution required to be licensed
pursuant to the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act;
(2) hospitalization or care facilities maintained by
the State or any department or agency thereof, where such department or agency has authority under law to establish and enforce standards for the hospitalization or care facilities under its management and control;
(3) hospitalization or care facilities maintained by
the federal government or agencies thereof;
(4) hospitalization or care facilities maintained by
any university or college established under the laws of this State and supported principally by public funds raised by taxation;
(5) any person or facility required to be licensed
pursuant to the Substance Use Disorder Act;
(6) any facility operated solely by and for persons
who rely exclusively upon treatment by spiritual means through prayer, in accordance with the creed or tenets of any well-recognized church or religious denomination;
(7) an Alzheimer's disease management center
alternative health care model licensed under the Alternative Health Care Delivery Act; or
(8) any veterinary hospital or clinic operated by a
veterinarian or veterinarians licensed under the Veterinary Medicine and Surgery Practice Act of 2004 or maintained by a State-supported or publicly funded university or college.
(B) "Person" means the State, and any political subdivision or municipal
corporation, individual, firm, partnership, corporation, company,
association, or joint stock association, or the legal successor thereof.
(C) "Department" means the Department of Public Health of the State of
(D) "Director" means the Director of Public Health of
the State of Illinois.
(E) "Perinatal" means the period of time
between the conception of an
infant and the end of the first month after birth.
(F) "Federally designated organ procurement agency" means the organ
procurement agency designated by the Secretary of the U.S. Department of Health
and Human Services for the service area in which a hospital is located; except
that in the case of a hospital located in a county adjacent to Wisconsin
which currently contracts with an organ procurement agency located in Wisconsin
that is not the organ procurement agency designated by the U.S. Secretary of
Health and Human Services for the service area in which the hospital is
located, if the hospital applies for a waiver pursuant to 42 USC
1320b-8(a), it may designate an organ procurement agency
located in Wisconsin to be thereafter deemed its federally designated organ
procurement agency for the purposes of this Act.
(G) "Tissue bank" means any facility or program operating in Illinois
that is certified by the American Association of Tissue Banks or the Eye Bank
Association of America and is involved in procuring, furnishing, donating,
or distributing corneas, bones, or other human tissue for the purpose of
injecting, transfusing, or transplanting any of them into the human body.
"Tissue bank" does not include a licensed blood bank. For the purposes of this
Act, "tissue" does not include organs.
(H) "Campus", as this terms applies to operations, has the same meaning as the term "campus" as set forth in federal Medicare regulations, 42 CFR 413.65.
(Source: P.A. 99-180, eff. 7-29-15; 100-759, eff. 1-1-19
(210 ILCS 85/6.08)
(from Ch. 111 1/2, par. 147.08)
(a) Every hospital shall provide notification as required in
this Section to police officers, firefighters, emergency
medical technicians, private emergency medical services providers, and
ambulance personnel who have provided or are about to provide transport services, emergency
care, or life support services to a patient who has been diagnosed as having
a dangerous communicable or infectious disease. Such notification shall
not include the name of the patient, and the emergency services provider
agency and any person receiving such
notification shall treat the information received as a confidential medical
(b) The Department shall utilize the Centers for Disease Control and Prevention's list of potentially life-threatening infectious diseases to determine the diseases for which notification shall
(c) The hospital shall send the letter of notification no later than 48 hours
after a confirmed diagnosis of any of the bloodborne communicable diseases listed by
the Department pursuant to subsection (b). The hospital shall attempt to make verbal communication, followed by written notification only
if the police officers, firefighters, emergency medical
technicians, private emergency medical services providers, or ambulance personnel have
indicated both verbally and on the ambulance run
sheet that a reasonable possibility exists that they have had blood or body
fluid contact with the patient, or if hospital personnel providing the
notification have reason to know of a possible exposure.
(c-5) The hospital shall send the letter of notification no later than 48 hours after a confirmed diagnosis of any of the airborne or droplet-transmitted communicable diseases listed by the Department pursuant to subsection (b) and the hospital shall attempt to make verbal communication, followed by written notification.
(d) Notification letters shall be sent to the designated officer at the
municipal or private provider agencies listed on the ambulance run sheet.
Except in municipalities with a population over 1,000,000, a list
attached to the
ambulance run sheet must contain all municipal and private provider
personnel who have provided any pre-hospital care immediately prior to
In municipalities with a population over 1,000,000, the
ambulance run sheet must contain the company number or unit
designation number for any fire department personnel who have
provided any pre-hospital care immediately prior to transport.
shall state the names of crew members listed on
the attachment to
run sheet and the name of the
communicable disease diagnosed, but shall not
contain the patient's name. Upon receipt of such notification letter, the
applicable private provider agency or the designated infectious disease
control officer of a municipal fire department or fire protection
district shall contact all personnel involved in the pre-hospital or
inter-hospital care and transport of the patient. Such notification letter
may, but is not required to, consist of the following form:
(NAME OF HOSPITAL)
TO:...... (Name of Organization)
FROM:.....(Infection Control Coordinator)
As required by Section 6.08 of the Illinois Hospital Licensing Act,
.....(name of hospital) is hereby providing notification that the following
members or agencies transported or provided pre-hospital care to a patient
on ..... (date), and the transported patient was later
of communicable disease): .....(list of crew members if known). The Hospital
Licensing Act requires you to maintain this information as a confidential
medical record. Disclosure of this information may therefore result in
civil liability for the individual or company breaching the patient's
confidentiality, or both.
If you have any questions regarding this patient, please contact me at
.....(telephone number), between .....(hours). Questions regarding exposure
or the financial aspects of obtaining medical care should be directed to your
(e) Upon discharge of a patient with a communicable disease to emergency
personnel, the hospital shall notify the emergency personnel of appropriate
precautions against the communicable disease, but shall not identify the
name of the disease.
(f) The hospital may, in its discretion, take any measures in addition
to those required in this Section to notify
police officers, firefighters,
emergency medical technicians, and ambulance
personnel of possible exposure to any communicable disease. However, in
all cases this information shall be maintained as a confidential medical
(g) Any person providing or failing to provide notification under the
protocol required by this Section shall have immunity from any liability,
either criminal or civil, that might result by reason of such action or
inaction, unless such action or inaction is willful.
(h) Any person who willfully fails to provide any notification required
pursuant to an applicable protocol which has been adopted and approved
pursuant to this Section commits a petty offense, and shall be subject
to a fine of $200 for the first offense, and $500 for a second or subsequent
(i) Nothing in this Section shall preclude a civil action by a
emergency medical technician, or ambulance crew member against
an emergency services provider
agency, municipal fire department, or fire protection district that fails to
inform the member in a timely
fashion of the
receipt of a notification letter.
(Source: P.A. 98-851, eff. 8-1-14.)
(210 ILCS 85/6.09)
(from Ch. 111 1/2, par. 147.09)
(a) In order to facilitate the orderly transition of aged
patients and patients with disabilities from hospitals to post-hospital care, whenever a
patient who qualifies for the
federal Medicare program is hospitalized, the patient shall be notified
of discharge at least
24 hours prior to discharge from
the hospital. With regard to pending discharges to a skilled nursing facility, the hospital must notify the case coordination unit, as defined in 89 Ill. Adm. Code 240.260, at least 24 hours prior to discharge. When the assessment is completed in the hospital, the case coordination unit shall provide a copy of the required assessment documentation directly to the nursing home to which the patient is being discharged prior to discharge. The Department on Aging shall provide notice of this requirement to case coordination units. When a case coordination unit is unable to complete an assessment in a hospital prior to the discharge of a patient, 60 years of age or older, to a nursing home, the case coordination unit shall notify the Department on Aging which shall notify the Department of Healthcare and Family Services. The Department of Healthcare and Family Services and the Department on Aging shall adopt rules to address these instances to ensure that the patient is able to access nursing home care, the nursing home is not penalized for accepting the admission, and the patient's timely discharge from the hospital is not delayed, to the extent permitted under federal law or regulation. Nothing in this subsection shall preclude federal requirements for a pre-admission screening/mental health (PAS/MH) as required under Section 2-201.5 of the Nursing Home Care Act or State or federal law or regulation. If home health services are ordered, the hospital must inform its designated case coordination unit, as defined in 89 Ill. Adm. Code 240.260, of the pending discharge and must provide the patient with the case coordination unit's telephone number and other contact information.
(b) Every hospital shall develop procedures for a physician with medical
staff privileges at the hospital or any appropriate medical staff member to
provide the discharge notice prescribed in subsection (a) of this Section. The procedures must include prohibitions against discharging or referring a patient to any of the following if unlicensed, uncertified, or unregistered: (i) a board and care facility, as defined in the Board and Care Home Act; (ii) an assisted living and shared housing establishment, as defined in the Assisted Living and Shared Housing Act; (iii) a facility licensed under the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act; (iv) a supportive living facility, as defined in Section 5-5.01a of the Illinois Public Aid Code; or (v) a free-standing hospice facility licensed under the Hospice Program Licensing Act if licensure, certification, or registration is required. The Department of Public Health shall annually provide hospitals with a list of licensed, certified, or registered board and care facilities, assisted living and shared housing establishments, nursing homes, supportive living facilities, facilities licensed under the ID/DD Community Care Act, the MC/DD Act, or the Specialized Mental Health Rehabilitation Act of 2013, and hospice facilities. Reliance upon this list by a hospital shall satisfy compliance with this requirement.
The procedure may also include a waiver for any case in which a discharge
notice is not feasible due to a short length of stay in the hospital by the patient,
or for any case in which the patient voluntarily desires to leave the
hospital before the expiration of the
24 hour period.
(c) At least
24 hours prior to discharge from the hospital, the
patient shall receive written information on the patient's right to appeal the
discharge pursuant to the
federal Medicare program, including the steps to follow to appeal
the discharge and the appropriate telephone number to call in case the
patient intends to appeal the discharge.
(d) Before transfer of a patient to a long term care facility licensed under the Nursing Home Care Act where elderly persons reside, a hospital shall as soon as practicable initiate a name-based criminal history background check by electronic submission to the Department of State Police for all persons between the ages of 18 and 70 years; provided, however, that a hospital shall be required to initiate such a background check only with respect to patients who:
(1) are transferring to a long term care facility for
(2) have been in the hospital more than 5 days;
(3) are reasonably expected to remain at the long
term care facility for more than 30 days;
(4) have a known history of serious mental illness or
(5) are independently ambulatory or mobile for more
than a temporary period of time.
A hospital may also request a criminal history background check for a patient who does not meet any of the criteria set forth in items (1) through (5).
A hospital shall notify a long term care facility if the hospital has initiated a criminal history background check on a patient being discharged to that facility. In all circumstances in which the hospital is required by this subsection to initiate the criminal history background check, the transfer to the long term care facility may proceed regardless of the availability of criminal history results. Upon receipt of the results, the hospital shall promptly forward the results to the appropriate long term care facility. If the results of the background check are inconclusive, the hospital shall have no additional duty or obligation to seek additional information from, or about, the patient.
(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; 99-143, eff. 7-27-15; 99-180, eff. 7-29-15; 99-642, eff. 7-28-16; 99-857, eff. 1-1-17
(210 ILCS 85/6.14c)
(Text of Section before amendment by P.A. 101-117
Posting of information.
Every hospital shall conspicuously post
for display in an
area of its offices accessible to patients, employees, and visitors the
(1) its current license;
(2) a description, provided by the Department, of
complaint procedures established under this Act and the name, address, and telephone number of a person authorized by the Department to receive complaints;
(3) a list of any orders pertaining to the hospital
issued by the Department during the past year and any court orders reviewing such Department orders issued during the past year; and
(4) a list of the material available for public
inspection under Section 6.14d.
(Source: P.A. 91-242, eff. 1-1-00.)
(Text of Section after amendment by P.A. 101-117
Posting of information.
Every hospital shall conspicuously post
for display in an
area of its offices accessible to patients, employees, and visitors the
(1) its current license;
(2) a description, provided by the Department, of
complaint procedures established under this Act and the name, address, and telephone number of a person authorized by the Department to receive complaints;
(3) a list of any orders pertaining to the hospital
issued by the Department during the past year and any court orders reviewing such Department orders issued during the past year; and
(4) a list of the material available for public
inspection under Section 6.14d.
Each hospital shall post, in each facility that has an emergency room, a notice in a conspicuous location in the emergency room with information about how to enroll in health insurance through the Illinois health insurance marketplace in accordance with Sections 1311 and 1321 of the federal Patient Protection and Affordable Care Act.
(Source: P.A. 101-117, eff. 1-1-20.)
(210 ILCS 85/6.17)
Protection of and confidential access to medical records
(a) Every hospital licensed under this Act shall develop a medical record
for each of its patients as required by the Department by rule.
(b) All information regarding a hospital patient gathered by the hospital's
medical staff and its agents and employees shall be the property and
responsibility of the hospital and must be protected from inappropriate
disclosure as provided in this Section.
(c) Every hospital shall preserve its medical records in a format and for a
duration established by hospital policy and for not less than 10 years,
provided that if the hospital has been notified in writing by an attorney
before the expiration of the 10 year retention period that there is litigation
pending in court involving the record of a particular patient as possible
evidence and that the patient is his client or is the person who has instituted
such litigation against his client, then the hospital shall retain the record
of that patient until notified in writing by the plaintiff's attorney, with the
approval of the defendant's attorney of record, that the case in court
such record has been concluded or for a period of 12 years from the date that
the record was produced, whichever occurs first in time.
(d) No member of a hospital's medical staff and no agent or employee of a
hospital shall disclose the nature or details of services provided to patients,
except that the information may be disclosed to the patient, persons authorized
by the patient, the party making treatment decisions, if the patient
is incapable of making decisions regarding the health services provided, those
parties directly involved with providing treatment to the patient or processing
the payment for that treatment, those parties responsible for peer review,
utilization review or quality assurance, risk management, or
defense of claims
brought against the hospital arising out of the care, and those parties
required to be notified under the Abused and Neglected Child Reporting Act, the
Illinois Sexually Transmissible Disease Control Act, or where otherwise
authorized or required by law.
(e) The hospital's medical staff members and the hospital's agents and
employees may communicate, at any time and in any fashion, with legal counsel
the hospital concerning the patient medical record privacy and retention
requirements of this Section and any care or treatment they provided or
assisted in providing to any patient within the scope of their employment
or affiliation with the hospital.
(e-5) Notwithstanding subsections (d) and (e), for actions filed on or
after January 1, 2004, after a complaint for healing art malpractice is
served upon the hospital or upon its agents or employees, members of the
hospital's medical staff who are not actual or alleged agents, employees, or
apparent agents of the hospital may not communicate with legal counsel for the
hospital or with risk management of the hospital concerning the claim alleged
the complaint for healing art malpractice against the hospital except with the
patient's consent or in discovery authorized by the Code of Civil Procedure or
the Supreme Court rules. For the purposes of this subsection (e-5),
"hospital" includes a hospital affiliate as defined in subsection (b) of
Section 10.8 of this Act.
(f) Each hospital licensed under this Act shall provide its
designated organ procurement agency and any tissue bank with which it has an
agreement with access to the medical records of deceased patients for the
(1) estimating the hospital's organ and tissue
(2) identifying the educational needs of the hospital
with respect to organ and tissue donation; and
(3) identifying the number of organ and tissue
donations and referrals to potential organ and tissue donors.
(g) All hospital and patient information, interviews, reports,
memoranda, and other data obtained or created by a tissue bank or federally
designated organ procurement agency from the medical records review described
in subsection (f) shall be privileged, strictly confidential, and
the purposes put forth in subsection (f) of this Section and shall
admissible as evidence nor discoverable in an action of any kind in court or
before a tribunal, board, agency, or person.
(h) Any person who, in good faith, acts in accordance with the
of this Section shall not be subject to any type of civil or criminal liability
discipline for unprofessional conduct for those actions under any
(i) Any individual who wilfully or wantonly discloses hospital or medical
record information in violation of
this Section is guilty of a Class A
misdemeanor. As used in this subsection, "wilfully or wantonly" means a course
of action that shows an actual or deliberate intention to cause harm or that,
if not intentional, shows an utter indifference to or conscious disregard for
the safety of others or their property.
(j) The changes to this Section made by this amendatory Act of the 93rd
General Assembly apply to any action filed on or after January 1, 2004.
(Source: P.A. 93-492, eff. 1-1-04.)
(210 ILCS 85/6.22)
Arrangement for transportation of patient by an ambulance service provider.
(a) In this Section:
"Ambulance service provider" means a Vehicle Service Provider as defined in the Emergency Medical Services (EMS) Systems Act who provides non-emergency transportation services by ambulance.
"Patient" means a person who is transported by an ambulance service provider.
(b) If a hospital arranges for medi-car, service car, or ground ambulance transportation of a patient of the hospital, the hospital must provide the ambulance service provider, at or prior to transport, a Physician Certification Statement formatted and completed in compliance with federal regulations or an equivalent form developed by the hospital. Each hospital shall develop a policy requiring a physician or the physician's designee to complete the Physician Certification
Statement. The Physician Certification
Statement shall be maintained as part of the patient's medical record. A hospital shall, upon request, furnish assistance to the ambulance service provider in the completion of the form if the Physician Certification
Statement is incomplete. The Physician Certification Statement or equivalent form is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome; however, a hospital shall provide a copy of the Physician Certification
Statement to the ambulance service provider at no charge within 10 days after the request.
(c) If a hospital is unable to provide a Physician Certification Statement or equivalent form, then the hospital shall provide to the patient a written notice and a verbal explanation of the written notice, which notice must meet all of the following requirements:
(1) The following caption must appear at the
beginning of the notice in at least 14-point type: Notice to Patient Regarding Non-Emergency Ambulance Services.
(2) The notice must contain each of the following
statements in at least 14-point type:
(A) The purpose of this notice is to help you
make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance.
(B) Your insurance may not cover the charges for
(C) You may be responsible for the cost of
(D) The estimated cost of ambulance
transportation is $(amount).
(3) The notice must be signed by the patient or by
the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy.
(d) The notice set forth in subsection (c) of this Section shall not be required if a delay in transport can be expected to negatively affect the patient outcome.
(e) If a patient is physically or mentally unable to sign the notice described in subsection (c) of this Section and no authorized representative of the patient is available to sign the notice on the patient's behalf, the hospital must be able to provide documentation of the patient's inability to sign the notice and the unavailability of an authorized representative. In any case described in this subsection (e), the hospital shall be considered to have met the requirements of subsection (c) of this Section.
(Source: P.A. 100-646, eff. 7-27-18.)
(210 ILCS 85/6.23a)
Sepsis screening protocols.
(a) Each hospital shall adopt, implement, and periodically update evidence-based protocols for the early recognition and treatment of patients with sepsis, severe sepsis, or septic shock (sepsis protocols) that are based on generally accepted standards of care. Sepsis protocols must include components specific to the identification, care, and treatment of adults and of children, and must clearly identify where and when components will differ for adults and for children seeking treatment in the emergency department or as an inpatient. These protocols must also include the following components:
(1) a process for the screening and early recognition
of patients with sepsis, severe sepsis, or septic shock;
(2) a process to identify and document individuals
appropriate for treatment through sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care;
(3) guidelines for hemodynamic support with explicit
physiologic and treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and timeframe goals;
(4) for infants and children, guidelines for fluid
resuscitation consistent with current, evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children;
(5) identification of the infectious source and
delivery of early broad spectrum antibiotics with timely re-evaluation to adjust to narrow spectrum antibiotics targeted to identified infectious sources; and
(6) criteria for use, based on accepted evidence of
(b) Each hospital shall ensure that professional staff with direct patient care responsibilities and, as appropriate, staff with indirect patient care responsibilities, including, but not limited to, laboratory and pharmacy staff, are periodically trained to implement the sepsis protocols required under subsection (a). The hospital shall ensure updated training of staff if the hospital initiates substantive changes to the sepsis protocols.
(c) Each hospital shall be responsible for the collection and utilization of quality measures related to the recognition and treatment of severe sepsis for purposes of internal quality improvement.
(d) The evidence-based protocols adopted under this Section shall be provided to the Department upon the Department's request.
(e) Hospitals submitting sepsis data as required by the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting program as of fiscal year 2016 are presumed to meet the sepsis protocol requirements outlined in this Section.
(f) Subject to appropriation, the Department shall:
(1) recommend evidence-based sepsis definitions and
metrics that incorporate evidence-based findings, including appropriate antibiotic stewardship, and that align with the National Quality Forum, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and the Joint Commission;
(2) establish and use a methodology for collecting,
analyzing, and disclosing the information collected under this Section, including collection methods, formatting, and methods and means for aggregate data release and dissemination;
(3) complete a digest of efforts and recommendations
no later than 12 months after the effective date of this amendatory Act of the 99th General Assembly; the digest may include Illinois-specific data, trends, conditions, or other clinical factors; a summary shall be provided to the Governor and General Assembly and shall be publicly available on the Department's website; and
(4) consult and seek input and feedback prior to the
proposal, publication, or issuance of any guidance, methodologies, metrics, rulemaking, or any other information authorized under this Section from statewide organizations representing hospitals, physicians, advanced practice registered nurses, pharmacists, and long-term care facilities. Public and private hospitals, epidemiologists, infection prevention professionals, health care informatics and health care data professionals, and academic researchers may be consulted.
If the Department receives an appropriation and carries out the requirements of paragraphs (1), (2), (3), and (4), then the Department may adopt rules concerning the collection of data from hospitals regarding sepsis and requiring that each hospital shall be responsible for reporting to the Department.
Any publicly released hospital-specific information under this Section is subject to data provisions specified in Section 25 of the Hospital Report Card Act.
(Source: P.A. 99-828, eff. 8-18-16; 100-513, eff. 1-1-18
(210 ILCS 85/6.25)
Safe patient handling policy.
(a) In this Section:
"Health care worker" means an individual providing direct patient care services who may be required to lift, transfer, reposition, or move a patient.
"Nurse" means an advanced practice registered nurse, a registered nurse, or a licensed practical nurse licensed under the Nurse Practice Act.
"Safe lifting equipment and accessories" means mechanical equipment designed to lift, move, reposition, and transfer patients, including, but not limited to, fixed and portable ceiling lifts, sit-to-stand lifts, slide sheets and boards, slings, and repositioning and turning sheets.
"Safe lifting team" means at least 2 individuals who are trained in the use of both safe lifting techniques and safe lifting equipment and accessories, including the responsibility for knowing the location and condition of such equipment and accessories.
(b) A hospital must adopt and ensure implementation of a policy to identify, assess, and develop strategies to control risk of injury to patients and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient. The policy shall establish a process that, at a minimum, includes all of the following:
(1) Analysis of the risk of injury to patients and
nurses and other health care workers posted by the patient handling needs of the patient populations served by the hospital and the physical environment in which the patient handling and movement occurs.
(2) Education and training of nurses and other direct
patient care providers in the identification, assessment, and control of risks of injury to patients and nurses and other health care workers during patient handling and on safe lifting policies and techniques and current lifting equipment.
(3) Evaluation of alternative ways to reduce risks
associated with patient handling, including evaluation of equipment and the environment.
(4) Restriction, to the extent feasible with existing
equipment and aids, of manual patient handling or movement of all or most of a patient's weight except for emergency, life-threatening, or otherwise exceptional circumstances.
(5) Collaboration with and an annual report to the
nurse staffing committee.
(6) Procedures for a nurse to refuse to perform or be
involved in patient handling or movement that the nurse in good faith believes will expose a patient or nurse or other health care worker to an unacceptable risk of injury.
(7) Submission of an annual report to the hospital's
governing body or quality assurance committee on activities related to the identification, assessment, and development of strategies to control risk of injury to patients and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient.
(8) In developing architectural plans for
construction or remodeling of a hospital or unit of a hospital in which patient handling and movement occurs, consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment.
(9) Fostering and maintaining patient safety,
dignity, self-determination, and choice, including the following policies, strategies, and procedures:
(A) the existence and availability of a trained
(B) a policy of advising patients of a range of
transfer and lift options, including adjustable diagnostic and treatment equipment, mechanical lifts, and provision of a trained safe lifting team;
(C) the right of a competent patient, or guardian
of a patient adjudicated incompetent, to choose among the range of transfer and lift options, subject to the provisions of subparagraph (E) of this paragraph (9);
(D) procedures for documenting, upon admission
and as status changes, a mobility assessment and plan for lifting, transferring, repositioning, or movement of a patient, including the choice of the patient or patient's guardian among the range of transfer and lift options; and
(E) incorporation of such safe lifting
procedures, techniques, and equipment as are consistent with applicable federal law.
(Source: P.A. 100-513, eff. 1-1-18
(210 ILCS 85/7)
(from Ch. 111 1/2, par. 148)
(a) The Director after notice and opportunity for hearing to the
applicant or licensee may deny, suspend, or revoke a permit to establish a
hospital or deny, suspend, or revoke a license to open, conduct, operate,
and maintain a hospital in any case in which he finds that there has been a
substantial failure to comply with the provisions of this Act, the Hospital
Report Card Act, or the Illinois Adverse Health Care Events Reporting Law of 2005 or the standards, rules, and regulations established by
virtue of any of those Acts. The Department may impose fines on hospitals, not to exceed $500 per occurrence, for failing to (1) initiate a criminal background check on a patient that meets the criteria for hospital-initiated background checks or (2) report the death of a person known to be a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act to the coroner or medical examiner within 24 hours as required by Section 6.09a of this Act. In assessing whether to impose such a fine for failure to initiate a criminal background check, the Department shall consider various factors including, but not limited to, whether the hospital has engaged in a pattern or practice of failing to initiate criminal background checks. Money from fines shall be deposited into the Long Term Care Provider Fund.
(b) Such notice shall be effected by registered mail or by personal
service setting forth the particular reasons for the proposed action and
fixing a date, not less than 15 days from the date of such mailing or
service, at which time the applicant or licensee shall be given an
opportunity for a hearing. Such hearing shall be conducted by the Director
or by an employee of the Department designated in writing by the Director
as Hearing Officer to conduct the hearing. On the basis of any such
hearing, or upon default of the applicant or licensee, the Director shall
make a determination specifying his findings and conclusions. In case of a
denial to an applicant of a permit to establish a hospital, such
determination shall specify the subsection of Section 6 under which the
permit was denied and shall contain findings of fact forming the basis of
such denial. A copy of such determination shall be sent by registered mail
or served personally upon the applicant or licensee. The decision denying,
suspending, or revoking a permit or a license shall become final 35 days
after it is so mailed or served, unless the applicant or licensee, within
such 35 day period, petitions for review pursuant to Section 13.
(c) The procedure governing hearings authorized by this Section shall be
in accordance with rules promulgated by the Department and approved by the
Hospital Licensing Board. A full and complete record shall be kept of all
proceedings, including the notice of hearing, complaint, and all other
documents in the nature of pleadings, written motions filed in the
proceedings, and the report and orders of the Director and Hearing Officer.
All testimony shall be reported but need not be transcribed unless the
decision is appealed pursuant to Section 13. A copy or copies of the
transcript may be obtained by any interested party on payment of the cost
of preparing such copy or copies.
(d) The Director or Hearing Officer shall upon his own motion, or on the
written request of any party to the proceeding, issue subpoenas requiring
the attendance and the giving of testimony by witnesses, and subpoenas
duces tecum requiring the production of books, papers, records, or
memoranda. All subpoenas and subpoenas duces tecum issued under the terms
of this Act may be served by any person of full age. The fees of witnesses
for attendance and travel shall be the same as the fees of witnesses before
the Circuit Court of this State, such fees to be paid when the witness is
excused from further attendance. When the witness is subpoenaed at the
instance of the Director, or Hearing Officer, such fees shall be paid in
the same manner as other expenses of the Department, and when the witness
is subpoenaed at the instance of any other party to any such proceeding the
Department may require that the cost of service of the subpoena or subpoena
duces tecum and the fee of the witness be borne by the party at whose
instance the witness is summoned. In such case, the Department in its
discretion, may require a deposit to cover the cost of such service and
witness fees. A subpoena or subpoena duces tecum issued as aforesaid shall
be served in the same manner as a subpoena issued out of a court.
(e) Any Circuit Court of this State upon the application of the
Director, or upon the application of any other party to the proceeding,
may, in its discretion, compel the attendance of witnesses, the production
of books, papers, records, or memoranda and the giving of testimony before
the Director or Hearing Officer conducting an investigation or holding a
hearing authorized by this Act, by an attachment for contempt, or
otherwise, in the same manner as production of evidence may be compelled
before the court.
(f) The Director or Hearing Officer, or any party in an investigation or
hearing before the Department, may cause the depositions of witnesses
within the State to be taken in the manner prescribed by law for like
depositions in civil actions in courts of this State, and to that end
compel the attendance of witnesses and the production of books, papers,
records, or memoranda.
(Source: P.A. 99-180, eff. 7-29-15.)
(210 ILCS 85/8)
(from Ch. 111 1/2, par. 149)
Facility plan review; fees.
(a) Before commencing construction of new facilities or specified types
of alteration or additions to an existing hospital involving major
construction, as defined by rule by the Department, with an estimated
cost greater than $100,000, architectural plans and
specifications therefor shall be submitted by the licensee to the
Department for review and approval.
A hospital may submit architectural drawings and specifications for other
construction projects for Department review according to subsection (b) that
shall not be subject to fees under subsection (d).
The Department must give a hospital that is planning to submit a construction
project for review the opportunity to discuss its plans and specifications with
the Department before the hospital formally submits the plans and
specifications for Department review.
Review of drawings and specifications shall be conducted by an employee of
the Department meeting the qualifications established by the Department of
Central Management Services class specifications for such an individual's
position or by a person contracting with the Department who meets those class
Final approval of the plans and specifications for compliance
with design and construction standards shall be obtained from the
Department before the alteration, addition, or new construction is begun. Subject to this Section 8, and prior to January 1, 2012, the Department shall consider the re-licensing of an existing hospital structure according to the standards for an existing hospital, as set forth in the Department's rules. Re-licensing under this provision shall occur only if that facility operated as a licensed hospital on July 1, 2005, has had no intervening use as other than a hospital, and exists in a county with a population of less than 20,000 that does not have another licensed hospital on the effective date of this amendatory Act of the 95th General Assembly.
(b) The Department shall inform an applicant in writing within 10 working
days after receiving drawings and specifications and the required fee, if any,
from the applicant whether the applicant's submission is complete or
incomplete. Failure to provide the applicant with this notice within 10
working days shall result in the submission being deemed complete for purposes
of initiating the 60-day review period under this Section. If the submission
is incomplete, the Department shall inform the applicant of the deficiencies
with the submission in writing. If the submission is complete and the required
fee, if any, has been paid,
the Department shall approve or disapprove drawings and specifications
submitted to the Department no later than 60 days following receipt by the
Department. The drawings and specifications shall be of sufficient detail, as
provided by Department rule, to
enable the Department to
render a determination of compliance with design and construction standards
under this Act.
If the Department finds that the drawings are not of sufficient detail for it
to render a determination of compliance, the plans shall be determined to be
incomplete and shall not be considered for purposes of initiating the 60 day
If a submission of drawings and specifications is incomplete, the applicant
may submit additional information. The 60-day review period shall not commence
until the Department determines that a submission of drawings and
specifications is complete or the submission is deemed complete.
If the Department has not approved or disapproved the
drawings and specifications within 60 days, the construction, major alteration,
or addition shall be deemed approved. If the drawings and specifications are
disapproved, the Department shall state in writing, with specificity, the
reasons for the disapproval. The entity submitting the drawings and
specifications may submit additional information in response to the written
comments from the Department or request a reconsideration of the disapproval.
A final decision of approval or disapproval shall be made within 45 days of the
receipt of the additional information or reconsideration request. A final decision shall be subject to review under the Administrative Review Law.
(c) The Department shall provide written approval for occupancy pursuant
to subsection (g) and shall not issue a violation to a facility as a result of
a licensure or complaint survey based upon the facility's physical structure
(1) the Department reviewed and approved or deemed
approved the drawing and specifications for compliance with design and construction standards;
(2) the construction, major alteration, or addition
(3) the law or rules have not been amended since the
(4) the conditions at the facility indicate that
there is a reasonable degree of safety provided for the patients.
(c-5) The Department shall not issue a violation to a facility if the
inspected aspects of the facility were previously found to be in compliance
with applicable standards, the relevant law or rules have not been amended,
conditions at the facility
reasonably protect the safety of its patients, and alterations or new hazards
have not been
(d) The Department shall charge the following fees in connection with its
reviews conducted before June 30, 2004 under this Section:
(3) If the estimated dollar value of the major
construction is greater than $500,000, the fee shall be established by the Department pursuant to rules that reflect the reasonable and direct cost of the Department in conducting the architectural reviews required under this Section. The estimated dollar value of the major construction subject to review under this Section shall be annually readjusted to reflect the increase in construction costs due to inflation.
The fees provided in this subsection (d) shall not apply to major
construction projects involving facility changes that are required by
Department rule amendments or to projects related to homeland security.
The fees provided in this subsection (d) shall also not apply to major
construction projects if 51% or more of the estimated cost of the project is
attributed to capital equipment. For major construction projects where 51% or
more of the estimated cost of the project is attributed to capital equipment,
the Department shall by rule establish a fee that is reasonably related to the
cost of reviewing the project.
Disproportionate share hospitals and rural hospitals shall only pay
one-half of the fees
required in this subsection (d).
For the purposes of this subsection (d),
(i) "disproportionate share hospital" means a hospital described in items (1)
through (5) of subsection (b) of Section 5-5.02 of the Illinois Public Aid
Code and (ii)
"rural hospital" means a hospital that
is (A) located
outside a metropolitan statistical area or (B) located 15 miles or less from a
county that is
outside a metropolitan statistical area and is licensed to perform
obstetrical services and has a combined total bed capacity of 75 or fewer beds
in these 2
service categories as of July 14, 1993, as determined by the Department.
The Department shall not commence the facility plan review process under this
Section until the applicable fee has been paid.
(e) All fees received by the Department under this Section shall be
deposited into the Health Facility Plan Review Fund, a special fund created in
the State treasury.
All fees paid by hospitals under subsection (d) shall be used only to cover
the direct and reasonable costs relating to the Department's review of hospital
projects under this
Moneys shall be appropriated from that Fund to the
Department only to pay the costs of conducting reviews under this Section.
None of the moneys in the Health Facility Plan Review Fund shall be used to
reduce the amount of General Revenue Fund moneys appropriated to the Department
for facility plan reviews conducted pursuant to this Section.
(g) The Department shall conduct an on-site inspection of the completed
project no later than 15 business days after notification from the
applicant that the
project has been completed and all certifications required by the Department
have been received and accepted by the Department. The Department may extend
this deadline only if a federally mandated survey time frame takes
precedence. The Department shall
provide written approval for occupancy to the applicant within 5 working days
of the Department's final inspection, provided the applicant has demonstrated
substantial compliance as defined by Department rule.
Occupancy of new major construction is prohibited until Department approval is
received, unless the Department has not acted within the time frames provided
in this subsection (g), in which case the construction shall be deemed
approved. Occupancy shall be authorized after any
required health inspection by the Department has been conducted.
(h) The Department shall establish, by rule, a procedure to conduct interim
on-site review of large or complex construction projects.
(i) The Department shall establish, by rule, an expedited process for
emergency repairs or replacement of like equipment.
(j) Nothing in this Section shall be construed to apply to maintenance,
upkeep, or renovation that does not affect the structural integrity of the
building, does not add beds or services over the number for which the facility
is licensed, and provides a reasonable degree of safety for the patients.
(Source: P.A. 99-639, eff. 7-28-16.)
(210 ILCS 85/9.6)
Patient protection from abuse.
(a) No administrator, agent, or employee of a hospital or a member of its medical staff may abuse a patient in the hospital.
(b) Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this Section.
(c) Retaliation against a person who lawfully and in good faith makes a report under this Section is prohibited.
(d) Upon receiving a report under subsection (b) of this Section, the hospital shall submit the report to the Department within 24 hours of obtaining such report. In the event that the hospital receives multiple reports involving a single alleged instance of abuse, the hospital shall submit one report to the Department.
(e) Upon receiving a report under this Section, the hospital shall promptly conduct an internal review to ensure the alleged victim's safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital's administrator and may include, but are not limited to, removing suspected violators from further patient contact during the hospital's internal review. If the alleged victim lacks decision-making capacity under the Health Care Surrogate Act and no health care surrogate is available, the hospital may contact the Illinois Guardianship and Advocacy Commission to determine the need for a temporary guardian of that person.
(f) All internal hospital reviews shall be conducted by a designated hospital employee or agent who is qualified to detect abuse and is not involved in the alleged victim's treatment. All internal review findings must be documented and filed according to hospital procedures and shall be made available to the Department upon request.
(g) Any other person may make a report of patient abuse to the Department if that person has reasonable cause to believe that a patient has been abused in the hospital.
(h) The report required under this Section shall include: the name of the patient; the name and address of the hospital treating the patient; the age of the patient; the nature of the patient's condition, including any evidence of previous injuries or disabilities; and any other information that the reporter believes might be helpful in establishing the cause of the reported abuse and the identity of the person believed to have caused the abuse.
(i) Except for willful or wanton misconduct, any individual, person, institution, or agency participating in good faith in the making of a report under this Section, or in the investigation of such a report or in making a disclosure of information concerning reports of abuse under this Section, shall have immunity from any liability, whether civil, professional, or criminal, that otherwise might result by reason of such actions. For the purpose of any proceedings, whether civil, professional, or criminal, the good faith of any persons required to report cases of suspected abuse under this Section or who disclose information concerning reports of abuse in compliance with this Section, shall be presumed.
(j) No administrator, agent, or employee of a hospital shall adopt or employ practices or procedures designed to discourage good faith reporting of patient abuse under this Section.
(k) Every hospital shall ensure that all new and existing employees are trained in the detection and reporting of abuse of patients and retrained at least every 2 years thereafter.
(l) The Department shall investigate each report of patient abuse made under this Section according to the procedures of the Department, except that a report of abuse which indicates that a patient's life or safety is in imminent danger shall be investigated within 24 hours of such report. Under no circumstances may a hospital's internal review of an allegation of abuse replace an investigation of the allegation by the Department.
(m) The Department shall keep a continuing record of all reports made pursuant to this Section, including indications of the final determination of any investigation and the final disposition of all reports. The Department shall inform the investigated hospital and any other person making a report under subsection (g) of its final determination or disposition in writing.
(n) The Department shall not disclose to the public any information regarding any reports and investigations under this Section unless and until the report of abuse is substantiated following a full and proper investigation.
(o) All patient identifiable information in any report or investigation under this Section shall be confidential and shall not be disclosed except as authorized by this Act or other applicable law.
(p) Nothing in this Section relieves a hospital administrator, employee, agent, or medical staff member from contacting appropriate law enforcement authorities as required by law.
(q) Nothing in this Section shall be construed to mean that a patient is a victim of abuse because of health care services provided or not provided by health care professionals.
(r) Nothing in this Section shall require a hospital, including its employees, agents, and medical staff members, to provide any services to a patient in contravention of his or her stated or implied objection thereto upon grounds that such services conflict with his or her religious beliefs or practices, nor shall such a patient be considered abused under this Section for the exercise of such beliefs or practices.
(s) The Department's implementation of this Section is subject to appropriations to the Department for that purpose.
(t) As used in this Section, the following terms have the following meanings:
"Abuse" means any physical or mental injury or sexual abuse intentionally inflicted by a hospital employee, agent, or medical staff member on a patient of the hospital and does not include any hospital, medical, health care, or other personal care services done in good faith in the interest of the patient according to established medical and clinical standards of care.
"Mental injury" means intentionally caused emotional distress in a patient from words or gestures that would be considered by a reasonable person to be humiliating, harassing, or threatening and which causes observable and substantial impairment.
"Sexual abuse" means any intentional act of sexual contact or sexual penetration of a patient in the hospital.
"Substantiated", with respect to a report of abuse, means that a preponderance of the evidence indicates that abuse occurred.
(Source: P.A. 96-692, eff. 1-1-10.)
(210 ILCS 85/10.4)
(from Ch. 111 1/2, par. 151.4)
Medical staff privileges.
(a) Any hospital licensed under this Act or any hospital organized under the
University of Illinois Hospital Act shall, prior to the granting of any medical
staff privileges to an applicant, or renewing a current medical staff member's
privileges, request of the Director of Professional Regulation information
concerning the licensure status and any disciplinary action taken against the
applicant's or medical staff member's license, except: (1) for medical personnel who
enter a hospital to obtain organs and tissues for transplant from a donor in accordance with the Illinois Anatomical Gift Act; or (2) for medical personnel who have been granted disaster privileges pursuant to the procedures and requirements established by rules adopted by the Department. Any hospital and any employees of the hospital or others involved in granting privileges who, in good faith, grant disaster privileges pursuant to this Section to respond to an emergency shall not, as a result of their 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 this Act. Individuals granted privileges who provide care in an emergency situation, in good faith and without direct compensation, shall not, as a result of their acts or omissions, except for acts or omissions involving willful and wanton misconduct, as that term is defined in Section 10.2 of this Act, on the part of the person, be liable for civil damages. The Director of
Professional Regulation shall transmit, in writing and in a timely fashion,
such information regarding the license of the applicant or the medical staff
member, including the record of imposition of any periods of
supervision or monitoring as a result of alcohol or
substance abuse, as provided by Section 23 of the Medical
Practice Act of 1987, and such information as may have been
submitted to the Department indicating that the application
or medical staff member has been denied, or has surrendered,
medical staff privileges at a hospital licensed under this
Act, or any equivalent facility in another state or
territory of the United States. The Director of Professional Regulation
shall define by rule the period for timely response to such requests.
No transmittal of information by the Director of Professional Regulation,
under this Section shall be to other than the president, chief
operating officer, chief administrative officer, or chief of
the medical staff of a hospital licensed under this Act, a
hospital organized under the University of Illinois Hospital Act, or a hospital
operated by the United States, or any of its instrumentalities. The
information so transmitted shall be afforded the same status
as is information concerning medical studies by Part 21 of Article VIII of the
Code of Civil Procedure, as now or hereafter amended.
(b) All hospitals licensed under this Act, except county hospitals as
defined in subsection (c) of Section 15-1 of the Illinois Public Aid Code,
shall comply with, and the medical staff bylaws of these hospitals shall
include rules consistent with, the provisions of this Section in granting,
limiting, renewing, or denying medical staff membership and
clinical staff privileges. Hospitals that require medical staff members to
faculty status with a specific institution of higher education are not required
to comply with subsection (1) below when the physician does not possess faculty
(1) Minimum procedures for pre-applicants and
applicants for medical staff membership shall include the following:
(A) Written procedures relating to the acceptance
and processing of pre-applicants or applicants for medical staff membership, which should be contained in medical staff bylaws.
(B) Written procedures to be followed in
determining a pre-applicant's or an applicant's qualifications for being granted medical staff membership and privileges.
(C) Written criteria to be followed in evaluating
a pre-applicant's or an applicant's qualifications.
(D) An evaluation of a pre-applicant's or an
applicant's current health status and current license status in Illinois.
(E) A written response to each pre-applicant or
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 notice of an adverse decision.
(B) An 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.
(C) 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 this subparagraph (C) 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. 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. 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. 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. Nothing in this subparagraph (C) 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. 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 State's licensing authority, no hearing shall be necessary.
(ii) Nothing in this subparagraph (C) 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.
(iii) 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 subparagraph (C) of this paragraph (2) 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-5) 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 this 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.
(E-5) The right to be represented by a personal
(F) A written notice and written explanation of
the decision resulting from the hearing.
(F-5) A written notice of a final adverse
decision by a hospital governing board.
(G) 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 this Section, including item (iii) of subparagraph (C) of this paragraph (2), and under the medical staff bylaws in order to allow sufficient time for the orderly provision of patient care.
(H) Nothing in this paragraph (2) of this
subsection (b) limits a medical staff member's right to waive, in writing, the rights provided in subparagraphs (A) through (G) of this paragraph (2) of this subsection (b) 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.
(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. These 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. The Hospital Licensing Board shall submit an initial study to the Governor and the General Assembly by January 1, 1996, and subsequent reports shall be submitted periodically thereafter.
(4) As used in this Section:
"Adverse decision" means a decision reducing,
restricting, suspending, revoking, denying, or not renewing medical staff membership or clinical privileges.
"Economic factor" means any information or reasons
for decisions unrelated to quality of care or professional competency.
"Pre-applicant" means a physician licensed to
practice medicine in all its branches who requests an application for medical staff membership or privileges.
"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.
(5) Any amendment to medical staff bylaws required
because of this amendatory Act of the 91st General Assembly shall be adopted on or before July 1, 2001.
(c) All hospitals shall consult with the medical staff prior to closing
membership in the entire or any portion of the medical staff or a department.
the hospital closes membership in the medical staff, any portion of the medical
staff, or the department over the objections of the medical staff, then the
shall provide a detailed written explanation for the decision to the medical
10 days prior to the effective date of any closure. No applications need to be
provided when membership in the medical staff or any relevant portion of the
medical staff is closed.
(Source: P.A. 96-445, eff. 8-14-09; 97-1006, eff. 8-17-12.)
(210 ILCS 85/10.7)
Clinical privileges; advanced practice registered nurses.
All hospitals licensed under this Act shall comply with the following
(1) No hospital policy, rule, regulation, or practice
shall be inconsistent with the provision of adequate collaboration and consultation in accordance with Section 54.5 of the Medical Practice Act of 1987.
(2) Operative surgical procedures shall be performed
only by a physician licensed to practice medicine in all its branches under the Medical Practice Act of 1987, a dentist licensed under the Illinois Dental Practice Act, or a podiatric physician licensed under the Podiatric Medical Practice Act of 1987, with medical staff membership and surgical clinical privileges granted at the hospital. A licensed physician, dentist, or podiatric physician may be assisted by a physician licensed to practice medicine in all its branches, dentist, dental assistant, podiatric physician, licensed advanced practice registered nurse, licensed physician assistant, licensed registered nurse, licensed practical nurse, surgical assistant, surgical technician, or other individuals granted clinical privileges to assist in surgery at the hospital. Payment for services rendered by an assistant in surgery who is not a hospital employee shall be paid at the appropriate non-physician modifier rate if the payor would have made payment had the same services been provided by a physician.
(2.5) A registered nurse licensed under the Nurse
Practice Act and qualified by training and experience in operating room nursing shall be present in the operating room and function as the circulating nurse during all invasive or operative procedures. For purposes of this paragraph (2.5), "circulating nurse" means a registered nurse who is responsible for coordinating all nursing care, patient safety needs, and the needs of the surgical team in the operating room during an invasive or operative procedure.
(3) An advanced practice registered nurse is not
required to possess prescriptive authority or a written collaborative agreement meeting the requirements of the Nurse Practice Act to provide advanced practice registered nursing services in a hospital. An advanced practice registered nurse must possess clinical privileges recommended by the medical staff and granted by the hospital in order to provide services. Individual advanced practice registered nurses may also be granted clinical privileges to order, select, and administer medications, including controlled substances, to provide delineated care. The attending physician must determine the advanced practice registered nurse's role in providing care for his or her patients, except as otherwise provided in medical staff bylaws. The medical staff shall periodically review the services of advanced practice registered nurses granted privileges. This review shall be conducted in accordance with item (2) of subsection (a) of Section 10.8 of this Act for advanced practice registered nurses employed by the hospital.
(4) The anesthesia service shall be under the
direction of a physician licensed to practice medicine in all its branches who has had specialized preparation or experience in the area or who has completed a residency in anesthesiology. An anesthesiologist, Board certified or Board eligible, is recommended. Anesthesia services may only be administered pursuant to the order of a physician licensed to practice medicine in all its branches, licensed dentist, or licensed podiatric physician.
(A) The individuals who, with clinical privileges
granted at the hospital, may administer anesthesia services are limited to the following:
(i) an anesthesiologist; or
(ii) a physician licensed to practice
medicine in all its branches; or
(iii) a dentist with authority to administer
anesthesia under Section 8.1 of the Illinois Dental Practice Act; or
(iv) a licensed certified registered nurse
(v) a podiatric physician licensed under the
Podiatric Medical Practice Act of 1987.
(B) For anesthesia services, an anesthesiologist
shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions. In the absence of 24-hour availability of anesthesiologists with medical staff privileges, an alternate policy (requiring participation, presence, and availability of a physician licensed to practice medicine in all its branches) shall be developed by the medical staff and licensed hospital in consultation with the anesthesia service.
(C) A certified registered nurse anesthetist is
not required to possess prescriptive authority or a written collaborative agreement meeting the requirements of Section 65-35 of the Nurse Practice Act to provide anesthesia services ordered by a licensed physician, dentist, or podiatric physician. Licensed certified registered nurse anesthetists are authorized to select, order, and administer drugs and apply the appropriate medical devices in the provision of anesthesia services under the anesthesia plan agreed with by the anesthesiologist or, in the absence of an available anesthesiologist with clinical privileges, agreed with by the operating physician, operating dentist, or operating podiatric physician in accordance with the hospital's alternative policy.
(Source: P.A. 99-642, eff. 7-28-16; 100-513, eff. 1-1-18
(210 ILCS 85/10.8)
Requirements for employment of physicians.
(a) Physician employment by hospitals and hospital affiliates. Employing
employ physicians to practice medicine in all of its branches provided that the
requirements are met:
(1) The employed physician is a member of the medical
staff of either the hospital or hospital affiliate. If a hospital affiliate decides to have a medical staff, its medical staff shall be organized in accordance with written bylaws where the affiliate medical staff is responsible for making recommendations to the governing body of the affiliate regarding all quality assurance activities and safeguarding professional autonomy. The affiliate medical staff bylaws may not be unilaterally changed by the governing body of the affiliate. Nothing in this Section requires hospital affiliates to have a medical staff.
(2) Independent physicians, who are not employed by
an employing entity, periodically review the quality of the medical services provided by the employed physician to continuously improve patient care.
(3) The employing entity and the employed physician
sign a statement acknowledging that the employer shall not unreasonably exercise control, direct, or interfere with the employed physician's exercise and execution of his or her professional judgment in a manner that adversely affects the employed physician's ability to provide quality care to patients. This signed statement shall take the form of a provision in the physician's employment contract or a separate signed document from the employing entity to the employed physician. This statement shall state: "As the employer of a physician, (employer's name) shall not unreasonably exercise control, direct, or interfere with the employed physician's exercise and execution of his or her professional judgment in a manner that adversely affects the employed physician's ability to provide quality care to patients."
(4) The employing entity shall establish a mutually
agreed upon independent review process with criteria under which an employed physician may seek review of the alleged violation of this Section by physicians who are not employed by the employing entity. The affiliate may arrange with the hospital medical staff to conduct these reviews. The independent physicians shall make findings and recommendations to the employing entity and the employed physician within 30 days of the conclusion of the gathering of the relevant information.
(b) Definitions. For the purpose of this Section:
"Employing entity" means a hospital licensed under the Hospital Licensing Act
or a hospital
"Employed physician" means a physician who receives an IRS W-2 form, or any
federal income tax form, from an employing entity.
"Hospital" means a hospital licensed under the Hospital Licensing Act, except
county hospitals as defined in subsection (c) of Section 15-1 of the Illinois Public Aid
"Hospital affiliate" means a corporation, partnership, joint venture, limited
or similar organization, other than a hospital, that is devoted primarily to
the provision, management,
or support of health care services and that directly or indirectly controls, is
controlled by, or is under
common control of the hospital. "Control" means having at least an equal or a
or membership interest. A hospital affiliate shall be 100% owned or controlled
by any combination
of hospitals, their parent corporations, or physicians licensed to practice
medicine in all its branches
"Hospital affiliate" does not include a health maintenance
organization regulated under the Health Maintenance
"Physician" means an individual licensed to practice medicine in all its
branches in Illinois.
"Professional judgment" means the exercise of a physician's independent
in providing medically appropriate diagnoses, care, and treatment to a
particular patient at a
particular time. Situations in which an employing entity does not interfere
with an employed
physician's professional judgment include, without limitation, the following:
(1) practice restrictions based upon peer review of
the physician's clinical practice to assess quality of care and utilization of resources in accordance with applicable bylaws;
(2) supervision of physicians by appropriately
licensed medical directors, medical school faculty, department chairpersons or directors, or supervising physicians;
(3) written statements of ethical or religious
(4) reasonable referral restrictions that do not,
in the reasonable professional judgment of the physician, adversely affect the health or welfare of the patient.
(c) Private enforcement. An employed physician aggrieved by a violation of
this Act may
seek to obtain an injunction or reinstatement of employment with the employing
entity as the court
may deem appropriate. Nothing in this Section limits or abrogates any common
law cause of action.
Nothing in this Section shall be deemed to alter the law of negligence.
(d) Department enforcement. The Department may enforce the provisions of
but nothing in this Section shall require or permit the Department to license,
certify, or otherwise
investigate the activities of a
hospital affiliate not otherwise required to be licensed by the
(e) Retaliation prohibited. No employing entity shall retaliate against any
physician for requesting a hearing or review under this Section.
No action may be taken that
the ability of a physician to practice during this review, except in
where the medical staff bylaws authorize summary suspension.
(f) Physician collaboration. No employing entity shall adopt or enforce,
either formally or
informally, any policy, rule, regulation, or practice inconsistent with
the provision of adequate
collaboration, including medical direction of licensed advanced practice registered
nurses or supervision
of licensed physician assistants and delegation to other personnel under
Section 54.5 of the Medical
Practice Act of 1987.
(g) Physician disciplinary actions. Nothing in this Section shall be
construed to limit or
prohibit the governing body of an employing entity or its medical staff, if
any, from taking
disciplinary actions against a physician as permitted by law.
(h) Physician review. Nothing in this Section shall be construed to prohibit
a hospital or
hospital affiliate from making a determination not to pay for a particular
health care service or to
prohibit a medical group, independent practice association, hospital medical
staff, or hospital
governing body from enforcing reasonable peer review or utilization review
protocols or determining
whether the employed physician complied with those protocols.
(i) Review. Nothing in this Section may be used or construed to establish
that any activity
of a hospital or hospital affiliate is subject to review under the Illinois
Health Facilities Planning Act.
(j) Rules. The Department shall adopt any
rules necessary to
implement this Section.
(Source: P.A. 100-201, eff. 8-18-17; 100-513, eff. 1-1-18
(210 ILCS 85/10.10)
Nurse Staffing by Patient Acuity.
(a) Findings. The Legislature finds and declares all of the following:
(1) The State of Illinois has a substantial interest
in promoting quality care and improving the delivery of health care services.
(2) Evidence-based studies have shown that the basic
principles of staffing in the acute care setting should be based on the complexity of patients' care needs aligned with available nursing skills to promote quality patient care consistent with professional nursing standards.
(3) Compliance with this Section promotes an
organizational climate that values registered nurses' input in meeting the health care needs of hospital patients.
(b) Definitions. As used in this Section:
"Acuity model" means an assessment tool selected and implemented by a hospital, as recommended by a nursing care committee, that assesses the complexity of patient care needs requiring professional nursing care and skills and aligns patient care needs and nursing skills consistent with professional nursing standards.
"Department" means the Department of Public Health.
"Direct patient care" means care provided by a registered professional nurse with direct responsibility to oversee or carry out medical regimens or nursing care for one or more patients.
"Nursing care committee" means an existing or newly created hospital-wide committee or committees of nurses whose functions, in part or in whole, contribute to the development, recommendation, and review of the hospital's nurse staffing plan established pursuant to subsection (d).
"Registered professional nurse" means a person licensed as a Registered Nurse under the Nurse
"Written staffing plan for nursing care services" means a written plan for guiding the assignment of patient care nursing staff based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units and the adopted acuity model aligning patient care needs with nursing skills required for quality patient care consistent with professional nursing standards.
(c) Written staffing plan.
(1) Every hospital shall implement a written
hospital-wide staffing plan, recommended by a nursing care committee or committees, that provides for minimum direct care professional registered nurse-to-patient staffing needs for each inpatient care unit. The written hospital-wide staffing plan shall include, but need not be limited to, the following considerations:
(A) The complexity of complete care, assessment
on patient admission, volume of patient admissions, discharges and transfers, evaluation of the progress of a patient's problems, ongoing physical assessments, planning for a patient's discharge, assessment after a change in patient condition, and assessment of the need for patient referrals.
(B) The complexity of clinical professional
nursing judgment needed to design and implement a patient's nursing care plan, the need for specialized equipment and technology, the skill mix of other personnel providing or supporting direct patient care, and involvement in quality improvement activities, professional preparation, and experience.
(C) Patient acuity and the number of patients for
whom care is being provided.
(D) The ongoing assessments of a unit's patient
acuity levels and nursing staff needed shall be routinely made by the unit nurse manager or his or her designee.
(E) The identification of additional registered
nurses available for direct patient care when patients' unexpected needs exceed the planned workload for direct care staff.
(2) In order to provide staffing flexibility to meet
patient needs, every hospital shall identify an acuity model for adjusting the staffing plan for each inpatient care unit.
(3) The written staffing plan shall be posted in a
conspicuous and accessible location for both patients and direct care staff, as required under the Hospital Report Card Act. A copy of the written staffing plan shall be provided to any member of the general public upon request.
(d) Nursing care committee.
(1) Every hospital shall have a nursing care
committee. A hospital shall appoint members of a committee whereby at least 50% of the members are registered professional nurses providing direct patient care.
(2) A nursing care committee's recommendations must
be given significant regard and weight in the hospital's adoption and implementation of a written staffing plan.
(3) A nursing care committee or committees shall
recommend a written staffing plan for the hospital based on the principles from the staffing components set forth in subsection (c). In particular, a committee or committees shall provide input and feedback on the following:
(A) Selection, implementation, and evaluation of
minimum staffing levels for inpatient care units.
(B) Selection, implementation, and evaluation of
an acuity model to provide staffing flexibility that aligns changing patient acuity with nursing skills required.
(C) Selection, implementation, and evaluation of
a written staffing plan incorporating the items described in subdivisions (c)(1) and (c)(2) of this Section.
(D) Review the following: nurse-to-patient
staffing guidelines for all inpatient areas; and current acuity tools and measures in use.
(4) A nursing care committee must address the items
described in subparagraphs (A) through (D) of paragraph (3) semi-annually.
(e) Nothing in this Section 10.10 shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by the hospital.
(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12; 97-813, eff. 7-13-12.)