State of Illinois
91st General Assembly
Legislation

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[ Engrossed ][ Enrolled ][ Senate Amendment 001 ]

91_SB0953

 
                                               LRB9100490ACsb

 1        AN  ACT  to  amend the Hospital Licensing Act by changing
 2    Section 10.4.

 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:

 5        Section  5.   The  Hospital  Licensing  Act is amended by
 6    changing Section 10.4 as follows:

 7        (210 ILCS 85/10.4) (from Ch. 111 1/2, par. 151.4)
 8        Sec. 10.4. Medical staff privileges.
 9        (a)  Any hospital licensed under this Act or any hospital
10    organized under  the  University  of  Illinois  Hospital  Act
11    shall,  prior to the granting of any medical staff privileges
12    to an applicant, or renewing a current medical staff member's
13    privileges,  request  of   the   Director   of   Professional
14    Regulation  information  concerning  the licensure status and
15    any disciplinary action  taken  against  the  applicant's  or
16    medical  staff member's license, except for medical personnel
17    who enter  a  hospital  to  obtain  organs  and  tissues  for
18    transplant  from  a  deceased  donor  in  accordance with the
19    Uniform Anatomical Gift Act.  The  Director  of  Professional
20    Regulation  shall  transmit,  in  writing  and  in  a  timely
21    fashion,  such  information  regarding  the  license  of  the
22    applicant  or  the medical staff member, including the record
23    of imposition of any periods of supervision or monitoring  as
24    a  result  of  alcohol  or  substance  abuse,  as provided by
25    Section 23 of the Medical Practice  Act  of  1987,  and  such
26    information  as  may  have  been  submitted to the Department
27    indicating that the application or medical staff  member  has
28    been  denied, or has surrendered, medical staff privileges at
29    a  hospital  licensed  under  this  Act,  or  any  equivalent
30    facility in another state or territory of the United  States.
31    The  Director of Professional Regulation shall define by rule
 
                            -2-                LRB9100490ACsb
 1    the period for timely response to such requests.
 2        No  transmittal  of  information  by  the   Director   of
 3    Professional Regulation, under this Section shall be to other
 4    than   the   president,   chief   operating   officer,  chief
 5    administrative officer, or chief of the medical  staff  of  a
 6    hospital  licensed under this Act, a hospital organized under
 7    the University  of  Illinois  Hospital  Act,  or  a  hospital
 8    operated    by   the   United   States,   or   any   of   its
 9    instrumentalities.  The information so transmitted  shall  be
10    afforded the same status as is information concerning medical
11    studies  by  Part  21  of  Article  VIII of the Code of Civil
12    Procedure, as now or hereafter amended.
13        (b)  All hospitals licensed under this Act, except county
14    hospitals as defined in subsection (c) of Section 15-1 of the
15    Illinois Public Aid Code, shall comply with, and the  medical
16    staff   bylaws   of   these  hospitals  shall  include  rules
17    consistent with, the provisions of this Section in  granting,
18    limiting,  renewing,  or denying medical staff membership and
19    clinical staff privileges.  All hospitals shall consult  with
20    the  medical  staff prior to closing membership in the entire
21    or any portion of the medical staff or  department.   If  the
22    hospital  closes membership in the medical staff, any portion
23    of the medical staff, or the department over  the  objections
24    of  the  medical  staff,  then  the  hospital shall provide a
25    detailed written explanation for the decision to the  medical
26    staff 10 days prior to the effective date of any closure.  No
27    applications  need  to  be  provided  when  membership in the
28    medical staff or any portion of the medical staff is closed.
29             (1)  Minimum procedures  for  pre-applicants,  those
30        requesting  an  application,  and  initial applicants for
31        medical staff membership shall include the following:
32                  (A)  Written   procedures   relating   to   the
33             acceptance  and  processing  of  pre-applicants   or
34             initial  applicants  for  medical  staff membership,
 
                            -3-                LRB9100490ACsb
 1             which should be contained in medical staff bylaws.
 2                  (B)  Written  procedures  to  be  followed   in
 3             determining  a  pre-applicant's  or  an  applicant's
 4             qualifications   for  being  granted  medical  staff
 5             membership and privileges.
 6                  (C)  Written  criteria  to   be   followed   in
 7             evaluating   a  pre-applicant's  or  an  applicant's
 8             qualifications.
 9                  (D)  An evaluation of a pre-applicant's  or  an
10             applicant's   current   health  status  and  current
11             license status in Illinois.
12                  (E)  A written response to  each  pre-applicant
13             or applicant that explains the reason or reasons for
14             any adverse decision (including all reasons based in
15             whole   or   in  part  on  the  applicant's  medical
16             qualifications  or  any   other   basis,   including
17             economic factors).
18             (2)  Minimum  procedures  with  respect  to  medical
19        staff  and  clinical  privilege determinations concerning
20        current members of the medical staff  shall  include  the
21        following:
22                  (A)  A written notice of an adverse decision by
23             the hospital governing board.
24                  (B)  An  explanation  of  the  reasons  for  an
25             adverse  decision including all reasons based on the
26             quality  of  medical  care  or  any   other   basis,
27             including economic factors.
28                  (C)  A  statement of the medical staff member's
29             right to request  a  fair  hearing  on  the  adverse
30             decision  before a hearing panel whose membership is
31             mutually agreed upon by the medical  staff  and  the
32             hospital  governing  board.  The hearing panel shall
33             have independent authority to  recommend  action  to
34             the  hospital  governing  board. Upon the request of
 
                            -4-                LRB9100490ACsb
 1             the medical staff member or the  hospital  governing
 2             board,   the   hearing  panel  shall  make  findings
 3             concerning the nature of each basis for any  adverse
 4             decision recommended to and accepted by the hospital
 5             governing board.
 6                       (i)  Nothing   in  this  subparagraph  (C)
 7                  limits a hospital's or medical staff's right to
 8                  summarily suspend, without a prior  hearing,  a
 9                  person's  medical  staff membership or clinical
10                  privileges if the continuation of practice of a
11                  medical staff member constitutes  an  immediate
12                  danger   to  the  public,  including  patients,
13                  visitors, and hospital employees and  staff.  A
14                  fair  hearing shall be commenced within 15 days
15                  after  the  suspension  and  completed  without
16                  delay.
17                       (ii)  Nothing  in  this  subparagraph  (C)
18                  limits a medical staff's right  to  permit,  in
19                  the medical staff bylaws, summary suspension of
20                  membership or clinical privileges in designated
21                  administrative  circumstances  as  specifically
22                  approved  by  the  medical  staff.  This  bylaw
23                  provision  must  specifically describe both the
24                  administrative circumstance that can result  in
25                  a  summary  suspension  and  the  length of the
26                  summary suspension. The opportunity for a  fair
27                  hearing  is  required  for  any  administrative
28                  summary  suspension. Any requested hearing must
29                  be commenced within 15 days after  the  summary
30                  suspension and completed without delay. Adverse
31                  decisions   other   than  suspension  or  other
32                  restrictions on the treatment or  admission  of
33                  patients may be imposed summarily and without a
34                  hearing    under    designated   administrative
 
                            -5-                LRB9100490ACsb
 1                  circumstances as specifically provided  for  in
 2                  the  medical  staff  bylaws  as approved by the
 3                  medical staff.
 4                       (iii)  If a hospital exercises its  option
 5                  to  enter  into  an exclusive contract and that
 6                  contract  results  in  the  total  or   partial
 7                  termination   or  reduction  of  medical  staff
 8                  membership or clinical privileges of a  current
 9                  medical   staff   member,  the  hospital  shall
10                  provide the affected medical  staff  member  60
11                  days  prior  notice of the effect on his or her
12                  medical  staff  membership  or  privileges.  An
13                  affected  medical  staff  member   desiring   a
14                  hearing   under   subparagraph   (C)   of  this
15                  paragraph (2) must request the  hearing  within
16                  14  days  after  the  date  he  or  she  is  so
17                  notified.   The   requested  hearing  shall  be
18                  commenced and  completed  (with  a  report  and
19                  recommendation  to  the  affected medical staff
20                  member, hospital governing board,  and  medical
21                  staff)  within  30  days  after the date of the
22                  medical staff member's request. If agreed  upon
23                  by  both  the  medical  staff  and the hospital
24                  governing board, the medical staff  bylaws  may
25                  provide for longer time periods.
26                  (D)  A  statement  of  the  member's  right  to
27             inspect  all pertinent information in the hospital's
28             possession with respect to the decision.
29                  (E)  A  statement  of  the  member's  right  to
30             present witnesses and other evidence at the  hearing
31             on the decision.
32                  (F)  A  written  notice and written explanation
33             of the decision resulting from the hearing.
34                  (F-5)  A written  notice  of  a  final  adverse
 
                            -6-                LRB9100490ACsb
 1             decision by a hospital governing board.
 2                  (G)  Notice given 15 days before implementation
 3             of  an  adverse medical staff membership or clinical
 4             privileges decision based substantially on  economic
 5             factors.  This  notice  shall  be  given  after  the
 6             medical   staff   member   exhausts  all  applicable
 7             procedures under this Section, including item  (iii)
 8             of subparagraph (C) of this paragraph (2), and under
 9             the   medical   staff   bylaws  in  order  to  allow
10             sufficient time for the orderly provision of patient
11             care.
12                  (H)  Nothing in  this  paragraph  (2)  of  this
13             subsection (b) limits a medical staff member's right
14             to   waive,  in  writing,  the  rights  provided  in
15             subparagraphs (A) through (G) of this paragraph  (2)
16             of  this  subsection  (b)  upon  being  granted  the
17             written   exclusive   right  to  provide  particular
18             services at a hospital, either individually or as  a
19             member  of  a  group.  If  an  exclusive contract is
20             signed by a representative of a group of physicians,
21             a waiver contained in the contract  shall  apply  to
22             all  members of the group unless stated otherwise in
23             the contract.
24             (3)  Every  adverse  medical  staff  membership  and
25        clinical  privilege  decision  based   substantially   on
26        economic  factors  shall  be  reported  to  the  Hospital
27        Licensing  Board before the decision takes effect.  These
28        reports shall not be disclosed in any form  that  reveals
29        the identity of any hospital or physician.  These reports
30        shall  be  utilized  to  study  the effects that hospital
31        medical staff membership and clinical privilege decisions
32        based upon economic factors have on access  to  care  and
33        the  availability  of  physician  services.  The Hospital
34        Licensing Board shall submit  an  initial  study  to  the
 
                            -7-                LRB9100490ACsb
 1        Governor and the General Assembly by January 1, 1996, and
 2        subsequent   reports   shall  be  submitted  periodically
 3        thereafter.
 4             (4)  As used in this Section:
 5             "Adverse  decision"  means  a   decision   reducing,
 6        restricting,   suspending,   revoking,  denying,  or  not
 7        renewing medical staff membership or clinical privileges.
 8             "Economic factor" means any information  or  reasons
 9        for   decisions   unrelated   to   quality   of  care  or
10        professional competency.
11             "Privilege" means permission to provide  medical  or
12        other   patient  care  services  and  permission  to  use
13        hospital resources, including equipment,  facilities  and
14        personnel  that  are  necessary  to  effectively  provide
15        medical  or  other patient care services. This definition
16        shall not be construed to require a hospital  to  acquire
17        additional   equipment,   facilities,   or  personnel  to
18        accommodate the granting of privileges.
19    (Source:  P.A.  90-14,  eff.  7-1-97;  90-149,  eff.  1-1-98;
20    90-655, eff. 7-30-98.)

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