State of Illinois
91st General Assembly
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Public Act 91-0166

SB953 Enrolled                                 LRB9100490ACsb

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

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

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

    (210 ILCS 85/10.4) (from Ch. 111 1/2, par. 151.4)
    Sec. 10.4. 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 for medical  personnel
who  enter  a  hospital  to  obtain  organs  and  tissues for
transplant from a  deceased  donor  in  accordance  with  the
Uniform  Anatomical  Gift  Act.  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  possess  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 status.
         (1)  Minimum  procedures  for   pre-applicants   and
    initial  applicants  for  medical  staff membership shall
    include the following:
              (A)  Written   procedures   relating   to   the
         acceptance  and  processing  of  pre-applicants   or
         initial  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 by
         the hospital governing board.
              (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.  A
              fair  hearing shall be commenced within 15 days
              after  the  suspension  and  completed  without
              delay.
                   (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.
              (D)  A  statement  of  the  member's  right  to
         inspect  all pertinent information in the hospital's
         possession with respect to the decision.
              (E)  A  statement  of  the  member's  right  to
         present witnesses and other evidence at the  hearing
         on the decision.
              (F)  A  written  notice and written explanation
         of the decision resulting from the 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.  If  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  hospital  shall provide a detailed written
explanation for the decision to the  medical  staff  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.  90-14,  eff.  7-1-97;  90-149,  eff.  1-1-98;
90-655, eff. 7-30-98.)

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