Public Act 90-0149 of the 90th General Assembly
Public Act 90-0149
HB0408 Enrolled LRB9000275DPcc
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 1-21 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 clinic staff privileges.
(1) Minimum procedures for initial applicants for
medical staff membership shall include the following:
(A) Written procedures relating to the
acceptance and processing of initial applicants for
medical staff membership.
(B) Written procedures to be followed in
determining an applicant's qualifications for being
granted medical staff membership and privileges.
(C) Written criteria to be followed in
evaluating an applicant's qualifications.
(D) An evaluation of an applicant's current
health status and current license status in
Illinois.
(E) A written response to each applicant that
explains the reason or reasons for any adverse
decision (including all reasons based in whole or in
part on the applicant's medical qualifications or
any other basis, including economic factors).
(2) Minimum procedures with respect to medical
staff and clinical privilege determinations concerning
current members of the medical staff shall include the
following:
(A) A written 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.
(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.
"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.
(Source: P.A. 88-654, eff. 1-1-95.)