Section 205.230  Standards of Professional Work


The owner or manager of the ambulatory surgical treatment center shall maintain proper standards of professional work in the facility.


a)         A qualified consulting committee shall be appointed in writing by the management or owner of the ambulatory surgical treatment center and shall establish and enforce standards for professional work in the facility and standards of competency for physicians.  The qualified consulting committee shall meet not less than quarterly and shall document all meetings with written minutes.  The minutes shall be maintained at the facility and shall be available for Department inspection.


1)         The membership of the qualified consulting committee shall reflect the types of procedures performed.  If the facility performs more than 50 procedures per month, or more than 10% of the total procedures performed are in a specific specialty area, then a consulting physician of that specialty shall be on the qualified consulting committee.


2)         The qualified consulting committee shall review the development and content of the facility's written policies and procedures, including the details of the quality assessment and performance improvement program, the infection control program, the patient rights plan, the disaster preparedness plan, the procedures for granting privileges, and the quality of the surgical procedures performed.  The reviews shall be documented in the minutes.


3)         The qualified consulting committee shall establish the scope of procedures to be performed at the facility and shall periodically review and amend the scope of procedures as appropriate.


4)         Physicians seeking practice privileges at the facility shall provide their credentials.  The credentials committee shall periodically reappraise and review physician credentials and shall identify and record specific practice privileges pursuant to the Health Care Professional Credentials Data Collection Code.  A record of accepted practice privileges shall be available for facility staff use and for public information within the facility.


5)         Each member of the medical staff granted specific surgical practice privileges shall provide, at every re-credentialing period, a notarized statement or documentation indicating the name of the Illinois licensed hospital or hospitals where he or she has skilled-equivalent practice privileges.  The statements or documentation shall be available for Department inspection.  A list of privileges granted to each medical staff member of the ambulatory surgical treatment center shall be available at all times for facility staff use and for Department inspection. As used in this subsection (a)(5), "skilled-equivalent" means the ability to perform similar procedures requiring the same level of training and expertise.


6)         The qualified consulting committee shall act as a tissue committee and shall review, at least quarterly, pathological reports from procedures performed by each physician on the staff, when applicable.  The review shall be documented in the minutes.


7)         A dentist may be privileged at an ambulatory surgical treatment center if it is determined that the patient under the care of the dentist requires sedation beyond the training that the dentist possesses.  The determination of need for sedation shall be made by the medical director of the facility where the procedure is to be performed.  A dentist performing a surgical procedure requiring sedation at a facility must either:


A)        Have admitting privileges at a nearby hospital where patients would receive care in the event of an emergency arising during a dental surgical procedure; or


B)        Have a memorandum of understanding with a physician who has admitting privileges at such a hospital.  (Section 6(3)(b) of the Act)


b)         A qualified physician shall be designated as the medical director.


1)         The medical director shall secure compliance with the policies and procedures pertaining to medical and surgical procedures, approved by the qualified consulting committee.


2)         The medical director shall implement medical policies and procedures contained in the facility's policies and procedures manual (Section 205.240) governing the professional personnel involved directly in the care of patients undergoing surgical procedures, including their preoperative and postoperative care and follow-up.


3)         The medical director shall establish and secure compliance with standards for patient observation by nursing personnel during the postoperative period.


(Source:  Amended at 44 Ill. Reg. 18358, effective November 2, 2020)