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91_SB0953enr
SB953 Enrolled 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
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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. Hospitals that require medical
20 staff members to possess faculty status with a specific
21 institution of higher education are not required to comply
22 with subsection (1) below when the physician does not possess
23 faculty status.
24 (1) Minimum procedures for pre-applicants and
25 initial applicants for medical staff membership shall
26 include the following:
27 (A) Written procedures relating to the
28 acceptance and processing of pre-applicants or
29 initial applicants for medical staff membership,
30 which should be contained in medical staff bylaws.
31 (B) Written procedures to be followed in
32 determining a pre-applicant's or an applicant's
33 qualifications for being granted medical staff
34 membership and privileges.
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1 (C) Written criteria to be followed in
2 evaluating a pre-applicant's or an applicant's
3 qualifications.
4 (D) An evaluation of a pre-applicant's or an
5 applicant's current health status and current
6 license status in Illinois.
7 (E) A written response to each pre-applicant
8 or applicant that explains the reason or reasons for
9 any adverse decision (including all reasons based in
10 whole or in part on the applicant's medical
11 qualifications or any other basis, including
12 economic factors).
13 (2) Minimum procedures with respect to medical
14 staff and clinical privilege determinations concerning
15 current members of the medical staff shall include the
16 following:
17 (A) A written notice of an adverse decision by
18 the hospital governing board.
19 (B) An explanation of the reasons for an
20 adverse decision including all reasons based on the
21 quality of medical care or any other basis,
22 including economic factors.
23 (C) A statement of the medical staff member's
24 right to request a fair hearing on the adverse
25 decision before a hearing panel whose membership is
26 mutually agreed upon by the medical staff and the
27 hospital governing board. The hearing panel shall
28 have independent authority to recommend action to
29 the hospital governing board. Upon the request of
30 the medical staff member or the hospital governing
31 board, the hearing panel shall make findings
32 concerning the nature of each basis for any adverse
33 decision recommended to and accepted by the hospital
34 governing board.
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1 (i) Nothing in this subparagraph (C)
2 limits a hospital's or medical staff's right to
3 summarily suspend, without a prior hearing, a
4 person's medical staff membership or clinical
5 privileges if the continuation of practice of a
6 medical staff member constitutes an immediate
7 danger to the public, including patients,
8 visitors, and hospital employees and staff. A
9 fair hearing shall be commenced within 15 days
10 after the suspension and completed without
11 delay.
12 (ii) Nothing in this subparagraph (C)
13 limits a medical staff's right to permit, in
14 the medical staff bylaws, summary suspension of
15 membership or clinical privileges in designated
16 administrative circumstances as specifically
17 approved by the medical staff. This bylaw
18 provision must specifically describe both the
19 administrative circumstance that can result in
20 a summary suspension and the length of the
21 summary suspension. The opportunity for a fair
22 hearing is required for any administrative
23 summary suspension. Any requested hearing must
24 be commenced within 15 days after the summary
25 suspension and completed without delay. Adverse
26 decisions other than suspension or other
27 restrictions on the treatment or admission of
28 patients may be imposed summarily and without a
29 hearing under designated administrative
30 circumstances as specifically provided for in
31 the medical staff bylaws as approved by the
32 medical staff.
33 (iii) If a hospital exercises its option
34 to enter into an exclusive contract and that
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1 contract results in the total or partial
2 termination or reduction of medical staff
3 membership or clinical privileges of a current
4 medical staff member, the hospital shall
5 provide the affected medical staff member 60
6 days prior notice of the effect on his or her
7 medical staff membership or privileges. An
8 affected medical staff member desiring a
9 hearing under subparagraph (C) of this
10 paragraph (2) must request the hearing within
11 14 days after the date he or she is so
12 notified. The requested hearing shall be
13 commenced and completed (with a report and
14 recommendation to the affected medical staff
15 member, hospital governing board, and medical
16 staff) within 30 days after the date of the
17 medical staff member's request. If agreed upon
18 by both the medical staff and the hospital
19 governing board, the medical staff bylaws may
20 provide for longer time periods.
21 (D) A statement of the member's right to
22 inspect all pertinent information in the hospital's
23 possession with respect to the decision.
24 (E) A statement of the member's right to
25 present witnesses and other evidence at the hearing
26 on the decision.
27 (F) A written notice and written explanation
28 of the decision resulting from the hearing.
29 (F-5) A written notice of a final adverse
30 decision by a hospital governing board.
31 (G) Notice given 15 days before implementation
32 of an adverse medical staff membership or clinical
33 privileges decision based substantially on economic
34 factors. This notice shall be given after the
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1 medical staff member exhausts all applicable
2 procedures under this Section, including item (iii)
3 of subparagraph (C) of this paragraph (2), and under
4 the medical staff bylaws in order to allow
5 sufficient time for the orderly provision of patient
6 care.
7 (H) Nothing in this paragraph (2) of this
8 subsection (b) limits a medical staff member's right
9 to waive, in writing, the rights provided in
10 subparagraphs (A) through (G) of this paragraph (2)
11 of this subsection (b) upon being granted the
12 written exclusive right to provide particular
13 services at a hospital, either individually or as a
14 member of a group. If an exclusive contract is
15 signed by a representative of a group of physicians,
16 a waiver contained in the contract shall apply to
17 all members of the group unless stated otherwise in
18 the contract.
19 (3) Every adverse medical staff membership and
20 clinical privilege decision based substantially on
21 economic factors shall be reported to the Hospital
22 Licensing Board before the decision takes effect. These
23 reports shall not be disclosed in any form that reveals
24 the identity of any hospital or physician. These reports
25 shall be utilized to study the effects that hospital
26 medical staff membership and clinical privilege decisions
27 based upon economic factors have on access to care and
28 the availability of physician services. The Hospital
29 Licensing Board shall submit an initial study to the
30 Governor and the General Assembly by January 1, 1996, and
31 subsequent reports shall be submitted periodically
32 thereafter.
33 (4) As used in this Section:
34 "Adverse decision" means a decision reducing,
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1 restricting, suspending, revoking, denying, or not
2 renewing medical staff membership or clinical privileges.
3 "Economic factor" means any information or reasons
4 for decisions unrelated to quality of care or
5 professional competency.
6 "Pre-applicant" means a physician licensed to
7 practice medicine in all its branches who requests an
8 application for medical staff membership or privileges.
9 "Privilege" means permission to provide medical or
10 other patient care services and permission to use
11 hospital resources, including equipment, facilities and
12 personnel that are necessary to effectively provide
13 medical or other patient care services. This definition
14 shall not be construed to require a hospital to acquire
15 additional equipment, facilities, or personnel to
16 accommodate the granting of privileges.
17 (5) Any amendment to medical staff bylaws required
18 because of this amendatory Act of the 91st General
19 Assembly shall be adopted on or before July 1, 2001.
20 (c) All hospitals shall consult with the medical staff
21 prior to closing membership in the entire or any portion of
22 the medical staff or a department. If the hospital closes
23 membership in the medical staff, any portion of the medical
24 staff, or the department over the objections of the medical
25 staff, then the hospital shall provide a detailed written
26 explanation for the decision to the medical staff 10 days
27 prior to the effective date of any closure. No applications
28 need to be provided when membership in the medical staff or
29 any relevant portion of the medical staff is closed.
30 (Source: P.A. 90-14, eff. 7-1-97; 90-149, eff. 1-1-98;
31 90-655, eff. 7-30-98.)
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