State of Illinois
2011 and 2012


Introduced 2/23/2011, by Rep. Timothy L. Schmitz


210 ILCS 85/10.4  from Ch. 111 1/2, par. 151.4

    Amends the Hospital Licensing Act. In a provision concerning a medical staff member's right to request a fair hearing, deletes language that provides that the hearing panel shall have independent authority to recommend action to the hospital governing board. Provides instead that the hearing panel shall have independent authority to preside over the fair hearing, consider evidence and testimony presented at the hearing, and issue a finding and decision on the matter. Provides that the fair hearing panel may uphold, rescind, modify, amend, or otherwise alter the original adverse decision issued against a medical staff member. Sets forth provisions concerning the findings of the hearing panel and adjudicatory recourse for an adversely affected physician. Effective January 1, 2012.

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1    AN ACT concerning health facilities.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Hospital Licensing Act is amended by
5changing Section 10.4 as follows:
6    (210 ILCS 85/10.4)  (from Ch. 111 1/2, par. 151.4)
7    Sec. 10.4. Medical staff privileges.
8    (a) Any hospital licensed under this Act or any hospital
9organized under the University of Illinois Hospital Act shall,
10prior to the granting of any medical staff privileges to an
11applicant, or renewing a current medical staff member's
12privileges, request of the Director of Professional Regulation
13information concerning the licensure status and any
14disciplinary action taken against the applicant's or medical
15staff member's license, except: (1) for medical personnel who
16enter a hospital to obtain organs and tissues for transplant
17from a donor in accordance with the Illinois Anatomical Gift
18Act; or (2) for medical personnel who have been granted
19disaster privileges pursuant to the procedures and
20requirements established by rules adopted by the Department.
21Any hospital and any employees of the hospital or others
22involved in granting privileges who, in good faith, grant
23disaster privileges pursuant to this Section to respond to an



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1emergency shall not, as a result of their acts or omissions, be
2liable for civil damages for granting or denying disaster
3privileges except in the event of willful and wanton
4misconduct, as that term is defined in Section 10.2 of this
5Act. Individuals granted privileges who provide care in an
6emergency situation, in good faith and without direct
7compensation, shall not, as a result of their acts or
8omissions, except for acts or omissions involving willful and
9wanton misconduct, as that term is defined in Section 10.2 of
10this Act, on the part of the person, be liable for civil
11damages. The Director of Professional Regulation shall
12transmit, in writing and in a timely fashion, such information
13regarding the license of the applicant or the medical staff
14member, including the record of imposition of any periods of
15supervision or monitoring as a result of alcohol or substance
16abuse, as provided by Section 23 of the Medical Practice Act of
171987, and such information as may have been submitted to the
18Department indicating that the application or medical staff
19member has been denied, or has surrendered, medical staff
20privileges at a hospital licensed under this Act, or any
21equivalent facility in another state or territory of the United
22States. The Director of Professional Regulation shall define by
23rule the period for timely response to such requests.
24    No transmittal of information by the Director of
25Professional Regulation, under this Section shall be to other
26than the president, chief operating officer, chief



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1administrative officer, or chief of the medical staff of a
2hospital licensed under this Act, a hospital organized under
3the University of Illinois Hospital Act, or a hospital operated
4by the United States, or any of its instrumentalities. The
5information so transmitted shall be afforded the same status as
6is information concerning medical studies by Part 21 of Article
7VIII of the Code of Civil Procedure, as now or hereafter
9    (b) All hospitals licensed under this Act, except county
10hospitals as defined in subsection (c) of Section 15-1 of the
11Illinois Public Aid Code, shall comply with, and the medical
12staff bylaws of these hospitals shall include rules consistent
13with, the provisions of this Section in granting, limiting,
14renewing, or denying medical staff membership and clinical
15staff privileges. Hospitals that require medical staff members
16to possess faculty status with a specific institution of higher
17education are not required to comply with subsection (1) below
18when the physician does not possess faculty status.
19        (1) Minimum procedures for pre-applicants and
20    applicants for medical staff membership shall include the
21    following:
22            (A) Written procedures relating to the acceptance
23        and processing of pre-applicants or applicants for
24        medical staff membership, which should be contained in
25        medical staff bylaws.
26            (B) Written procedures to be followed in



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1        determining a pre-applicant's or an applicant's
2        qualifications for being granted medical staff
3        membership and privileges.
4            (C) Written criteria to be followed in evaluating a
5        pre-applicant's or an applicant's qualifications.
6            (D) An evaluation of a pre-applicant's or an
7        applicant's current health status and current license
8        status in Illinois.
9            (E) A written response to each pre-applicant or
10        applicant that explains the reason or reasons for any
11        adverse decision (including all reasons based in whole
12        or in part on the applicant's medical qualifications or
13        any other basis, including economic factors).
14        (2) Minimum procedures with respect to medical staff
15    and clinical privilege determinations concerning current
16    members of the medical staff shall include the following:
17            (A) A written notice of an adverse decision.
18            (B) An explanation of the reasons for an adverse
19        decision including all reasons based on the quality of
20        medical care or any other basis, including economic
21        factors.
22            (C) A statement of the medical staff member's right
23        to request a fair hearing on the adverse decision
24        before a hearing panel whose membership is mutually
25        agreed upon by the medical staff and the hospital
26        governing board. The hearing panel shall have



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1        independent authority to preside over the fair
2        hearing, consider evidence and testimony presented at
3        the hearing, and issue a finding and decision on the
4        matter. The fair hearing panel may uphold, rescind,
5        modify, amend, or otherwise alter the original adverse
6        decision issued against the medical staff member, and
7        the hospital governing board shall adopt and abide by
8        the findings and decision of the hearing panel, unless
9        the fair hearing panel decision is arbitrary,
10        capricious, or against the manifest weight of the
11        evidence recommend action to the hospital governing
12        board. Upon the request of the medical staff member or
13        the hospital governing board, the hearing panel shall
14        make findings concerning the nature of each basis for
15        any adverse decision recommended to and accepted by the
16        hospital governing board or otherwise explain the
17        reasons the hearing panel has chosen to uphold,
18        rescind, modify, amend, or otherwise alter the
19        original adverse decision issued against the medical
20        staff member. If a hospital refuses to fully adopt and
21        abide by the findings of the hearing panel based on an
22        allegation that the panel's decision was arbitrary,
23        capricious, or against the manifest weight of the
24        evidence, then the adversely affected physician shall
25        be authorized to immediately file an action in local
26        circuit court for the purpose of determining whether



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1        the panel's decision was arbitrary, capricious, or
2        against the manifest weight of the evidence and also
3        whether the medical staff bylaws were followed as
4        relates to the adverse decision. Under the rule of
5        limited review in hospital privileging issues, the
6        court shall give great weight and deference to the
7        findings and decisions made by the fair hearing panel.
8        The legal concept of fundamental fairness shall apply
9        to any adversely affected physician during the fair
10        hearing and any appellate reviews or final decisions
11        against the physician. If an adversely affected
12        physician substantially prevails against a hospital in
13        circuit court, then the court may issue any reasonable
14        award to the physician, including attorney's fees and
15        costs.
16                (i) Nothing in this subparagraph (C) limits a
17            hospital's or medical staff's right to summarily
18            suspend, without a prior hearing, a person's
19            medical staff membership or clinical privileges if
20            the continuation of practice of a medical staff
21            member constitutes an immediate danger to the
22            public, including patients, visitors, and hospital
23            employees and staff. In the event that a hospital
24            or the medical staff imposes a summary suspension,
25            the Medical Executive Committee, or other
26            comparable governance committee of the medical



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1            staff as specified in the bylaws, must meet as soon
2            as is reasonably possible to review the suspension
3            and to recommend whether it should be affirmed,
4            lifted, expunged, or modified if the suspended
5            physician requests such review. A summary
6            suspension may not be implemented unless there is
7            actual documentation or other reliable information
8            that an immediate danger exists. This
9            documentation or information must be available at
10            the time the summary suspension decision is made
11            and when the decision is reviewed by the Medical
12            Executive Committee. If the Medical Executive
13            Committee recommends that the summary suspension
14            should be lifted, expunged, or modified, this
15            recommendation must be reviewed and considered by
16            the hospital governing board, or a committee of the
17            board, on an expedited basis. Nothing in this
18            subparagraph (C) shall affect the requirement that
19            any requested hearing must be commenced within 15
20            days after the summary suspension and completed
21            without delay unless otherwise agreed to by the
22            parties. A fair hearing shall be commenced within
23            15 days after the suspension and completed without
24            delay, except that when the medical staff member's
25            license to practice has been suspended or revoked
26            by the State's licensing authority, no hearing



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1            shall be necessary.
2                (ii) Nothing in this subparagraph (C) limits a
3            medical staff's right to permit, in the medical
4            staff bylaws, summary suspension of membership or
5            clinical privileges in designated administrative
6            circumstances as specifically approved by the
7            medical staff. This bylaw provision must
8            specifically describe both the administrative
9            circumstance that can result in a summary
10            suspension and the length of the summary
11            suspension. The opportunity for a fair hearing is
12            required for any administrative summary
13            suspension. Any requested hearing must be
14            commenced within 15 days after the summary
15            suspension and completed without delay. Adverse
16            decisions other than suspension or other
17            restrictions on the treatment or admission of
18            patients may be imposed summarily and without a
19            hearing under designated administrative
20            circumstances as specifically provided for in the
21            medical staff bylaws as approved by the medical
22            staff.
23                (iii) If a hospital exercises its option to
24            enter into an exclusive contract and that contract
25            results in the total or partial termination or
26            reduction of medical staff membership or clinical



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1            privileges of a current medical staff member, the
2            hospital shall provide the affected medical staff
3            member 60 days prior notice of the effect on his or
4            her medical staff membership or privileges. An
5            affected medical staff member desiring a hearing
6            under subparagraph (C) of this paragraph (2) must
7            request the hearing within 14 days after the date
8            he or she is so notified. The requested hearing
9            shall be commenced and completed (with a report and
10            recommendation to the affected medical staff
11            member, hospital governing board, and medical
12            staff) within 30 days after the date of the medical
13            staff member's request. If agreed upon by both the
14            medical staff and the hospital governing board,
15            the medical staff bylaws may provide for longer
16            time periods.
17            (C-5) All peer review used for the purpose of
18        credentialing, privileging, disciplinary action, or
19        other recommendations affecting medical staff
20        membership or exercise of clinical privileges, whether
21        relying in whole or in part on internal or external
22        reviews, shall be conducted in accordance with the
23        medical staff bylaws and applicable rules,
24        regulations, or policies of the medical staff. If
25        external review is obtained, any adverse report
26        utilized shall be in writing and shall be made part of



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1        the internal peer review process under the bylaws. The
2        report shall also be shared with a medical staff peer
3        review committee and the individual under review. If
4        the medical staff peer review committee or the
5        individual under review prepares a written response to
6        the report of the external peer review within 30 days
7        after receiving such report, the governing board shall
8        consider the response prior to the implementation of
9        any final actions by the governing board which may
10        affect the individual's medical staff membership or
11        clinical privileges. Any peer review that involves
12        willful or wanton misconduct shall be subject to civil
13        damages as provided for under Section 10.2 of this Act.
14            (D) A statement of the member's right to inspect
15        all pertinent information in the hospital's possession
16        with respect to the decision.
17            (E) A statement of the member's right to present
18        witnesses and other evidence at the hearing on the
19        decision.
20            (F) A written notice and written explanation of the
21        decision resulting from the hearing.
22            (F-5) A written notice of a final adverse decision
23        by a hospital governing board.
24            (G) Notice given 15 days before implementation of
25        an adverse medical staff membership or clinical
26        privileges decision based substantially on economic



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1        factors. This notice shall be given after the medical
2        staff member exhausts all applicable procedures under
3        this Section, including item (iii) of subparagraph (C)
4        of this paragraph (2), and under the medical staff
5        bylaws in order to allow sufficient time for the
6        orderly provision of patient care.
7            (H) Nothing in this paragraph (2) of this
8        subsection (b) limits a medical staff member's right to
9        waive, in writing, the rights provided in
10        subparagraphs (A) through (G) of this paragraph (2) of
11        this subsection (b) upon being granted the written
12        exclusive right to provide particular services at a
13        hospital, either individually or as a member of a
14        group. If an exclusive contract is signed by a
15        representative of a group of physicians, a waiver
16        contained in the contract shall apply to all members of
17        the group unless stated otherwise in the contract.
18        (3) Every adverse medical staff membership and
19    clinical privilege decision based substantially on
20    economic factors shall be reported to the Hospital
21    Licensing Board before the decision takes effect. These
22    reports shall not be disclosed in any form that reveals the
23    identity of any hospital or physician. These reports shall
24    be utilized to study the effects that hospital medical
25    staff membership and clinical privilege decisions based
26    upon economic factors have on access to care and the



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1    availability of physician services. The Hospital Licensing
2    Board shall submit an initial study to the Governor and the
3    General Assembly by January 1, 1996, and subsequent reports
4    shall be submitted periodically thereafter.
5        (4) As used in this Section:
6        "Adverse decision" means a decision reducing,
7    restricting, suspending, revoking, denying, or not
8    renewing medical staff membership or clinical privileges.
9        "Economic factor" means any information or reasons for
10    decisions unrelated to quality of care or professional
11    competency.
12        "Pre-applicant" means a physician licensed to practice
13    medicine in all its branches who requests an application
14    for medical staff membership or privileges.
15        "Privilege" means permission to provide medical or
16    other patient care services and permission to use hospital
17    resources, including equipment, facilities and personnel
18    that are necessary to effectively provide medical or other
19    patient care services. This definition shall not be
20    construed to require a hospital to acquire additional
21    equipment, facilities, or personnel to accommodate the
22    granting of privileges.
23        (5) Any amendment to medical staff bylaws required
24    because of this amendatory Act of the 91st General Assembly
25    shall be adopted on or before July 1, 2001.
26    (c) All hospitals shall consult with the medical staff



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1prior to closing membership in the entire or any portion of the
2medical staff or a department. If the hospital closes
3membership in the medical staff, any portion of the medical
4staff, or the department over the objections of the medical
5staff, then the hospital shall provide a detailed written
6explanation for the decision to the medical staff 10 days prior
7to the effective date of any closure. No applications need to
8be provided when membership in the medical staff or any
9relevant portion of the medical staff is closed.
10(Source: P.A. 95-331, eff. 8-21-07; 96-445, eff. 8-14-09.)
11    Section 99. Effective date. This Act takes effect January
121, 2012.