Full Text of SB2336 98th General Assembly
SB2336 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB2336 Introduced 2/15/2013, by Sen. Don Harmon SYNOPSIS AS INTRODUCED: |
| 210 ILCS 85/10.4 | from Ch. 111 1/2, par. 151.4 |
| Amends the Hospital Licensing Act. Makes a technical change in a Section concerning medical staff privileges.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Hospital Licensing Act is amended by | 5 | | changing 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 | 9 | | organized under the
the
University of Illinois Hospital Act | 10 | | shall, prior to the granting of any medical
staff privileges to | 11 | | an applicant, or renewing a current medical staff member's
| 12 | | privileges, request of the Director of Professional Regulation | 13 | | information
concerning the licensure status and any | 14 | | disciplinary action taken against the
applicant's or medical | 15 | | staff member's license, except: (1) for medical personnel who
| 16 | | enter a hospital to obtain organs and tissues for transplant | 17 | | from a donor in accordance with the Illinois Anatomical Gift | 18 | | Act; or (2) for medical personnel who have been granted | 19 | | disaster privileges pursuant to the procedures and | 20 | | requirements established by rules adopted by the Department. | 21 | | Any hospital and any employees of the hospital or others | 22 | | involved in granting privileges who, in good faith, grant | 23 | | disaster privileges pursuant to this Section to respond to an |
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| 1 | | emergency shall not, as a result of their acts or omissions, be | 2 | | liable for civil damages for granting or denying disaster | 3 | | privileges except in the event of willful and wanton | 4 | | misconduct, as that term is defined in Section 10.2 of this | 5 | | Act. Individuals granted privileges who provide care in an | 6 | | emergency situation, in good faith and without direct | 7 | | compensation, shall not, as a result of their acts or | 8 | | omissions, except for acts or omissions involving willful and | 9 | | wanton misconduct, as that term is defined in Section 10.2 of | 10 | | this Act, on the part of the person, be liable for civil | 11 | | damages. The Director of
Professional Regulation shall | 12 | | transmit, in writing and in a timely fashion,
such information | 13 | | regarding the license of the applicant or the medical staff
| 14 | | member, including the record of imposition of any periods of
| 15 | | supervision or monitoring as a result of alcohol or
substance | 16 | | abuse, as provided by Section 23 of the Medical
Practice Act of | 17 | | 1987, and such information as may have been
submitted to the | 18 | | Department indicating that the application
or medical staff | 19 | | member has been denied, or has surrendered,
medical staff | 20 | | privileges at a hospital licensed under this
Act, or any | 21 | | equivalent facility in another state or
territory of the United | 22 | | States. The Director of Professional Regulation
shall define by | 23 | | rule the period for timely response to such requests. | 24 | | No transmittal of information by the Director of | 25 | | Professional Regulation,
under this Section shall be to other | 26 | | than the president, chief
operating officer, chief |
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| 1 | | administrative officer, or chief of
the medical staff of a | 2 | | hospital licensed under this Act, a
hospital organized under | 3 | | the University of Illinois Hospital Act, or a hospital
operated | 4 | | by the United States, or any of its instrumentalities. The
| 5 | | information so transmitted shall be afforded the same status
as | 6 | | is information concerning medical studies by Part 21 of Article | 7 | | VIII of the
Code of Civil Procedure, as now or hereafter | 8 | | amended.
| 9 | | (b) All hospitals licensed under this Act, except county | 10 | | hospitals as
defined in subsection (c) of Section 15-1 of the | 11 | | Illinois Public Aid Code,
shall comply with, and the medical | 12 | | staff bylaws of these hospitals shall
include rules consistent | 13 | | with, the provisions of this Section in granting,
limiting, | 14 | | renewing, or denying medical staff membership and
clinical | 15 | | staff privileges. Hospitals that require medical staff members | 16 | | to
possess
faculty status with a specific institution of higher | 17 | | education are not required
to comply with subsection (1) below | 18 | | when 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 recommend action to the
| 2 | | hospital governing board. Upon the request of the | 3 | | medical staff member or the
hospital governing board, | 4 | | the hearing panel shall make findings concerning the
| 5 | | nature of each basis for any adverse decision | 6 | | recommended to and accepted by
the hospital governing | 7 | | board.
| 8 | | (i) Nothing in this subparagraph (C) limits a | 9 | | hospital's or medical
staff's right to summarily | 10 | | suspend, without a prior hearing, a person's | 11 | | medical
staff membership or clinical privileges if | 12 | | the continuation of practice of a
medical staff | 13 | | member constitutes an immediate danger to the | 14 | | public, including
patients, visitors, and hospital | 15 | | employees and staff. In the event that a hospital | 16 | | or the medical staff imposes a summary suspension, | 17 | | the Medical Executive Committee, or other | 18 | | comparable governance committee of the medical | 19 | | staff as specified in the bylaws, must meet as soon | 20 | | as is reasonably possible to review the suspension | 21 | | and to recommend whether it should be affirmed, | 22 | | lifted, expunged, or modified if the suspended | 23 | | physician requests such review. A summary | 24 | | suspension may not be implemented unless there is | 25 | | actual documentation or other reliable information | 26 | | that an immediate danger exists. This |
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| 1 | | documentation or information must be available at | 2 | | the time the summary suspension decision is made | 3 | | and when the decision is reviewed by the Medical | 4 | | Executive Committee. If the Medical Executive | 5 | | Committee recommends that the summary suspension | 6 | | should be lifted, expunged, or modified, this | 7 | | recommendation must be reviewed and considered by | 8 | | the hospital governing board, or a committee of the | 9 | | board, on an expedited basis. Nothing in this | 10 | | subparagraph (C) shall affect the requirement that | 11 | | any requested hearing must be commenced within 15 | 12 | | days after the summary suspension and completed | 13 | | without delay unless otherwise agreed to by the | 14 | | parties. A fair hearing shall be
commenced within | 15 | | 15 days after the suspension and completed without | 16 | | delay, except that when the medical staff member's | 17 | | license to practice has been suspended or revoked | 18 | | by the State's licensing authority, no hearing | 19 | | shall be necessary.
| 20 | | (ii) Nothing in this subparagraph (C) limits a | 21 | | medical staff's right
to permit, in the medical | 22 | | staff bylaws, summary suspension of membership or
| 23 | | clinical privileges in designated administrative | 24 | | circumstances as specifically
approved by the | 25 | | medical staff. This bylaw provision must | 26 | | specifically describe
both the administrative |
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| 1 | | circumstance that can result in a summary | 2 | | suspension
and the length of the summary | 3 | | suspension. The opportunity for a fair hearing is
| 4 | | required for any administrative summary | 5 | | suspension. Any requested hearing must
be | 6 | | commenced within 15 days after the summary | 7 | | suspension and completed without
delay. Adverse | 8 | | decisions other than suspension or other | 9 | | restrictions on the
treatment or admission of | 10 | | patients may be imposed summarily and without a
| 11 | | hearing under designated administrative | 12 | | circumstances as specifically provided
for in the | 13 | | medical staff bylaws as approved by the medical | 14 | | staff.
| 15 | | (iii) If a hospital exercises its option to | 16 | | enter into an exclusive
contract and that contract | 17 | | results in the total or partial termination or
| 18 | | reduction of medical staff membership or clinical | 19 | | privileges of a current
medical staff member, the | 20 | | hospital shall provide the affected medical staff
| 21 | | member 60 days prior notice of the effect on his or | 22 | | her medical staff
membership or privileges. An | 23 | | affected medical staff member desiring a hearing
| 24 | | under subparagraph (C) of this paragraph (2) must | 25 | | request the hearing within 14
days after the date | 26 | | he or she is so notified. The requested hearing |
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| 1 | | shall be
commenced and completed (with a report and | 2 | | recommendation to the affected
medical staff | 3 | | member, hospital governing board, and medical | 4 | | staff) within 30
days after the date of the medical | 5 | | staff member's request. If agreed upon by
both the | 6 | | medical staff and the hospital governing board, | 7 | | the medical staff
bylaws may provide for longer | 8 | | time periods.
| 9 | | (C-5) All peer review used for the purpose of | 10 | | credentialing, privileging, disciplinary action, or | 11 | | other recommendations affecting medical staff | 12 | | membership or exercise of clinical privileges, whether | 13 | | relying in whole or in part on internal or external | 14 | | reviews, shall be conducted in accordance with the | 15 | | medical staff bylaws and applicable rules, | 16 | | regulations, or policies of the medical staff. If | 17 | | external review is obtained, any adverse report | 18 | | utilized shall be in writing and shall be made part of | 19 | | the internal peer review process under the bylaws. The | 20 | | report shall also be shared with a medical staff peer | 21 | | review committee and the individual under review. If | 22 | | the medical staff peer review committee or the | 23 | | individual under review prepares a written response to | 24 | | the report of the external peer review within 30 days | 25 | | after receiving such report, the governing board shall | 26 | | consider the response prior to the implementation of |
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| 1 | | any final actions by the governing board which may | 2 | | affect the individual's medical staff membership or | 3 | | clinical privileges. Any peer review that involves | 4 | | willful or wanton misconduct shall be subject to civil | 5 | | damages as provided for under Section 10.2 of this Act.
| 6 | | (D) A statement of the member's right to inspect | 7 | | all pertinent
information in the hospital's possession | 8 | | with respect to the decision.
| 9 | | (E) A statement of the member's right to present | 10 | | witnesses and other
evidence at the hearing on the | 11 | | decision.
| 12 | | (E-5) The right to be represented by a personal | 13 | | attorney.
| 14 | | (F) A written notice and written explanation of the | 15 | | decision resulting
from the hearing.
| 16 | | (F-5) A written notice of a final adverse decision | 17 | | by a hospital
governing board.
| 18 | | (G) Notice given 15 days before implementation of | 19 | | an adverse medical
staff membership or clinical | 20 | | privileges decision based substantially on
economic | 21 | | factors. This notice shall be given after the medical | 22 | | staff member
exhausts all applicable procedures under | 23 | | this Section, including item (iii) of
subparagraph (C) | 24 | | of this paragraph (2), and under the medical staff | 25 | | bylaws in
order to allow sufficient time for the | 26 | | orderly provision of patient care.
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| 1 | | (H) Nothing in this paragraph (2) of this | 2 | | subsection (b) limits a
medical staff member's right to | 3 | | waive, in writing, the rights provided in
| 4 | | subparagraphs (A) through (G) of this paragraph (2) of | 5 | | this subsection (b) upon
being granted the written | 6 | | exclusive right to provide particular services at a
| 7 | | hospital, either individually or as a member of a | 8 | | group. If an exclusive
contract is signed by a | 9 | | representative of a group of physicians, a waiver
| 10 | | contained in the contract shall apply to all members of | 11 | | the group unless stated
otherwise in the contract.
| 12 | | (3) Every adverse medical staff membership and | 13 | | clinical privilege decision
based substantially on | 14 | | economic factors shall be reported to the Hospital
| 15 | | Licensing Board before the decision takes effect. These | 16 | | reports shall not be
disclosed in any form that reveals the | 17 | | identity of any hospital or physician.
These reports shall | 18 | | be utilized to study the effects that hospital medical
| 19 | | staff membership and clinical privilege decisions based | 20 | | upon economic factors
have on access to care and the | 21 | | availability of physician services. The
Hospital Licensing | 22 | | Board shall submit an initial study to the Governor and the
| 23 | | General Assembly by January 1, 1996, and subsequent reports | 24 | | shall be submitted
periodically thereafter.
| 25 | | (4) As used in this Section:
| 26 | | "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 for | 4 | | decisions unrelated
to quality of care or professional | 5 | | competency.
| 6 | | "Pre-applicant" means a physician licensed to practice | 7 | | medicine in all
its
branches who requests an application | 8 | | for medical staff membership or
privileges.
| 9 | | "Privilege" means permission to provide
medical or | 10 | | other patient care services and permission to use hospital
| 11 | | resources, including equipment, facilities and personnel | 12 | | that are necessary to
effectively provide medical or other | 13 | | patient care services. This definition
shall not be | 14 | | construed to
require a hospital to acquire additional | 15 | | equipment, facilities, or personnel to
accommodate the | 16 | | granting of privileges.
| 17 | | (5) Any amendment to medical staff bylaws required | 18 | | because of
this amendatory Act of the 91st General Assembly | 19 | | 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 the | 22 | | 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 prior |
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| 1 | | to the effective date of any closure. No applications need to | 2 | | be
provided when membership in the medical staff or any | 3 | | relevant portion of the
medical staff is closed.
| 4 | | (Source: P.A. 96-445, eff. 8-14-09; 97-1006, eff. 8-17-12.)
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