Illinois General Assembly - Full Text of HB0068
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Full Text of HB0068  102nd General Assembly


Rep. Mary E. Flowers

Filed: 3/22/2021





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2    AMENDMENT NO. ______. Amend House Bill 68 by replacing
3everything after the enacting clause with the following:
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, proper
14credentials, required certificates, and any disciplinary
15action taken against the applicant's or medical staff member's
16license, except: (1) for medical personnel who enter a



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1hospital to obtain organs and tissues for transplant from a
2donor in accordance with the Illinois Anatomical Gift Act; or
3(2) for medical personnel who have been granted disaster
4privileges pursuant to the procedures and requirements
5established by rules adopted by the Department. Any hospital
6and any employees of the hospital or others involved in
7granting privileges who, in good faith, grant disaster
8privileges pursuant to this Section to respond to an emergency
9shall not, as a result of their acts or omissions, be liable
10for civil damages for granting or denying disaster privileges
11except in the event of willful and wanton misconduct, as that
12term is defined in Section 10.2 of this Act. Individuals
13granted privileges who provide care in an emergency situation,
14in good faith and without direct compensation, shall not, as a
15result of their acts or omissions, except for acts or
16omissions involving willful and wanton misconduct, as that
17term is defined in Section 10.2 of this Act, on the part of the
18person, be liable for civil damages. The Director of
19Professional Regulation shall transmit, in writing and in a
20timely fashion, such information regarding the license of the
21applicant or the medical staff member, including the record of
22imposition of any periods of supervision or monitoring as a
23result of alcohol or substance abuse, as provided by Section
2423 of the Medical Practice Act of 1987, and such information as
25may have been submitted to the Department indicating that the
26application or medical staff member has been denied, or has



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1surrendered, medical staff privileges at a hospital licensed
2under this Act, or any equivalent facility in another state or
3territory of the United States. The Director of Professional
4Regulation shall define by rule the period for timely response
5to such requests.
6    No transmittal of information by the Director of
7Professional Regulation, under this Section shall be to other
8than the president, chief operating officer, chief
9administrative officer, or chief of the medical staff of a
10hospital licensed under this Act, a hospital organized under
11the University of Illinois Hospital Act, or a hospital
12operated by the United States, or any of its
13instrumentalities. The information so transmitted shall be
14afforded the same status as is information concerning medical
15studies by Part 21 of Article VIII of the Code of Civil
16Procedure, as now or hereafter amended.
17    (b) All hospitals licensed under this Act, except county
18hospitals as defined in subsection (c) of Section 15-1 of the
19Illinois Public Aid Code, shall comply with, and the medical
20staff bylaws of these hospitals shall include rules consistent
21with, the provisions of this Section in granting, limiting,
22renewing, or denying medical staff membership and clinical
23staff privileges. Hospitals that require medical staff members
24to possess faculty status with a specific institution of
25higher education are not required to comply with subsection
26(1) below when the physician does not possess faculty status.



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1        (1) Minimum procedures for pre-applicants and
2    applicants for medical staff membership shall include the
3    following:
4            (A) Written procedures relating to the acceptance
5        and processing of pre-applicants or applicants for
6        medical staff membership, which should be contained in
7        medical staff bylaws.
8            (B) Written procedures to be followed in
9        determining a pre-applicant's or an applicant's
10        qualifications for being granted medical staff
11        membership and privileges.
12            (C) Written criteria to be followed in evaluating
13        a pre-applicant's or an applicant's qualifications.
14            (D) An evaluation of a pre-applicant's or an
15        applicant's current health status and current license
16        status in Illinois.
17            (E) A written response to each pre-applicant or
18        applicant that explains the reason or reasons for any
19        adverse decision (including all reasons based in whole
20        or in part on the applicant's medical qualifications
21        or any other basis, including economic factors).
22        (2) Minimum procedures with respect to medical staff
23    and clinical privilege determinations concerning current
24    members of the medical staff shall include the following:
25            (A) A written notice of an adverse decision.
26            (B) An explanation of the reasons for an adverse



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1        decision including all reasons based on the quality of
2        medical care or any other basis, including economic
3        factors.
4            (C) A statement of the medical staff member's
5        right to request a fair hearing on the adverse
6        decision before a hearing panel whose membership is
7        mutually agreed upon by the medical staff and the
8        hospital governing board. The hearing panel shall have
9        independent authority to recommend action to the
10        hospital governing board. Upon the request of the
11        medical staff member or the hospital governing board,
12        the hearing panel shall make findings concerning the
13        nature of each basis for any adverse decision
14        recommended to and accepted by the hospital governing
15        board.
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
2            soon as is reasonably possible to review the
3            suspension and to recommend whether it should be
4            affirmed, lifted, expunged, or modified if the
5            suspended physician requests such review. A
6            summary suspension may not be implemented unless
7            there is actual documentation or other reliable
8            information 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
17            the 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
10            and recommendation to the affected medical staff
11            member, hospital governing board, and medical
12            staff) within 30 days after the date of the
13            medical staff member's request. If agreed upon by
14            both the medical staff and the hospital governing
15            board, the medical staff bylaws may provide for
16            longer 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
14        Act.
15            (D) A statement of the member's right to inspect
16        all pertinent information in the hospital's possession
17        with respect to the decision.
18            (E) A statement of the member's right to present
19        witnesses and other evidence at the hearing on the
20        decision.
21            (E-5) The right to be represented by a personal
22        attorney.
23            (F) A written notice and written explanation of
24        the decision resulting from the hearing.
25            (F-5) A written notice of a final adverse decision
26        by a hospital governing board.



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



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



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1    because of this amendatory Act of the 91st General
2    Assembly shall be adopted on or before July 1, 2001.
3    (c) All hospitals shall consult with the medical staff
4prior to closing membership in the entire or any portion of the
5medical staff or a department. If the hospital closes
6membership in the medical staff, any portion of the medical
7staff, or the department over the objections of the medical
8staff, then the hospital shall provide a detailed written
9explanation for the decision to the medical staff 10 days
10prior to the effective date of any closure. No applications
11need to be provided when membership in the medical staff or any
12relevant portion of the medical staff is closed.
13(Source: P.A. 96-445, eff. 8-14-09; 97-1006, eff. 8-17-12.)
14    Section 10. The Hospital Report Card Act is amended by
15changing Section 25 as follows:
16    (210 ILCS 86/25)
17    Sec. 25. Hospital reports.
18    (a) Individual hospitals shall prepare a quarterly report
19including all of the following:
20        (1) Nursing hours per patient day, average daily
21    census, and average daily hours worked for each clinical
22    service area.
23        (2) Infection-related measures for the facility for
24    the specific clinical procedures and devices determined by



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1    the Department by rule under 2 or more of the following
2    categories:
3            (A) Surgical procedure outcome measures.
4            (B) Surgical procedure infection control process
5        measures.
6            (C) Outcome or process measures related to
7        ventilator-associated pneumonia.
8            (D) Central vascular catheter-related bloodstream
9        infection rates in designated critical care units.
10        (3) Information required under paragraph (4) of
11    Section 2310-312 of the Department of Public Health Powers
12    and Duties Law of the Civil Administrative Code of
13    Illinois.
14        (4) Additional infection measures mandated by the
15    Centers for Medicare and Medicaid Services that are
16    reported by hospitals to the Centers for Disease Control
17    and Prevention's National Healthcare Safety Network
18    surveillance system, or its successor, and deemed relevant
19    to patient safety by the Department.
20        (5) Each instance of preterm birth and infant
21    mortality within the reporting period, including the
22    racial and ethnic information of the mothers of those
23    infants.
24        (6) Each instance of maternal mortality within the
25    reporting period, including the racial and ethnic
26    information of those mothers.



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1        (7) The number of female patients who have died within
2    the reporting period.
3        (8) The number of female patients admitted to the
4    hospital with a diagnosis of COVID-19 and at least one
5    known underlying condition identified by the United States
6    Centers for Disease Control and Prevention as a condition
7    that increases the risk of mortality from COVID-19 who
8    subsequently died at the hospital within the reporting
9    period.
10    The infection-related measures developed by the Department
11shall be based upon measures and methods developed by the
12Centers for Disease Control and Prevention, the Centers for
13Medicare and Medicaid Services, the Agency for Healthcare
14Research and Quality, the Joint Commission on Accreditation of
15Healthcare Organizations, or the National Quality Forum. The
16Department may align the infection-related measures with the
17measures and methods developed by the Centers for Disease
18Control and Prevention, the Centers for Medicare and Medicaid
19Services, the Agency for Healthcare Research and Quality, the
20Joint Commission on Accreditation of Healthcare Organizations,
21and the National Quality Forum by adding reporting measures
22based on national health care strategies and measures deemed
23scientifically reliable and valid for public reporting. The
24Department shall receive approval from the State Board of
25Health to retire measures deemed no longer scientifically
26valid or valuable for informing quality improvement or



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1infection prevention efforts. The Department shall notify the
2Chairs and Minority Spokespersons of the House Human Services
3Committee and the Senate Public Health Committee of its intent
4to have the State Board of Health take action to retire
5measures no later than 7 business days before the meeting of
6the State Board of Health.
7    The Department shall include interpretive guidelines for
8infection-related indicators and, when available, shall
9include relevant benchmark information published by national
11    The Department shall collect the information reported
12under paragraphs (5) and (6) and shall use it to illustrate the
13disparity of those occurrences across different racial and
14ethnic groups.
15    (b) Individual hospitals shall prepare annual reports
16including vacancy and turnover rates for licensed nurses per
17clinical service area.
18    (c) None of the information the Department discloses to
19the public may be made available in any form or fashion unless
20the information has been reviewed, adjusted, and validated
21according to the following process:
22        (1) The Department shall organize an advisory
23    committee, including representatives from the Department,
24    public and private hospitals, direct care nursing staff,
25    physicians, academic researchers, consumers, health
26    insurance companies, organized labor, and organizations



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1    representing hospitals and physicians. The advisory
2    committee must be meaningfully involved in the development
3    of all aspects of the Department's methodology for
4    collecting, analyzing, and disclosing the information
5    collected under this Act, including collection methods,
6    formatting, and methods and means for release and
7    dissemination.
8        (2) The entire methodology for collecting and
9    analyzing the data shall be disclosed to all relevant
10    organizations and to all hospitals that are the subject of
11    any information to be made available to the public before
12    any public disclosure of such information.
13        (3) Data collection and analytical methodologies shall
14    be used that meet accepted standards of validity and
15    reliability before any information is made available to
16    the public.
17        (4) The limitations of the data sources and analytic
18    methodologies used to develop comparative hospital
19    information shall be clearly identified and acknowledged,
20    including but not limited to the appropriate and
21    inappropriate uses of the data.
22        (5) To the greatest extent possible, comparative
23    hospital information initiatives shall use standard-based
24    norms derived from widely accepted provider-developed
25    practice guidelines.
26        (6) Comparative hospital information and other



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1    information that the Department has compiled regarding
2    hospitals shall be shared with the hospitals under review
3    prior to public dissemination of such information and
4    these hospitals have 30 days to make corrections and to
5    add helpful explanatory comments about the information
6    before the publication.
7        (7) Comparisons among hospitals shall adjust for
8    patient case mix and other relevant risk factors and
9    control for provider peer groups, when appropriate.
10        (8) Effective safeguards to protect against the
11    unauthorized use or disclosure of hospital information
12    shall be developed and implemented.
13        (9) Effective safeguards to protect against the
14    dissemination of inconsistent, incomplete, invalid,
15    inaccurate, or subjective hospital data shall be developed
16    and implemented.
17        (10) The quality and accuracy of hospital information
18    reported under this Act and its data collection, analysis,
19    and dissemination methodologies shall be evaluated
20    regularly.
21        (11) Only the most basic identifying information from
22    mandatory reports shall be used, and information
23    identifying a patient, employee, or licensed professional
24    shall not be released. None of the information the
25    Department discloses to the public under this Act may be
26    used to establish a standard of care in a private civil



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1    action.
2    (d) Quarterly reports shall be submitted, in a format set
3forth in rules adopted by the Department, to the Department by
4April 30, July 31, October 31, and January 31 each year for the
5previous quarter. Data in quarterly reports must cover a
6period ending not earlier than one month prior to submission
7of the report. Annual reports shall be submitted by December
831 in a format set forth in rules adopted by the Department to
9the Department. All reports shall be made available to the
10public on-site and through the Department.
11    (e) If the hospital is a division or subsidiary of another
12entity that owns or operates other hospitals or related
13organizations, the annual public disclosure report shall be
14for the specific division or subsidiary and not for the other
16    (f) The Department shall disclose information under this
17Section in accordance with provisions for inspection and
18copying of public records required by the Freedom of
19Information Act provided that such information satisfies the
20provisions of subsection (c) of this Section.
21    (g) Notwithstanding any other provision of law, under no
22circumstances shall the Department disclose information
23obtained from a hospital that is confidential under Part 21 of
24Article VIII of the Code of Civil Procedure.
25    (h) No hospital report or Department disclosure may
26contain information identifying a patient, employee, or



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1licensed professional.
2(Source: P.A. 101-446, eff. 8-23-19.)".