Public Act 097-1006
 
HB5548 EnrolledLRB097 20017 DRJ 65326 b


  
    AN ACT concerning regulation.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  
 
 
    Section 5. The Hospital Licensing Act is amended  by 
changing Section 10.4 as follows:
 



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



    Sec. 10.4. Medical staff privileges. 

    (a) Any hospital licensed under this Act or any hospital 
organized under the
University of Illinois Hospital Act shall, 
prior to the granting of any medical
staff privileges to an 
applicant, or renewing a current medical staff member's

privileges, request of the Director of Professional Regulation 
information
concerning the licensure status and any 
disciplinary action taken against the
applicant's or medical 
staff member's license, except: (1) for medical personnel who

enter a hospital to obtain organs and tissues for transplant 
from a donor in accordance with the Illinois Anatomical Gift 
Act; or (2) for medical personnel who have been granted 
disaster privileges pursuant to the procedures and 
requirements established by rules adopted by the Department. 
Any hospital and any employees of the hospital or others 
involved in granting privileges who, in good faith, grant 
disaster privileges pursuant to this Section to respond to an 
emergency shall not, as a result of their acts or omissions,  be 
liable for civil damages for granting or denying disaster 
privileges except in the event of willful and wanton  
misconduct, as that term is defined in Section 10.2 of this 
Act.  Individuals granted privileges who provide care in an 
emergency situation, in good faith and without direct 
compensation, shall not, as a result of their acts or 
omissions, except for acts or omissions involving willful and 
wanton misconduct, as that term is defined in Section 10.2 of 
this Act, on the part of the person, be liable for civil 
damages. The Director of
Professional Regulation shall 
transmit, in writing and in a timely fashion,
such information 
regarding the license of the applicant or the medical staff

member, including the record of imposition of any periods of

supervision or monitoring as a result of alcohol or
substance 
abuse, as provided by Section 23 of the Medical
Practice Act of 
1987, and such information as may have been
submitted to the 
Department indicating that the application
or medical staff 
member has been denied, or has surrendered,
medical staff 
privileges at a hospital licensed under this
Act, or any 
equivalent facility in another state or
territory of the United 
States.  The Director of Professional Regulation
shall define by 
rule the period for timely response to such requests.

    No transmittal of information by the Director of 
Professional Regulation,
under this Section shall be to other 
than the president, chief
operating officer, chief 
administrative officer, or chief of
the medical staff of a 
hospital licensed under this Act, a
hospital organized under 
the University of Illinois Hospital Act, or a hospital
operated 
by the United States, or any of its instrumentalities.  The

information so transmitted shall be afforded the same status
as 
is information concerning medical studies by Part 21 of Article 
VIII of the
Code of Civil Procedure, as now or hereafter 
amended.

    (b) All hospitals licensed under this Act, except county 
hospitals as
defined in subsection (c) of Section 15-1 of the 
Illinois Public Aid Code,
shall comply with, and the medical 
staff bylaws of these hospitals shall
include rules consistent 
with, the provisions of this Section in granting,
limiting, 
renewing, or denying medical staff membership and
clinical 
staff privileges.  Hospitals that require medical staff members 
to
possess
faculty status with a specific institution of higher 
education are not required
to comply with subsection (1) below 
when the physician does not possess faculty
status.


        (1) Minimum procedures for
pre-applicants and 
    applicants for medical staff
membership shall include the 
    following:


            (A) Written procedures relating to the acceptance 
        and processing of
pre-applicants or applicants for 
        medical staff membership, which should be
contained in

        medical staff bylaws.


            (B) Written procedures to be followed in 
        determining
a pre-applicant's or
an applicant's

        qualifications for being granted medical staff 
        membership and privileges.


            (C) Written criteria to be followed in evaluating
a 
        pre-applicant's or
an applicant's
qualifications.


            (D) An evaluation of
a pre-applicant's or
an 
        applicant's current health status and current
license 
        status in Illinois.


            (E) A written response to each
pre-applicant or

        applicant that explains the reason or
reasons for any 
        adverse decision (including all reasons based in whole 
        or
in part on the applicant's medical qualifications or 
        any other basis,
including economic factors).


        (2) Minimum procedures with respect to medical staff 
    and clinical
privilege determinations concerning current 
    members of the medical staff shall
include the following:


            (A) A written notice of an adverse decision.


            (B) An explanation of the reasons for an adverse 
        decision including all
reasons based on the quality of 
        medical care or any other basis, including
economic 
        factors.


            (C) A statement of the medical staff member's right 
        to request a fair
hearing on the adverse decision 
        before a hearing panel whose membership is
mutually 
        agreed upon by the medical staff and the hospital 
        governing board. The
hearing panel shall have 
        independent authority to recommend action to the

        hospital governing board. Upon the request of the 
        medical staff member or the
hospital governing board, 
        the hearing panel shall make findings concerning the

        nature of each basis for any adverse decision 
        recommended to and accepted by
the hospital governing 
        board.


                (i) Nothing in this subparagraph (C) limits a 
            hospital's or medical
staff's right to summarily 
            suspend, without a prior hearing, a person's 
            medical
staff membership or clinical privileges if 
            the continuation of practice of a
medical staff 
            member constitutes an immediate danger to the 
            public, including
patients, visitors, and hospital 
            employees and staff. In the event that a hospital 
            or the medical staff imposes a summary suspension, 
            the Medical Executive Committee, or other 
            comparable governance committee of the medical 
            staff as specified in the bylaws, must meet as soon 
            as is reasonably possible to review the suspension 
            and to recommend whether it should be affirmed, 
            lifted, expunged, or modified if the suspended 
            physician requests such review.  A summary 
            suspension may not be implemented unless there is 
            actual documentation or other reliable information 
            that an immediate danger exists.  This 
            documentation or information must be available at 
            the time the summary suspension decision is made 
            and when the decision is reviewed by the Medical 
            Executive Committee.  If the Medical Executive 
            Committee recommends that the summary suspension 
            should be lifted, expunged, or modified, this 
            recommendation must be reviewed and considered by 
            the hospital governing board, or a committee of the 
            board, on an expedited basis.  Nothing in this 
            subparagraph (C) shall affect the requirement that 
            any requested hearing must be commenced within 15 
            days after the summary suspension and completed 
            without delay unless otherwise agreed to by the 
            parties. A fair hearing shall be
commenced within 
            15 days after the suspension and completed without 
            delay, except that when the medical staff member's 
            license to practice has been suspended or revoked 
            by the State's licensing authority, no hearing 
            shall be necessary.


                (ii) Nothing in this subparagraph (C) limits a 
            medical staff's right
to permit, in the medical 
            staff bylaws, summary suspension of membership or

            clinical privileges in designated administrative 
            circumstances as specifically
approved by the 
            medical staff. This bylaw provision must 
            specifically describe
both the administrative 
            circumstance that can result in a summary 
            suspension
and the length of the summary 
            suspension. The opportunity for a fair hearing is

            required for any administrative summary 
            suspension. Any requested hearing must
be 
            commenced within 15 days after the summary 
            suspension and completed without
delay. Adverse 
            decisions other than suspension or other 
            restrictions on the
treatment or admission of 
            patients may be imposed summarily and without a

            hearing under designated administrative 
            circumstances as specifically provided
for in the 
            medical staff bylaws as approved by the medical 
            staff.


                (iii) If a hospital exercises its option to 
            enter into an exclusive
contract and that contract 
            results in the total or partial termination or

            reduction of medical staff membership or clinical 
            privileges of a current
medical staff member, the 
            hospital shall provide the affected medical staff

            member 60 days prior notice of the effect on his or 
            her medical staff
membership or privileges. An 
            affected medical staff member desiring a hearing

            under subparagraph (C) of this paragraph (2) must 
            request the hearing within 14
days after the date 
            he or she is so notified. The requested hearing 
            shall be
commenced and completed (with a report and 
            recommendation to the affected
medical staff 
            member, hospital governing board, and medical 
            staff) within 30
days after the date of the medical 
            staff member's request. If agreed upon by
both the 
            medical staff and the hospital governing board, 
            the medical staff
bylaws may provide for longer 
            time periods.

            (C-5)  All peer review used for the purpose of 
        credentialing, privileging, disciplinary action, or 
        other recommendations affecting medical staff 
        membership or exercise of clinical privileges, whether 
        relying in whole or in part on internal or external 
        reviews, shall be conducted in accordance with the 
        medical staff bylaws and applicable rules, 
        regulations, or policies of the medical staff.  If 
        external review is obtained, any adverse report 
        utilized shall be in writing and shall be made part of 
        the internal peer review process under the bylaws.  The 
        report shall also be shared with a medical staff peer 
        review committee and the individual under review.  If 
        the medical staff peer review committee or the 
        individual under review prepares a written response to 
        the report of the external peer review within 30 days 
        after receiving such report, the governing board shall 
        consider the response prior to the implementation of 
        any final actions by the governing board which may 
        affect the individual's medical staff membership or 
        clinical privileges.  Any peer review that involves 
        willful or wanton misconduct shall be subject to civil 
        damages as provided for under Section 10.2 of this Act. 

            (D) A statement of the member's right to inspect 
        all pertinent
information in the hospital's possession 
        with respect to the decision.


            (E) A statement of the member's right to present 
        witnesses and other
evidence at the hearing on the 
        decision.

            (E-5) The right to be represented by a personal 
        attorney. 

            (F) A written notice and written explanation of the 
        decision resulting
from the hearing.


            (F-5) A written notice of a final adverse decision 
        by a hospital
governing board.


            (G) Notice given 15 days before implementation of 
        an adverse medical
staff membership or clinical 
        privileges decision based substantially on
economic 
        factors. This notice shall be given after the medical 
        staff member
exhausts all applicable procedures under 
        this Section, including item (iii) of
subparagraph (C) 
        of this paragraph (2), and under the medical staff 
        bylaws in
order to allow sufficient time for the 
        orderly provision of patient care.


            (H) Nothing in this paragraph (2) of this 
        subsection (b) limits a
medical staff member's right to 
        waive, in writing, the rights provided in

        subparagraphs (A) through (G) of this paragraph (2) of 
        this subsection (b) upon
being granted the written 
        exclusive right to provide particular services at a

        hospital, either individually or as a member of a 
        group. If an exclusive
contract is signed by a 
        representative of a group of physicians, a waiver

        contained in the contract shall apply to all members of 
        the group unless stated
otherwise in the contract.


        (3) Every adverse medical staff membership and 
    clinical privilege decision
based substantially on 
    economic factors shall be reported to the Hospital

    Licensing Board before the decision takes effect.  These 
    reports shall not be
disclosed in any form that reveals the 
    identity of any hospital or physician.
These reports shall 
    be utilized to study the effects that hospital medical

    staff membership and clinical privilege decisions based 
    upon economic factors
have on access to care and the 
    availability of physician services.  The
Hospital Licensing 
    Board shall submit an initial study to the Governor and the

    General Assembly by January 1, 1996, and subsequent reports 
    shall be submitted
periodically thereafter.


        (4) As used in this Section:


        "Adverse decision" means a decision reducing, 
    restricting, suspending,
revoking, denying, or not 
    renewing medical staff membership or clinical
privileges.


        "Economic factor" means any information or reasons for 
    decisions unrelated
to quality of care or professional 
    competency.


        "Pre-applicant" means a physician licensed to practice 
    medicine in all
its
branches who requests an application 
    for medical staff membership or
privileges.


        "Privilege" means permission to provide
medical or 
    other patient care services and permission to use hospital

    resources, including equipment, facilities and personnel 
    that are necessary to
effectively provide medical or other 
    patient care services. This definition
shall not be 
    construed to
require a hospital to acquire additional 
    equipment, facilities, or personnel to
accommodate the 
    granting of privileges.


        (5) Any amendment to medical staff bylaws required 
    because of
this amendatory Act of the 91st General Assembly 
    shall be adopted on or
before July 1, 2001.

    (c) All hospitals shall consult with the medical staff 
prior to closing
membership in the entire or any portion of the 
medical staff or a department.
If
the hospital closes 
membership in the medical staff, any portion of the medical

staff, or the department over the objections of the medical 
staff, then the
hospital
shall provide a detailed written 
explanation for the decision to the medical
staff
10 days prior 
to the effective date of any closure.  No applications need to 
be
provided when membership in the medical staff or any 
relevant portion of the
medical staff is closed.

(Source: P.A. 95-331, eff. 8-21-07; 96-445, eff. 8-14-09.)

 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.