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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Hospital Licensing Act is amended by | |||||||||||||||||||||
5 | changing Section 10.4 and by adding Section 10.5 as follows:
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6 | (210 ILCS 85/10.4) (from Ch. 111 1/2, par. 151.4)
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7 | Sec. 10.4. Medical staff privileges.
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8 | (a) Any hospital licensed under this Act or any hospital | |||||||||||||||||||||
9 | organized under the
University of Illinois Hospital Act shall, | |||||||||||||||||||||
10 | prior to the granting of any medical
staff privileges to an | |||||||||||||||||||||
11 | applicant, or renewing a current medical staff member's
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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
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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
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14 | member, including the record of imposition of any periods of
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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.
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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
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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.
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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.
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19 | (1) Minimum procedures for
pre-applicants and | ||||||
20 | applicants for medical staff
membership shall include the | ||||||
21 | following:
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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
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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
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2 | qualifications for being granted medical staff | ||||||
3 | membership and privileges.
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4 | (C) Written criteria to be followed in evaluating
a | ||||||
5 | pre-applicant's or
an applicant's
qualifications.
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6 | (D) An evaluation of
a pre-applicant's or
an | ||||||
7 | applicant's current health status and current
license | ||||||
8 | status in Illinois.
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9 | (E) A written response to each
pre-applicant or
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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).
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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:
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17 | (A) A written notice of an adverse decision.
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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.
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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
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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
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5 | nature of each basis for any adverse decision | ||||||
6 | recommended to and accepted by
the hospital governing | ||||||
7 | board.
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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. An immediate danger must be | ||||||
16 | evidenced by a documented act or acts that directly | ||||||
17 | threaten patient care in the hospital and are not | ||||||
18 | of an administrative nature. A fair hearing shall | ||||||
19 | be
commenced within 15 days after the suspension | ||||||
20 | and completed without delay , except that when the | ||||||
21 | medical staff member's license to practice has | ||||||
22 | been suspended or revoked by the State's licensing | ||||||
23 | authority, no hearing is necessary .
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24 | (ii) Nothing in this subparagraph (C) limits a | ||||||
25 | medical staff's right
to permit, in the medical | ||||||
26 | staff bylaws, summary suspension of membership or
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1 | clinical privileges in designated administrative | ||||||
2 | circumstances as specifically
approved by the | ||||||
3 | medical staff. This bylaw provision must | ||||||
4 | specifically describe
both the administrative | ||||||
5 | circumstance that can result in a summary | ||||||
6 | suspension
and the length of the summary | ||||||
7 | suspension. The opportunity for a fair hearing is
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8 | required for any administrative summary | ||||||
9 | suspension. Any requested hearing must
be | ||||||
10 | commenced within 15 days after the summary | ||||||
11 | suspension and completed without
delay. Adverse | ||||||
12 | decisions other than suspension or other | ||||||
13 | restrictions on the
treatment or admission of | ||||||
14 | patients may be imposed summarily and without a
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15 | hearing under designated administrative | ||||||
16 | circumstances as specifically provided
for in the | ||||||
17 | medical staff bylaws as approved by the medical | ||||||
18 | staff.
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19 | (iii) If a hospital exercises its option to | ||||||
20 | enter into an exclusive
contract and that contract | ||||||
21 | results in the total or partial termination or
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22 | reduction of medical staff membership or clinical | ||||||
23 | privileges of a current
medical staff member, the | ||||||
24 | hospital shall provide the affected medical staff
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25 | member 60 days prior notice of the effect on his or | ||||||
26 | her medical staff
membership or privileges. An |
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1 | affected medical staff member desiring a hearing
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2 | under subparagraph (C) of this paragraph (2) must | ||||||
3 | request the hearing within 14
days after the date | ||||||
4 | he or she is so notified. The requested hearing | ||||||
5 | shall be
commenced and completed (with a report and | ||||||
6 | recommendation to the affected
medical staff | ||||||
7 | member, hospital governing board, and medical | ||||||
8 | staff) within 30
days after the date of the medical | ||||||
9 | staff member's request. If agreed upon by
both the | ||||||
10 | medical staff and the hospital governing board, | ||||||
11 | the medical staff
bylaws may provide for longer | ||||||
12 | time periods.
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13 | (C-5) All peer review shall be conducted in | ||||||
14 | accordance with the medical staff bylaws. Outside peer | ||||||
15 | review shall be conducted and used in the medical staff | ||||||
16 | credentialing and privileging process only when | ||||||
17 | authorized by the medical staff's executive committee. | ||||||
18 | No adverse decision may be based on external peer | ||||||
19 | review not authorized by the medical staff's executive | ||||||
20 | committee. | ||||||
21 | (C-10) All peer review shall be conducted in | ||||||
22 | accordance with the medical staff bylaws. Any medical | ||||||
23 | staff requirements for a minimum number of procedures | ||||||
24 | or types of cases with acceptable outcomes may not | ||||||
25 | require that all of a practitioner's experience be at | ||||||
26 | the hospital. A practitioner must be allowed to submit |
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1 | evidence of total experience across all settings of | ||||||
2 | care to meet any such requirements.
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3 | (D) A statement of the member's right to inspect | ||||||
4 | all pertinent
information in the hospital's possession | ||||||
5 | with respect to the decision.
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6 | (E) A statement of the member's right to present | ||||||
7 | witnesses and other
evidence at the hearing on the | ||||||
8 | decision.
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9 | (F) A written notice and written explanation of the | ||||||
10 | decision resulting
from the hearing.
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11 | (F-5) A written notice of a final adverse decision | ||||||
12 | by a hospital
governing board.
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13 | (G) Notice given 15 days before implementation of | ||||||
14 | an adverse medical
staff membership or clinical | ||||||
15 | privileges decision based substantially on
economic | ||||||
16 | factors. This notice shall be given after the medical | ||||||
17 | staff member
exhausts all applicable procedures under | ||||||
18 | this Section, including item (iii) of
subparagraph (C) | ||||||
19 | of this paragraph (2), and under the medical staff | ||||||
20 | bylaws in
order to allow sufficient time for the | ||||||
21 | orderly provision of patient care.
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22 | (H) Nothing in this paragraph (2) of this | ||||||
23 | subsection (b) limits a
medical staff member's right to | ||||||
24 | waive, in writing, the rights provided in
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25 | subparagraphs (A) through (G) , excluding subparagraphs | ||||||
26 | (C-5) and (C-10), of this paragraph (2) of this |
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1 | subsection (b) upon
being granted the written | ||||||
2 | exclusive right to provide particular services at a
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3 | hospital, either individually or as a member of a | ||||||
4 | group. If an exclusive
contract is signed by a | ||||||
5 | representative of a group of physicians, a waiver
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6 | contained in the contract shall apply to all members of | ||||||
7 | the group unless stated
otherwise in the contract.
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8 | (3) Every adverse medical staff membership and | ||||||
9 | clinical privilege decision
based substantially on | ||||||
10 | economic factors shall be reported to the Hospital
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11 | Licensing Board before the decision takes effect. These | ||||||
12 | reports shall not be
disclosed in any form that reveals the | ||||||
13 | identity of any hospital or physician.
These reports shall | ||||||
14 | be utilized to study the effects that hospital medical
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15 | staff membership and clinical privilege decisions based | ||||||
16 | upon economic factors
have on access to care and the | ||||||
17 | availability of physician services. The
Hospital Licensing | ||||||
18 | Board shall submit an initial study to the Governor and the
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19 | General Assembly by January 1, 1996, and subsequent reports | ||||||
20 | shall be submitted
periodically thereafter.
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21 | (4) As used in this Section:
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22 | "Adverse decision" means a decision reducing, | ||||||
23 | restricting, suspending,
revoking, denying, or not | ||||||
24 | renewing medical staff membership or clinical
privileges.
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25 | "Economic factor" means any information or reasons for | ||||||
26 | decisions unrelated
to quality of care or professional |
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1 | competency.
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2 | "Pre-applicant" means a physician licensed to practice | ||||||
3 | medicine in all
its
branches who requests an application | ||||||
4 | for medical staff membership or
privileges.
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5 | "Privilege" means permission to provide
medical or | ||||||
6 | other patient care services and permission to use hospital
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7 | resources, including equipment, facilities and personnel | ||||||
8 | that are necessary to
effectively provide medical or other | ||||||
9 | patient care services. This definition
shall not be | ||||||
10 | construed to
require a hospital to acquire additional | ||||||
11 | equipment, facilities, or personnel to
accommodate the | ||||||
12 | granting of privileges.
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13 | (5) Any amendment to medical staff bylaws required | ||||||
14 | because of
this amendatory Act of the 91st General Assembly | ||||||
15 | shall be adopted on or
before July 1, 2001.
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16 | (c) All hospitals shall consult with the medical staff | ||||||
17 | prior to closing
membership in the entire or any portion of the | ||||||
18 | medical staff or a department.
If
the hospital closes | ||||||
19 | membership in the medical staff, any portion of the medical
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20 | staff, or the department over the objections of the medical | ||||||
21 | staff, then the
hospital
shall provide a detailed written | ||||||
22 | explanation for the decision to the medical
staff
10 days prior | ||||||
23 | to the effective date of any closure. No applications need to | ||||||
24 | be
provided when membership in the medical staff or any | ||||||
25 | relevant portion of the
medical staff is closed.
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26 | (Source: P.A. 95-331, eff. 8-21-07.)
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1 | (210 ILCS 85/10.5 new) | ||||||
2 | Sec. 10.5. Medical staff self-governance. | ||||||
3 | (a) The General Assembly finds and declares that providing | ||||||
4 | quality medical care in hospitals depends on the mutual | ||||||
5 | accountability, interdependence, and responsibility of the | ||||||
6 | medical staff and the hospital governing board for the proper | ||||||
7 | performance of their respective obligations. | ||||||
8 | The General Assembly further finds and declares that both | ||||||
9 | the governing board and the medical staff of a hospital must | ||||||
10 | act to protect the quality of medical care provided. Nothing in | ||||||
11 | this Act shall be construed to undermine this authority. The | ||||||
12 | final authority of the hospital governing board may be | ||||||
13 | exercised for the responsible governance of the hospital or for | ||||||
14 | the conduct of the business affairs of the hospital; that final | ||||||
15 | authority may be exercised, however, only with a reasonable and | ||||||
16 | good faith belief that the medical staff has failed to fulfill | ||||||
17 | a substantive duty or responsibility in matters pertaining to | ||||||
18 | the quality of patient care. It would be a violation of the | ||||||
19 | medical staff's self-governance and independent rights for the | ||||||
20 | hospital governing board to assume a duty or responsibility of | ||||||
21 | the medical staff precipitously, unreasonably, or in bad faith. | ||||||
22 | Finally, the General Assembly finds and declares that the | ||||||
23 | specific actions that would constitute bad faith or | ||||||
24 | unreasonable action on the part of either the medical staff or | ||||||
25 | the hospital governing board will always be fact-specific and |
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1 | cannot be precisely described in statute. The provisions set | ||||||
2 | forth in this Section do nothing more than provide for the | ||||||
3 | basic independent rights and responsibilities of a | ||||||
4 | self-governing medical staff. Ultimately, a successful | ||||||
5 | relationship between a hospital's medical staff and governing | ||||||
6 | board depends on the mutual respect of each for the rights and | ||||||
7 | responsibilities of the other. | ||||||
8 | (b) The medical staff's right of self-governance includes, | ||||||
9 | but is not limited to, all of the following: | ||||||
10 | (1) Establishing, in medical staff bylaws, rules, or | ||||||
11 | regulations, criteria and requirements, consistent with | ||||||
12 | Section 10.4 of this Act, for medical staff membership and | ||||||
13 | privileges, and enforcing those criteria and requirements. | ||||||
14 | (2) Establishing, in medical staff bylaws, rules, or | ||||||
15 | regulations, clinical criteria and requirements to oversee | ||||||
16 | and manage quality assurance, utilization review, and | ||||||
17 | other medical staff activities, including, but not limited | ||||||
18 | to, periodic meetings of the medical staff and its | ||||||
19 | committees and departments and review and analysis of | ||||||
20 | patient medical records. | ||||||
21 | (3) Selecting and removing medical staff officers. | ||||||
22 | (4) Assessing medical staff dues and utilizing the | ||||||
23 | medical staff dues as appropriate for the purposes of the | ||||||
24 | medical staff. | ||||||
25 | (5) The ability to retain and be represented by | ||||||
26 | independent legal counsel. |
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1 | (6) Initiating, developing, and adopting medical staff | ||||||
2 | bylaws, rules, and regulations, and amendments thereto, | ||||||
3 | subject to the approval of the hospital governing board, | ||||||
4 | which approval shall not be unreasonably withheld. | ||||||
5 | (c) The medical staff bylaws shall not interfere with the | ||||||
6 | independent rights of the medical staff to do any of the | ||||||
7 | following, but shall set forth the procedures for: | ||||||
8 | (1) Selecting and removing medical staff officers. | ||||||
9 | (2) Assessing medical staff dues and utilizing the | ||||||
10 | medical staff dues as appropriate for the purposes of the | ||||||
11 | medical staff. | ||||||
12 | (3) The ability to retain and be presented by | ||||||
13 | independent legal counsel. | ||||||
14 | (d) Neither the medical staff nor the hospital governing | ||||||
15 | board may unilaterally amend, change, or otherwise alter | ||||||
16 | adopted medical staff bylaws. | ||||||
17 | (e) With respect to any dispute arising under this Section, | ||||||
18 | the medical staff and the hospital governing board shall meet | ||||||
19 | and confer in good faith to resolve the dispute. Whenever any | ||||||
20 | person or entity has engaged in or is about to engage in any | ||||||
21 | act or practice that hinders, restricts, or otherwise obstructs | ||||||
22 | the ability of the medical staff to exercise its rights, | ||||||
23 | obligations, or responsibilities under this Section, the | ||||||
24 | circuit court of any county, on application of the medical | ||||||
25 | staff, and after determining that reasonable efforts, | ||||||
26 | including reasonable administrative remedies provided in the |
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1 | medical staff bylaws, rules, or regulations, have failed to | ||||||
2 | resolve the dispute, may issue an injunction, writ of mandamus, | ||||||
3 | or other appropriate order.
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4 | Section 99. Effective date. This Act takes effect January | ||||||
5 | 1, 2009.
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