96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB0546

 

Introduced 2/4/2009, by Rep. Timothy L. Schmitz

 

SYNOPSIS AS INTRODUCED:
 
210 ILCS 85/10.4   from Ch. 111 1/2, par. 151.4

    Amends the Hospital Licensing Act. Provides that 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, and provides that a summary suspension may not be implemented unless there is actual documentation or other reliable information that an immediate danger exists. Adds provisions concerning peer review used for the purpose of credentialing, privileging, disciplinary action, or other recommendations affecting medical staff membership or exercise of clinical privileges. Effective June 1, 2009.


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A BILL FOR

 

HB0546 LRB096 04272 DRJ 14318 b

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 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
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             (F) A written notice and written explanation of the
13         decision resulting from the hearing.
14             (F-5) A written notice of a final adverse decision
15         by a hospital governing board.
16             (G) Notice given 15 days before implementation of
17         an adverse medical staff membership or clinical
18         privileges decision based substantially on economic
19         factors. This notice shall be given after the medical
20         staff member exhausts all applicable procedures under
21         this Section, including item (iii) of subparagraph (C)
22         of this paragraph (2), and under the medical staff
23         bylaws in order to allow sufficient time for the
24         orderly provision of patient care.
25             (H) Nothing in this paragraph (2) of this
26         subsection (b) limits a medical staff member's right to

 

 

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1         waive, in writing, the rights provided in
2         subparagraphs (A) through (G) of this paragraph (2) of
3         this subsection (b) upon being granted the written
4         exclusive right to provide particular services at a
5         hospital, either individually or as a member of a
6         group. If an exclusive contract is signed by a
7         representative of a group of physicians, a waiver
8         contained in the contract shall apply to all members of
9         the group unless stated otherwise in the contract.
10         (3) Every adverse medical staff membership and
11     clinical privilege decision based substantially on
12     economic factors shall be reported to the Hospital
13     Licensing Board before the decision takes effect. These
14     reports shall not be disclosed in any form that reveals the
15     identity of any hospital or physician. These reports shall
16     be utilized to study the effects that hospital medical
17     staff membership and clinical privilege decisions based
18     upon economic factors have on access to care and the
19     availability of physician services. The Hospital Licensing
20     Board shall submit an initial study to the Governor and the
21     General Assembly by January 1, 1996, and subsequent reports
22     shall be submitted periodically thereafter.
23         (4) As used in this Section:
24         "Adverse decision" means a decision reducing,
25     restricting, suspending, revoking, denying, or not
26     renewing medical staff membership or clinical privileges.

 

 

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1         "Economic factor" means any information or reasons for
2     decisions unrelated to quality of care or professional
3     competency.
4         "Pre-applicant" means a physician licensed to practice
5     medicine in all its branches who requests an application
6     for medical staff membership or privileges.
7         "Privilege" means permission to provide medical or
8     other patient care services and permission to use hospital
9     resources, including equipment, facilities and personnel
10     that are necessary to effectively provide medical or other
11     patient care services. This definition shall not be
12     construed to require a hospital to acquire additional
13     equipment, facilities, or personnel to accommodate the
14     granting of privileges.
15         (5) Any amendment to medical staff bylaws required
16     because of this amendatory Act of the 91st General Assembly
17     shall be adopted on or before July 1, 2001.
18     (c) All hospitals shall consult with the medical staff
19 prior to closing membership in the entire or any portion of the
20 medical staff or a department. If the hospital closes
21 membership in the medical staff, any portion of the medical
22 staff, or the department over the objections of the medical
23 staff, then the hospital shall provide a detailed written
24 explanation for the decision to the medical staff 10 days prior
25 to the effective date of any closure. No applications need to
26 be provided when membership in the medical staff or any

 

 

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1 relevant portion of the medical staff is closed.
2 (Source: P.A. 95-331, eff. 8-21-07.)
 
3     Section 99. Effective date. This Act takes effect June 1,
4 2009.