Public Act 096-0445
HB0546 Enrolled LRB096 04272 DRJ 14318 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
    (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
            (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
            (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
                (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
                (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
            (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
        "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.)
    Section 99. Effective date. This Act takes effect June 1,

Effective Date: 8/14/2009