Bill Text: IL HB0068 | 2021-2022 | 102nd General Assembly | Engrossed

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Bill Title: Amends the Hospital Licensing Act. Provides that any hospital licensed under the 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 proper credentials and required certificates of the applicant. Amends the Hospital Report Card Act. Provides that the quarterly report prepared by individual hospitals shall include (1) the number of female patients who have died within the reporting period and (2) the number of female patients admitted to the hospital with a diagnosis of COVID-19 and at least one known underlying condition identified by the United States Centers for Disease Control and Prevention as a condition that increases the risk of mortality from COVID-19 who subsequently died at the hospital within the reporting period.

Spectrum: Partisan Bill (Democrat 11-0)

Status: (Passed) 2021-08-06 - Public Act . . . . . . . . . 102-0256 [HB0068 Detail]

Download: Illinois-2021-HB0068-Engrossed.html

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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, proper
credentials, required certificates, 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

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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

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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.

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(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

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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

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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

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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

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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

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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

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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.

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(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

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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. 96-445, eff. 8-14-09; 97-1006, eff. 8-17-12.)
Section 10. The Hospital Report Card Act is amended by
changing Section 25 as follows:
(210 ILCS 86/25)
Sec. 25. Hospital reports.
(a) Individual hospitals shall prepare a quarterly report
including all of the following:
(1) Nursing hours per patient day, average daily
census, and average daily hours worked for each clinical
service area.
(2) Infection-related measures for the facility for
the specific clinical procedures and devices determined by
the Department by rule under 2 or more of the following
categories:
(A) Surgical procedure outcome measures.
(B) Surgical procedure infection control process
measures.
(C) Outcome or process measures related to
ventilator-associated pneumonia.

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(D) Central vascular catheter-related bloodstream
infection rates in designated critical care units.
(3) Information required under paragraph (4) of
Section 2310-312 of the Department of Public Health Powers
and Duties Law of the Civil Administrative Code of
Illinois.
(4) Additional infection measures mandated by the
Centers for Medicare and Medicaid Services that are
reported by hospitals to the Centers for Disease Control
and Prevention's National Healthcare Safety Network
surveillance system, or its successor, and deemed relevant
to patient safety by the Department.
(5) Each instance of preterm birth and infant
mortality within the reporting period, including the
racial and ethnic information of the mothers of those
infants.
(6) Each instance of maternal mortality within the
reporting period, including the racial and ethnic
information of those mothers.
(7) The number of female patients who have died within
the reporting period.
(8) The number of female patients admitted to the
hospital with a diagnosis of COVID-19 and at least one
known underlying condition identified by the United States
Centers for Disease Control and Prevention as a condition
that increases the risk of mortality from COVID-19 who

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subsequently died at the hospital within the reporting
period.
The infection-related measures developed by the Department
shall be based upon measures and methods developed by the
Centers for Disease Control and Prevention, the Centers for
Medicare and Medicaid Services, the Agency for Healthcare
Research and Quality, the Joint Commission on Accreditation of
Healthcare Organizations, or the National Quality Forum. The
Department may align the infection-related measures with the
measures and methods developed by the Centers for Disease
Control and Prevention, the Centers for Medicare and Medicaid
Services, the Agency for Healthcare Research and Quality, the
Joint Commission on Accreditation of Healthcare Organizations,
and the National Quality Forum by adding reporting measures
based on national health care strategies and measures deemed
scientifically reliable and valid for public reporting. The
Department shall receive approval from the State Board of
Health to retire measures deemed no longer scientifically
valid or valuable for informing quality improvement or
infection prevention efforts. The Department shall notify the
Chairs and Minority Spokespersons of the House Human Services
Committee and the Senate Public Health Committee of its intent
to have the State Board of Health take action to retire
measures no later than 7 business days before the meeting of
the State Board of Health.
The Department shall include interpretive guidelines for

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infection-related indicators and, when available, shall
include relevant benchmark information published by national
organizations.
The Department shall collect the information reported
under paragraphs (5) and (6) and shall use it to illustrate the
disparity of those occurrences across different racial and
ethnic groups.
(b) Individual hospitals shall prepare annual reports
including vacancy and turnover rates for licensed nurses per
clinical service area.
(c) None of the information the Department discloses to
the public may be made available in any form or fashion unless
the information has been reviewed, adjusted, and validated
according to the following process:
(1) The Department shall organize an advisory
committee, including representatives from the Department,
public and private hospitals, direct care nursing staff,
physicians, academic researchers, consumers, health
insurance companies, organized labor, and organizations
representing hospitals and physicians. The advisory
committee must be meaningfully involved in the development
of all aspects of the Department's methodology for
collecting, analyzing, and disclosing the information
collected under this Act, including collection methods,
formatting, and methods and means for release and
dissemination.

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(2) The entire methodology for collecting and
analyzing the data shall be disclosed to all relevant
organizations and to all hospitals that are the subject of
any information to be made available to the public before
any public disclosure of such information.
(3) Data collection and analytical methodologies shall
be used that meet accepted standards of validity and
reliability before any information is made available to
the public.
(4) The limitations of the data sources and analytic
methodologies used to develop comparative hospital
information shall be clearly identified and acknowledged,
including but not limited to the appropriate and
inappropriate uses of the data.
(5) To the greatest extent possible, comparative
hospital information initiatives shall use standard-based
norms derived from widely accepted provider-developed
practice guidelines.
(6) Comparative hospital information and other
information that the Department has compiled regarding
hospitals shall be shared with the hospitals under review
prior to public dissemination of such information and
these hospitals have 30 days to make corrections and to
add helpful explanatory comments about the information
before the publication.
(7) Comparisons among hospitals shall adjust for

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patient case mix and other relevant risk factors and
control for provider peer groups, when appropriate.
(8) Effective safeguards to protect against the
unauthorized use or disclosure of hospital information
shall be developed and implemented.
(9) Effective safeguards to protect against the
dissemination of inconsistent, incomplete, invalid,
inaccurate, or subjective hospital data shall be developed
and implemented.
(10) The quality and accuracy of hospital information
reported under this Act and its data collection, analysis,
and dissemination methodologies shall be evaluated
regularly.
(11) Only the most basic identifying information from
mandatory reports shall be used, and information
identifying a patient, employee, or licensed professional
shall not be released. None of the information the
Department discloses to the public under this Act may be
used to establish a standard of care in a private civil
action.
(d) Quarterly reports shall be submitted, in a format set
forth in rules adopted by the Department, to the Department by
April 30, July 31, October 31, and January 31 each year for the
previous quarter. Data in quarterly reports must cover a
period ending not earlier than one month prior to submission
of the report. Annual reports shall be submitted by December

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31 in a format set forth in rules adopted by the Department to
the Department. All reports shall be made available to the
public on-site and through the Department.
(e) If the hospital is a division or subsidiary of another
entity that owns or operates other hospitals or related
organizations, the annual public disclosure report shall be
for the specific division or subsidiary and not for the other
entity.
(f) The Department shall disclose information under this
Section in accordance with provisions for inspection and
copying of public records required by the Freedom of
Information Act provided that such information satisfies the
provisions of subsection (c) of this Section.
(g) Notwithstanding any other provision of law, under no
circumstances shall the Department disclose information
obtained from a hospital that is confidential under Part 21 of
Article VIII of the Code of Civil Procedure.
(h) No hospital report or Department disclosure may
contain information identifying a patient, employee, or
licensed professional.
(Source: P.A. 101-446, eff. 8-23-19.)