Bill Text: IL SB2336 | 2013-2014 | 98th General Assembly | Introduced

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Bill Title: Amends the Hospital Licensing Act. Makes a technical change in a Section concerning medical staff privileges.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Failed) 2015-01-13 - Session Sine Die [SB2336 Detail]

Download: Illinois-2013-SB2336-Introduced.html

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98TH GENERAL ASSEMBLY State of Illinois 2013 and 2014 SB2336 Introduced 2/15/2013, by Sen. Don Harmon SYNOPSIS AS INTRODUCED:
210 ILCS 85/10.4 from Ch. 111 1/2, par. 151.4
Amends the Hospital Licensing Act. Makes a technical change in a Section concerning medical staff privileges.
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A BILL FOR
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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 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

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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

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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

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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

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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

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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

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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

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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

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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.

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(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,

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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

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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.)