Section 250.310 Organization

Section 250

TITLE 77: PUBLIC HEALTH

CHAPTER I: DEPARTMENT OF PUBLIC HEALTH

SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES

PART 250 HOSPITAL LICENSING REQUIREMENTS

SECTION 250.310 ORGANIZATION

Section 250.310  Organization

a)         For the purposes of this Section only:

1)

Adverse Decision − means a decision reducing,

restricting, suspending, revoking, denying, or not renewing medical staff

membership or clinical privileges

.  (Section 10.4(b) of the Act)

2)         A Distant-site Hospital − means an Illinois licensed

hospital or a Medicare participating hospital.

3)         A Distant-site Telemedicine Entity – means an entity

consisting of a group of licensed physicians that:

A)        Provides telemedicine services;

B)        Is not a Medicare-participating hospital; and

C)        Provides contracted services in a manner that enables a

hospital using its services to meet all applicable Medicare conditions of

participation, particularly those requirements related to the credentialing and

privileging of practitioners providing telemedicine services to the patients of

a hospital. A distant-site telemedicine entity would include a distant-site

hospital that does not participate in the Medicare program that is providing

telemedicine services to a Medicare-participating hospital.

4)

Economic Factor − means any information or reasons

for decisions unrelated to quality of care or professional competency

tioners providing telemedicine services to the patients of

a hospital. A distant-site telemedicine entity would include a distant-site

hospital that does not participate in the Medicare program that is providing

telemedicine services to a Medicare-participating hospital.

4)

Economic Factor − means any information or reasons

for decisions unrelated to quality of care or professional competency

.

(Section 10.4(b) of the Act)

5)         Non-simultaneously − means that, while the telemedicine

physician or practitioner still provides clinical services to the patient upon

a formal request from the patient's attending physician, these services may,

for example, involve after-the-fact interpretation of diagnostic tests,

consultations between a physician or practitioner and a person outside the

State of Illinois, or second opinions provided to an Illinois-licensed

physician or practitioner in order to provide an assessment of the patient's

condition and do not necessarily require the telemedicine practitioner to

directly assess the patient in real time or establish a provider-to-patient

relationship or interaction.  An example of after-the-fact interpretation of

diagnostic tests would be similar to the services provided by an on-site

radiologist who interprets a patient's x-ray or CT scan and then communicates the

assessment to the patient's attending physician who then bases a diagnosis and

treatment plan on these findings.

6)

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

s 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

. (Section 10.4(b) of the Act)

7)         Simultaneously − means that the clinical services (for

example, assessment of the patient with a clinical plan for treatment,

including any medical orders needed) are provided to the patient in real time

by the telemedicine physician or practitioner, similar to the actions of an

on-site physician or practitioner.

8)         Telemedicine − means the provision of clinical services

to patients by physicians or practitioners remotely via electronic

communications. The distant-site telemedicine physician or practitioner

provides clinical services to the hospital patient either simultaneously, as is

often the case with teleICU services, for example, or non-simultaneously, as

may be the case with many teleradiology services.  Telemedicine may also

include provider-to-provider consultations between Illinois-licensed physicians

or practitioners and physicians or practitioners licensed in the United States.

b)         The

medical staff shall be organized in accordance with written bylaws, rules and

regulations approved by the governing board.  The bylaws, rules and regulations

shall specifically provide, but are not limited to:

1)         establishing

written procedures relating to the acceptance and processing of initial

applications for medical staff membership, granting and denying of medical

staff reappointment, and medical staff membership or clinical privileges

disciplinary matters in accordance with subsection (e) for county hospitals as

defined in Section 15-1(c) of the Illinois Public Aid Code, or subsection (f)

for all other hospitals

en procedures relating to the acceptance and processing of initial

applications for medical staff membership, granting and denying of medical

staff reappointment, and medical staff membership or clinical privileges

disciplinary matters in accordance with subsection (e) for county hospitals as

defined in Section 15-1(c) of the Illinois Public Aid Code, or subsection (f)

for all other hospitals.  The procedures for initial applicants at any

particular hospital may differ from those for current medical staff members.  However,

the procedures at any particular hospital shall be applied equally to each

practitioner eligible for medical staff membership as defined in Section 250.100.

The procedures shall provide that,

prior to the granting of any medical

staff privileges to an applicant, or renewing a current medical staff member's

privileges,

the hospital

shall request of the Director of the Department

of Financial and 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.

This

provision shall not apply to

medical personnel who enter a hospital to

obtain organs and tissues for transplant from a deceased donor in accordance

with the Illinois Anatomical Gift Act

.  This provision shall not apply to

medical

personnel who have been granted disaster privileges pursuant to the procedures

and requirements established

in this Section

or medical staff member's license.

This

provision shall not apply to

medical personnel who enter a hospital to

obtain organs and tissues for transplant from a deceased donor in accordance

with the Illinois Anatomical Gift Act

.  This provision shall not apply to

medical

personnel who have been granted disaster privileges pursuant to the procedures

and requirements established

in this Section.  (Section 10.4(a) of the

Act);

2)         identifying

divisions and departments as are warranted (as a minimum, active and consulting

divisions are required);

3)         identifying

officers as are warranted;

4)         establishing

committees as are warranted to assure the responsibility for functions such as

pharmacy and therapeutics, infection control, utilization review, patient care

evaluation, and the maintenance of complete medical records;

5)         assuring

that active medical staff meetings are held regularly, and that written minutes

of all meetings are kept;

6)         reviewing

and analyzing the clinical experience of the hospital at regular intervals −

the medical records of patients to be the basis for review and analysis;

7)         identifying

conditions or situations that require consultation, including consultation

between medical staff members in complicated cases;

8)         examining

tissue removed during operations by a qualified pathologist and requiring that

the findings are made a part of the patient's medical record;

9)         keeping

completed medical records;

10)         maintaining

a Utilization Review Plan, which shall be in accordance with the Conditions of

Participation for Hospitals;

11)         establishing

Medical Care Evaluation Studies;

12)         establishing

policies requiring a physician as first assistant to major or hazardous

surgery, including written criteria to determine when an assistant is

necessary;

13)         assuring,

through credentialing by the medical staff, that a qualified surgical

assistant, whether a physician or non-physician, assist

Hospitals;

11)         establishing

Medical Care Evaluation Studies;

12)         establishing

policies requiring a physician as first assistant to major or hazardous

surgery, including written criteria to determine when an assistant is

necessary;

13)         assuring,

through credentialing by the medical staff, that a qualified surgical

assistant, whether a physician or non-physician, assists the operating surgeon

in the operating room;

14)         determining

additional privileges that may be granted a staff member for the use of the

staff member's employed allied health personnel in the hospital in accordance

with policies and procedures recommended by the medical staff and approved by

the governing body.  The policies and procedures shall include, at least,

requirements that the staff member requesting this additional privilege shall

submit the following for review and approval by the medical staff and the

governing body of the hospital:

A)        a

curriculum vitae of the identified allied health personnel, and

B)        a

written protocol with a description of the duties, assignments and functions,

including a description of the manner of performance within the hospital by the

allied health personnel in relationship with other hospital staff;

15)         establishing

a mechanism for assisting medical staff members in addressing physical and

mental health problems;

16)         implementing

a procedure for preserving medical staff credentialing files in the event of

the closure of the hospital;

17)         establishing a procedure for granting telemedicine

privileges, based upon the privileging decisions of a distant-site hospital or

telemedicine entity that has a written agreement that meets Medicare

requirements; and

18)         establishing

a procedure for granting disaster privileges

re for preserving medical staff credentialing files in the event of

the closure of the hospital;

17)         establishing a procedure for granting telemedicine

privileges, based upon the privileging decisions of a distant-site hospital or

telemedicine entity that has a written agreement that meets Medicare

requirements; and

18)         establishing

a procedure for granting disaster privileges.

A)        When

the emergency management plan has been activated and the hospital is unable to

handle patients' immediate needs, it shall:

i)          identify

in writing the individuals responsible for granting disaster privileges;

ii)         describe

in writing the responsibilities of the individuals granting disaster

privileges.  The responsible individual is not required to grant privileges to

any individual and is expected to make decisions on a case-by-case basis at his

or her discretion;

iii)        describe

in writing a mechanism to manage individuals who receive disaster privileges;

iv)        include

a mechanism to allow staff to readily identify individuals who receive disaster

privileges;

v)         require

that medical staff address the verification process as a high priority and

begin the verification process of the credentials and privileges of individuals

who receive disaster privileges as soon as the immediate situation is under

control.

B)        The

individual responsible for granting disaster privileges may grant disaster

privileges upon presentation of any of the following:

i)          a

current picture hospital ID card;

ii)         a

current license to practice and a valid picture ID issued by a state, federal

or regulatory agency;

iii)        identification

indicating that the individual is a member of a Disaster Medical Assistance

Team (DMAT) or an Illinois Medical Emergency Response Team (IMERT);

iv)        identification

indicating that the individual has been granted authority to render patient

care, treatment and services in disaster circumstances (authority having bee

ued by a state, federal

or regulatory agency;

iii)        identification

indicating that the individual is a member of a Disaster Medical Assistance

Team (DMAT) or an Illinois Medical Emergency Response Team (IMERT);

iv)        identification

indicating that the individual has been granted authority to render patient

care, treatment and services in disaster circumstances (authority having been

granted by a federal, state or municipal entity); or

v)         presentation

by current hospital or medical staff members with personal knowledge regarding

practitioner's identity.

C)

Any

hospital and any employees of the hospital or others involved in granting

privileges who, in good faith, grant disaster privileges, pursuant to Section

10.4 of

the

Act, 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

the

Act.

D)

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

the

Act, on the

part of the person, be liable for civil damages.

(Section 10.4 of the Act)

c)         General

Acute or Critical Access Hospitals without a licensed pediatric unit or board

certified or board eligible pediatrician in the hospital or on call 24 hours a

day, 7 days a week that provide limited inpatient or observation services to

pediatric patients (neonate (less than 28 days of age) to 14 years old):

1)         Shall

have a written agreement with a children’s hospital or hospital with a licensed

pediatric unit

s Hospitals without a licensed pediatric unit or board

certified or board eligible pediatrician in the hospital or on call 24 hours a

day, 7 days a week that provide limited inpatient or observation services to

pediatric patients (neonate (less than 28 days of age) to 14 years old):

1)         Shall

have a written agreement with a children’s hospital or hospital with a licensed

pediatric unit. The agreement shall include provider-to-patient and/or

provider-to-provider consultations that meet the telemedicine requirements

provided in subsections (a)(2) through (a)(8) remotely via electronic

communications, whether synchronous or asynchronous, and specify other

information including communication frequency, equipment, education, transfers,

case reviews, and critical criteria for emergency transfers;

2)         Must

have an agreement with one primary hospital, for the purposes of continuing

education and consultation, but are encouraged to have agreements with multiple

hospitals, in order to ensure options when a transfer is warranted but

restricted from accommodation due to primary hospital census or family

preference;

3)         May

have agreements with out-of-state hospitals who have agreements with the

Department under the Regionalized Perinatal Health Care Code (77 Ill. Adm. Code

640) and designated as a trauma center by the Department in accordance with

Section 3.90 of the Emergency Medical Services (EMS) Systems Act;

4)         May

include a fee for provider-to-patient and/or provider-to-provider consultations

with the consulting hospital in the written agreement, but the fee may not be

transferred to the patient;

5)         Shall

have until June 1, 2024 to enter into an agreement, or amend an existing

agreement, as required in this subsection (c);

6)         Shall

consult with the children’s hospital or hospital with licensed pediatric unit

prior to the patient being moved to a medical/surgical unit from either the

emergency department or post-operative procedure unit

t be

transferred to the patient;

5)         Shall

have until June 1, 2024 to enter into an agreement, or amend an existing

agreement, as required in this subsection (c);

6)         Shall

consult with the children’s hospital or hospital with licensed pediatric unit

prior to the patient being moved to a medical/surgical unit from either the

emergency department or post-operative procedure unit.  In cases where the

consultation cannot occur prior to the move, the consultation must occur within

one hour after the patient has been placed on the medical/surgical unit as an

inpatient or in observation status.  The frequency of the consultations during

the pediatric patient’s stay shall be determined by the health care provider

and shall continue until the patient is discharged or transferred;

7)         Shall

maintain a record of the consultation in the pediatric patient’s medical file;

8)         Shall

report pediatric services provided pursuant to the requirements of this

subsection (c) to the Department quarterly as required by Section 250.1520(i);

and

9)         Shall

not require providers who give provider-to-provider consultations to be

privileged at the hospital where the patient is receiving treatment.

d)         If a

hospital is part of a hospital system consisting of two or more separately

licensed hospitals, and the system elects to have a unified, integrated medical

staff for its separately licensed member hospitals, each separately licensed

hospital shall permit the medical staff members of each separately licensed hospital

in the system (in other words, all medical staff members who hold specific

privileges to practice at that hospital) to vote, in accordance with medical

staff bylaws, whether to accept a unified, integrated medical staff structure

or to maintain a separate and distinct medical staff for their respective

licensed hospital

all permit the medical staff members of each separately licensed hospital

in the system (in other words, all medical staff members who hold specific

privileges to practice at that hospital) to vote, in accordance with medical

staff bylaws, whether to accept a unified, integrated medical staff structure

or to maintain a separate and distinct medical staff for their respective

licensed hospital.

1)         If

the medical staffs of the separately licensed hospitals vote to accept an

integrated, unified medical staff structure, they shall meet the following

conditions:

A)        Adopt

written bylaws, rules and requirements that describe the processes for

self-governance, appointment, credentialing, privileging and oversight, as well

as peer review policies and due process rights guarantees, including a process

for the members of the medical staff of each separately licensed hospital to be

advised of their rights to opt out of the unified and integrated medical staff

structure after a majority vote by the members to maintain a separate and

distinct medical staff for their hospital;

B)        Take

into account each member hospital's unique circumstances and any significant

differences in patient populations and services offered in each hospital; and

C)        Establish

and implement written policies and procedures, including meetings that shall occur

at least twice per fiscal or calendar year, to ensure that the needs and

concerns expressed by members of the medical staffs at each separately licensed

hospital, regardless of practice or location, are given due consideration, and

that the unified, integrated medical staff has mechanisms in place to ensure

that issues localized to particular hospitals are considered and addressed.

2)         The

unified, integrated medical staff shall be organized in accordance with the

Conditions of Participation for Hospitals related to medical staff

ensed

hospital, regardless of practice or location, are given due consideration, and

that the unified, integrated medical staff has mechanisms in place to ensure

that issues localized to particular hospitals are considered and addressed.

2)         The

unified, integrated medical staff shall be organized in accordance with the

Conditions of Participation for Hospitals related to medical staff.

3)         Medical

staffs may vote, no more than every two years, whether to remain or discontinue

as an integrated, unified medical staff.

4)         This

subsection (d) shall not apply to hospitals that are required to have a

unified, integrated medical staff under 42 CFR 413.65(d) and (e) as being a

multi-campus hospital under one Medicare certification number.

e)         The

medical staff bylaws for county hospitals as defined in Section 15-1(c) of the

Illinois Public Aid Code shall include at least the following:

1)         The

procedures relating to evaluating individuals for staff membership, whether the

practitioners are or are not currently members of the medical staff, shall

include procedures for determining qualifications and privileges; criteria for evaluating

qualifications; and procedures requiring information about current health

status, current license status in Illinois, and biennial review of renewed

license.

2)         Written procedures that allow the medical staff to rely upon

the credentialing and privileging decisions of a distant-site hospital or

telemedicine entity as an option for recommending the privileging of

telemedicine physicians.

3)         The

procedure shall grant to current medical staff members at least: written notice

of an adverse decision by the governing board; an explanation and reasons for

an adverse decision; the right to examine and/or present copies of relevant

information, if any, related to an adverse decision; an opportunity to appeal

an adverse decision; and written notice of the decision resulting from the

appeal

procedure shall grant to current medical staff members at least: written notice

of an adverse decision by the governing board; an explanation and reasons for

an adverse decision; the right to examine and/or present copies of relevant

information, if any, related to an adverse decision; an opportunity to appeal

an adverse decision; and written notice of the decision resulting from the

appeal.  The procedures for providing written notice shall include timeframes

for giving notice.

f)         The medical staff bylaws for

all hospitals except county hospitals

shall include at least the following

provisions

for

granting,

limiting, renewing, or denying medical staff membership and clinical staff

privileges

:

1)

Minimum procedures for pre-applicants or applicants for

medical staff membership, including the following:

A)

Written procedures relating to the acceptance and processing

of pre-applicants or applicants for medical staff membership.

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).

F)         Written procedures that allow the medical staff to rely upon

the credentialing and privileging decisions of a distant-site hospital or

telemedicine entity as an option for recommending the privileging of

telemedicine physicians

adverse decision (including all reasons

based in whole or in part on the applicant's medical qualifications or any

other basis, including economic factors).

F)         Written procedures that allow the medical staff to rely upon

the credentialing and privileging decisions of a distant-site hospital or

telemedicine entity as an option for recommending the privileging of

telemedicine physicians.

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 and

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.

B)

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 board.

i)

Nothing in

this subsection (f)(2)(B)

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

ed by the hospital

governing board.

i)

Nothing in

this subsection (f)(2)(B)

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.

ii)

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

medical

staff member

requests a review.

iii)

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.

iv)

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.

v)

Nothing in this

subsection (f)(2)(B)

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.

vi)

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

Department

of Financial and Professional Regulation,

no hearing shall be necessary

15 days

after the summary suspension and completed without delay unless otherwise

agreed to by the parties.

vi)

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

Department

of Financial and Professional Regulation,

no hearing shall be necessary.

(Section

10.4(b)(2)(C)(i) of the Act)

vii)

Nothing in

this subsection (f)(2)(B)

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 staff.

(Section 10.4(b)(2)(C)(ii) of the

Act)

viii)

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

this subsection (f)(2)(B)

must request the hearing within 14 days

after the date he or she is so notified

dical 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

this subsection (f)(2)(B)

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.

(Section 10.4(b)(2)(C)(iii) of

the Act)

C)        A

statement of the member's right to inspect all pertinent

information in the hospital's possession with respect to the decision.

D)

A statement of the member's right to present witnesses and

other evidence at the hearing on the decision.

E)

The right to be represented by a personal attorney.

F)

A written notice and written explanation of the decision

resulting from the hearing.

G)

A written notice of a final adverse decision by the hospital

governing board.

H)

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

subsection (f)(2)(B)(viii),

and

under the medical staff bylaws in order to allow sufficient time for the

orderly provision of patient care

)

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

subsection (f)(2)(B)(viii),

and

under the medical staff bylaws in order to allow sufficient time for the

orderly provision of patient care.

(Section 10.4(b)(2)(D) through (G) of

the Act)

3)

Nothing in

subsection (f)(2)

limits a medical staff

member's right to waive, in writing, the rights provided

in

subsection (f)(2)(A) through (H)

upon being granted

privileges to

provide telemedicine services or

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.

(Section 10.4(b)(2)(H)

of the Act)

4)

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

all 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 the

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

the

Act.

(Section 10.4(b)(2)(C-5)

of the Act)

5)

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.  The 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

rted to

the Hospital Licensing Board before the decision takes effect.  The 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

.

(Section 10.4(b)(3) of the Act)

g)         If a hospital enters into agreement for telemedicine services

with a distant-site hospital or distant-site entity, the governing body of the

hospital whose patients are receiving the telemedicine services may choose, in

lieu of the hospital performing the credentialing and privileging requirements,

to rely upon the credentialing and privileging decisions made by the

distant-site hospital when making recommendations on privileges for the

individual distant-site physicians and practitioners providing the services.

The hospital's governing body ensures, through its written agreement with the

distant-site hospital, that the distant-site hospital meets the Conditions of

Participation for Hospitals for credentialing and privileging of physicians and

practitioners.  The agreement shall be in writing and shall verify:

1)         That the distant-site hospital providing the telemedicine

services is an Illinois licensed hospital or a Medicare participating hospital;

2)         That the individual distant-site physician or practitioner is

privileged at the distant-site hospital that provides the telemedicine services

and provides to the hospital a current list of the distant-site physician's

privileges;

3)         That the individual distant-site physician or practitioner holds

a license issued or recognized by the State of Illinois; and

4)         That, if the hospital conducts an internal review of the

distant-site physician's or practitioner's performance, it provides the

distant-site hospital with the performance information for use in the

distant-site hospital's

physician's

privileges;

3)         That the individual distant-site physician or practitioner holds

a license issued or recognized by the State of Illinois; and

4)         That, if the hospital conducts an internal review of the

distant-site physician's or practitioner's performance, it provides the

distant-site hospital with the performance information for use in the

distant-site hospital's periodic appraisal of the distant-site physician or

practitioner. At a minimum, this information shall include all adverse events

that result from the telemedicine services provided by the distant-site

physician or practitioner to the hospital's patients and all complaints the

hospital has received about the distant-site physician or practitioner.

h)         The hospital's governing body shall grant privileges to each

telemedicine physician or practitioner providing services at the hospital under

an agreement with a distant-site hospital or telemedicine entity before the

telemedicine physician or practitioner may provide telemedicine services. The

scope of the privileges granted to the telemedicine physician or practitioner shall

reflect the provision of the services offered via a telecommunications system.

i)          When the hospital's governing body exercises the option to

grant privileges based on its medical staff recommendations, which rely upon

the privileging decisions of a distant-site telemedicine hospital or entity,

the governing body may, but is not required to, maintain a separate file on

each telemedicine physician or practitioner. In lieu of maintaining a separate

file on each telemedicine physician or practitioner, the hospital may have a

file on all telemedicine physicians or practitioners providing services at the

hospital under each agreement with a distant-site hospital or telemedicine

entity, indicating which telemedicine services privileges the hospital has

granted to each physician or practitioner on the list

. In lieu of maintaining a separate

file on each telemedicine physician or practitioner, the hospital may have a

file on all telemedicine physicians or practitioners providing services at the

hospital under each agreement with a distant-site hospital or telemedicine

entity, indicating which telemedicine services privileges the hospital has

granted to each physician or practitioner on the list. The file or files may be

kept in a format determined by the hospital.

j)          Regardless

of any other categories (divisions of the medical staff) having privileges in

the hospital, the hospital shall have an active staff, which shall include

physicians and may also include podiatrists and dentists, properly organized, who

perform all the organizational duties pertaining to the medical staff.  These

duties include:

1)         Maintaining

the proper quality of all medical care and treatment of inpatients and

outpatients in the hospital.  Proper quality of medical care and treatment

includes:

A)        availability

and use of accurate diagnostic testing for the types of patients admitted;

B)        availability

and use of medical, surgical, and psychiatric treatment for patients admitted;

C)        availability

and use of consultation, diagnostic tools and treatment modalities for the care

of patients admitted, including the care needed for complications that may be

expected to occur; and

D)        availability

and performance of auxiliary and associate staff with documented training and

experience in diagnostic and treatment modalities in use by the medical staff

and documented training and experience in managing complications that may be

expected to occur

lities for the care

of patients admitted, including the care needed for complications that may be

expected to occur; and

D)        availability

and performance of auxiliary and associate staff with documented training and

experience in diagnostic and treatment modalities in use by the medical staff

and documented training and experience in managing complications that may be

expected to occur.

2)         Organizing

the medical staff, including adoption of rules and regulations for its

government (which require the approval of the governing body), election of its

officers or recommendations to the governing body for appointment of the

officers, and recommendations to the governing body upon all appointments to

the staff and grants of hospital privileges.

3)         Making

other recommendations to the governing body regarding matters within the

purview of the medical staff.

k)         The

medical staff may include one or more divisions in addition to the active

staff, but this in no way modifies the duties and responsibilities of the

active staff.