(210 ILCS 85/3)
Sec. 3.
As used in this Act:
(A) "Hospital" means any institution, place, building, or agency, public or private, whether organized for profit or not, devoted primarily to the maintenance and operation of facilities for the diagnosis and treatment or care of 2 or more unrelated persons admitted for overnight stay or longer in order to obtain medical, including obstetric, psychiatric and nursing, care of illness, disease, injury, infirmity, or deformity.
The term "hospital", without regard to length of stay, shall also include:
(a) any facility which is devoted primarily to
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| providing psychiatric and related services and programs for the diagnosis and treatment or care of 2 or more unrelated persons suffering from emotional or nervous diseases; |
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(b) all places where pregnant females are received, |
| cared for, or treated during delivery irrespective of the number of patients received. |
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The term "hospital" includes general and specialized hospitals, tuberculosis sanitaria, mental or psychiatric hospitals and sanitaria, and includes maternity homes, lying‑in homes, and homes for unwed mothers in which care is given during delivery.
The term "hospital" does not include:
(1) any person or institution required to be licensed |
| pursuant to the Nursing Home Care Act or the MR/DD Community Care Act; |
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(2) hospitalization or care facilities maintained by |
| the State or any department or agency thereof, where such department or agency has authority under law to establish and enforce standards for the hospitalization or care facilities under its management and control; |
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(3) hospitalization or care facilities maintained by |
| the federal government or agencies thereof; |
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(4) hospitalization or care facilities maintained by |
| any university or college established under the laws of this State and supported principally by public funds raised by taxation; |
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(5) any person or facility required to be licensed |
| pursuant to the Alcoholism and Other Drug Abuse and Dependency Act; |
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(6) any facility operated solely by and for persons |
| who rely exclusively upon treatment by spiritual means through prayer, in accordance with the creed or tenets of any well‑recognized church or religious denomination; |
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(7) an Alzheimer's disease management center |
| alternative health care model licensed under the Alternative Health Care Delivery Act; or |
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(8) any veterinary hospital or clinic operated by a |
| veterinarian or veterinarians licensed under the Veterinary Medicine and Surgery Practice Act of 2004 or maintained by a State‑supported or publicly funded university or college. |
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(B) "Person" means the State, and any political subdivision or municipal corporation, individual, firm, partnership, corporation, company, association, or joint stock association, or the legal successor thereof.
(C) "Department" means the Department of Public Health of the State of Illinois.
(D) "Director" means the Director of Public Health of the State of Illinois.
(E) "Perinatal" means the period of time between the conception of an infant and the end of the first month after birth.
(F) "Federally designated organ procurement agency" means the organ procurement agency designated by the Secretary of the U.S. Department of Health and Human Services for the service area in which a hospital is located; except that in the case of a hospital located in a county adjacent to Wisconsin which currently contracts with an organ procurement agency located in Wisconsin that is not the organ procurement agency designated by the U.S. Secretary of Health and Human Services for the service area in which the hospital is located, if the hospital applies for a waiver pursuant to 42 USC 1320b‑8(a), it may designate an organ procurement agency located in Wisconsin to be thereafter deemed its federally designated organ procurement agency for the purposes of this Act.
(G) "Tissue bank" means any facility or program operating in Illinois that is certified by the American Association of Tissue Banks or the Eye Bank Association of America and is involved in procuring, furnishing, donating, or distributing corneas, bones, or other human tissue for the purpose of injecting, transfusing, or transplanting any of them into the human body. "Tissue bank" does not include a licensed blood bank. For the purposes of this Act, "tissue" does not include organs.
(Source: P.A. 96‑219, eff. 8‑10‑09; 96‑339, eff. 7‑1‑10; 96‑1000, eff. 7‑2‑10.) |
(210 ILCS 85/6) (from Ch. 111 1/2, par. 147)
Sec. 6. (a) Upon receipt of an application for a permit to establish a hospital the Director shall issue a permit if he finds (1) that the applicant is fit, willing, and able to provide a proper standard of hospital service for the community with particular regard to the qualification, background, and character of the applicant, (2) that the financial resources available to the applicant demonstrate an ability to construct, maintain, and operate a hospital in accordance with the standards, rules, and regulations adopted pursuant to this Act, and (3) that safeguards are provided which assure hospital operation and maintenance consistent with the public interest having particular regard to safe, adequate, and efficient hospital facilities and services.
The Director may request the cooperation of county and multiple‑county health departments, municipal boards of health, and other governmental and non‑governmental agencies in obtaining information and in conducting investigations relating to such applications.
A permit to establish a hospital shall be valid only for the premises and person named in the application for such permit and shall not be transferable or assignable.
In the event the Director issues a permit to establish a hospital the applicant shall thereafter submit plans and specifications to the Department in accordance with Section 8 of this Act.
(b) Upon receipt of an application for license to open, conduct, operate, and maintain a hospital, the Director shall issue a license if he finds the applicant and the hospital facilities comply with standards, rules, and regulations promulgated under this Act. A license, unless sooner suspended or revoked, shall be renewable annually upon approval by the Department. Each license shall be issued only for the premises and persons named in the application and shall not be transferable or assignable. Licenses shall be posted in a conspicuous place on the licensed premises. The Department may, either before or after the issuance of a license, request the cooperation of the State Fire Marshal, county and multiple county health departments, or municipal boards of health to make investigations to determine if the applicant or licensee is complying with the minimum standards prescribed by the Department. The report and recommendations of any such agency shall be in writing and shall state with particularity its findings with respect to compliance or noncompliance with such minimum standards, rules, and regulations.
The Director may issue a provisional license to any hospital which does not substantially comply with the provisions of this Act and the standards, rules, and regulations promulgated by virtue thereof provided that he finds that such hospital has undertaken changes and corrections which upon completion will render the hospital in substantial compliance with the provisions of this Act, and the standards, rules, and regulations adopted hereunder, and provided that the health and safety of the patients of the hospital will be protected during the period for which such provisional license is issued. The Director shall advise the licensee of the conditions under which such provisional license is issued, including the manner in which the hospital facilities fail to comply with the provisions of the Act, standards, rules, and regulations, and the time within which the changes and corrections necessary for such hospital facilities to substantially comply with this Act, and the standards, rules, and regulations of the Department relating thereto shall be completed.
(Source: P.A. 80‑56.) |
(210 ILCS 85/6.08) (from Ch. 111 1/2, par. 147.08)
Sec. 6.08. (a) Every hospital shall provide notification as required in this Section to police officers, firefighters, emergency medical technicians, and ambulance personnel who have provided or are about to provide emergency care or life support services to a patient who has been diagnosed as having a dangerous communicable or infectious disease. Such notification shall not include the name of the patient, and the emergency services provider agency and any person receiving such notification shall treat the information received as a confidential medical record.
(b) The Department shall establish by regulation a list of those communicable reportable diseases and conditions for which notification shall be provided.
(c) The hospital shall send the letter of notification within 72 hours after a confirmed diagnosis of any of the communicable diseases listed by the Department pursuant to subsection (b), except confirmed diagnoses of Acquired Immunodeficiency Syndrome (AIDS). If there is a confirmed diagnosis of AIDS, the hospital shall send the letter of notification only if the police officers, firefighters, emergency medical technicians, or ambulance personnel have indicated on the ambulance run sheet that a reasonable possibility exists that they have had blood or body fluid contact with the patient, or if hospital personnel providing the notification have reason to know of a possible exposure.
(d) Notification letters shall be sent to the designated contact at the municipal or private provider agencies listed on the ambulance run sheet. Except in municipalities with a population over 1,000,000, a list attached to the ambulance run sheet must contain all municipal and private provider agency personnel who have provided any pre‑hospital care immediately prior to transport. In municipalities with a population over 1,000,000, the ambulance run sheet must contain the company number or unit designation number for any fire department personnel who have provided any pre‑hospital care immediately prior to transport. The letter shall state the names of crew members listed on the attachment to the ambulance run sheet and the name of the communicable disease diagnosed, but shall not contain the patient's name. Upon receipt of such notification letter, the applicable private provider agency or the designated infectious disease control officer of a municipal fire department or fire protection district shall contact all personnel involved in the pre‑hospital or inter‑hospital care and transport of the patient. Such notification letter may, but is not required to, consist of the following form: NOTIFICATION LETTER (NAME OF HOSPITAL) (ADDRESS) TO:...... (Name of Organization)
FROM:.....(Infection Control Coordinator)
DATE:.....
As required by Section 6.08 of the Illinois Hospital Licensing Act, .....(name of hospital) is hereby providing notification that the following crew members or agencies transported or provided pre‑hospital care to a patient on ..... (date), and the transported patient was later diagnosed as having .....(name of communicable disease): .....(list of crew members). The Hospital Licensing Act requires you to maintain this information as a confidential medical record. Disclosure of this information may therefore result in civil liability for the individual or company breaching the patient's confidentiality, or both.
If you have any questions regarding this patient, please contact me at .....(telephone number), between .....(hours). Questions regarding exposure or the financial aspects of obtaining medical care should be directed to your employer.
(e) Upon discharge of a patient with a communicable disease to emergency personnel, the hospital shall notify the emergency personnel of appropriate precautions against the communicable disease, but shall not identify the name of the disease.
(f) The hospital may, in its discretion, take any measures in addition to those required in this Section to notify police officers, firefighters, emergency medical technicians, and ambulance personnel of possible exposure to any communicable disease. However, in all cases this information shall be maintained as a confidential medical record.
(g) Any person providing or failing to provide notification under the protocol required by this Section shall have immunity from any liability, either criminal or civil, that might result by reason of such action or inaction, unless such action or inaction is willful.
(h) Any person who willfully fails to provide any notification required pursuant to an applicable protocol which has been adopted and approved pursuant to this Section commits a petty offense, and shall be subject to a fine of $200 for the first offense, and $500 for a second or subsequent offense.
(i) Nothing in this Section shall preclude a civil action by a firefighter, emergency medical technician, or ambulance crew member against an emergency services provider agency, municipal fire department, or fire protection district that fails to inform the member in a timely fashion of the receipt of a notification letter.
(Source: P.A. 92‑363, eff. 1‑1‑02.) |
(210 ILCS 85/6.13) (from Ch. 111 1/2, par. 147.13)
Sec. 6.13. Any hospital licensed under this Act may provide a program or service for the temporary custodial care of mildly ill children who, because of their illness, are unable to attend school or to participate in their normal day care program. The Department shall develop minimum standards, rules and regulations to govern the operation of a sick child day program which is operated by a hospital and located on the hospital's licensed premises. Any such standards, rules and regulations shall provide that:
(a) a sick child day program may be located anywhere on the hospital's licensed premises, including patient care units, when the following conditions are met:
(1) Children in the sick child day program shall not |
| simultaneously occupy the same room as a hospital patient; and | |
(2) Children in the sick child day program who are |
| recovering from non‑contagious conditions shall be cared for in a room separate from children registered in the program who have contagious conditions. | |
(b) children registered in a sick child day program are not considered to be hospital patients, and are not required to be under the professional care of a member of the hospital's medical staff except in those cases where emergency medical treatment is needed during the time the child is on the program premises; and
(c) medication may be administered to a child in a sick child program when the following conditions are met:
(1) Prescription medications shall be labeled with |
| the child's name, directions for administering the medication, the date, the physician's name, the prescription number, and the dispensing drug store or pharmacy. Only current prescription medications will be administered by the program. Nothing in this paragraph (1) shall be construed to prohibit program staff from administering medication prescribed by any licensed professional who is permitted by law to do so, whether or not the professional is a member of the hospital's medical staff. | |
(2) Written parental permission shall be obtained |
| before non‑prescription medication is administered. Such medication shall be administered in accordance with package instructions. | |
(Source: P.A. 86‑1461; 87‑435.) |
(210 ILCS 85/6.17)
Sec. 6.17. Protection of and confidential access to medical records and information.
(a) Every hospital licensed under this Act shall develop a medical record for each of its patients as required by the Department by rule.
(b) All information regarding a hospital patient gathered by the hospital's medical staff and its agents and employees shall be the property and responsibility of the hospital and must be protected from inappropriate disclosure as provided in this Section.
(c) Every hospital shall preserve its medical records in a format and for a duration established by hospital policy and for not less than 10 years, provided that if the hospital has been notified in writing by an attorney before the expiration of the 10 year retention period that there is litigation pending in court involving the record of a particular patient as possible evidence and that the patient is his client or is the person who has instituted such litigation against his client, then the hospital shall retain the record of that patient until notified in writing by the plaintiff's attorney, with the approval of the defendant's attorney of record, that the case in court involving such record has been concluded or for a period of 12 years from the date that the record was produced, whichever occurs first in time.
(d) No member of a hospital's medical staff and no agent or employee of a hospital shall disclose the nature or details of services provided to patients, except that the information may be disclosed to the patient, persons authorized by the patient, the party making treatment decisions, if the patient is incapable of making decisions regarding the health services provided, those parties directly involved with providing treatment to the patient or processing the payment for that treatment, those parties responsible for peer review, utilization review or quality assurance, risk management, or defense of claims brought against the hospital arising out of the care, and those parties required to be notified under the Abused and Neglected Child Reporting Act, the Illinois Sexually Transmissible Disease Control Act, or where otherwise authorized or required by law.
(e) The hospital's medical staff members and the hospital's agents and employees may communicate, at any time and in any fashion, with legal counsel for the hospital concerning the patient medical record privacy and retention requirements of this Section and any care or treatment they provided or assisted in providing to any patient within the scope of their employment or affiliation with the hospital.
(e‑5) Notwithstanding subsections (d) and (e), for actions filed on or after January 1, 2004, after a complaint for healing art malpractice is served upon the hospital or upon its agents or employees, members of the hospital's medical staff who are not actual or alleged agents, employees, or apparent agents of the hospital may not communicate with legal counsel for the hospital or with risk management of the hospital concerning the claim alleged in the complaint for healing art malpractice against the hospital except with the patient's consent or in discovery authorized by the Code of Civil Procedure or the Supreme Court rules. For the purposes of this subsection (e‑5), "hospital" includes a hospital affiliate as defined in subsection (b) of Section 10.8 of this Act.
(f) Each hospital licensed under this Act shall provide its federally designated organ procurement agency and any tissue bank with which it has an agreement with access to the medical records of deceased patients for the following purposes:
(1) estimating the hospital's organ and tissue |
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(2) identifying the educational needs of the |
| hospital with respect to organ and tissue donation; and | |
(3) identifying the number of organ and tissue |
| donations and referrals to potential organ and tissue donors. | |
(g) All hospital and patient information, interviews, reports, statements, memoranda, and other data obtained or created by a tissue bank or federally designated organ procurement agency from the medical records review described in subsection (f) shall be privileged, strictly confidential, and used only for the purposes put forth in subsection (f) of this Section and shall not be admissible as evidence nor discoverable in an action of any kind in court or before a tribunal, board, agency, or person.
(h) Any person who, in good faith, acts in accordance with the terms of this Section shall not be subject to any type of civil or criminal liability or discipline for unprofessional conduct for those actions under any professional licensing statute.
(i) Any individual who wilfully or wantonly discloses hospital or medical record information in violation of this Section is guilty of a Class A misdemeanor. As used in this subsection, "wilfully or wantonly" means a course of action that shows an actual or deliberate intention to cause harm or that, if not intentional, shows an utter indifference to or conscious disregard for the safety of others or their property.
(j) The changes to this Section made by this amendatory Act of the 93rd General Assembly apply to any action filed on or after January 1, 2004.
(Source: P.A. 93‑492, eff. 1‑1‑04.) |
(210 ILCS 85/6.22)
Sec. 6.22.
Arrangement for transportation of patient by ambulance.
(a) In this Section:
"Ambulance service provider" means a Vehicle Service
| Provider as defined in the Emergency Medical Services (EMS) Systems Act who provides non‑emergency transportation services by ambulance. | |
"Patient" means a person who is transported by an |
| ambulance service provider. | |
(b) If a hospital arranges for transportation of a patient of the hospital by ambulance, the hospital must provide the ambulance service provider, prior to transport, a Physician Certification Statement formatted and completed in compliance with federal regulations or an equivalent form developed by the hospital. The Physician Certification Statement or equivalent form is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome.
(c) If a hospital is unable to provide a Physician Certification Statement or equivalent form, then the hospital shall provide to the patient a written notice and a verbal explanation of the written notice, which notice must meet all of the following requirements:
(1) The following caption must appear at the |
| beginning of the notice in at least 14‑point type: Notice to Patient Regarding Non‑Emergency Ambulance Services. | |
(2) The notice must contain each of the following |
| statements in at least 14‑point type: | |
(A) The purpose of this notice is to help you |
| make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance. | |
(B) Your insurance may not cover the charges for |
| ambulance transportation. | |
(C) You may be responsible for the cost of |
| ambulance transportation. | |
(D) The estimated cost of ambulance |
| transportation is $(amount). | |
(3) The notice must be signed by the patient or by |
| the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy. | |
(d) The notice set forth in subsection (c) of this |
| Section shall not be required if a delay in transport can be expected to negatively affect the patient outcome. | |
(e) If a patient is physically or mentally unable to sign |
| the notice described in subsection (c) of this Section and no authorized representative of the patient is available to sign the notice on the patient's behalf, the hospital must be able to provide documentation of the patient's inability to sign the notice and the unavailability of an authorized representative. In any case described in this subsection (e), the hospital shall be considered to have met the requirements of subsection (c) of this Section. | |
(Source: P.A. 94‑1063, eff. 1‑31‑07 .) |
(210 ILCS 85/6.25)
Sec. 6.25.
Safe patient handling policy.
(a) In this Section:
"Health care worker" means an individual providing direct patient care services who may be required to lift, transfer, reposition, or move a patient.
"Nurse" means an advanced practice nurse, a registered nurse, or a licensed practical nurse licensed under the Nurse Practice Act.
(b) A hospital must adopt and ensure implementation of a policy to identify, assess, and develop strategies to control risk of injury to patients and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient. The policy shall establish a process that, at a minimum, includes all of the following:
(1) Analysis of the risk of injury to patients and
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| nurses and other health care workers posted by the patient handling needs of the patient populations served by the hospital and the physical environment in which the patient handling and movement occurs. |
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(2) Education of nurses in the identification, |
| assessment, and control of risks of injury to patients and nurses and other health care workers during patient handling. |
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(3) Evaluation of alternative ways to reduce risks |
| associated with patient handling, including evaluation of equipment and the environment. |
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(4) Restriction, to the extent feasible with existing |
| equipment and aids, of manual patient handling or movement of all or most of a patient's weight except for emergency, life‑threatening, or otherwise exceptional circumstances. |
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(5) Collaboration with and an annual report to the |
| nurse staffing committee. |
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(6) Procedures for a nurse to refuse to perform or be |
| involved in patient handling or movement that the nurse in good faith believes will expose a patient or nurse or other health care worker to an unacceptable risk of injury. |
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(7) Submission of an annual report to the hospital's |
| governing body or quality assurance committee on activities related to the identification, assessment, and development of strategies to control risk of injury to patients and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient. |
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(8) In developing architectural plans for |
| construction or remodeling of a hospital or unit of a hospital in which patient handling and movement occurs, consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment. |
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(Source: P.A. 96‑389, eff. 1‑1‑10; 96‑1000, eff. 7‑2‑10.) |
(210 ILCS 85/8)
(from Ch. 111 1/2, par. 149)
Sec. 8.
Facility plan review; fees.
(a) Before commencing construction of new facilities or specified types of alteration or additions to an existing hospital involving major construction, as defined by rule by the Department, with an estimated cost greater than $100,000, architectural plans and specifications therefor shall be submitted by the licensee to the Department for review and approval. A hospital may submit architectural drawings and specifications for other construction projects for Department review according to subsection (b) that shall not be subject to fees under subsection (d). The Department must give a hospital that is planning to submit a construction project for review the opportunity to discuss its plans and specifications with the Department before the hospital formally submits the plans and specifications for Department review. Review of drawings and specifications shall be conducted by an employee of the Department meeting the qualifications established by the Department of Central Management Services class specifications for such an individual's position or by a person contracting with the Department who meets those class specifications. Final approval of the plans and specifications for compliance with design and construction standards shall be obtained from the Department before the alteration, addition, or new construction is begun. Subject to this Section 8, and prior to January 1, 2012, the Department shall consider the re‑licensing of an existing hospital structure according to the standards for an existing hospital, as set forth in the Department's rules. Re‑licensing under this provision shall occur only if that facility operated as a licensed hospital on July 1, 2005, has had no intervening use as other than a hospital, and exists in a county with a population of less than 20,000 that does not have another licensed hospital on the effective date of this amendatory Act of the 95th General Assembly.
(b) The Department shall inform an applicant in writing within 10 working days after receiving drawings and specifications and the required fee, if any, from the applicant whether the applicant's submission is complete or incomplete. Failure to provide the applicant with this notice within 10 working days shall result in the submission being deemed complete for purposes of initiating the 60‑day review period under this Section. If the submission is incomplete, the Department shall inform the applicant of the deficiencies with the submission in writing. If the submission is complete and the required fee, if any, has been paid, the Department shall approve or disapprove drawings and specifications submitted to the Department no later than 60 days following receipt by the Department. The drawings and specifications shall be of sufficient detail, as provided by Department rule, to enable the Department to render a determination of compliance with design and construction standards under this Act. If the Department finds that the drawings are not of sufficient detail for it to render a determination of compliance, the plans shall be determined to be incomplete and shall not be considered for purposes of initiating the 60 day review period. If a submission of drawings and specifications is incomplete, the applicant may submit additional information. The 60‑day review period shall not commence until the Department determines that a submission of drawings and specifications is complete or the submission is deemed complete. If the Department has not approved or disapproved the drawings and specifications within 60 days, the construction, major alteration, or addition shall be deemed approved. If the drawings and specifications are disapproved, the Department shall state in writing, with specificity, the reasons for the disapproval. The entity submitting the drawings and specifications may submit additional information in response to the written comments from the Department or request a reconsideration of the disapproval. A final decision of approval or disapproval shall be made within 45 days of the receipt of the additional information or reconsideration request. If denied, the Department shall state the specific reasons for the denial and the applicant may elect to seek dispute resolution pursuant to Section 25 of the Illinois Building Commission Act, which the Department must participate in.
(c) The Department shall provide written approval for occupancy pursuant to subsection (g) and shall not issue a violation to a facility as a result of a licensure or complaint survey based upon the facility's physical structure if:
(1) the Department reviewed and approved or deemed
| approved the drawing and specifications for compliance with design and construction standards; | |
(2) the construction, major alteration, or addition |
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(3) the law or rules have not been amended since the |
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(4) the conditions at the facility indicate that |
| there is a reasonable degree of safety provided for the patients. | |
(c‑5) The Department shall not issue a violation to a facility if the inspected aspects of the facility were previously found to be in compliance with applicable standards, the relevant law or rules have not been amended, conditions at the facility reasonably protect the safety of its patients, and alterations or new hazards have not been identified.
(d) The Department shall charge the following fees in connection with its reviews conducted before June 30, 2004 under this Section:
(1) (Blank).
(2) (Blank).
(3) If the estimated dollar value of the major |
| construction is greater than $500,000, the fee shall be established by the Department pursuant to rules that reflect the reasonable and direct cost of the Department in conducting the architectural reviews required under this Section. The estimated dollar value of the major construction subject to review under this Section shall be annually readjusted to reflect the increase in construction costs due to inflation. | |
The fees provided in this subsection (d) shall not apply to major construction projects involving facility changes that are required by Department rule amendments or to projects related to homeland security.
The fees provided in this subsection (d) shall also not apply to major construction projects if 51% or more of the estimated cost of the project is attributed to capital equipment. For major construction projects where 51% or more of the estimated cost of the project is attributed to capital equipment, the Department shall by rule establish a fee that is reasonably related to the cost of reviewing the project.
Disproportionate share hospitals and rural hospitals shall only pay one‑half of the fees required in this subsection (d). For the purposes of this subsection (d), (i) "disproportionate share hospital" means a hospital described in items (1) through (5) of subsection (b) of Section 5‑5.02 of the Illinois Public Aid Code and (ii) "rural hospital" means a hospital that is (A) located outside a metropolitan statistical area or (B) located 15 miles or less from a county that is outside a metropolitan statistical area and is licensed to perform medical/surgical or obstetrical services and has a combined total bed capacity of 75 or fewer beds in these 2 service categories as of July 14, 1993, as determined by the Department.
The Department shall not commence the facility plan review process under this Section until the applicable fee has been paid.
(e) All fees received by the Department under this Section shall be deposited into the Health Facility Plan Review Fund, a special fund created in the State treasury. All fees paid by hospitals under subsection (d) shall be used only to cover the direct and reasonable costs relating to the Department's review of hospital projects under this Section. Moneys shall be appropriated from that Fund to the Department only to pay the costs of conducting reviews under this Section. None of the moneys in the Health Facility Plan Review Fund shall be used to reduce the amount of General Revenue Fund moneys appropriated to the Department for facility plan reviews conducted pursuant to this Section.
(f) (Blank).
(g) The Department shall conduct an on‑site inspection of the completed project no later than 15 business days after notification from the applicant that the project has been completed and all certifications required by the Department have been received and accepted by the Department. The Department may extend this deadline only if a federally mandated survey time frame takes precedence. The Department shall provide written approval for occupancy to the applicant within 5 working days of the Department's final inspection, provided the applicant has demonstrated substantial compliance as defined by Department rule. Occupancy of new major construction is prohibited until Department approval is received, unless the Department has not acted within the time frames provided in this subsection (g), in which case the construction shall be deemed approved. Occupancy shall be authorized after any required health inspection by the Department has been conducted.
(h) The Department shall establish, by rule, a procedure to conduct interim on‑site review of large or complex construction projects.
(i) The Department shall establish, by rule, an expedited process for emergency repairs or replacement of like equipment.
(j) Nothing in this Section shall be construed to apply to maintenance, upkeep, or renovation that does not affect the structural integrity of the building, does not add beds or services over the number for which the facility is licensed, and provides a reasonable degree of safety for the patients.
(Source: P.A. 95‑707, eff. 1‑11‑08.) |
(210 ILCS 85/8.5)
Sec. 8.5. Waiver or alternative compliance. Upon application by a hospital, the Department may grant or renew a waiver or alternative compliance methodology with a rule or standard, including without limitation rules and standards for (i) design and construction, (ii) engineering and maintenance of the physical plant, site, equipment, and systems (heating, cooling, electrical, ventilation, plumbing, water, sewer, and solid waste disposal), (iii) fire and safety, and (iv) other rules or standards that may present a barrier to the development, adoption, or implementation of an innovation designed to improve patient care, for a period not to exceed the duration of the current license or, in the case of an application for license renewal, the duration of the renewal period. The waiver may be conditioned upon the hospital taking action prescribed by the Department as a measure equivalent to compliance. In determining whether to grant or renew a waiver, the Department shall consider the duration and basis for any current waiver with respect to the same rule or standard and the validity and effect upon patient health and safety of extending it on the same basis, the effect upon the health and safety of patients, the quality of patient care, the hospital's history of compliance with the rules and standards of this Act, and the hospital's attempts to comply with the particular rule or standard in question. The Department may provide, by rule, for the automatic renewal of waivers concerning construction or physical plant requirements upon the renewal of a license. The Department shall renew waivers relating to construction or physical plant standards issued pursuant to this Section at the time of the indicated reviews, unless it can show why such waivers should not be extended for the following reasons:
(1) the condition of the physical plant has |
| deteriorated or its use substantially changed so that the basis upon which the waiver was issued is materially different; or | |
(2) the hospital is renovated or substantially |
| remodeled in such a way as to permit compliance with the applicable rules and standards without substantial increase in cost. | |
A copy of each waiver application and each waiver granted or renewed shall be on file with the Department and available for public inspection.
The Department shall advise hospitals of any applicable federal waivers about which it is aware and for which the hospital may apply.
In the event that the Department does not grant or renew a waiver of a rule or standard, the Department must notify the hospital in writing detailing the specific reasons for not granting or renewing the waiver and must discuss possible options, if any, the hospital could take to have the waiver approved.
This Section shall apply to both new and existing construction.
(Source: P.A. 92‑803, eff. 8‑16‑02; 93‑41, eff. 6‑27‑03.) |
(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 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 |
| 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 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 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 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 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 decision. | |
(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 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 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; 96‑445, eff. 8‑14‑09.) |
(210 ILCS 85/10.7)
Sec. 10.7.
Clinical privileges; advanced practice nurses.
All hospitals licensed under this Act shall comply with the following requirements:
(1) No hospital policy, rule, regulation, or practice shall be inconsistent with the provision of adequate collaboration and consultation in accordance with Section 54.5 of the Medical Practice Act of 1987.
(2) Operative surgical procedures shall be performed only by a physician licensed to practice medicine in all its branches under the Medical Practice Act of 1987, a dentist licensed under the Illinois Dental Practice Act, or a podiatrist licensed under the Podiatric Medical Practice Act of 1987, with medical staff membership and surgical clinical privileges granted at the hospital. A licensed physician, dentist, or podiatrist may be assisted by a physician licensed to practice medicine in all its branches, dentist, dental assistant, podiatrist, licensed advanced practice nurse, licensed physician assistant, licensed registered nurse, licensed practical nurse, surgical assistant, surgical technician, or other individuals granted clinical privileges to assist in surgery at the hospital. Payment for services rendered by an assistant in surgery who is not a hospital employee shall be paid at the appropriate non‑physician modifier rate if the payor would have made payment had the same services been provided by a physician.
(2.5) A registered nurse licensed under the Nurse Practice Act and qualified by training and experience in operating room nursing shall be present in the operating room and function as the circulating nurse during all invasive or operative procedures. For purposes of this paragraph (2.5), "circulating nurse" means a registered nurse who is responsible for coordinating all nursing care, patient safety needs, and the needs of the surgical team in the operating room during an invasive or operative procedure.
(3) An advanced practice nurse is not required to possess prescriptive authority or a written collaborative agreement meeting the requirements of the Nurse Practice Act to provide advanced practice nursing services in a hospital. An advanced practice nurse must possess clinical privileges recommended by the medical staff and granted by the hospital in order to provide services. Individual advanced practice nurses may also be granted clinical privileges to order, select, and administer medications, including controlled substances, to provide delineated care. The attending physician must determine the advance practice nurse's role in providing care for his or her patients, except as otherwise provided in medical staff bylaws. The medical staff shall periodically review the services of advanced practice nurses granted privileges. This review shall be conducted in accordance with item (2) of subsection (a) of Section 10.8 of this Act for advanced practice nurses employed by the hospital.
(4) The anesthesia service shall be under the direction of a physician licensed to practice medicine in all its branches who has had specialized preparation or experience in the area or who has completed a residency in anesthesiology. An anesthesiologist, Board certified or Board eligible, is recommended. Anesthesia services may only be administered pursuant to the order of a physician licensed to practice medicine in all its branches, licensed dentist, or licensed podiatrist.
(A) The individuals who, with clinical privileges
| granted at the hospital, may administer anesthesia services are limited to the following: | |
(i) an anesthesiologist; or
(ii) a physician licensed to practice medicine |
|
(iii) a dentist with authority to administer |
| anesthesia under Section 8.1 of the Illinois Dental Practice Act; or | |
(iv) a licensed certified registered nurse |
|
(v) a podiatrist licensed under the Podiatric |
| Medical Practice Act of 1987. | |
(B) For anesthesia services, an anesthesiologist |
| shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions. In the absence of 24‑hour availability of anesthesiologists with medical staff privileges, an alternate policy (requiring participation, presence, and availability of a physician licensed to practice medicine in all its branches) shall be developed by the medical staff and licensed hospital in consultation with the anesthesia service. | |
(C) A certified registered nurse anesthetist is not |
| required to possess prescriptive authority or a written collaborative agreement meeting the requirements of Section 65‑35 of the Nurse Practice Act to provide anesthesia services ordered by a licensed physician, dentist, or podiatrist. Licensed certified registered nurse anesthetists are authorized to select, order, and administer drugs and apply the appropriate medical devices in the provision of anesthesia services under the anesthesia plan agreed with by the anesthesiologist or, in the absence of an available anesthesiologist with clinical privileges, agreed with by the operating physician, operating dentist, or operating podiatrist in accordance with the hospital's alternative policy. | |
(Source: P.A. 94‑915, eff. 1‑1‑07; 95‑639, eff. 10‑5‑07; 95‑911, eff. 8‑26‑08.) |
(210 ILCS 85/10.8)
Sec. 10.8. Requirements for employment of physicians.
(a) Physician employment by hospitals and hospital affiliates. Employing entities may employ physicians to practice medicine in all of its branches provided that the following requirements are met:
(1) The employed physician is a member of the |
| medical staff of either the hospital or hospital affiliate. If a hospital affiliate decides to have a medical staff, its medical staff shall be organized in accordance with written bylaws where the affiliate medical staff is responsible for making recommendations to the governing body of the affiliate regarding all quality assurance activities and safeguarding professional autonomy. The affiliate medical staff bylaws may not be unilaterally changed by the governing body of the affiliate. Nothing in this Section requires hospital affiliates to have a medical staff. | |
(2) Independent physicians, who are not employed by |
| an employing entity, periodically review the quality of the medical services provided by the employed physician to continuously improve patient care. | |
(3) The employing entity and the employed physician |
| sign a statement acknowledging that the employer shall not unreasonably exercise control, direct, or interfere with the employed physician's exercise and execution of his or her professional judgment in a manner that adversely affects the employed physician's ability to provide quality care to patients. This signed statement shall take the form of a provision in the physician's employment contract or a separate signed document from the employing entity to the employed physician. This statement shall state: "As the employer of a physician, (employer's name) shall not unreasonably exercise control, direct, or interfere with the employed physician's exercise and execution of his or her professional judgment in a manner that adversely affects the employed physician's ability to provide quality care to patients." | |
(4) The employing entity shall establish a mutually |
| agreed upon independent review process with criteria under which an employed physician may seek review of the alleged violation of this Section by physicians who are not employed by the employing entity. The affiliate may arrange with the hospital medical staff to conduct these reviews. The independent physicians shall make findings and recommendations to the employing entity and the employed physician within 30 days of the conclusion of the gathering of the relevant information. | |
(b) Definitions. For the purpose of this Section:
"Employing entity" means a hospital licensed under the Hospital Licensing Act or a hospital affiliate.
"Employed physician" means a physician who receives an IRS W‑2 form, or any successor federal income tax form, from an employing entity.
"Hospital" means a hospital licensed under the Hospital Licensing Act, except county hospitals as defined in subsection (c) of Section 15‑1 of the Public Aid Code.
"Hospital affiliate" means a corporation, partnership, joint venture, limited liability company, or similar organization, other than a hospital, that is devoted primarily to the provision, management, or support of health care services and that directly or indirectly controls, is controlled by, or is under common control of the hospital. "Control" means having at least an equal or a majority ownership or membership interest. A hospital affiliate shall be 100% owned or controlled by any combination of hospitals, their parent corporations, or physicians licensed to practice medicine in all its branches in Illinois. "Hospital affiliate" does not include a health maintenance organization regulated under the Health Maintenance Organization Act.
"Physician" means an individual licensed to practice medicine in all its branches in Illinois.
"Professional judgment" means the exercise of a physician's independent clinical judgment in providing medically appropriate diagnoses, care, and treatment to a particular patient at a particular time. Situations in which an employing entity does not interfere with an employed physician's professional judgment include, without limitation, the following:
(1) practice restrictions based upon peer review of |
| the physician's clinical practice to assess quality of care and utilization of resources in accordance with applicable bylaws; | |
(2) supervision of physicians by appropriately |
| licensed medical directors, medical school faculty, department chairpersons or directors, or supervising physicians; | |
(3) written statements of ethical or religious |
|
(4) reasonable referral restrictions that do not, |
| in the reasonable professional judgment of the physician, adversely affect the health or welfare of the patient. | |
(c) Private enforcement. An employed physician aggrieved by a violation of this Act may seek to obtain an injunction or reinstatement of employment with the employing entity as the court may deem appropriate. Nothing in this Section limits or abrogates any common law cause of action. Nothing in this Section shall be deemed to alter the law of negligence.
(d) Department enforcement. The Department may enforce the provisions of this Section, but nothing in this Section shall require or permit the Department to license, certify, or otherwise investigate the activities of a hospital affiliate not otherwise required to be licensed by the Department.
(e) Retaliation prohibited. No employing entity shall retaliate against any employed physician for requesting a hearing or review under this Section. No action may be taken that affects the ability of a physician to practice during this review, except in circumstances where the medical staff bylaws authorize summary suspension.
(f) Physician collaboration. No employing entity shall adopt or enforce, either formally or informally, any policy, rule, regulation, or practice inconsistent with the provision of adequate collaboration, including medical direction of licensed advanced practice nurses or supervision of licensed physician assistants and delegation to other personnel under Section 54.5 of the Medical Practice Act of 1987.
(g) Physician disciplinary actions. Nothing in this Section shall be construed to limit or prohibit the governing body of an employing entity or its medical staff, if any, from taking disciplinary actions against a physician as permitted by law.
(h) Physician review. Nothing in this Section shall be construed to prohibit a hospital or hospital affiliate from making a determination not to pay for a particular health care service or to prohibit a medical group, independent practice association, hospital medical staff, or hospital governing body from enforcing reasonable peer review or utilization review protocols or determining whether the employed physician complied with those protocols.
(i) Review. Nothing in this Section may be used or construed to establish that any activity of a hospital or hospital affiliate is subject to review under the Illinois Health Facilities Planning Act.
(j) Rules. The Department shall adopt any rules necessary to implement this Section.
(Source: P.A. 92‑455, eff. 9‑30‑01.) |
(210 ILCS 85/10.10)
Sec. 10.10.
Nurse Staffing by Patient Acuity.
(a) Findings. The Legislature finds and declares all of the following:
(1) The State of Illinois has a substantial interest
| in promoting quality care and improving the delivery of health care services. | |
(2) Evidence‑based studies have shown that the basic |
| principles of staffing in the acute care setting should be based on the complexity of patients' care needs aligned with available nursing skills to promote quality patient care consistent with professional nursing standards. | |
(3) Compliance with this Section promotes an |
| organizational climate that values registered nurses' input in meeting the health care needs of hospital patients. | |
(b) Definitions. As used in this Section:
"Acuity model" means an assessment tool selected and implemented by a hospital, as recommended by a nursing care committee, that assesses the complexity of patient care needs requiring professional nursing care and skills and aligns patient care needs and nursing skills consistent with professional nursing standards.
"Department" means the Department of Public Health.
"Direct patient care" means care provided by a registered professional nurse with direct responsibility to oversee or carry out medical regimens or nursing care for one or more patients.
"Nursing care committee" means an existing or newly created hospital‑wide committee or committees of nurses whose functions, in part or in whole, contribute to the development, recommendation, and review of the hospital's nurse staffing plan established pursuant to subsection (d).
"Registered professional nurse" means a person licensed as a Registered Nurse under the Nurse Practice Act.
"Written staffing plan for nursing care services" means a written plan for guiding the assignment of patient care nursing staff based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units and the adopted acuity model aligning patient care needs with nursing skills required for quality patient care consistent with professional nursing standards.
(c) Written staffing plan.
(1) Every hospital shall implement a written |
| hospital‑wide staffing plan, recommended by a nursing care committee or committees, that provides for minimum direct care professional registered nurse‑to‑patient staffing needs for each inpatient care unit. The written hospital‑wide staffing plan shall include, but need not be limited to, the following considerations: | |
(A) The complexity of complete care, assessment |
| on patient admission, volume of patient admissions, discharges and transfers, evaluation of the progress of a patient's problems, ongoing physical assessments, planning for a patient's discharge, assessment after a change in patient condition, and assessment of the need for patient referrals. | |
(B) The complexity of clinical professional |
| nursing judgment needed to design and implement a patient's nursing care plan, the need for specialized equipment and technology, the skill mix of other personnel providing or supporting direct patient care, and involvement in quality improvement activities, professional preparation, and experience. | |
(C) Patient acuity and the number of patients for |
| whom care is being provided. | |
(D) The ongoing assessments of a unit's patient |
| acuity levels and nursing staff needed shall be routinely made by the unit nurse manager or his or her designee. | |
(E) The identification of additional registered |
| nurses available for direct patient care when patients' unexpected needs exceed the planned workload for direct care staff. | |
(2) In order to provide staffing flexibility to meet |
| patient needs, every hospital shall identify an acuity model for adjusting the staffing plan for each inpatient care unit. | |
(3) The written staffing plan shall be posted in a |
| conspicuous and accessible location for both patients and direct care staff, as required under the Hospital Report Card Act. | |
(d) Nursing care committee.
(1) Every hospital shall have a nursing care |
| committee. A hospital shall appoint members of a committee whereby at least 50% of the members are registered professional nurses providing direct patient care. | |
(2) A nursing care committee's recommendations must |
| be given significant regard and weight in the hospital's adoption and implementation of a written staffing plan. | |
(3) A nursing care committee or committees shall |
| recommend a written staffing plan for the hospital based on the principles from the staffing components set forth in subsection (c). In particular, a committee or committees shall provide input and feedback on the following: | |
(A) Selection, implementation, and evaluation of |
| minimum staffing levels for inpatient care units. | |
(B) Selection, implementation, and evaluation of |
| an acuity model to provide staffing flexibility that aligns changing patient acuity with nursing skills required. | |
(C) Selection, implementation, and evaluation of |
| a written staffing plan incorporating the items described in subdivisions (c)(1) and (c)(2) of this Section. | |
(D) Review the following: nurse‑to‑patient |
| staffing guidelines for all inpatient areas; and current acuity tools and measures in use. | |
(4) A nursing care committee must address the items |
| described in subparagraphs (A) through (D) of paragraph (3) semi‑annually. | |
(e) Nothing is this Section 10.10 shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by the hospital.
(Source: P.A. 95‑401, eff. 1‑1‑08; 96‑328, eff. 8‑11‑09.) |