Amendments to Illinois Hospital Licensing Act Align Illinois Law with CoPs


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On June 23, 2017, the Illinois register will publish a number of significant amendments to the rules and regulations promulgated under the Illinois Hospital Licensing Act (the Act), at 77 Ill. Admin. Code § 250 et seq. These amendments are of importance to Illinois hospitals, as they bring Illinois law into closer alignment with the CMS Conditions of Participation for Hospitals (CoPs) and expand the ability of hospitals to adopt certain corporate and medical staff structures.

Closer Alignment with CoPs and Accreditation Requirements. The regulatory amendments bring Illinois law into clearer alignment with the CoPs and accrediting organization standards, and will (1) explicitly allow a health care system or “parent” board to serve as the single governing body for multiple hospitals in a health care system (referred to as the “system board”), and (2) require a hospital governing body (whether a system board or individual hospital board) to consult directly, at least twice per year, with the individual who is responsible for the organization and conduct of the hospital’s medical staff. The unified governing body and medical staff consultation requirements are already part of the CoPs and accreditation organization requirements, and the requirements for Illinois hospitals mirror the requirements set forth in the CoPs.

Unified Medical Staff Option. An important change to the rules and regulations will also permit Illinois health care systems to pursue a unified medical staff structure as provided by the CoPs. Illinois regulations have long provided that each licensed hospital must have its own, separate medical staff. The amendments to the regulations will allow two or more separately licensed and enrolled hospitals that are part of a hospital system with a system board to elect the option of an integrated and unified medical staff. This unified staff option may be enacted based upon an “opt-in” vote approved by a majority of the medical staff members of the participating hospitals. Upon adoption, the system board will have the authority and responsibilities previously held by the separate hospital boards with respect to medical staff matters, including privileging and approval of bylaws. Once formed, the unified medical staff is responsible for development of a uniform set of medical staff bylaws, which must include among its provisions a process for the members of the medical staff of each separately licensed hospital to later “opt-out” of the unified structure. The proposed timetable for unified medical staff meetings is twice per fiscal or calendar year. The medical staff members at each licensed hospital must be provided the opportunity to vote, no more than every two years, on whether to maintain or discontinue the unified medical staff structure (which opt-out right is not afforded to multi-campus hospitals). Importantly, Illinois will consider a properly structured, unified medical staff to be a “committee of a licensed hospital” for purposes of the Medical Studies Act, thereby affording the unified body certain protections.

Next Steps for Illinois Hospitals. Consider whether your hospital or health system might benefit from the potential efficiencies of restructuring its governing body or medical staff as permitted under state law and in alignment with the CoPs. Our McDermott Health Team is positioned to assist in exploring the possibilities and identifying the key action steps when considering these types of changes. Please contact Clare Ranalli, Sandra DiVarco or your regular McDermott Will & Emery lawyer contact for more information.