Ill. Admin. Code tit. 77 § 250.210

Current through Register Vol. 48, No. 45, November 8, 2024

Section 250.210 - The Governing Board

a) Each hospital shall have a governing authority, called the board, responsible for the organization, management, control and operation of the hospital, including the appointment of the medical staff. For two or more hospitals within a health care system, the system board may serve as the single governing authority of each hospital (which shall be referred to as the "system board"). When this option is exercised, the system board shall be responsible for compliance with the medical staff requirements in the Act and its regulations.

b) The board shall be organized in accordance with a written constitution and bylaws that clearly set forth organization, duties, responsibilities and relationships. The Department may require a copy for its files.

c) The board shall meet regularly. Monthly meetings are recommended. Written reports of all meetings shall be maintained.

d) The board shall employ a competent executive officer or administrator and vest him or her with authority and responsibility to carry out its policies. A qualified individual shall be responsible to the administrator in matters of administration and shall represent him or her during the administrator's absence.

e) The board shall ensure the availability of competent, well qualified personnel for all hospital departments in order to efficiently carry out the functions of the hospital and meet patient care needs. The board shall also provide a mechanism for assisting employees in addressing physical and mental health problems.

f) The board shall be responsible for the maintenance of standards of professional work in the hospital and shall require that the medical staff function competently. Clinical audits shall be performed by the medical staff and reviewed by a committee of the governing authority and the medical staff. The board shall consult directly with the individual who is responsible for the organization and conduct of the hospital's medical staff. The direct consultation shall occur at least twice per year and shall include discussion of matters related to the quality of medical care provided to the patients of the hospital. For a hospital system using a system board, the system board shall consult directly with the individual responsible for the organized medical staff (or his or her designee) of each hospital within the system. Direct consultation occurs when the governing body, or a subcommittee of the governing body, meets with the leaders of the medical staffs, or their designee, either face-to-face or via a telecommunications system that permits immediate, synchronous communication.

g) The board shall establish a policy providing for the investigation of unusual incidents that may occur. (Refer to Section 250.990.)

h) Two or more separately licensed hospitals that are part of a hospital system with a system board may elect to use the option of a unified medical staff, conditioned upon acceptance by a majority vote of the medical staff members of the participating hospitals. Members who hold privileges to practice at the hospital shall vote in accordance with the medical staff bylaws. Nothing in this Section shall be construed to require a unified medical staff for any hospital.

1) The system board shall be responsible for the decisions of the unified medical staff and may direct the unified medical staff to consider any matter or reconsider any decision. The system board shall take final action on all medical staff matters, on behalf of the hospitals within the system that share a unified medical staff, including, but not limited to:

A) The appointment, reappointment and delineation of clinical privileges of the medical staff;

B) The denial or revocation of a medical staff appointment and the denial, revocation, suspension, restriction or reduction of clinical privileges;

C) The approval of bylaws and policies; and

D) The maintenance of standards for professional work in the hospital and the review of clinical audits, pursuant to subsection (f).

2) The unified medical staff shall be considered a committee of a licensed hospital for purposes of Section 8-2101 of the Code of Civil Procedure.

3) All of the activities of the system board shall be in compliance with the medical staff provisions of the Act and this Part.

4) If two or more hospitals within a hospital system designate a system board, each hospital in the hospital system shall still individually comply with the Act and this Part.

Ill. Admin. Code tit. 77, § 250.210

Amended at 15 Ill. Reg. 5328, effective May 1, 1991

Amended at 41 Ill. Reg. 7154, effective 6/12/2017