Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart B - OWNERSHIP AND MANAGEMENT › Section 205.230 - Standards of Professional Work

Current through Register Vol. 48, No. 28, July 12, 2024
The owner or manager of the ambulatory surgical treatment
				  center shall maintain proper standards of professional work in the
				  facility.
a) A qualified consulting
				committee shall be appointed in writing by the management or owner of the
				ambulatory surgical treatment center and shall establish and enforce standards
				for professional work in the facility and standards of competency for
				physicians. The qualified consulting committee shall meet not less than
				quarterly and shall document all meetings with written minutes. The minutes
				shall be maintained at the facility and shall be available for Department
				inspection.
1) The membership of the
				qualified consulting committee shall reflect the types of procedures performed.
				If the facility performs more than 50 procedures per month, or more than 10% of
				the total procedures performed are in a specific specialty area, then a
				consulting physician of that specialty shall be on the qualified consulting
				committee.
2) The qualified
				consulting committee shall review the development and content of the facility's
				written policies and procedures, including the details of the quality
				assessment and performance improvement program, the infection control program,
				the patient rights plan, the disaster preparedness plan, the procedures for
				granting privileges, and the quality of the surgical procedures performed. The
				reviews shall be documented in the minutes.
3) The qualified consulting committee shall
				establish the scope of procedures to be performed at the facility and shall
				periodically review and amend the scope of procedures as appropriate.
4) Physicians seeking practice privileges at
				the facility shall provide their credentials. The credentials committee shall
				periodically reappraise and review physician credentials and shall identify and
				record specific practice privileges pursuant to the Health Care Professional
				Credentials Data Collection Code. A record of accepted practice privileges
				shall be available for facility staff use and for public information within the
				facility.
5) Each member of the
				medical staff granted specific surgical practice privileges shall provide, at
				every re-credentialing period, a notarized statement or documentation
				indicating the name of the Illinois licensed hospital or hospitals where he or
				she has skilled-equivalent practice privileges. The statements or documentation
				shall be available for Department inspection. A list of privileges granted to
				each medical staff member of the ambulatory surgical treatment center shall be
				available at all times for facility staff use and for Department inspection. As
				used in this subsection (a)(5), "skilled-equivalent" means the ability to
				perform similar procedures requiring the same level of training and
				expertise.
6) The qualified
				consulting committee shall act as a tissue committee and shall review, at least
				quarterly, pathological reports from procedures performed by each physician on
				the staff, when applicable. The review shall be documented in the
				minutes.
7)
A dentist may
				be privileged at an ambulatory surgical treatment center if it is determined
				that the patient under the care of the dentist requires sedation beyond the
				training that the dentist possesses. The determination of need for sedation
				shall be made by the medical director of the facility where the procedure is to
				be performed. A dentist performing a surgical procedure requiring sedation at a
				facility must either
:
A)
Have
				admitting privileges at a nearby hospital where patients would receive care in
				the event of an emergency arising during a dental surgical procedure;
				or
B)
Have a
				memorandum of understanding with a physician who has admitting privileges at
				such a hospital.
(Section 6(3)(b) of the Act)