Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 250 - HOSPITAL LICENSING REQUIREMENTS › Subpart B - ADMINISTRATION AND PLANNING › Section 250.210 - The Governing Board

Current through Register Vol. 48, No. 28, July 12, 2024
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).