Hospital Licensing Amendments

July 12, 2017


Adopted Amendments Allow Single Governing Body for Multiple Hospitals, Consolidated Medical Staffs

The Illinois Department of Public Health (IDPH) has adopted amendments to the Hospital Licensing requirements (see pp. 7154-7226 of the June 23, 2017 Illinois Register) that allow for the creation of a single governing authority for two or more hospitals within a health system and allow for two or more separately licensed hospitals within a health system to consolidate their medical staffs into a unified medical staff.

These changes help align state hospital regulations with changes made to the Centers for Medicare and Medicaid Services’ Conditions of Participation (CoP) on May 12, 2014.

IDPH has also adopted several technical changes under the Hospital Licensure Requirements of the Illinois Administrative Code (77 Ill. Adm. Code 250).

Key components of the adopted amendments include:

  • Allowing for two or more hospitals within a health system to be governed by a single board known as the “system board.” In cases where this option is exercised, the system board will be responsible for compliance with the medical staff requirements of the Hospital Licensing Act and its corresponding rules.
  • Requiring a hospital board to meet at least twice a year with the chief medical officer or other entity in charge of the medical staff at each hospital to discuss matters related to
    the quality of medical care provided to the patients of the hospital.
  • Allowing for hospitals with a single governing board to combine medical staffs into a unified medical staff. This would require a majority vote of the members of the medical staff at the impacted hospitals. The system board would be responsible for all decisions made by the unified medical staff.
  • Medical staffs that vote to become a single, unified staff must meet certain requirements including:
    • Adopting written bylaws and rules for issues such as appointment, credentialing, privileging, peer review processes and due process rights;
    • Taking into account the unique circumstances of each hospital and the patient populations they serve; and
    • Meeting at least twice per fiscal or calendar year to address issues and problems brought up by members of the medical staff and develop procedures on how those issues will be addressed.

Through our advocacy efforts, IHA played an important role in shaping these rules to better align Illinois’s regulations with CoP, allowing for greater flexibility in the continually changing environment for hospitals and health systems. Read IHA's comment letter with recommendations on how to amend the requirements.