Current through Register Vol. 48, No. 12, March 22, 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)
b) A qualified physician shall be
designated as the medical director.
1) The
medical director shall secure compliance with the policies and procedures
pertaining to medical and surgical procedures, approved by the qualified
consulting committee.
2) The
medical director shall implement medical policies and procedures contained in
the facility's policies and procedures manual (Section
205.240)
governing the professional personnel involved directly in the care of patients
undergoing surgical procedures, including their preoperative and postoperative
care and follow-up.
3) The medical
director shall establish and secure compliance with standards for patient
observation by nursing personnel during the postoperative period.