77 Ill. Adm. Code 2500.250.1210
Surgery
Section 250
TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1210 SURGERY
Section 250.1210 Surgery
a) Where a hospital provides surgical services, the service shall
be provided in a manner sufficient to meet surgical needs of the patients. The
surgical department/service shall have a defined organization and shall be
integrated with other departments and services of the hospital and shall be
governed by written policies and procedures.
b) The Director of Surgical Services or their designee shall
design and implement an education program to orient new physicians, residents,
physician assistants, advanced practice providers, and other employees and
shall collaborate with the nursing administrator or their designee to establish
orientation and continuing education programs for the nursing staff. The
programs shall be planned, scheduled, documented by a written outline of its
contents, and evaluated at least annually.
c) The education program may be conducted using resources
internal or external to the hospital. Teaching material and suitable reference
shall be supplied as needed for each patient care unit.
d) A member of the hospital's medical staff shall direct the
surgical services and shall be qualified by training and experience, preferably
Board Certified by the American Board of Surgery and approved by the hospital's
medical staff and board.