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.

(Source:  Amended at 49 Ill. Reg. 14395, effective October 27, 2025)