Definition of Hospital Substantial Compliance

Healthcare organizations strive to provide safe and professional care. Hospitals receive regular visits from regulating agencies to determine compliance with state and federal rules. "Substantial compliance" refers to meeting the standards set forth by the regulating entities.

Regulating Entities

• Each state contains a regulating organization that oversees all healthcare provisions, commissioned by the Centers for Medicare and Medicaid Services. The Joint Commission program inspects healthcare entities such as hospitals against set regulations of safety and security.

Review Process

• The review process varies among entities, but provides similar investigation of the hospital's qualities. The review inspects such factors as environment, organization, staffing, patient rights, fiscal services, nursing services, medical services, dietary services, and confidentiality. The hospital receives a report of findings after a review takes place.

Results

• A report of findings highlights practices that appear satisfactory as well as deficient practices. Facilities submit a plan of corrections to regulating entities once the report is digested. If a hospital meets all requirements and regulations upon a review, the facility is considered within substantial compliance.