Quality and Clinical Reports 

Accreditation

We proudly report that Alexandra Marine and General Hospital has received full accreditation status from Accreditation Canada for 2017-2021. In May 2022, accreditation surveyors toured our organization and followed patients through their "journey of care", reviewing documentation, process, safety and quality. Alexandra Marine and General Hospital’s participation in accreditation demonstrates an ongoing commitment to quality and accountability to our staff, physicians, volunteers, patients and community. In addition to evaluating the quality of care and service provided, the accreditation process allows the opportunity to celebrate its successes, and plan a roadmap for improvements into the future.

AMGH voluntarily participates in the Accreditation Canada program to ensure the care/service received meets these standards.

Infection Rates

Hospitals are required by the Ministry of Health and Long-Term Care to publicly report some key rates. Alexandra Marine and General Hospital has posted these rates and will continue to update on a monthly basis.  

Infection Control Fact Sheets

• Infection Control Fact sheet Clostridium difficile
• Infection Control Fact sheet Vancomycin Resistant Enterococci (VRE)
• Infection Control Fact sheet Methicillin Resistant Staphylococcus aureus (MRSA)
• Infection Control Fact sheet Hand Hygiene

Quality Improvement Plan

Quality Improvement is a systematic approach to making changes that lead to better patient outcomes (health), stronger system performance (care) and enhanced professional development. Quality Improvement draws on the combined and continuous efforts of all stakeholders - health care professionals, patients and their families, researchers, planners and educators - to make better and sustained improvements.

The Excellent Care for All Act (ECFAA), which came into law in June 2010, seeks to strengthen the health care sector’s organizational focus and accountability to deliver high quality patient care. Quality Improvement Plans (QIPs) are a key enabler to support this goal.

 
The QIP is an organization-owned plan that establishes a platform for quality improvement. The QIP is aligned with strategic priorities, Accreditation Canada requirements and service accountability agreements. The QIP is our guide to achieving quality care by putting focus on our quality improvement priorities and provides an opportunity to highlight our commitment to delivering high quality care, creating a positive patient experience and ensuring we are responsible and accountable to the public.

2024-2025 Quality Improvement Plan

Overview 

Quality is the cornerstone of our organization. Our vision is “a quality-driven health care system focused on the changing needs of our communities.” With this vision in mind, we have set our strategic priorities to include:

• Partnering with patients and families
• We will partner with patients and families in the provision of quality person-centred care
• Empowering our people
• We are passionate about our people and work hard to support an empowered and engaged team
• Ensuring operational excellence
• We will optimize our processes and align operational efforts to make the best use of our resources
• Innovating through partnership
• We will work with our partners to find innovative approaches that meet the needs of the communities we serve

Each of these strategic priorities have a quality focus embedded within them, including our strategic imperatives to invest in our technology and infrastructure, embed a continuous improvement approach, and establish a high trust culture.

Our Quality Improvement Plan (QIP) aligns with our vision and strategic plan, as it focuses on:

1. Better understanding how our Emergency Department (ED) Length of Stay (LOS) aligns with staffing levels and patient volumes over days of the week so we can ensure operational excellence.
2. Ensuring staff training on diversity, equity and inclusion is monitored and encouraged.
3. Educating our ED nursing staff on Sickle Cell disease presentation and management to empower our staff to be ready for  changing demographics.
4. Optimizing the feedback from our patients through updated questionnaires aligned with provincial reporting and pulling in key questions of the organization.
5. Educating our nursing staff on the impact of delirium on patient outcomes, falls risk and the importance of routine screening. This will help us identify those showing signs of delirium as early as possible and treat it effectively. Thus empowering our people to deliver excellent care.

Patient / Client / Resident Experience

We strive to include representatives from our community and patients in our quality and decision-making processes. During development of our Strategic Plan, community sessions were held in communities throughout Huron County to ensure that the voices and needs of community members, patients, and families were considered and included in the direction of our organizations. Stakeholder engagement was a critical component of our strategic plan development, including additional surveys, feedback avenues, and information sessions for community members, patients, staff and physicians.

The Huron Health System Board of Directors includes patient and public representatives.

The Quality Assurance Committee is a subcommittee of the Board who approve and monitor the quality initiatives within our Quality Improvement Plan.

A separate subcommittee is the “Patient Advisory  Committee” that provide insight into the needs and experiences of patients and families,  and includes patients and community members to provide  further voice and engagement of our clients.

In addition, we have a Patient Experience Panel (PEP) who meets regularly each year and provide valuable feedback on the quality initiatives brought to them. Patient stories are routinely captured and reviewed at Quality Assurance Committee and Board of Director meetings, and provide key information and direction to our team developing our quality initiatives. Experiences from patients, patient feedback, and our patient and family involvement and engagement in our Board and Committees of the Board guide our organizational response, and the development of our QIP. We strive to ensure feedback from our patients and community is sought through multiple means including our Quality Board, Patient Experience Panel, and our Patient Satisfaction Surveys, and add additional avenues for feedback and engagement regularly.

Executive Compensation

The Excellent Care for All Act (ECFAA) requires that the compensation of the CEO and executives reporting to the CEO be tied to the achievement of  the QIP. This drives leadership alignment, accountability and transparency in the delivery and pursuit of improved quality through the QIP. ECFAA  mandates that hospital QIPs must include information detailing executive compensation related to the achievement of QIP targets. The Board approved a Pay-for-Performance structure for meeting the targets set out in the QIP. Each executive role may achieve up to 5% of their base salary as Pay-for-Performance based on the organization’s ability to meet or exceed the targets as outlined in the QIP. 

Each quality initiative put forward in the QIP is weighted equally. Pay-for-Performance for executives will be awarded as follows, barring any extenuating circumstances for which the Quality Assurance Committee will have discretion:

• The five indicators below carry an equal weight of 20%
• For the five compensation-based indicators, there are three levels of achievement:
• Less than 50% of target achieved: no Pay-for-Performance awarded for that particular indicator
• Midpoint between 50% of target and target: prorated Pay-for-Performance will be awarded for that particular indicator equal to the percent towards target achieved
• Equal to or greater than 100% of target achieved: 100% of Pay-for-Performance awarded for that particular indicator

• Indicator 1: Safety / Effectiveness
• The requirement of delirium assessment on all inpatients over 65yrs of age is new and this year's data will establish a baseline by tracking % of inpatients over 65yrs who have delirium assessments recorded in the Health Information System (HIS)
• Education of inpatient nursing staff on delirium in hospitalized patients and the impact on patient outcomes, falls risk and importance of routine screening of all patients >65yrs for delirium
• Target: 90% of assigned Confusion Assessment Method (CAM) assessments completed during Q3 F2425

• Indicator 2: Equity:
• Equity and inclusiveness are two key values in the HHS strategic plan. To ensure continued focus on improving healthcare equity, access to services, and inclusiveness, we have embedded and will continue to improve cultural safety training within our organizational practices.
• Target: 85% of staff have completed equity and diversity training by end of Q3

• Indicator 3: Equity:
• This indicator focuses on the education of staff on sickle cell disease, which will prepare them to deliver quality patient-centred care with the anticipated increase in prevalence of sickle cell in our community 
• Target: 85% of Emergency Department Nursing Staff by end of Q3 F2425

• Indicator 4: Experience / Patient-Centred:
• This indicator focuses on redevelopment of Patient Experience Surveys in Acute Inpatient and Emergency Departments areas to achieve a 50% increase of survey completion in order to improve patient care through patient feedback
• Target: 50% more surveys completed in the ED and Inpatient areas in Q3 F2425

• Indicator 5: Access and Flow / Timely:
• This indicator focuses on determining increased Emergency Department Length of Stay (LOS) and volumes vs staffing levels in order to utilize this data in the most effective program planning 
• Target: To maintain ED LOS less than 90th percentile of the provincial average