Quality and Clinical Reports

Quality and Clinical Reports

Accreditation

We proudly report that Alexandra Marine and General Hospital has received full accreditation status from Accreditation Canada for 2012-2017. In October 2013, 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 in to the future.

 

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

Please click below to view the most recent AMGH Accreditation reports.

 

 

Infection Rates

As of September 2008, 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 quarterly basis.

Q1- April-June            Q2- July-Sept            Q3-Oct-Dec             Q4-Jan-Mar

 

Bacteremia – MRSA

 

Target

0/1000 pt days

2013/14

2014/15

2015/16

2016/17

Q1

0

Q2

0

Q3

0

Q4

0

Q1

0

Q2

0

Q3

 0

Q4

0

Q1

0

Q2

0

Q3

0

Q4

 0

Q1

  0 

Q2

0

Q3

0

Q4




















Bacteremia – VRE

 

Target

0/1000 pt

days

2013/14

2014/15

2015/16

2016/17

Q1

 0

Q2

 0

Q3

 0

Q4

 0

Q1

 0

Q2

 0

Q3

 0

Q4

 0

Q1

 0

Q2

 0

Q3

 0

Q4

 0

Q1

 0

Q2

 0

Q3

 0

Q4




















Costridium.difficile

 

Target

0/1000 pt

days

2013/14

2014/15

2015/16

2016/17

Q1

 2

Q2

 0

Q3

 0

Q4

 0

Q1

 0

Q2

 0

Q3

 0

Q4

 0

Q1

 0

Q2

 0

Q3

0.3

Q4

 0

Q1

 0

Q2

 0

Q3

 0

Q4

 



















Hand Hygiene

Hand Hygiene Prior to Patient Contact

Target

2013/14

2015/16

2015/16

2016/17

100%

Q1

94%

Q2

94%

Q3

95%

Q4

91%

Q1

94%

Q2

96%

Q3

83%

Q4

96%

Q1

96%

Q2

96%

Q3

94%

Q4

97%

Q1

95%

Q2

90%

Q3

97%

Q4

 



















Hand Hygiene

Hand Hygiene After  Patient Contact

Target

2013/14

2014/15

2015/16

2016/17

100%

Q1

97%

Q2

96%

Q3

98%

Q4

95%

Q1

95%

Q2

97%

Q3

99%

Q4

99%

Q1

100%

Q2

100%

Q3

98%

Q4

98%

Q1

98%

Q2

97%

Q3

95%

Q4




















Infection Control Fact Sheets


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.

 

Our 2017/18 QIP will focus on Patient safety and Improving the Patient Experience. With the plan, we are able to clearly see our targeted areas for improvement and chart our progress.

 

Please click below to view the components of our 2017/18 Quality Improvement Plan.

 

 

Information regarding our progress/performance can be seen on our Quality Scorecard.