Quality and Clinical Reports
Accreditation
Huron Health System recently participated in a joint Accreditation with the Huron Perth & Area Ontario Health Team. We proudly report that we have been awarded Exemplary Standing this year from Accreditation Canada. 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 Rates - Target: 0/1000 patient days
Infection
|
Apr 2024
|
May 2024
|
Jun 2024
|
Jul 2024
|
Aug 2024
|
Sep 2024
|
Oct 2024
|
Nov 2024
|
Dec 2024
|
Jan 2025
|
Feb 2025
|
Mar 2025
|
MRSA
|
|
|
| 1 | 0 | 0 | 0 | 2 | 0 | 0 | 0 | 0 |
VRE
|
|
|
| 0 | 0 | 0 | 1 | 3 | 0 | 0 | 5 | 2 |
Clostridium difficile
|
|
|
| 0 | 2 | 2 | 0 | 3 | 2 | 2 | 1 | 1 |
Hand Hygiene Rate Prior to Patient Contact - Target: 100%
Year Range
|
Q1
|
Q2
|
Q3
|
Q4
|
2024/2025
|
|
78.5%
|
89%
|
86.7%
|
2023/2024
|
93%
|
95%
|
95%
|
95%
|
Hand Hygiene Rate After Patient Contact - Target: 100%
Year Range
|
Q1
|
Q2
|
Q3
|
Q4
|
2024/2025
|
|
81.5%
|
94%
|
87%
|
2023/2024
|
94% | 92% | 94% |
92%
|
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.
Measure | Target | Starting | Q1 | Q2 | Q3 | Q4 |
Access & Flow |
90th %tile Ambulance Offload Time | 30min | 23min | | | | |
90th %tile ED wait time to physician initial assessment (PIA) | 3.60 | 3.70 | | | | |
% of patients who left the ED without seeing a provider | collect baseline | N/A | | | | |
Equity |
% of all staff who have completed relevant EID-AR education | 80% | 0% | | | | |
Experience |
% patients/families discharged from ED who completed a Patient Experience Survey | 5% | 3.7 | | | | |
% of patients/families discharged from Med/Surg/Rehab inpatient unit who completed a Patient Experience Survey | 8% | 5 | | | | |
Safety |
Medication Reconciliation at discharge: % of inpatients | collect baseline | N/A | | | | |