Quality and Clinical Reports


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

2

0

0

0

VRE




0

0

0

1

3

5

2

Clostridium difficile




0

2

2

0

3

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.

 

2025-2026 Quality Improvement Plan

MeasureTargetStartingQ1Q2Q3Q4
Access & Flow
90th %tile Ambulance Offload Time30min23min    
90th %tile ED wait time to physician initial assessment (PIA)3.603.70    
% of patients who left the ED without seeing a providercollect baselineN/A    
Equity
% of all staff who have completed relevant EID-AR education80%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 inpatientscollect baselineN/A