Accountability

SHH is committed to being fully accessible. We want our building, as well as our services to be easy to use and understand. We will do our best to support you, whether you come to our hospital, or visit our website.

It is important that you can fully access our services without barriers. Please talk to someone on our healthcare team about your accessibility needs. Your experience matters to us.

  View SHH’S latest Accessibility Compliance Report

Contact Information

Madison Blacklock
Human Resources Associate
519-235-2700 ext. 5172
madison.blacklock@shha.on.ca

South Huron Hospital is accredited through Accreditation Canada. Its most recent four-year accreditation cycle in October 2017 awarded SHH the status of “Accredited”.

The final report indicates: “SHHA has met the requirements of the Qmentum accreditation program and has shown a commitment to quality improvement…South Huron Hospital Association is participating in the Accreditation Canada Qmentum accreditation program. Qmentum helps organizations strengthen their quality improvement efforts by identifying what they are doing well and where improvements are needed. Organizations that become accredited with Accreditation Canada do so as a mark of pride and as a way to create a strong and sustainable culture of quality and safety. Accreditation Canada commends South Huron Hospital Association for its ongoing work to integrate accreditation into its operations to improve the quality and safety of its programs and services.”

SHH’s Pharmacy is accredited through the Ontario College of Pharmacists and undergoes on-site reviews and assessments every two years. SHH renews its accreditation status annually and is undergoing an assessment in 2021.

SHH’s Laboratory is accredited through Accreditation Canada Diagnostics every four years as part of the 12-member InterHospital Laboratory Partnership (ILHP). In 2021, SHH completed a mid-cycle review and each year it completes a laboratory quality improvement plan (QIP) to ensure continued high quality services.

In 2010, the Government of Ontario passed the Broader Public Sector Accountability Act (BPSAA). This Act requires hospital Presidents & CEOs to sign a document annually verifying that they will comply with the rules outlined in the BPSAA. These rules relate to the use of consultants, the prohibition against using public funds to pay for lobbyists, and the directives on expense claims and procurement. This document is referred to as an attestation.

 View SHH's Latest BPSAA Attestation
 

VIEW SHH'S LATEST REPORT ON CONSULTANT USE

Ontario Regulation 507/18 encourages energy conservation, renewable energy production, and promotes a green economy. This Regulation requires all public hospitals to report their energy consumption and greenhouse gas emissions on an annual basis.

The Broader Public Sector Accountability Act requires all public hospitals to semi-annually post expense claims made by designated individuals, including members of the Board of Directors, the hospital CEO, and senior leaders reporting to the CEO.

All expenses are in accordance with SHH’s Travel, Meal and Hospitality Expense Reimbursement Policy.

VIEW SHH'S LATEST EXPENSE REPORT 

The Broader Public Sector Business Documents Directive requires that all public hospitals make their audited financial documents available online.

VIEW SHH'S LATEST AUDITED FINANCIAL STATEMENTS

Each hospital in Ontario is required to negotiate a Hospital Service Accountability Agreement (HSAA) with Ontario Health West (OHW). Typically, the HSAA is a two-year contract that stipulates accountability and performance obligations for planning, integration, and delivery of programs and services.

Each hospital in Ontario is required to routinely report some key patient safety indicators. These rates can be found below, and will continue to be updated on a monthly or quarterly basis.

More information on these patient safety indicators can be found on the Health Quality Ontario website.

The SHH Patient Safety Plan is guided in large part by compliance with and adherence to Accreditation Canada's Required Organizational Practices by focusing on their six patient safety domains:

• Safety Culture
• Communication
• Medication Use
• Worklife/Workforce
• Infection Control
• Risk Assessment

 View SHH's Patient Safety Plan

receive public funding from the Province of Ontario are required to disclose the names, positions, salaries, and taxable benefits of employees who earn $100,000 or more within the calendar year.

• View SHHA's Public Sector Salary Disclosure - 2022
  
• View SHHA's Public Sector Salary Disclosure - 2021 
• View SHHA’s Public Sector Salary Disclosure – 2020
• View SHHA’s Public Sector Salary Disclosure – 2019
• View SHHA’s Public Sector Salary Disclosure – 2018
• View SHHA’s Public Sector Salary Disclosure – 2017
• View SHHA’s Public Sector Salary Disclosure – 2016
• View SHHA’s Public Sector Salary Disclosure – 2015

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