Physician in a white coat with stethoscope in hand. Patients in the background out of focus.

Accountability

As a publicly funded organization, it is important that the South Huron Hospital (SHH) remain accountable to the communities we serve and provide timely, relevant information to the general public on our performance and other public reporting indicators.

In this section you can review our performance as we remain dedicated to quality care and uncompromising standards.

 

View Archive

Accessibility

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

Accreditation

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.


View SHH’s latest Accreditation Report

 

Broader Public Sector Accountability Act (BPSAA)

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

 

More information on the Broader Public Service Accountability Act is available on the Ministry of Health and Long-Term Care website.


Energy Conservation & Management Plan

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.


View our Energy Conservation & Management Plan

 

View our latest Energy Consumption & Greenhouse Gas Emissions Report

Expense Reports

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 

Financial Statements

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


Hospital Service Accountability Agreements

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.


View SHH’s latest HSAA

View SHH's Latest Amending Agreement

Patient Safety Indicators

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.

 

Patient Safety Plan

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

Public Sector Salary Disclosure

Quality Improvement

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 

 

 

Infection Rates - Target: 0/1000 patient days

Infection

Apr

2023

May

2023

Jun

2023

Jul

2023

Aug

2023

Sep

2023

Oct

2023

Nov

2023

Dec

2023

 Jan

2024

Feb

2024

Mar

2024

 MRSA 00
0
0
0
0
00
00
0
0
 VRE 000000
00
0
00
0
 Clostrium difficile

2.062
0
0
0
 00
0
2.18
0
0
 0

 

Hand Hygiene Rate Prior to Patient Contact - Target 100%

 

 Year Range
Q1
Q2
Q3
Q4
 2022/2023 92%90%
91%
86%
 2023/2024 90% 93%96%
 92%

 

Hand Hygiene Rate After Patient Contact - Target: 100%

 

 Year Range
Q1
Q2
Q3
Q4
 2022/2023 92%96%
92%
90%
 2023/2024 90% 92%94%
93%

 

 

 

2025 QIP Dashboard
MeasureTargetStartingQ1Q2Q3Q4
Access & Flow90th %tile Ambulance Offload Time38min60min    
90th %tile ED wait time to Physician Initial Assessment (PIA)2.6hr2.7hr    
% of patients who left the ED without seeing a provider collect baselineN/A    
Equity% of all staff who have completed the EID-AR education80%0%    
Experience% of patients/families discharged from the ED who completed a Patient Experience Survey5%0.60    
% of patients/families discharged from Med/Surg/Rehab who completed a Patient Experience Survey8%6.8    
SafetyMedication Reconciliation at discharge: % of inpatients95%92%