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


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.


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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


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



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.



Financial Statements

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



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.


Hospital Acquired Infection Rates - Target: 0/1000 Patient Days
April 2022May 2022June 2022July 2022Aug 2022Sept 2022Oct 2022Nov 2022Dec 2022Jan 2023Feb 2023March 2023
Clostridium difficile1.9960001.953.6700    

Hand Hygiene Rate Prior to Patient Contact - Target 100%

Hand Hygiene Rate After Patient Contact - Target: 100%


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

The Excellent Care for All Act (ECFAA), requires all Ontario hospitals to create and make public an annual Quality Improvement Plan (QIP).

The QIP is an organization-owned document, developed with input from patients, hospital leadership, and HHS Quality Committee that establishes a plan for quality improvement over the coming year. It is designed to be a lever for change on system-wide quality issues identified by Health Quality Ontario, while also identifying South Huron Hospital specific areas for improvement.


The following is a summary of the six quality themes and indicators that HHS is focusing on in F23/24. 


1.       Theme 1: Timely and efficient transitions (internally developed quality focus area):

  •         To ensure and track focus on access to timely and efficient care, we developed a theme and indicator that will track our performance with regards to providers initial assessment times in the Emergency Room as compared to the CIHI wait-time guidance based on Canadian Triage and Acuity Scale (CTAS) levels of patients. This ensures that our performance can be measured based on actual acuity of patients, rather than an arbitrary average wait time in the ER (i.e. an average wait time doesn’t take into account the acuity of patients, any extenuating circumstances or disasters, etc.). The CIHI guidance and targets we will be tracking ourselves against are:
  • CTAS Level 1 patients see a provider in <5 minutes 100% of the time
  • CTAS Level 2 patients see a provider in <15 minutes 80% of the time
  • CTAS Level 3 patients see a provider in <30 minutes 75% of the time
  • CTAS Level 4 patients see a provider in <60 minutes 70% of the time
  • CTAS Level 5 patients see a provider in <120 minutes 70% of the time

2.    Theme 2: Service Excellence (theme required by HQO):

  •        This theme focuses on the patient experience, and whether patients feel that they received enough information upon discharge. To ensure that we are providing this information and reaffirming this discharge information, the indicator developed to further this work is:
  • The establishment and completion of a post-discharge phone call to all eligible discharged patients, and completion of a checklist of pertinent information to be re-communicated to patients
  • Target: post-discharge phone call and checklist completed and document >90% of the time.

3.       Theme 3: Safe and Effective Care (theme required by HQO):

  •        This theme focuses on the establishment of a best possible medication history (BPMH) through the completion of a best possible medication discharge plan for discharged patients. Our Hospital Information Systems (HIS) at both hospitals are capable of holding and tracking this information, which is a practice that we expect to be completed regularly for eligible patients
  • Target: completion of Discharge Medication Plan >90% of the time

4.       Theme 4: Workplace safety (theme required by HQO)

  •        This theme focuses on cultivating safety culture within our hospitals, which we will achieve through improving how we deliver and track workplace violence education for our leaders and staff, and creating an environment where staff feel comfortable reporting all incidents of workplace violence.
  • Target:
  • Completion of Public Health Safety training for >90% of leaders
  • Completion of initial workplace violence training (eLearning) within 90 days of hire for >95% of all new fulltime hires
  • Completion of initial workplace violence training (eLearning) within 90 days of hire for >90% of all new part-time hires

5.       Theme 5: Infection prevention and control (internally developed quality focus area)

  •         Ensuring clean and safe clinical environments is vital to patient care, and our focus will be on optimizing our infection prevention and control through focus on cDifficile management, and increasing education of staff and providers to achieve this.
  • Target: <1 instance of hospital acquired cDifficile per 1000/patient days.


6.       Theme 6: Equity and diversity (internally developed quality focus area)

  •         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 will embed cultural safety training within our organizational practices.
  • Target: 70% completion of training by all fulltime staff by end of Feb 2024.

More information on Quality Improvement Plans can be found on the  Ministry of Health and Long-Term Care website


Infection Rates

Hospitals are required by the Ministry of Health and Long-Term Care to publicly report some key rates. South Huron Hospital has posted these rates and will continue to update on a monthly basis.


Infection Rates - Target: 0/1000 patient days


























 MRSA 00
 VRE 00000       
 Clostrium difficile


Hand Hygiene Rate Prior to Patient Contact - Target 100%


 Year Range
 2022/2023 92%90%
 2023/2024 90%   


Hand Hygiene Rate After Patient Contact - Target: 100%


 Year Range
 2022/2023 92%96%
 2023/2024 90%