Quality and Clinical Reports

Accreditation

We proudly report that Alexandra Marine and General Hospital has received full accreditation status from Accreditation Canada for 2017-2021. In May 2022, 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 Control Fact Sheets

• Infection Control Fact sheet Clostridium difficile
• Infection Control Fact sheet Vancomycin Resistant Enterococci (VRE)
• Infection Control Fact sheet Methicillin Resistant Staphylococcus aureus (MRSA)
• Infection Control Fact sheet Hand Hygiene

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.

Our QIP will focus on Patient safety and Improving the Patient Experience. With the plan, we are able to clearly see our targeted areas for improvement and chart our progress.

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

•  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

• 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.

• 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

• 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

• 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.

• 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.