Women's College Hospital - Health Care for Women, Revolutionized

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Public Accountability, Quality and Performance

Accountability Agreements 

Being accountable to our patients and community is essential to earning your trust and building a reputation for excellence. "Accountability" means making the right clinical and managerial decisions, managing resources efficiently, measuring our performance and doing that in an open and transparent manner.

One of the foundations of accountability in the Ontario health-care system is the agreement each provider enters into with the Local Health Integration Network (LHIN) in order to qualify for funding from the Ministry of Health and Long-Term Care.  The Hospital Services Accountability Agreement (H-SAA) sets out the standard framework of the relationship between the hospital and the LHIN as well as the specific performance requirements for the hospital.  The H-SAA for Women’s College Hospital for 2008/09 and 2009/10 is available here.


Executive Compensation

ECFAA Quality Improvement Plan

Quality improvement is an ongoing priority that helps Women’s College Hospital to continually find new and better ways of doing things so that we can enhance care for patients, increase satisfaction and achieve even better clinical outcomes.

In June 2010, the Ontario Government passed the Excellent Care for All Act. This legislation will help support hospitals to further improve the quality and safety of care they provide for members of our community.

A key component of the Excellent Care for All Act and one of the ways that the Act is helping hospitals meet our community’s expectations regarding quality, patient safety and accountability is through the public reporting of Quality Improvement Plans (QIP). The Quality Improvement Plan provides a meaningful way for Women’s College Hospital to clearly articulate our accountability to our community, patients and staff, to outline our organization’s priorities for quality improvement and articulate a strategy for implementation. Our QIP is focused on creating a positive patient experience and delivering high quality health care.

Our Quality Improvement Plan, or QIP, is one of many tools that we are using to help us document and review our current performance in a variety of areas. With this plan, we will be able to very clearly see our targeted areas for improvement and chart our progress.

Beginning April 1, 2011, and in every fiscal year thereafter, health care organizations are required to develop and publicly post a QIP. 

Quality Improvement Plan (QIP)

Patient Safety Indicators

In 2008, the Ministry of Health and Long-Term Care (MOHLTC) announced new public reporting requirements on patient safety indicators as part of a comprehensive plan to create an unprecedented level of transparency in Ontario’s hospitals.

The Ontario Hospital Association (OHA) and Women’s College Hospital supports public reporting on patient safety and quality indicators because we believe it will inspire improved performance, enhance patient safety and strengthen public confidence in Ontario’s hospitals.

While we strongly support the provincial government’s new public reporting regime for hospital acquired infections, as an ambulatory care hospital, we do not fit the reporting criteria for some of the Patient Safety Indicators. As a result, we are not required to report data on the following indicators:

  • Clostridium difficile infection rate
  • Methicillin-resistant Staphylococcus aureus (MRSA) rate
  • Vancomycin-resistant Enterococci (VRE) rate
  • Ventilator-associated Pneumonia (VAP) rate
  • Central Line-Associated Primary Blood Stream Infection (CLI) rate
  • Surgical Site Infection (SSI) prevention rate in hip and knee joint replacement surgeries
  • Hospital Standardized Mortality Ratio (HSMR)

At Women’s College Hospital, we track and report on:

For more information on Health Quality Ontario’s patient safety indicators, click here.  

Hand Hygiene Compliance

What is Hand Hygiene? Hand hygiene is the removal of visible soil or killing of microorganisms from the hands. Hand hygiene can be done using soap and running water or an alcohol-based hand rub.

Why is Hand Hygiene important? Hands can easily spread germs from one person to another. Performing hand hygiene is the single most effective method to stop the spread of germs. At WCH, we have a comprehensive hand hygiene program to measure hand hygiene compliance of healthcare providers and allowing us to make continuous improvement.

How do we measure Hand Hygiene Compliance? At WCH, we invite our patients to observe the hand hygiene practices of their health care professional. During your visit, you may be asked to complete a short survey. If you are willing to participate, you will be provided a simple survey card that asks you to see whether or not your health care professional cleaned their hands immediately before physical contact with you. After your visit, you can fill out the card and drop it into the survey collection box located nearby. Each participating department is informed that we have invited you to observe their hand hygiene practices. Your health care professional would be happy to answer any questions you might have about hand hygiene or infection prevention and control. This initiative is ongoing and will inform us on any improvements that need to be made to ensure we are providing the highest quality of care possible.

See below to find out how we’re doing:

Hand Hygiene Compliance Results

Q1: 16/17

Q2: 16/17

Q3: 16/17

Before patient contact




Learn more about Infection Prevention and Control.

If you have any questions about infection rates or about our hospital’s infection prevention and control program, please contact the Infection Prevention & Control Department at 416-323-6400 ext. 3102

Surgical Safety Checklist Compliance

The surgical safety checklist is a patient safety communication tool that is used by a team of operating room professionals (nurses, surgeons, anesthesiologists, and others) to discuss important details about each surgical case. In many ways, the surgical safety checklist is similar to an airline pilot’s checklist used just before take-off. It is a final check prior to surgery that is used to make sure everyone knows the important medical information they need to know about the patient, all equipment is available and in working order, and everyone is ready to proceed.

There are three phases to the surgical safety checklist: “Briefing”, “Time-out”, and “Debriefing”.

Surgical Safety Checklist Compliance Rate (%)

Wait Times

The Ministry of Health and Long-Term Care provides wait time information to the public, with a breakdown by individual hospitals across Ontario. Find out more about Surgical and Diagnostic Imaging Wait Times.

Women’s College Hospital Oncology Wait Times Summary:
Q1-Q2 - 2012/2013:

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  • Fully affiliated with:
  • University of Toronto
  • A member of:
  • Council of Academic Hospitals of Ontario (CAHO)