Public Accountability, Quality, and Performance

Service 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 2023 – 2024 H-SAA for Women’s College Hospital.

The Multi Sector Service Accountability Agreement (MSAA) between the LHIN and Women’s College Hospital for 2023 – 2024

Women’s College Hospital is committed to accountability and transparency. As part of that commitment, we are happy to share our key financial information with our community – our patients and families, our staff, and the broader public.

Sharing this information is also in keeping with the Ontario government’s push towards that same accountability and transparency within the public sector.

Our Quality Vision – Care and Services that are:

  • Safe
  • Effective
  • Equitable
  • Patient-centred
  • Efficient
  • Timely

Quintuple Aim Quality Framework

infographic of the WCH vision for quality


  • Equity & Accessibility
  • Best Possible Health Outcomes
  • Best Use of Resources
  • Workforce Experience
  • Patient Experience

At WCH we are committed to providing the safest and highest quality care possible. Our quintuple aim framework guides all the work that we do to achieve:

Quality improvement (QI) describes a variety of proven tools, methods, and approaches to accelerating improvement in healthcare. In QI, teams work together towards a common improvement aim, test promising change ideas on a small scale, make modifications based on rapid feedback, and systematically spread successful initiatives.

All QI models are based on the principles of (a) focusing on the client or patient, (b) understanding systems and processes, (c) teamwork, and (d) being guided by data.

This fun whiteboard video by Dr. Mike Evans explains why QI matters in healthcare and how it’s done.

The Women’s College Hospital Quality Improvement Plan

The Women’s College Hospital Quality Improvement Plan (QIP) is one of the tools we use to communicate and track our performance. It outlines our quality and safety priorities in terms of specific goals, targets, and actions. Each year, in accordance with the Excellent Care for All Act, we post our QIP publicly and submit it to the provincial government to help improve care across the health system. It’s our commitment to ensuring the care and services we provide to our patients and the community are safe, effective, person-centred, timely, equitable and efficient.

Our 2024 – 2025 QIP outlines six priority quality goals:

Access & Flow1.  Reduce Wait Time: % referrals acknowledged within 14 days
2. Improve Access to Care: % virtual care adoption when appropriate  
Experience3. Improve Patient Experience: % top box ratings for overall care  
Equity4. Improve Health Equity: completion rate for “We ask because we care” survey
Safety5. Improve Workforce Safety: # workplace incivility incidents  
6. Improve Medication Safety: % medication reconciliation completed    

For helpful tips on how to stay safe in the hospital and at home, visit our WCH Patient Safety page.
WCH publicly reports several wait time indicators to Ontario Health. For more the most recent results, visit Wait Times page on the Ontario Health web site.

Executive Compensation

The executive contracts contained here are posted for the purpose of public disclosure; the hospital has taken this step with the consent of the hospital executives. The contracts posted are the original employment contracts negotiated at time of hire. Legislative changes, changes to role accountabilities, movement along salary scales, cost of living increases and hospital policy changes have impacted how the hospital currently administers these contracts. The contracts posted are the only existing contracts for these individuals.

Women’s College Hospital has a comprehensive executive performance management program. The Board of Directors annually establishes measurable goals and objectives in collaboration with the Chief Executive Officer (CEO) and Chief of Staff (COS). Each executive’s performance against these goals is combined with a 360 degree performance evaluation that provides the Board with a basis for determining if the executive has succeeded in achieving his or her goals. The outcome of the annual review is tied to compensation.

The CEO in turn establishes measurable goals and objectives with each member of her executive team. Each executive’s performance against these goals along with a comprehensive list of measurable leadership competencies are evaluated by the CEO as part of the executive’s annual performance review.

The CEO and the COS have the opportunity to earn a merit incentive of up to 20% of their base salary. The Board annually determines the individual’s performance based upon the outcome of a performance review and the achievement of the individual’s goals and objectives.

With the Ontario Government’s introduction of the Excellent Care for All Act for fiscal year 2011-2012, the Hospital’s Board of Directors has apportioned one quarter of the CEO and COS 20% incentive potential to goals and objectives that are tied to the specific Quality Improvement Plan (QIP).

As an incentive structure did not exist for the CEO’s senior executives, each executive’s base salary was reduced by 5% to create a pay at risk cash reserve that the individual can earn back by achieving specific Quality Improvement Plan (QIP) goals and objectives.

The Government of Ontario enacted in August 2011, a Broader Public Sector Perquisite Directive. This Directive requires hospitals to reduce the range of perquisites that may be made available to hospital employees. In August 2011, Women’s College Hospital implemented the perquisite policy to ensure ongoing compliance with the Government of Ontario Directives. Employees that had perquisite entitlements in their contracts were informed that some of these perquisites would be eliminated from their contracts, and each of these employees has acknowledged these changes by signing a letter of acknowledgment which is now attached to their employment contract.

Posted Policies Governing Senior Executive Compensation: