FPHC Quality Improvement Plan

Women’s College Hospital’s Family Practice Health Centre (FPHC) is committed to delivering high-quality, patient-centered care. Our Quality Improvement Plan (QIP) outlines key initiatives aimed at enhancing patient experiences, improving health outcomes and ensuring equitable, accessible and efficient care. View our latest Quality Improvement Plan by navigating through the tabs at the top of this page.

What is a Quality Improvement Plan (QIP)?

A documented set of quality commitments we make to patients, staff and the community.

An opportunity for accountability to ourselves and Ontario health.

A progress report we can use to reflect on our growth.

A benchmark for continual improvement.

How We Measure Success

Regular performance assessments provide us with the opportunity to pinpoint and analyze areas of improvement to serve you better. The WCH Family Practice Health Centre always strives to remain in range of QIP performance targets set out by Ontario Health.

Our Commitment to You

As part of our patient-centered approach, we welcome ongoing feedback from patients, families and community members. Your insights help shape our quality improvement initiatives. If you would like to share your feedback with the team, you can do so on this page.

Other Frequently Asked Questions

A Quality Improvement Plan (QIP) is a formal, documented set of quality commitments aligned with system and provincial priorities that a healthcare organization makes to its patients/clients/residents, staff and community to improve quality through focused targets and actions. By submitting our QIP to Health Quality Ontario (HQO), we as a system can begin to understand what progress organizations are making in achieving targets on priority improvement areas. Additionally, the QIP provides rich information for the system to better understand how we collectively can spearhead improvement efforts.

Quality improvement objectives may be similar across organizations. The QIP provides an opportunity to learn from our peers on the types of actions we can take to achieve quality objectives to reduce wide variation with approaches taken. In addition to being owned by the organization, QIPs are developed under the umbrella of a common provincial vision and provide a system-wide platform for quality improvement. This provincial vision is expressed through the priority indicators that are included in the QIP. These quality themes reflect Ontario’s vision for a high-performing healthcare system and were prioritized through consultation with key stakeholders, representative associations and informed by other partner organizations including HQO.

A QIP is owned by each healthcare organization and is a way for the organization to focus its efforts on key quality improvement priorities.

Healthcare organizations may be undertaking a range of quality improvement projects at any given time. Organizations should consider system-, sector- and organization-level quality improvement priorities when developing their annual QIPs. The QIP helps to organize quality improvement projects, prioritize them, and makes sure they’re aligned with the overall quality improvement goals of the organization and system at large.

QIPs are also a way for patients/clients/residents to become engaged in a dialogue about the quality of care provided by health care organizations. Patients/clients/residents, their families and caregivers should have access to an organization’s QIP (e.g., through public posting), feel they can ask questions about the QIP, and contribute to the QIP development process (e.g., by filling out an experience survey or through an organization’s patient relations process).

Finally, QIPs are a way for the entire healthcare system to collectively focus on key priorities that will help to put patients, residents and clients first. By setting priority indicators and publishing QIP guidance materials, the Ministry of Health and Long-Term Care (ministry) is supporting a focus on broader health system improvement and shared improvement priorities.

Every organization will be at a different starting point when it comes to developing a QIP. The guidance materials have been developed to ensure that every health care organization completing a QIP can “see themselves” in the system-level commitments and priorities expressed in this guidance.

While the QIPs are not used as a performance management tool between the ministry (or LHIN) and healthcare organizations, they are meant to be a mechanism through which an organization’s leadership holds the organization to account for the commitments made for improved quality of care. Organizations have a responsibility to report on progress and be available to explain their performance on commitments made in their QIP. The QIP progress report is one means by which organizations can account for progress made against their commitments.

Use organizational-level data to identify current performance and/or baseline for the priority.
Review the priority indicators as set out by HQO and determine which are relevant for WCH. This includes a review of current performance against provincial benchmarks/theoretical best for all priority indicators.
Use the guidance provided by HQO to create a plan to address each of the system level priorities we have identified for improvement. A plan includes setting a target, identifying change ideas to be tested, methods and process measures, as per the QIP.
Ensure proper communication of these priorities to WCH communities.
Sign-off: Once the QIP has been approved by the Board, the Quality Committee (if applicable) and key senior leadership, those involved must “sign-off” on the QIP. This is an important component to help demonstrate the shared accountabilities and responsibilities for the QIP at the governance, clinical and administrative levels.

QIPs are not an accountability or compliance tool, but rather a tool to guide an organization’s quality improvement efforts. A QIP is a formal commitment that we are making to our patients/residents/clients, staff, and community to improve quality through focused targets and actions.

Not only is transparency an important way of ensuring that our publicly-funded healthcare system remains accountable to the people of Ontario, it is also a way for healthcare organizations to foster dialogue with the communities they serve. By publicly posting our QIPs, the Family Practice Health Centre can communicate local quality improvement priorities to our patients, clients and residents, and demonstrate our overall commitment to quality.

Our 2025-2025 QIP outlines the following priority quality goals:

Issue: Access & Flow
Quality Dimension: Efficient

Percentage of patients with type 2 diabetes mellitus who are up to date with HbA1c (glycated hemoglobin) blood glucose monitoring.

Change Ideas / What is being doing to help improve this measure?

Use a standard diabetes form in each patient’s chart to remind our care team when the test is due.
Include an HbA1c lab form with diabetes referrals so patients can get tested within 3-6 months.
Review our electronic records to better track who needs the needs the test.

Issue: Access & Flow
Quality Dimension: Timely

Percentage of screen-eligible people who are up to date with cervical screening.

Change Ideas / What is being doing to help improve this measure?

As part of the improved cervical screening, we’re offering two HPV methods of testing to patients: clinician performed or patient performed.

Issue: Access & Flow
Quality Dimension: Timely

Improve how patients rate their overall satisfaction when booking appointments by phone.

Change Ideas / What is being doing to help improve this measure?

Increase online appointment booking window from 28 days to 3 months. This gives patients more options and helps reduce the # of phone calls.
Promote online booking through our phone system. This will help shorten phone wait times and make booking quicker and easier.
Work with our Patient & Family Advisory Committee (PFAC) to improve our website.

Issue: Access & Flow
Quality Dimension: Timely

Percentage of patients who needed urgent care in the past year and were able to see a healthcare professional (staff/resident doctor, nurse, or nurse practitioner) the same day or the next day after trying to book an appointment.

Change Ideas / What is being doing to help improve this measure?

Review how often same-day and next-day spots are used in physician schedules to see if they help patients get care faster.

Issue: Equity
Quality Dimension: Equitable

Percentage of patients who completed our “We ask because we care” (Health Equity) survey.

Change Ideas / What is being doing to help improve this measure?

Increasing the involvement of Health Care Aides (HCAs) and volunteers to actively engage patients in completing the survey.

We are in the process of collecting baseline information for the following:

Issue: Equity
Quality Dimension: Equitable
Percentage of staff who have completed Anti-Black Racism education (relevant to equity, diversity, inclusion, and anti-racism education)
Issue: Equity
Quality Dimension: Equitable
Percentage of staff who have completed Anti-Indigenous Racism education (relevant to equity, diversity, inclusion, and anti-racism education)
Issue: Equity
Quality Dimension: Equitable
Percentage of staff who have completed LGBTQ+ and Trans Sensitivity education (relevant to equity, diversity, inclusion, and anti-racism education)
Issue: Access and Flow
Quality Dimension: Safe
Number of faxes sent per 1,000 rostered patients

Glossary of Terms

About the Quality Improvement Plan
Our Quality Improvement Plan (QIP) outlines how we’re working to make your care better, safer, and more fair. It focuses on key areas that help us improve how we deliver care every day.

Access and Flow
You should be able to get the care you need, when and where you need it. We will continue to reduce wait times and make sure your care is well-coordinated from start to finish.
Equity
Everyone deserves fair access to health care. We look at how things like race, income, language, and gender can affect care and we will continue to work on removing barriers, so no one is left behind.
Experience
Your experience matters. We listen to your feedback to understand how you feel about your care. This helps us improve how we communicate, treat, and support you.
Safety
We want every part of your care to be safe. That means preventing mistakes, using best practices, and making sure treatments are right for you.

References
Health Quality Ontario. (2024). Quality Improvement Plan (QIP) Matrix 2025/26. Retrieved from https://www.hqontario.ca/Portals/0/documents/qi/qip/2025-26-QIP-matrix-en.pdf

QIP Category: Safety – Effective

60% of our Type 2 diabetes patients are up-to-date with their glycated hemoglobin (HbA1C) tests.

Current Performance: 60%
Benchmark*: 48%
Target: 65%

What is being done to help improve this measure?

Allocated appointment slots for daytime same day urgent care
Added clinic hours to the After hours Urgent Care Clinic

QIP Category: Safety – Effective

Medication reconciliation completed by Family Practice post in-patient hospital discharge.

DATA COMING SOON.

What is being done to help improve this measure?

Design and document the workflow of the medication reconciliation process, including relevant data elements to be captured for reporting.
Routinely monitor the use of the medication reconciliation stamp in the EMR to evaluate process uptake.

QIP Category: Access & Flow – Efficient

65% of our patients said yes when asked if they could access urgent care on the same or next day.

Current Performance: 65%
Benchmark*: 61%
Target: 68%

What is being done to help improve this measure?

Developing an online booking tool for patients to decide between virtual, in-person or emergency visit needs.
Assess use of the same/next day scheduling template incorporated in physician calendars within EMR.
Reviewing appointment triage at the team level.

QIP Category: Access & Flow – Efficient

66% of our patients said they had a good experience with booking an appointment over the phone.

Current Performance: 66%
Benchmark*: 67%
Target: 68%

What is being done to help improve this measure?

Expanding online appointment booking.
Re-designing the central appointment booking line to be used by all patients to book, cancel or reschedule an appointment outside of their regular team secretary.

QIP Category: Access & Flow – Equitable

We have collected 25% of our patients socioeconomic data

What is Socioeconomic data?

We collect basic background information through the Health Equity Survey i.e./ age, gender, income, and race—to help us understand people’s needs and make health care fair for everyone.

Current Performance: 25%
Benchmark*: N/A
Target: 60%

What is being done to help improve this measure?

Embed a link to the equity survey within appointment reminders to prompt patients.
Remind patients that have not yet completed the survey every six months via Ocean Email.
Introduce tablets in clinic waiting rooms for surveys.

QIP Category: Experience – Patient-centred

Do our patients feel involved in decisions about their care?

Current Performance: 96%
Benchmark:* 96%
Target: 93%

What is being done to help improve this measure?

Routinely review Patient Experience Survey data with our patient advisors to understand how to best improve this indicator.

*Benchmarks are calculated using the University of Toronto’s Department of Family & Community Medicine (DFCM) averages (based on 14 academic teaching sites), or the Toronto Central Local Health Integration Network average.

2023/24 update

Glossary of Terms

Access and Flow
You should be able to get the care you need, when and where you need it. We will continue to reduce wait times and make sure your care is well-coordinated from start to finish.
Equity
Everyone deserves fair access to health care. We look at how things like race, income, language, and gender can affect care and we will continue to work on removing barriers, so no one is left behind.
Experience
Your experience matters. We listen to your feedback to understand how you feel about your care. This helps us improve how we communicate, treat, and support you.
Safety
We want every part of your care to be safe. That means preventing mistakes, using best practices, and making sure treatments are right for you.

References
Health Quality Ontario. (2024). Quality Improvement Plan (QIP) Matrix 2025/26. Retrieved from https://www.hqontario.ca/Portals/0/documents/qi/qip/2025-26-QIP-matrix-en.pdf

QIP Category: Timely and Efficient Transitions

Do our patients feel involved in decisions Can our patients access urgent care on the same or next day?