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Quality & Patient Safety


At Hôtel-Dieu Grace Healthcare patient safety and quality improvements are key strategic priorities. The paramount importance of patient safety is reflected in our vision and strategic plan and it is also embedded into the job descriptions of everyone employed by the hospital. Our Board of Directors has established a Quality Committee of the Board that ensures that requirements from the Hospital Management Regulation as it relates to quality are met. This committee meets monthly, and reviews patient safety related indicators and issues as well as overseeing the preparation of our annual Quality Improvement Plan.


Our Patient Safety Plan is designed to improve patient safety, reduce risk and respect the dignity of those we serve by assuring a safe environment. Recognizing that effective medical/health care error reduction requires an integrated and coordinated approach, the following plan relates specifically to a systematic hospital-wide program to minimize physical injury, accidents and undue psychological stress during hospitalization. The organization-wide safety program will include all activities contributing to the maintenance and improvement of patient safety.


Quality is achieved by providing the right care to the right patient by the right care provider at the right time. It's our goal at HDGH to establish an engaged and accountable culture focused on quality and safety to provide exceptional patient and family centred care. All of our 1,100 plus staff recognize that quality and safety is the responsibility of each and every one of us at HDGH. Quality is always the result of high intention, sincere effort, intelligent direction, and skillful execution. It is not an act. It is a habit.


To show just how quality flows through our organization we have created the Quality Committee Framework as a visual representation. The Quality Committee Framework is a series of linked committees that coordinate and provide a connecting link from the Board of Directors to the frontline staff. 


At the centre of this framework sits our Patient and Family Engagement Council (PFEC) because the patient and family are at the centre of everything we do at HDGH. It is important that our patients and their families have a voice and are involved in direct decision making about their care. Each committee or group around PFEC makes decisions about how quality and safety are executed throughout HDGH. The HDGH Research and Evaluation Department works with each of the councils and committees with program planning and evaluation as well as knowledge transfer and education opportunities. 


The Quality Framework serves as the foundation for quality improvement throughout the organization. It is specific to each one of our strategic drivers: Our Patients, Our People, and Our Identity.


Our Patient Safety Plan, our Strategic Indicators and our Quality Framework are reviewed routinely to ensure continued alignment to our vision and mission and our commitment to continuous improvement and quality of care. More information is available on HDGH's Quality Improvement Plan.


Learn more about HDGH's Quality Improvement Initiatives through the 2017/2018 Quality Matters: Year in Review


Public Reporting

Improving patient safety is about creating an environment that is transparent and committed to change. This is the mandate of the Ontario government's Patient Safety Initiative.


The government announced public reporting of eight indicators on May 28, 2008 as part of a comprehensive plan to create an unprecedented level of transparency in Ontario's hospitals. A Public Hospitals Act (PHA) regulatory amendment, effective July 28, 2008, requires hospitals to publicly report on patient safety indicators related to hospital-acquired infections, actions undertaken to reduce such infections, and mortality. Under Regulation 965 of the PHA, hospitals are required to disclose the results of reach indicator through their website.


As of 2010 Ontario hospitals publicly report on nine patient safety indicators. Standardized data elements, case definitions and reporting requirements have been developed for all indicators. The following is a list of patient safety indicators and timeframes for reporting them:



Patient Safety Indicator

Date of Initial Public Reporting

Reporting Frequency

Clostridium difficile Infection (CDI) rate

September 26, 2008


Methicillin-resistant Staphylococcus aureus (MRSA) rate

December 30, 2008

Quarterly in January, April, July and October

Vancomycin-resistant Enterococci (VRE) rate

December 30, 2008

Quarterly in January, April, July and October

Hand Hygiene Compliance

April 30, 2009

Annually in April


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Voice Directory: (519) 257-5100



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1453 Prince Rd.


Windsor, ON N9C 3Z4