Quality & Patient Safety


At Hôtel-Dieu Grace Healthcare patient safety is a key strategic priority. 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. Quality improvement is an ongoing priority that helps us continually find new and better ways of doing things so that we can enhance care for our patients, increase satisfaction and achieve better clinical outcomes. The Quality Framework serves as the foundation for quality improvement throughout the organization.


The quality improvement monitoring and reporting structure is a series of linked committees that coordinate and provide a connecting link from the Board of Directors right to the frontline workers. Through a series of reports and continuous monitoring of indicators, the structure maintains a cycle of quality improvement and ensures the use of evidence based research in all of its work.


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.


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


Contact Us


General Info: (519) 257-5111


Voice Directory: (519) 257-5100



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1453 Prince Rd.


Windsor, ON N9C 3Z4