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Quality Improvement Plan

Our commitment to quality care

The Niagara Health System is “looking forward”, charting its future to deliver high quality and safe care.  Our hospital’s organizational goals and priorities and our action steps for quality improvement are outlined in our annual Quality Improvement Plan (QIP). The QIP is just one of the ways that we are keeping our focus on constantly doing better. Through our QIP, our community will be able to very clearly see our targeted areas for improvement and will be able to chart our progress.

What is the QIP?

The Excellent Care for All Act (ECFAA) came into effect in Ontario in June 2010. This new legislation requires all hospitals to create and make public annual Quality Improvement Plans. Many significant improvements have been made since our first plan was developed in April 2011.

ECFAA sets out a number of requirements for hospitals including:

  • establishing quality committees;
  • implementing patient and care provider satisfaction surveys;
  • developing a declaration of values with public consultation;
  • establishing a patient relations process to address and improve the patient experience; and
  • involving patients and families in the development of QIPs.

 Our NHS 2016/17 Quality Improvement Plan

The NHS has realized several significant achievements over the past year, including the engagement in Quality and Safety through “Route NHS” and “Bridge to Extraordinary”, the introduction of Unit Based Teams, launching the Critical Care Response Team, improving communication through the use of huddle boards and patient story boards, implementing the We Check ID Campaign and renewing our Ethics Framework.  All of these efforts have led to our organization being Accredited with Exemplary Standing following an on-site survey and evaluation by Accreditation Canada.

Leveraging these achievements, as well as our organizational goals and priorities, the NHS is committed to quality and extraordinary caring to build a healthier Niagara.  There are five (5) key areas of improvement focus in our 2016/17 NHS QIP across the safe and timely dimensions of quality, as outlined below.


We will improve the safety of care we provide by increasing the proportion of patients who have their medications reconciled on admission to 43.4%, for a 90% compliance rate.

We will improve the safety of care by reducing the number of patients who fall in complex care from 12.1% to 10% and reducing the number of harmful falls in acute care by 5%.

We will improve the safety of care we provide by reducing the hospital acquired C. Difficile infection rate by 10%.


We will improve timely access to our services by reducing emergency department Wait Times for Admitted Patients to the provincial average and LHIN target of 28 hours. Our target in this area is a reduction of time patients who are admitted to hospital wait in the ED before moving to their inpatient bed.

Our Extended Care Unit (ECU) 2016/17 Quality Improvement Plan

This will mark the second year that Long-Term Care and Extended Care Units are required to submit and publicly post a QIP.  There are seven (7) key areas of improvement focus in our 2016/17 ECU QIP across the safety, effectiveness and resident engagement dimensions of quality, as outlined below.


We will improve the effectiveness of our services by striving for a 100% compliance rate in the area of hand hygiene in order to reduce the spread of infectious disease.

Resident Engagement:

We will improve the resident experience by improving our scores in the following areas:

  • Increasing the number of Residents recommending the Home to others  to 95%
  • Increasing the positive responses to food services to 89%
  • Improving overall resident experience to 95.5%.


We will improve our resident safety by reducing the number of resident fall to 13.3%.  We will also improve our resident safety by reducing the number of worsening pressure ulcers to meet the Provincial average of 3.3%.  Finally, we will improve our resident safety by reducing the number of residents requiring the use of restraints to 10.4%

Our performance to date

Tracking our progress and performance enables us to build on the areas where we are doing well and identify the areas where there is room to improve.

Contact Information

Niagara Health System
Marilyn Kalmats
905-378-4647 ext. 45549

Visit the MOHLTC Excellent Care for All webpage