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Quality Improvement Plan

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Niagara Health is committed to providing all of our patients, their families, staff, physician, students, learners and volunteers Extraordinary experiences.  Our hospital’s Quality Improvement Plan (QIP) outlines our organizational goals, priorities and action steps for quality improvement.

Contact Information

Email Sonia Pagura
905-378-4647 ext. 45549

Visit the MOHLTC Excellent Care for All webpage

QIP Archives

QIP Narrative 2018/19

QIP Workplan 2018/19

ECU Workplan 2018/19

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.  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.

QIP Progress Report 2018/19 | QIP ECU Progress Report 2018/19

What is the QIP?

The Excellent Care for All Act (ECFAA) came into effect in Ontario in June 2010. This 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 2019/20 Quality Improvement Plan

Our QIP connects and integrates our quality improvement goals with our strategic plan to provide the safest care, in partnership with our patients and families to improve access, eliminate 'hallway medicine' and create a better environment for our physicians, staff, volunteers and students  where they feel safe and respected.

QIP Narrative 2019/20 | NH QIP Workplan 2019/20 | ECU QIP Workplan 2019/20

2019/20 Quality Improvement Plan - Hospital


  • We will improve the wait that patients experience when admitted in the Emergency Department to the time they arrive in an in-patient bed or operating room by 20%. Our patients will not wait longer than our current performance of 64.5 hours.

Patient Care

  • We will continue to acknowledge the concerns of our patients and families within 5 business days 98.4% of the time.
  • We will improve how we provide information to our patients when they leave the hospital by 5% as reflected on our client experience survey.


  • We will create a safe culture for our staff through workplace violence reporting and maintain our results through the same number of incidents reported.
  • We will reduce the number of new pressure injuries for our complex care patients by 1.3%.


  • We will ensure that 90% of our patients have their Medication Reconciliation completed on admission.
  • We will improve the percentage of patients having their Medication Reconciliation at discharge by 40% to ensure 90% have safe transitions.
  • We will reduce the number of patients with Mental Illness or Addiction being re-admitted to hospital by 5%.


2019/20 Quality Improvement Plan - Extended Care Unit

Patient Centred

  • We will increase the percentage of residents who respond positively that they feel listened to by 4.2%.
  • We will increase the number of residents who respond that they feel they can express their opinions without fear or consequences by 1%.


  • We will reduce the number of harmful falls our residents experience by 5%
  • we will reduce the new or worsened pressure injuries our residents experience by 5%.
  • We will reduce the percentage of residents that require physical restraints for safety by 5%.



Niagara Health System