St. Mary’s General Hospital Continues to be Among Canada’s Top Performing Hospitals

June 10th, 2015

June 10, 2015 (Kitchener) – St. Mary’s General Hospital performed better than the national hospital average across three key hospital indicators, according to a new report released by the Canadian Institute for Health Information (CIHI).

The online report by CIHI provides a snapshot of overall health system and hospital performance, including the percentage of patients that are readmitted to hospital within 30 days, Hospital Standardized Mortality Ratio (HSMR) and total time admitted patients wait in the emergency department.

Of the overall results, St. Mary’s was among the top achievers in Canada for three consecutive years for low percentage of patients readmitted to hospital within 30 days of their initial discharge. In 2013-14, 7.1% of patients returned to St. Mary’s urgently within 30 days after discharge, compared to the national average of 8.9%.

St. Mary’s also continued to perform better than the national average in Hospital Standardized Mortality Ratio (HSMR) for 2013-14, achieving a score of 79 versus the national average of 84. For 2014-15, St. Mary’s HSMR has been further reduced to 73.

“St. Mary’s continues to provide safe, high quality care thanks to the commitment to continuous quality improvement by our staff, physicians and volunteers,” says President Don Shilton. “Our success in keeping readmission rates low is a team effort, and includes a strong emphasis on infection control, outpatient support and education, and integrated support for patients as they transition from hospital to home through our Integrated Comprehensive Care Project.” (see backgrounder)

St. Mary’s has also continued to reduce wait times in its emergency department, despite an 8.5% increase in patient volumes, from 46,119 in 2012-13 to 50,053 in 2014-15. Wait times to see a physician or nurse practitioner upon arrival in the emergency department have been reduced by 35% from 5.4 hours in 2012-13 to 3.5 hours in 2014-15, and the total time that admitted patients wait in the emergency department for an inpatient bed has been reduced 24% over this same period from 26.9 hours in 2013-13 to 20.4 hours in 2014-15. St. Mary’s wait time for admitted patients for 2014-15 was the 15th best of 126 hospital sites in Ontario. The wait time for admitted patients in the emergency departments across the Waterloo Wellington Local health Integration Network was lowest in the province.

“We know that it is very difficult for patients and families to continue to wait in the emergency department for transfer to an inpatient bed,” says Barbara Guidolin, Vice President, Patient Services and Chief Nursing Executive. “We are trying to address some of the bottlenecks, including the length of time that beds are occupied by patients who are in isolation or who are waiting for discharge to a long-term care or rehabilitation bed. This month we also created the new role of full-time hospital supervisor to help manage patient flow after hours.”



Contact: Anne Kelly, Interim Manager of Communications 519-749-6578 ext. 1501 • 226-339-1903 (mobile) •


St. Mary’s continues to improve its efforts to provide safe, patient-centred care by:

  • Establishing in 2014 an Ambulatory Treatment Area with dedicated staffing by physicians and nurse practitioners who see less serious cases in a timelier manner. By creating separate streams for less serious and more serious cases, overall patient flow through the department has improved.
  • Improving discharge planning to help patients avoid readmission. This includes the Integrated Comprehensive Care (ICC) pilot project launched in August 2013 to improve patient care coordination from hospital admission to discharge and beyond. Preliminary data shows patients are less likely to be readmitted to hospital and the original ICC program at St. Joseph’s Healthcare in Hamilton has demonstrated a proven decrease in readmissions and return visits to the emergency department.
  • Inviting patients and families to be part of quality of care reviews and creating a new Patient and Family Advisory Council (interviews now underway for a scheduled fall launch).


Returning to Hospital: Also known as “30-Day Overall Readmissions”. This measure looks at how many patients were readmitted to any hospital within 30 days of their initial discharge.

Return to Hospital methodology: This measures the percentage of patients who had to urgently return to any hospital within 30 days. Some adjustments are made to account for differences between patients. For example, older patients are more likely to return to hospital than younger patients. Patients who were treated in hospital for mental health problems or who received end-of-life care are not included in this measure.

Source: Canadian Institute for Health Information More information available at

Hospital Standardized Mortality Ratio (HSMR): This indicator of healthcare quality measures whether the number of deaths at a hospital is higher or lower than you would expect, based on the average experience of Canadian hospitals (set at 100 in 2009). The average experience of Canadian hospitals is set at 100 and is based on data collected in 2009. A ratio greater than 100 means that a hospital’s death rate is higher than the average in 2009, after considering the types of patients it cares for. A ratio lower than 100 means that a hospital is performing better than the average.

HSMR methodology: This measure compares the number of actual deaths seen in a hospital with the number of expected deaths. The formula to calculate it is as follows: (# of actual deaths / # of expected deaths) X 100 = Hospital Standardized Mortality Ratio (HSMR)

Source: Canadian Institute for Health Information More information available at