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Quality, Performance & Accountability

Publicly Reported Indicators and Documents

In this section are documents and resources related to transparency and accountability at St. Mary’s. The links below provide easy access to legislated disclosure on quality and safety (i.e.infection rates and mortality ratio), financial accountability (audited statements) and corporate accountabilities (i.e. executive compensation and expense disclosure).

Public Disclosure – Corporate Documents

  • Quality & Safety – Read about infection rates, hand hygiene compliance and HSMR.
  • Financial Accountability – Read our audited financial statements.
  • Corporate Accountability – View executive expense disclosure and executive compensation information
  • Accessible Customer Service Standards Policy – View our compliance with the Accessibility for Ontarians with Disabilties Act 2005 (AODA) and Accessibility Standards for Customer Service.
  • Multi Year Accessibility Work Plan 2020
  • Workplace Ethics and Reporting (Whistleblower)
    Reporting a concern about workplace ethics is sometimes referred to as whistleblowing. St. Mary’s employees who have identified what they believe is a serious violation of St. Mary’s Workplace Ethics Policy, and who feel that an internal reporting process has not adequately addressed the concern, can report it online or by phone to the Workplace Ethics Reporting Line at www.GrantThorntonCARE.ca or call 1-855-484-2273.

    Board members, management, professional staff and all employees are required to observe high standards of personal ethics in the conduct of their duties. Compliance is expected with all applicable laws, regulations and hospital policies. Employees with ethical dilemmas are encouraged in most situations to consult their immediate supervisors or managers. If employees are uncomfortable talking to their supervisor or manager, or find those individuals cannot help, they are encouraged to speak with the next level manager or Human Resources, Risk Management, a professional practice lead, related regulated college, or in case of a physician, the Head of Service or Chief of Department.  If employees feel their concerns have not been adequately addressed, they can access the Workplace Ethics Reporting Line.

St. Mary’s General Hospital is committed to continually improving our services. That is why St. Mary’s voluntarily participates in accreditation under the Accreditation Canada standards. This program is an extensive self-assessment process, which includes a third-party evaluation of our care and services by Accreditation Canada surveyors. Accreditation is a quality improvement process; it helps our organization identify what we’re doing well and where we need to focus our improvement efforts.

St. Mary’s was last evaluated in 2019 and was accredited with Exemplary Standing. The full report can be accessed hereThe next on-site survey is scheduled for June of 2023.

St. Mary’s participates as a commitment to our vision to be the safest and most effective hospital in Canada. By shining a light on our processes, accreditation helps to foster improved teamwork, collaboration and a higher quality of care for our patients.

To learn more about Accreditation Canada, visit their website here.

The Government of Ontario’s Green Energy Act 2009, requires public agencies, including hospitals, to report on their energy consumption and greenhouse gas emissions annually, as well as posting their five-year energy Conservation and Demand Management plans. Click on the links below for:

St. Mary’s has a proud history of being open, transparent, and accountable to our patients, community, and funders. The Excellent Care for All Act was introduced by the Government of Ontario to put patients first, while improving the quality and value of the patient experience. St. Mary’s is fully compliant with this legislation.

St. Mary’s Declaration of Patient Values was created following extensive consultation with our patients, community, and health care partners in Waterloo Wellington. 

Click here to read the Patient Declaration of Values.

St. Mary’s welcomes and appreciates all feedback and suggestions from our patients and families. Read more about our patient relations process and accountabilities by clicking here. If you would like to speak to someone about your/your loved one’s care, we encourage you to first speak with the Program Manager in the area of your concern. For further assistance, contact our Patient Relations Representative at 519-749-6578 ext. 6867, or by click here to send an email. Please do not include personal health information by email.

The Board of Trustees receives regular reports on quality through the Board Quality Committee. Prior to the monthly meeting, committee members are given the opportunity to visit a department within the hospital to speak with staff and physicians regarding challenges and quality initiatives that may be underway in that particular unit. The committee is also provided with a written report which is discussed at the meeting.

The Quality Committee’s mandate is to assist the Board in monitoring, evaluating and ensuring that care at St. Mary’s is safe, kind, effective and timely, and that it is provided in an environment of inquiry and learning, using our mission, vision and values as our guiding principles.