Quality Improvement

At the North Shore Health Network (NSHN), we strive to provide safe, high-quality, person-centred care. Across our three sites in Blind River, Thessalon, and Richards Landing we operate as one unified team delivering equitable, high-quality rural health services to our communities. We are committed to maintaining a high standard of care, guided by our core values of Compassion, Accountability, Respect, Equity, and Sustainability (NSHN C.A.R.E.S.). We strive to create a safe, comfortable, and home-like environment that supports the privacy, dignity, and security of our patients, residents, and clients.

Measuring quality in healthcare is essential. Quality indicators help ensure consistency of care, inform decision-making and planning, and identify opportunities for improvement in the services we provide. At NSHN, we recognize that not all aspects of patient safety and comfort can be easily measured. However, by analyzing quality indicators, we gain a broader understanding of system performance. This allows us to examine specific processes, programs, and services more closely, and to allocate resources where they will have the greatest impact on patient care and outcomes.

To see NSHN's current and past Quality Improvement Plans, click here.

CLICK IMAGE ABOVE (VIDEO)
Quality Improvement in Healthcare - Dr. Mike Evans

Important Legislation

The Excellent Care for All Act, 2010

The Excellent Care for All Act (ECFAA, 2010) places patients at the centre of Ontario’s health care system by promoting high-quality, evidence-based care and improving the overall patient experience. The Act aims to strengthen health care delivery while ensuring sustainability for future generations.

Implementation of ECFAA began in the hospital sector, with outcomes evaluated prior to expanding requirements to other areas of the health system.The legislation requires health care organizations to:

establish Quality Committees that report to the organization on quality-related matters
develop and publicly post annual Quality Improvement Plans (QIPs)
link executive compensation to the achievement of QIP performance targets
conduct regular patient and family member Experience Surveys
conduct staff surveys to assess workplace experience and perspectives on quality of care
develop a Declaration of Values or Declaration of Rights and Responsibilities
maintain a Patient Relations process to address patient experience concerns

Fixing Long-Term Care Act, 2021

The Fixing Long-Term Care Act (FLTCA, 2021) is designed to improve the quality of care and quality of life for residents in Ontario’s long-term care homes. The Act reinforces a resident-centred approach, emphasizing safety, dignity, respect, and accountability, while strengthening oversight and transparency across the long-term care sector.

The legislation establishes clear expectations for long-term care home operators and staff, with a focus on continuous quality improvement and enhanced resident protections. Key requirements under the Act include:

a strong emphasis on resident-centred care, ensuring residents’ rights, dignity, and choices are respected
minimum staffing standards, including increased direct care hours provided by nursing and personal support staff
ongoing quality improvement and regular evaluation of care and services
mandatory training and education for staff to support safe, competent care
enhanced infection prevention and control (IPAC) measures
strengthened inspection, compliance, and enforcement processes
improved transparency and accountability through reporting and public access to information
resident, family, and caregiver engagement in care planning and decision-making
a formalized complaints process to address concerns and improve the resident experience

Health Quality Ontario
Quality Improvement Plan Program

Under the ECFAA (2010) and other accountability agreements, all public hospitals, interprofessional primary care organizations, Home and Community Care providers, and long-term care homes are required to develop an annual Quality Improvement Plan (QIP).

Each organization must create a QIP that outlines specific goals, targets, and actions aligned with Ontario’s provincial health care priorities, while also addressing local quality improvement needs. QIPs must be developed annually, publicly posted, and submitted to Health Quality Ontario (HQO), the

provincial advisor on health care quality.

QIP development is informed by multiple sources, including:

mandatory and priority indicators established by HQO
the needs of patients, family members, and care partners
insights from the patient relations process
patient experience surveys and critical incident reviews
employee and physician engagement results and related initiatives
commitments outlined in Strategic Plans, Hospital Service Accountability Agreements, and Ministry of Health priorities
Accreditation Canada standards and processes

2026-27 NSHN Quality Improvement - Facebook post & website image.png

What is Accreditation Canada?

Accreditation Canada is a national, independent, not-for-profit organization that evaluates and certifies healthcare and social service organizations across Canada. At its core, it’s about making sure care is safe, high-quality, and continuously improving.

What they actually do:

Accreditation Canada assesses organizations like:

Hospitals
Long-term care homes
Community health services
Mental health and addiction programs

They use a structured review process to see whether organizations meet established standards in areas like:

Patient safety
Infection prevention and control
Medication management
Leadership and governance
Patient and family engagement

How the Accreditation process works:

Organizations go through a cycle (usually every 4 years) that includes:

Self-assessment against standards
On-site survey by external reviewers (often peers in healthcare)
Feedback and scoring on performance
Accreditation decision (e.g., accredited, accredited with commendation, etc.)

Why it matters:

Accreditation Canada helps organizations:

Identify risks before they cause harm
Improve consistency and quality of care
Strengthen accountability and transparency
Build public trust

For patients and families, it’s a signal that a healthcare organization is committed to safe, reliable care and continuous improvement, not just meeting minimum requirements.

NSHN is currently Accredited with Commendation, which means that during our last onsite survey, our organization met:

>85% of Normal Criteria
> 85% of High Priority Criteria
> 90% of ROPs

ROP: Patient Safety Education & Training

Required Organizational Practices ("ROPs")

What is an ROP?

An ROP is a specific, evidence-based practice that healthcare organizations are expected to have in place to enhance patient safety and minimize risk. Set by Accreditation Canada, ROPs focus on areas where there is a high risk of harm and where consistent practices are known to improve outcomes.

In simple terms:
An ROP is a “must-do” safety practice that organizations are evaluated on during accreditation.

The Annual Patient Safety Training & Education ROP

This ROP requires organizations to ensure that patient safety education is provided at least once every year to:

Leaders
Team members (staff)
Volunteers

The goal is to make sure everyone in the organization understands key safety risks and how to prevent harm.

Organizations must:

Identify specific patient safety focus areas (e.g., medication safety, infection control, communication, incident reporting, human factors)
Provide annual education and training on these topics
Ensure the education is relevant to each person’s role
Make training accessible and track participation

CLICK HERE FOR INFORMATION ON NSHN's CURRENT FOCUS: Patient Identification & Engagement