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Accountability

pen on paper

North Wellington Health Care and Groves Memorial Community Hospital formed an administrative alliance in 2005. The Wellington Health Care Alliance shares the Chief Executive Officer and a senior management team.This alliance allows all three hospitals to work closely together to provide a broad range of services and quality care to our communities. Working together we have a stronger voice for rural health care.

Attestations

Audited Financial Statements

Please click here to view the audited 2017/18 NWHC Finanical Statements.
 

Employment Contracts

Employment Contracts

Please find below the Wellington Health Care Alliance Senior Management Team’s employment contracts. The purpose of publicly and proactively disclosing the employment contracts is to demonstrate the Senior Management Team’s commitment to be transparent and accountable to the communities they serve.

Please click on the name of the individual below to access the contract.

Stephen Street
President and CEO

 

Executive Compensation

Expense Policy

Expense Policy

North Wellington Health Care’s Expense Policy sets out rules and principles for the reimbursement of expenses to ensure fair and reasonable practices; and to provide a framework of accountability to guide the effective oversight of resources in the reimbursement of expenses.

To access the North Wellington Health Care’s Expense Policy please click here.

Expense Reports

Expense Reports

In accordance with the Broader Public Service Accountability Act, all hospitals are required to post executive expenses. The public disclosure of such expenses is posted on a semi-annual basis. These reports will include information on travel, meals and hospitality expenses made by every member of the Board of Directors and our Senior Management team. Wellington Health Care Alliance staff expenses are paid by North Wellington Health Care. The expenses are then split 50-50 with Groves Memorial Community Hospital. Please click on the name below to access expense reports.

Wellington Health Care Alliance Senior Management Team Expense Reports

Jerome Quenneville
President and CEO
 
Diane Wilkinson
Vice President Patient Services/Chief Nursing Executive
 
Stephen Street
Vice President Corporate Services & Planning (CIO\CPO)
 
Stephen Street

President and CEO
 
Marsha Martin
Chief Financial Officer
 
Sherri Ferguson
Chief Human Resources Officer NWHC Board of Directors Expense Reports
 
Stepahnie Pearsall
Vice President Patient Services/Chief Nursing Executive
 
Lisette Columbus
Acting-Vice President Patient Services/Chief Nursing Executive
 
Dan Coghlan
Vice President Corporate Services & Planning (CIO\CPO)
 
NORTH WELLINGTON HEALTH CARE BOARD MEMBERS
Al Hodgson
Maxine Rybka
Mary Lou Brown
David Craig
 
Bob Becker
Patti-Jo McLellan-Shaw
 
Dave Anderson
 
John Williams
 
Tom Sullivan
 
Bonnie Stevenson
 
Matt Aston
 
Patrick Downey
 
Janice Benson
 
Michael O'Dwyer
 
Marion Redpath
 
 
 
 
 

Green Energy Plam

Health Information, Release of Information and Privacy

Health Information, Release of Information and Privacy

North Wellington Health Care (NWHC) is committed to protecting the privacy and confidentiality of patient health information.  Our policies and procedures comply with the provincial legislation.

Accurate health information is essential to make sure you get appropriate care.  We record and maintain information about your current condition and care, including the results of tests, procedures and therapies.  Information such as your name, address and date of birth is recorded for the purposes of identification, contact and billing.  Your personal information whether stored on paper or electronically, is kept safe and secure. 

Policies and procedures are in place that protects how your information is collected and used.  We will share your health information with your family doctor, specialist or other health care providers who are involved in your care.  You may request that your health information not be shared with your health care providers, to do this contact Release of Information.  Your consent is required to share your health information with third parties such as lawyers, insurance companies or police. 

Further information about how the hospital collects, uses and discloses health information can be obtained from the Your Health Information and Your Privacy in Our Hospital pamphlet available to all visitors and staff.

How to make a Release of Information Request?

The patient health record is the property of the hospital; however you may request a copy of your health information or to share your information outside of the hospital.  Contact Health Information Services – Release of Information to make a request during office hours (Monday – Friday 8:00 am – 4:00 pm).

How to report a Privacy Concern?

If you have a concern about how your health information has been shared please contact the Privacy Officer at 519-843-2010 ext. 3254. You can also contact the Information and Privacy Commissioner of Ontario at 1-800-387-0073.

Mailing address:

Health Information Services Department

Release of Information Office

235 Union Street East
Fergus, Ontario
N1M 1W3

Freedom of Information

Freedom of Information and Protection of Privacy (FIPPA) provides the right for every person to access information held by hospitals and a formal process is in place for people to make Freedom of Information (FOI) requests for records that came into the hospital’s custody and control on or after June 2007.

FIPPA has been amended as of January 01, 2012 so certain types of hospital records are excluded from the act. For example:

  • Records that relate to the operations of a hospital foundation
  • Records regarding charitable donations
  • Administrative records of a regulated health care professional
  • Records relating to certain labor relations or employment matters
  • Quality of Care Information
  • Certain records associated with research/teaching

Personal health information is subject to the Personal Health Information Protection Act(PHIPA) and is not subject to FIPPA

Who can make a FOI request?

Any person can make an FOI request. The requestor does not have to be a Canadian citizen

How to make a FOI request?

The request can be made in writing to the hospital and accompanied by the $5.00 application fee (i.e. a cheque payable to the hospital)

Mailing address:

Privacy & Freedom of Information Office
Wellington Healthcare Alliance
235 Union Street East
Fergus, Ontario
N1M 1W3

Hospital Service Accountability Agreement

Infection Prevention and Control Reporting

Patient Safety

Surgical Safety Checklist

A surgical safety checklist is a patient safety communication tool that is used by a team of operating room professionals (nurses, surgeons, anesthesiologists, and others) to discuss important details about each surgical case. In many ways, the surgical checklist is similar to an airline pilot’s checklist used just before take-off. It is a final check prior to surgery used to make sure everyone knows the important medical information they need to know about the patient, all equipment is available and in working order, and everyone is ready to proceed.

Patient Safety Indicator Report Surgical Safety Compliance
  Palmerston and District Hospital Louise Marshall Hospital
January 2014 98.48% 99.38%
July 2014 98.43% 98.88%
January 2015 99.12% 97.20%
July 2015 98.37% 96.20%
January 2016 100% 98.50%
July 2016 98.61% 94.93%
January 2017 100% 97.0%
July 2017 100% 97.0%
January 2018 99.60% 93.69%
July 2018 100% 98.5%

Infection prevention and control reporting

Clostridium difficile Associated Disease (CDAD)

Clostridium difficile is one of many types of bacteria that can be found in feces and has been a known cause of hospital-associated diarrhea for about 30 years. C. diff is found in the intestine, occurring naturally in three to five percent of adults. It can be picked up on the hands from exposure to contamination in the environment and gets into the stomach once the mouth is touched, or if food is handled and then swallowed.

What do we do at NWHC to prevent Clostridium difficile infections?

  • We promote hand hygiene and work hard to provide clean environments to prevent infection all the time.
  • We monitor closely for new cases and watch for signs of transmission among patients.
  • We implement control measures (use of single rooms, careful hand hygiene, gowning, use of gloves, enhanced environmental cleaning) at the first sign of symptoms.  The precautions continue until patients are no long infectious.
  • We provide ongoing education to health care, nutritional services, maintenance and housekeeping staff in our hospitals.
  • We use antibiotics with care.

 If you require anything further you can contact Sandra Hamilton, Infection Prevention & Control at shamilton@nwhealthcare.ca

Patient Safety Indicator Report C.Difficile
 

Rate of acquired CDAD/1,000 patient days

Rate of acquired CDAD/1,000 patient days Number of NWHC acquired CDAD cases Number of NWHC acquired CDAD cases
  Palmerston and District Hospital (PDH) Louise Marshall Hospital (LMH) PDH LMH
Jan 2015 0 0 0 0
Feb 2015 0 0 0 0
Mar 2015 0 0 0 0
Apr 2015  0 0 0 0
May 2015 0 0 0 0
June2015 0 0 0 0
July 2015 0 0 0 0
Aug 2015 0 0 0 0
Sept.2015 0 0 0 0
Oct. 2015 0 0 0 0
Nov. 2015 0 0 0 0
Dec. 2015 0 0 0 0
Jan. 2016 0 0 0 0
Feb. 2016 0 0 0 0
Mar 2016 0 0 0 0
Apr 2016 0 0 0 0
May 2016 0 0 0 0
June2016 0 0 0 0
July 2016 0 0 0 0
Aug 2016 0 0 0 0
Sept.2016 0 0 0 0
Oct. 2016 0 0 0 0
Nov 2016 0 0 0 0
Dec 2016 0 0 0 0
Jan 2017 0 0 0 0
Feb 2017 0 0 0 0
Mar 2017 0 0 0 0
Apr 2017 0 0 0 0
May 2017 0 0 0 0
June2017 0 0 0 0
July 2017 0 0 0 0
Aug 2017 0 0 0 0
Sept2017 0 0 0 0
Oct 2017 0 0 0 0
Nov 2017 0 2.20 0 1
Dec 2017 3.03 0 1 0
Jan. 2018 0 0 0 0
Feb 2018 0 0 0 0
Mar 2018 0 0 0 0
Apr 2018 0 0 0 0
May 2018 0 0 0 0
June2018 0 0 0 0
July 2018 0 0 0 0
Aug 2018 0 0 0 0

Methicillin-resistant Staphylococcus Aureas (MRSA)/Vancomycin-resistant Enterococcus (VRE)

Bacteraemia means an infection in the blood stream. Cases of MRSA and VRE bacteraemia mean that the patients have confirmed bloodstream infections with either of these bacteria as proven through laboratory testing.

 

Patient Safety Indicator Report

MRSA/VRE bacteraemia

 

Rate of NWHC acquired MRSA/VRE bacteraemia per 1,000 patient days

Number of NWHC acquired MRSA/VRE bacteraemia cases

MRSA bacteraemia

Palmerston and District Hospital

Louise Marshall Hospital

Palmerston and District Hospital

Louise Marshall Hospital

Jan - March 2014 0 0 0 0
April - June 2014 0 0 0 0
July - Sept 2014 0 0 0 0
Oct - Dec 2015 0 0 0 0
Jan - Mar 2015 0 0 0 0
April - June 2015 0 0 0 0
July - Sept. 2015  0 0 0 0
Oct - Dec. 2015 0 0 0 0
Jan - March 2016  0 0 0 0
April - June 2016 0 0 0 0
July - Sept 2016 0 0 0 0
Oct - Dec 2016 0 0 0 0
Jan - March 2017 0 0 0 0
April - June 2017 1 0.92 0 0
July - Sept 2017 0 0 0 0
Oct - Dec 2017 0 0 0 0
Jan - March 2018 0 0 0 0
April - June 2018 0 0 0 0

VRE bacteraemia

Palmerston and District Hospital

Louise Marshall Hospital

Palmerston and District Hospital

Louise Marshall Hospital

Jan - March 2014 0 0 0 0
April - June 2014 0 0 0 0
July - Sept 2014 0 0 0 0
Oct - Dec 2014 0 0 0 0
Jan - Mar 2015 0 0 0 0
Apr - June 2015 0 0 0 0
July - Sept. 2015  0 0 0 0
Oct - Dec. 2015  0 0 0 0
Jan - March 2016  0 0 0 0
April - June 2016 0 0 0 0
July - Sept. 2016 0 0 0 0
Oct - Dec 2016 0 0 0 0
Jan - March 2017 0 0 0 0
April - June 2017 0 0 0 0
July - Sept 2017 0 0 0 0
Oct - Dec 2017 0 0 0 0
Jan - March 2018 0 0 0 0
April - June 2018 0 0 0 0

Hand Hygiene Compliance Rates

Ontario hospitals are posting their hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care.

April 1, 2014 - March 31, 2015

Type of Indication

% Compliance

 

Palmerston & District Hospital

Louise Marshall Hospital

Before initial patient/patient environment contact

84%

82%

After initial patient/patient environment contact

98%

96%

April 1, 2015 - March 31, 2016

Type of Indication

% Compliance

 

Palmerston & District Hospital

Louise Marshall Hospital

Before initial patient/patient environment contact

81%

85%

After initial patient/patient environment contact

90%

94%

April 1, 2016 - March 31, 2017

Type of Indication

% Compliance

 

Palmerston & District Hospital

Louise Marshall Hospital

Before initial patient/patient environment contact

92%

82%

After initial patient/patient environment contact

90%

93%

 

April 1, 2017 - March 31, 2018

Type of Indication

% Compliance

 

Palmerston & District Hospital

Louise Marshall Hospital

Before initial patient/patient environment contact

80%

80%

After initial patient/patient environment contact

92%

97%

We are not required to report on the following:

Central Line Infection (CLI) Surgical Site Infection (SSI) Ventilator associated pneumonia (VAP)

Organizational Chart

To access our organizational chart please click here.

Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario

As outlined in Patients First: Action Plan for Health Care, Ontario is committed to giving patients better access to care no matter where they live.

As part of this plan, Ontario is releasing this proposal for feedback. It outlines ways to:

  • Make it easier for patients to find a primary health care provider when they need one, see that person quickly when they are sick, and find the care they need, closer to home.
  • Improve communication and connections between primary health care providers, hospitals and home and community care.
  • Ensure the province has the right number of doctors, nurses, and other health care providers, and plan locally to make sure they are available to patients where and when they are needed.

The ministry looks forward to hearing from health care providers, patients and caregivers around the province on these recommendations. Feedback would be appreciated before 5 p.m. on February 29, 2016. Feedback and questions can be sent to health.feedback@ontario.ca

Patients First: Proposal to Strengthen Patient-Centred Health Care in Ontario

Patients First: Executive Summary

Public Sector Salary Disclosure

North Wellington Health Care annually posts employee salaries greater than $100,000 a year. These are generally posted in March for the previous calendar year. Below you will find links to our salary disclosures provided by the Ontario Treasury Board Secretariat:

Procurement Policy/Reporting

The Wellington Health Care Purchasing Procedure Policy helps to govern how Groves Memorial Community Hospital conducts sourcing, contracting and purchasing activities, including approval segregation and limits, competitive and non-competitive procurement, purchasing, contract awarding, conflict of interest and bid protest procedures.

Please read the WHCA Purchasing Procedure Policy

Quality Improvement Plan/Reporting

Quality Improvement Plan/Reporting

In June 2010, the Ontario Government passed the Excellent Care for All Act. This legislation will help support hospitals to further improve the quality and safety of care they provide for members of our community.

One of the ways that the Excellent Care for All Act is helping hospitals meet our community’s expectations regarding quality, patient safety and accountability is through the public reporting of Quality Improvement Plans.

Quality Improvement Plans (QIP) provide a meaningful way for North Wellington Health Care to clearly articulate our accountability to our community, patients and staff. Our QIP is focused on creating a positive patient experience and delivering high quality health care.

Our Quality Improvement Plan is made up of two parts:

  1. A document that provides a brief overview of our quality improvement plan, highlighting and listing our hospital’s top priorities for the year.
  2. A spreadsheet that includes our improvement targets and initiatives. The spreadsheet includes a core set of indicators that all similar hospitals across the province are working on. Please click here to read our Quality Improvement Plan. The Ontario Health Quality Council has requested that all hospitals report on a series of core indicators to support province-wide comparisons. The core indicators that apply to our hospital are reflected in our QIP. The QIP is only one of the ways we are working to improve our patients’ experiences. Please feel free to contact us with any questions you may have.

Please find below our annual Quality Improvement Plans:

2018/19 Quality Improvement Plan

2018/19 Quality Improvement Plan Narrative

The Ontario Health Quality Council has requested that all hospitals report on a series of core indicators to support province-wide comparisons. The core indicators that apply to our hospital are reflected in our QIP. The QIP is only one of the ways we are working to improve our patients’ experiences. Please feel free to contact us with any questions you may have.

Strategic Plan 2018-2021

The Wellington Health Care Alliance's Common Strategic Plan explains what we are going to focus on over the next three years in order to realize our Mission, Vision and Values:

Vision:                  Your Health Matters

Mission:               Together, advancing exceptional care and wellness

Values:                 We are compassionate, respectful, innovative, professional and collaborative

 

The Strategic Directions that are included in the plan will help us to focus on what is most important:

  • Best possible care and experience, informed by our patients
  • Inspired people – feeling valued, performing their best
  • Optimize system resources to deliver seamless care
  • Accountable organizations, meeting community needs, through a strong Alliance

Please click here to read the full plan.

North Wellington Health Care

  • Louise Marshall Hospital

  • 630 Dublin Street, Mount Forest,
    ON N0G 2L3
  • Map
  • Phone: (519) 323-2210
  • Palmerston and District Hospital

  • 500 Whites Road, Palmerston,
    ON N0G 2P0
  • Map
  • Phone: (519) 343-2030