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Accessibility  

Accessibility Plan

Under O Reg 191/11 (Integrated Accessibility Standards) under the Accessibility for Ontarians with Disabilities Act, 2005, hospitals must develop, implement, and maintain accessibility policies outlining how the organization will meet accessibility requirements. They are required to include a statement of commitment to meeting the acce​ssibility needs of persons with disabilities in a timely manner. Hospitals must also prepare one or more documents describing these policies, make them publicly available and provide them in an accessible format upon request (s 3).

A hospital is also required to establish, implement, and document a multi-year accessibility plan with strategies to prevent and remove barriers. This multi-year plan must be reviewed and updated at least every five years. Hospitals must also prepare an annual status report detailing progress in implementing the accessibility strategy.

Both the multi-year accessibility plan and the annual status report must be posted on the hospital's website, if applicable, and made available in an accessible format upon request (s 4)​.​

Facilities and Environmental  

Conservation and Demand Management (CDM) Plan

Under O Reg 25/23 under the Electricity Act, hospitals must develop and post an energy conservation and demand management (CDM) plan. The plan must be approved by the hospital's senior management team and published on the hospital's website. It must also be in printed form upon request (Electricity Act, s 25.35.2; O Reg 25/23, s 3).

Health Care and Public Health 

Patient Safety Indicators

Under Regulation 965 of the Public Hospitals Act, hospitals must publicly report certain public safety indicators, including hospital-acquired infections, activities to reduce hospital-acquired infections, and mortality rates. These indicators must be disclosed on the hospital's website, with reporting frequencies and deadlines varying depending on the indicator (s 22.2).

The reporting requirements include the following:

• Diagnoses of hospital-acquired infections: Hospitals must report the rates of specified infections, such as Clostridium difficile (C. Difficile), Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), and other infections as prescribed by the government.

• Activities undertaken to reduce hospital-acquired infections: Hospitals must publicly disclose initiatives to reduce hospital-acquired infections, including hand hygiene compliance among health care workers and surgical safety checklist completion.

• Mortality rates: Hospitals are required to report standardized mortality rates and other mortality-related indicators as outlined in guidance documents and directives.
  

For a detailed overview of the required patient safety indicators and up-to-date reporting timelines, refer to the Patient Safety Indicator Reporting.

Declaration of Patient Values and Patient Relations Process

Under the Excellent Care for All Act, 2010, all hospitals must have a publicly available patient declaration of values (s 7). Hospitals must also have a patient relations process that aligns with the content of patient declaration of values, complies with regulatory requirements, and is publicly accessible (s 6; O Reg 188/15). Typically, both the declaration of values and the patient relations process are made publicly available by posting them on the hospital's website.

Annual Quality Improvement Plans (QIPs)

Under the Excellent Care for All Act, 2010, all hospitals must develop an annual Quality Improvement Plan (QIP) that complies with regulatory requirements and is made publicly available by April 1 for the upcoming fiscal year (s 8, O Reg 187/15).

In developing the QIP, hospitals must consider aggregated critical incident data, patient surveys, and patient relations data. At a minimum, QIPs must specify measurable targets for quality improvement for the year ahead, along with a rationale for selecting these targets, a description of how executive compensation (where applicable) is tied to the achievement of the stated target and any additional factors outlined in the applicable regulations (O Reg 187/15 Annual Quality Improvement Plan).

Hospitals are required to make the completed QIP publicly available, typically by posting it on their website. 

For guidance and templates, hospitals can refer to resources available through Health Quality Ontario, which provides support for QIP development and reporting. 

Information, Privacy and Access 

Under the Personal Health Information Protection Act, 2004 (PHIPA), hospitals, as health information custodians, must designate a contact person (e.g., a Privacy Officer) responsible for ensuring compliance with PHIPA. This includes informing hospital agents of their duties, responding to inquiries about the hospital's information practices, handling requests for access to or correction of Personal Health Information (PHI), and addressing complaints related to PHIPA compliance (s 15).

Hospitals must also provide a written statement to the public describing their information practices. This statement must include contact information for the designated person (see above), instructions on how to request access to or correction of PHI, and details on how to file a complaint (s 16).

While PHIPA does not mandate a specific method of publication, this requirement can be met by posting the information on the hospital's website.

Public Sector Accountability, Operations and Governance  

Broader Public Sector (BPS) Expense Posting and Attestation Requirements

Under the Broader Public Sector Accountability Act, 2010 (BPSAA), hospitals must establish expense rules in accordance with the Act, its regulations, and guidelines or issued directives. These rules, along with expense claims, must be posted on the hospital's website (ss 8-11).

Hospital must publicly post expense claims biannually:

• By November 30 for the reporting period of April 1 to September 30​
• ​By May 31 for the reporting period of October 1 to March 31.

Expense claims must remain on the hospital's website for at least two years from the date of posting. 

• ​Type of expense 
• ​Amount claimed
  
• Date incurred
• Description of the expense
  

Additionally, hospitals must make annual attestations confirming compliance with the requirements of the BPSAA, its regulations, and any issued directives. Attestations must be made by the hospital's administrator, approved by the hospital's board of directors, and posted on the hospital's website by August 31 every year (s 15; BPS Hospital Reporting Directive, s 4). 

For a detailed overview of the BPS expense posting and attestation requirements, refer to the Government of Ontario's website: Broader public sector accountability.