Keeping you informed
We are committed to providing transparent and comprehensive quality reporting as a cornerstone of our dedication to patient-centered care. Our quality reports offer detailed insights into various performance metrics, including clinical effectiveness, patient safety, and service efficiency.
Section Access
To enhance your browsing experience, this page features anchor buttons that allow you to easily navigate up and down the page, making it simple to access the information you need quickly and efficiently.
Emergency Wait Times
The TADH’s Emergency Department (ED) team works to provide quality care as quickly as possible. The most seriously ill patients are seen first even though they may come into the department after other patients. This is why the triage nurse assesses everyone as soon as possible after they arrive.
Understanding Wait Times
When you hear about Emergency wait times in the media there are some important things you should know:
- Emergency wait times measure the total time spent during your entire visit in the Emergency Department and not the amount of time you wait to see a health-care provider. Your visit is measured from your arrival until the point at which you are sent home or admitted to hospital. Depending on your health care needs, your visit can be lengthy to ensure that you get the care you need.
- The provincial wait times are reported for Ontario. They are an average of all hospitals and it is important to recognize that the types of patients and the care they require cannot be compared easily between Emergency Departments.
Wait Time Categories
Wait times will vary based on a patient’s condition, and are generally divided into two categories:
High Acuity – Complex conditions requiring more time for diagnosis, treatment or hospital bed admission
These include a range of conditions from the most serious such as cardiac arrest, major trauma or a potential threat to life or limb function, to conditions that can potentially turn into to a serious problem without emergency intervention, such as asthma or moderate trauma. Some of these patients will require admission to hospital while others will not.
Low Acuity – Minor or uncomplicated conditions requiring less time for diagnosis, treatment or observation
These include less serious conditions such as urinary symptoms, mild abdominal pain, a sore throat or chronic health problems.
Surgical Wait Times
Launched in 2004, Ontario’s Wait Time Strategy was originally developed to improve access to five key health services with a goal to reducing wait times for these areas: cancer surgery, cardiac procedures, cataract surgery, hip and knee replacement, and MRI and CT scans. The strategy has since evolved – expanding to include all surgeries performed in Ontario and a new strategy being developed to reduce emergency room (ER) wait times. These strategies have been supported through significant investments to increase the number of surgeries and procedures being delivered, implementing new initiatives to improve ER processes and creating a system of accountability through transparent reporting of wait time information.
Please visit the Ministry of Health website to obtain the TADH’s data on wait times.
Please note that cancer surgery is part of every specialty and cancer surgery wait-times are reported to Cancer Care Ontario according to cancer site (type). You can find these wait times on the Cancer Care Ontario website.
Indicator Reporting
The TADH publicly reports on several patient safety indicators and immediately reports Clostridium Difficile (C. difficile) outbreaks to the local public health units so that Medical Officers of Health have the information they need to monitor and respond to emergent outbreaks.
Please visit Health Quality Ontario (HQO) to view patient/family experience indicators and data for TADH.
Central Line Infections
When a patient requires long-term access to medication or fluids through an IV, a central line is put in place to provide easy access to a vein. It is placed into a large vein in the neck, chest, groin, arm or abdomen. This is used instead of having to frequently insert needles for treatments such as chemotherapy, antibiotics and intravenous fluids, and feeding, or to take samples of blood for testing.
A central line blood stream infection (CLI-BSI) can occur when bacteria and/or fungi enters the blood stream, causing a patient to become sick. The bacteria can come from a variety of places (e.g., skin, wounds, environment, etc.), though it most often comes from the patient’s skin.
Hospitals follow best practices on how to prevent bacteria from entering into a central line. Patients in the Intensive Care Unit (ICU) often require a central line since they are seriously ill, and will require a lot of medication, for a long period of time.
More patient-specific information is available at
Measuring compliance rates
In Ontario, all hospitals with ICUs are required to report into the Critical Care Information System (CCIS) – a centralized data collection system where hospitals report a variety of critical care information. Included in the data is the CLI rate.
These Ontario hospitals are posting their quarterly CLI-BSI rate and case count for those infections acquired in their facility, using the following formula:
total # of ICU related CLI-BSIs after 48 hours of central line placement x 1000
total # of central line days for ICU patients 18 years and older
Infection Rate
Central line blood stream infection rates at TADH as of August 2024 = 0
Clostridium Difficile
C. difficile is just one of the many types of bacteria that can be found in the environment and the intestines. For most people, it does not pose a health risk. However, C. difficile associated disease (CDAD) can sometimes occur when antibiotics are prescribed. Antibiotics work by killing off bacteria – the bad bacteria – but also good bacteria. This can allow the C. difficile bacteria to multiply, which may cause diarrhea and can damage the bowel.
CDAD is the most common cause of infectious diarrhea in healthcare facilities. The effects of CDAD are usually mild but can sometimes be more severe. In severe cases, surgery may be needed, and in extreme cases CDAD may cause death.
Rates of C. difficile are the first of eight patient safety indicators that hospitals are required to publicly report. All of these indicators will be posted on the Ministry of Health website and also on each hospital’s own website.
It’s important to understand that the reporting of these rates is not the overall solution to reducing the rates of healthcare associated infections. They are tools which will provide hospitals with good information to assist them in understanding where patient safety issues exist and help them to take action to improve their safety standards.
The public reporting builds on other initiatives such as Just Clean Your Hands – a hand hygiene program for all Ontario Hospitals that was launched in March 2008 and the creation of 14 Regional Infection Control Networks across the province.
More patient-specific information can be found below
Rates of C. difficile
It is important to note that C. difficile rates, as is the case for all infections, can fluctuate over the course of a year for a number of reasons. For example in winter, we admit more patients with respiratory infection than at other times of the year. An increase of respiratory infections often results in more antibiotics being prescribed, a leading factor in new cases of C. difficile.
An increase in the rates of C. difficile may also be related to periods of increased occupancy levels. An increased number of patients mean that more patients are being cared for closer together. Close physical proximity can result in C. difficile being spread more easily.
When we experience cases of C. difficile, they are usually contained in a limited geographic area or unit of the hospital. Also, patients and families should know that compared to the overall number of patients admitted each year, these cases are relatively low in number.
That said, TADH pays close attention and follows a number of procedures to control and manage new cases of C. difficile. As described in the provincial best practice standards for managing C. difficile, we are:
- Isolating individuals identified or suspected to have C. difficile, wearing gowns and gloves to enter their rooms.
- Ensuring that all patients suspected of having C. difficile in hospital are tested.
- Reminding all staff of the importance of proper hand hygiene.
- Ensuring proper cleaning of all patient rooms, including rooms of C. difficile cases.
- Ensuring that visitors are instructed in hand washing and other control measures.
- Providing education where needed so that all members of our team are up-to-date with current management strategies.
- Ensuring that all patients with C. difficile infection are appropriately treated.
Measuring compliance rates
The C. difficile infection rate is calculated as a rate per 1,000 patient days. The “total patient days” represents the sum of the number of days during which services were provided to all inpatients during the given time period.
The rate is calculated as follows:
Number of new hospital acquired cases of C. difficile in our facility x 1000
Total number of patient days (for one month)
Infection Rate
C-difficile Rates at TADH as of August 2024 = 0.2%
Hand Hygiene Compliance
Patient safety remains the most important priority for TADH and we are working to create a culture of patient safety that involves everyone – health-care administration, health-care professionals, and, of course, patients and families.
Research shows that hand hygiene is the single most effective way to reduce the risk of healthcare-associated infections. Hand hygiene is a key issue for our hospital, and we continually work to improve compliance. Of course it is something we all do but we want to continue to do better and ensure everyone cleans their hands at the right times and in the right way.
Patients can help improve their own safety
Hand hygiene involves everyone in the hospital, including patients. Hand cleaning is one of the best ways you and your health-care team can prevent the spread of many infections. Patients and their visitors should also practice good hand hygiene before and after entering patient rooms.
More patient-specific information is available on the Ministry of Health website.
Measuring Compliance Rates
Ontario hospitals are posting their hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health, using the following formula:
Number of times hand hygiene performed x 1000
Number of observed hand hygiene indications
These Percentages Also Reflect
- Hand hygiene before initial patient/patient environment contact by combined health-care provider type (e.g., nurses, health professionals, physicians, housekeeping, support staff, etc.).
- Hand hygiene after patient/patient environment contact by combined health-care provider type (e.g., nurses, health professionals, physicians, housekeeping, support staff, etc.).
Compliance Rates
Hand hygiene compliance before initial patient/environment contact at TADH as of August 2024 = 91%
Hand hygiene compliance after patient/environment contact at TADH as of August 2024 = 92%
Hospital Standardized Mortality Ratio
The hospital standardized mortality ratio (HSMR) is an important measurement tool for hospitals and health regions that compares a hospital’s death rate with the overall overage rate. When tracked over time the HSMR indicates how successful hospitals or health regions have been in reducing inpatient deaths and improving care. HSMR helps consumers indirectly by providing hospital with a starting point to access mortality rates and identify areas for performance improvement.
Canadian Institute for Health Information has made HSMR results public only for “eligible” hospitals – those with more than 2,500 HSMR cases. It has not released results for hospitals, like ours, with less than 2,500 HSMR cases in any of the reporting years because low numbers make the results less stable and, therefore, less reliable.
Ontario’s hospitals are among the most accountable anywhere, and our hospital takes a great deal of pride in how open and transparent we are to the people we serve. The purpose of HSMR is to show statistically stable and reliable information.
We encourage the public to refer to the North East Level result, which can give you an indication of performance on this particular indicator in this region.
What is HSMR?
The hospital standardized mortality ratio (HSMR) is a measure of patient safety that compares a hospital’s mortality rate with a national standard. It is used by many hospitals worldwide to assess and analyze mortality rates and has been proven useful in identifying areas that can be changed to improve patient safety and the quality of care.
HSMR gives hospital administrators and health providers a snapshot of a hospital’s performance at a given time and must be viewed in context with other indicators to help track progress over time.
Measuring compliance rates
HSMR is a ratio of “observed” to “expected” deaths, multiplied by 100. A ratio greater than 100 means more deaths occurred than expected, while a ratio less than 100 suggests fewer deaths occurred than expected.
Observed Deaths x 100
Expected Deaths
- HSMR is based on diagnosis groups that account for 80% of deaths.
- HSMR is adjusted for factors affecting mortality (e.g. age, sex, length of stay).
Methicillin-resistant Staphylococcus Aureus
MRSA stands for methicillin-resistant Staphylococcus aureus. Staphylococcus aureus is a common bacterium or germ which commonly lives in the nose and on the skin. Most people who carry the Staphylococcus aureus bacteria do not have an infection. Sometimes people develop infections with this bacterium and require treatment. Infection in the bloodstream is called bacteremia.
When common antibiotics are not able to destroy Staphylococcus aureus, the bacterium is called “resistant”, or MRSA. Infections caused by MRSA are not more serious than infections caused by the regular Staphylococcus aureus bacterium. However, only a few antibiotics will treat MRSA infections.
More patient-specific information
For more information about MRSA, who gets it and how it is treated, please view the following resources.
Compliance Rates
MRSA rates at TADH as of August 2024 = 0.2%
Surgical Safety Checklist
Building on the government’s patient safety indicator initiative, TADH is reporting on its surgical safety checklist compliance.
The surgical safety checklist covers the most common tasks and items that operating room teams carry out, and has been shown to reduce rates of death and complications among patients. It is a one-page list of items that surgical teams must discuss at three key times:
- Before the patient is given anesthesia with all team members present.
- Before skin incision.
- While all team members are present before closing the patient.
TADH has been performing surgical safety checklists since 2005, and began using the formal list mandated by the province in June 2009. By implementing the surgical safety checklist, TADH is ensuring overall patient safety, teamwork and communication, and elevate surgical teams to an even higher standard of performance.
The dedicated health professionals who work at TADH are committed to providing the best possible care to patients, and they believe that a public reporting regime will inspire improved performance, enhance patient safety and strengthen the public’s confidence.
Surgical Safety Checklists Public Reporting
Ongoing monitoring and support of the surgical safety checklist process is essential to ensuring proper adherence. All Ontario hospitals that perform surgeries are required to report on their use of the surgical safety checklist to the Ontario government, and to the public.
Surgical safety checklist rates at TADH for 2023-2024 =100%
Surgical Site Infections
A surgical site infection (SSI) occurs at the site of a surgical incision (cut). Germs can sometimes get into the incision and cause an infection. An infection can occur any time after surgery but most commonly develops shortly afterward, usually within 30 days of an operation. Sometimes infections can occur much later, especially if an implant (such as a joint replacement, for example) is used.
SSIs are among the most common health-care-associated infections. SSIs can be minor, but occasionally they can result in a longer length of stay in the hospital, or can lead to readmission to hospital. As a patient you can help reduce your chance of infection by following all of the pre-operative instructions given to you by your surgeon and health care team and by not shaving the area where the incision will be made.
For some operations, such as joint replacements, giving an antibiotic just before surgery is one of the best ways to reduce the risk of infection. This indicator ensures that one of the most important steps in preventing SSIs is being used – i.e., ensuring that antibiotics are administered at the right time, just before a hip or knee joint replacement surgery.
The public reporting of this indicator reveals the percentage of all first time hip and knee replacement surgery patients who get antibiotics at the right time, just before joint replacement surgery. It is important to note that this indicator does not measure actual surgical site infections.
Measuring compliance rates
All hospitals that perform hip and/or knee joint replacement surgery must publicly report the SSI Prevention indicator data. These Ontario hospitals are posting their quarterly SSI Prevention percentages for their facility, using the following formula:
Number of Hip/Knee joint replacement surgery patients who received antibiotics 100% within 60 min of skin inscision + Number of Hip/Knee joint replacement surgery patients who received antibiotics within 120 min of skin incision.
Total number of patients during the reporting period who had a primary knee/hip joint replacement surgical procedure.
Compliance Rates
SSI rates at TADH as of August 2024 = 100% (Hip & Knee)
More patient-specific information is available at the Ministry of Health website.
Vancomycin-resistant Enterococci
VRE stands for vancomycin-resistant enterococcus. Vancomycin is an antibiotic used to treat infections. Enterococcus is a common bacterium that is normally found in the lower intestine. Sometimes people develop infections with this bacterium and require treatment. Only a few antibiotics can effectively treat enterococcal infections, and one of them is vancomycin. If the enterococcus bacterium develops resistance to vancomycin (vancomycin-resistant enterococcus), the antibiotic vancomycin will not be able to destroy the bacteria. There are other antibiotics that will treat VRE infections.
More patient-specific information
For more information about VRE, who gets it and how it is treated, please view the following resources.
Compliance Rate
VRE rates at TADH as of August 2024 =0
Ventilator-associated Pneumonia
For our public reporting purposes, ventilator associated pneumonia (VAP) is defined as a pneumonia (lung infection) occurring in patients in an intensive care unit (ICU), requiring, external mechanical breathing support (a ventilator) intermittently or continuously, through a breathing tube for more than 48 hours.
VAP can develop in patients for many reasons. Because they are relying on an external machine to breath, their normal coughing, yawning, and deep breath reflexes are suppressed. Furthermore, they may have a depressed immune system, making them more vulnerable to infection. ICU teams have many ways to try to assist patients with these normal breathing reflexes, but despite this, patients are still at risk for developing pneumonia.
Measuring compliance rates
All hospitals with ICUs are required to report into the Critical Care Information System (CCIS) – a centralized data collection system where hospitals report a variety of critical care information – must publicly report the VAP indicator data.
These Ontario hospitals are posting their quarterly VAP rate and case count for those infections acquired in their facility, using the following formula:
total # of ICU cases of VAP after 48 hours of mechanical ventilation x 1000
total # of ventilator days for ICU patients 18 years and older
Compliance Rates
VAP infection rates at TADH as of August 2024 = 0
More patient-specific information is available at the Ministry of Health website.
