Quality Improvement Indicators

Improve the health care system of tomorrow by facing today's challenges.

Learn about quality indicators, and how progress is tracked through Quality Improvement Plans (QIPs) by health care organizations across the province.

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          Effective transitions
          Timely access to care Services
          Medication safety
          Person experience
          Access to right level of care
          Palliative care

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          Showing 10 of 43 results

          Time to inpatient bed
          Sector:
          Hospital
          Quality Issue:
          Effective transitions
          Status:
          Current
          Search:
          Time to inpatient bed
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          Time to inpatient bed reflects patient flow in the hospital. It may be influenced by many factors, including the availability of inpatient beds, the alternate level of care rate, the patient population and the hospital’s resources.

          Click here to visit Health Quality Ontario’s Indicator Library to view how to measure this indicator.

          Key resources

          Achieving Hospital-wide Patient Flow: The Right Care, in the Right Place at the Right Time by the Institute for Healthcare Improvement

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          Optimize patient flow throughout the hospital

          Reduce avoidable hospital readmissions to increase bed availability

          Timely access to a primary care provider
          Sector:
          Primary care
          Quality Issue:
          Timely access to care Services
          Status:
          Current
          Search:
          Timely access to a primary care provider
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          Timely access to primary care is about getting supply and demand in equilibrium in order to supply timely, patient-centred care.

          This indicator is measured through a patient survey question, and therefore measures patient perception of timely access to a primary care provider.

          Click here to visit Health Quality Ontario's Indicator Library to view how to measure timely access to a primary care provider.

          Key resources

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          Implement key approaches outlined in the Advanced Access and Efficiency Workbook for Primary Care

          Improve patient awareness of appointment availability

          • Create a communications plan to ensure patients are aware that same day-next day appointments are available

          Sickle cell indicators
          Sector:
          Hospital
          Quality Issue:
          Medication safety
          Status:
          Current
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          Sickle cell indicators
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          Indicator: Average emergency department (ED) wait time to physician initial assessment (PIA) for individuals with sickle cell disease (SCD; CTAS 1 or 2)

          This indicator measures the wait time between triage PIA for patients with SCD that have been triaged as CTAS 1 or 2. This indicator will use average time to PIA as its evaluation metric.

          Key Resources

          Sickle Cell Disease Quality Standard

          Black Health Plan

          Sickle Cell Patient Guide

          Sickle Cell Disease Quality Standard Implementation Toolkit

          Vaso-occlusive Crisis Handbook

          Canhaem Sickle Cell Disease Consensus Statement

          Sickle Cell Awareness Group of Ontario Counselling Supports for Patients

          SCAGO Accredited Education Modules on Sickle Cell Disease

          Youth Rex Anti-Black Racism Certificate

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          Understand data

          Identify best practices for care of patients with sickle cell disease

          Community supports

          Anti-racism education and training

          Resident experience/Do residents feel they can speak up without fear of consequences?/Do residents feel they have a voice and are listened to by staff?
          Sector:
          Long-term care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Resident experience/Do residents feel they can speak up without fear of consequences?/Do residents feel they have a voice and are listened to by staff?
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          Specific Indicators

          • Do residents feel they can speak up without fear of consequences?
          • Do residents feel they have a voice and are listened to by staff?

          Gathering and acting on feedback from residents about their care experiences, and the services they receive, is vital to improving their quality of life. Health outcomes and mental health are often better for residents who have positive experiences and who are engaged in their own care. By actively seeking and responding to resident feedback, long-term care homes can build a culture of continuous improvement and trust, ultimately leading to a better quality of life for residents.

          Key resources

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          Improve how the home demonstrates respect for residents' values, preferences, and expressed needs

          • Educate residents and families on their rights under provincial legislation and the home’s policies and procedures
            Residents' Bill of Rights
            Formal complaints process
            Policy to promote zero tolerance of abuse and neglect
            Whistle-blowing protection policy
          • Promote participation in the home’s Residents’ Council and work with the council to make improvements in the home
            Appoint a Residents’ Council assistant who is acceptable to that council to assist the Residents’ Council (in accordance with Part V section 64 of the Fixing Long-term Care Act)
            - Residents Council Assistant Forums
            Use the Ontario Association of Residents' Councils Tools to Make the Most of Your Residents’ Council Meetings
          • Ask residents which actions on the part of the home (such as religious and spiritual accommodations) or activities (e.g., recreation and dining experiences) bring them enjoyment; put more of these actions into place and offer more of these activities
            Ontario Centres for Learning, Research and Innovation in Long-Term Care Diversity and Inclusion Calendar, for keeping track of days that may have special meaning for residents and families
            Ontario Centres for Learning, Research and Innovation in Long-Term Care program information and toolkit: The CHOICE+ Program: Enhancing the Mealtime Experience in Long-Term Care
            Ontario Centres for Learning, Research and Innovation in Long-Term Care toolkit: How to Run a Taste Test Event in Your LTC Home
          • Implement multiple avenues of communication for residents to provide feedback and learn about home updates and important information
            Put up a communication board that can include printouts of the home’s quality improvement plan, Resident Council meeting minutes, ombudsman contact information, etc.
            Set up an anonymous suggestion box
            Provide email contacts for department leads
            Establish an open-door policy

          Help staff become more knowledgeable about providing resident-centred care

          Incorporate residents’ knowledge, values, beliefs, and cultural background into care planning and delivery

          • Implement evidence-based practices and recommendations for person- and family-centred care
            RNAO Clinical Pathways

          Improve the resident experience by using models of care that best suit your resident population

          Repeat emergency department visits for mental health and addictions conditions
          Sector:
          Hospital
          Quality Issue:
          Person experience
          Status:
          Archived
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          Repeat emergency department visits for mental health and addictions conditions
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          Repeat emergency visits for mental health can occur due to issues such as poor access to adequate community-based care and/or challenges in medication adherence and self-care. They may be indicative of a negative clinical outcome or lack of services.

          Click here to visit Health Quality Ontario’s Indicator Library to view how to measure repeat emergency visits for mental health.

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          Motivate patients/clients towards self-care and enhance system navigation ability

          Engage patients/clients in discharge planning

          Connect patients/clients to community services that meet their needs

          Readmission within 30 days for mental health and addictions conditions
          Sector:
          Hospital
          Quality Issue:
          Person experience
          Status:
          Archived
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          Readmission within 30 days for mental health and addictions conditions
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          A readmission within 30 days for mental health or an addiction can occur due to issues such as poor access to adequate community-based care and/or challenges in medication adherence and self-care. It may be indicative of a negative clinical outcome or lack of services.

          Click here to visit Health Quality Ontario’s Indicator Library to view how to measure readmissions within 30 days for mental health and addiction.

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          Promote self-management and patient education

          Tailor discharge planning to the individual

          Plan for following up with patients after discharge

          Rate of workplace violence incidents resulting in lost time injury
          Sector:
          Hospital
          Quality Issue:
          Medication safety
          Status:
          Current
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          Rate of workplace violence incidents resulting in lost time injury
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          A health system with a culture of quality creates the conditions for staff to thrive, and ensuring their safety is one element of this. By addressing violence in our hospitals, we’ll be creating safer environments for our workers and improving patient care.

          Key resources

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          Ensure leadership support

          Risk assessment

          Education and training

          Reporting

          Rate of potentially avoidable emergency department visits for long-term care residents
          Sector:
          Long-term care
          Quality Issue:
          Access to right level of care
          Status:
          Current
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          Rate of potentially avoidable emergency department visits for long-term care residents
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          Avoidable emergency department (ED) visits pose significant clinical risks, stress, and anxiety for older, vulnerable residents in long-term care homes. Such visits can often be disruptive, leading to adverse health outcomes, including hospital-acquired infections, delirium, and a decline in functional abilities. Overcrowding and escalating costs in hospital EDs in Ontario have long been a concern, highlighting the need for a comprehensive strategy to manage avoidable transfers from long-term care homes. Strengthening in-home care capabilities, improving staff training, and enhancing care coordination are critical to address this pressing issue from all angles.

          Key resources

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          Educate staff, residents, and families about the benefits of preventing ED visits and the services the home has to manage care within the home

          • Enhance staff training on early recognition and management of common conditions that may result in ED visits, such as infections and dehydration
            Preview ED Observation Tool
          • Educate staff on effective communication techniques between members of the health care team and external clinical supports about a resident’s condition
            SBAR Tool; SBAR example
          • Strengthen fall prevention programs to reduce injury-related ED visits by using environmental modifications, regular assessments, and mobility aids
          • Increase access to on-site diagnostic tools, tests, and treatments (e.g., x-rays, ultrasounds, bladder scanner, lab tests, intravenous therapy) to manage conditions within the home
          • Introduce virtual consultations for nonurgent health concerns to provide residents with timely care
          • Work collaboratively with clinical supports, such as nurse-led outreach teams at local hospitals, nurse practitioners supporting teams averting transfers, and on-site nurse practitioners, to deliver education, training, and clinical guidance to home staff and participate in decisions to transfer a resident to a hospital
          • Enhance palliative approach to care within the long-term care home
            Strengthening a Palliative Approach in Long-Term Care
            LEAP – Learning Essential Approaches to Palliative Care offered by Pallium Canada
          • Complete advance care planning and ensure all residents have up-to-date care directives to guide decision-making and reduce unnecessary hospital transfers
          • Involve the resident and their family, care partner or substitute decision-maker in care conferences to review care plan goals and preferences, particularly around end-of-life care

          Resources for Health Care Professionals

          • Use evidence-based tools to identify residents who would benefit from a palliative approach to care
            The Ontario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outline recommended tools that can be integrated into various care settings
          • Implement an evidence-based model of care for providing palliative care in long-term care
            The Ontario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide the organization and delivery of palliative care and includes a patient pathway
          • Provide access to evidence-informed tools to support long-term care clinicians with palliative care delivery. Resources should include:
            Palliative care or comfort care order sets (typically, these are facility specific and established locally)
            Symptom management guides
            - e.g., The BC Centre for Palliative Care’s Inter-professional Palliative Symptom Management Guidelines, Ontario Health’s symptom management guidelines
            Resources to support serious illness conversations and Goals of Care discussions:
            - Ariadne Lab and the Dana-Farber Cancer Institute’s Serious Illness Conversation Guide
            - Advance Care Planning Canada’s Just Ask: A Conversation Guide for Goals of Care Discussions
            - Guide and template for Documenting Goals of Care discussions
          • Consider supplemental education on pain and symptom management and skills training to support goal of care discussions to help build capacity within the home
          • Build linkages with community palliative care partners to supplement long-term care staff and create more specialized palliative care knowledge and skills in long-term care homes. Providers and organizations to engage include: 
            • Palliative pain and symptom management consultants
            • Local hospice residences
            • Nurse-led outreach teams
            • Paramedics and palliative care programs

          Rate of hospital-acquired pressure injuries (stages 3 and 4 and unstageable)
          Sector:
          Hospital
          Quality Issue:
          Medication safety
          Status:
          Archived
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          Rate of hospital-acquired pressure injuries (stages 3 and 4 and unstageable)
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          Patients within hospitals are at risk of developing pressure injuries. Cases of pressure injuries have risen steadily in Ontario, from about 1,245 per 100,000 hospitalizations in 2020/21 to about 1,920 per 100,000 hospitalizations in 2024/25. Advanced-stage (stages 3 and 4 and unstageable) and hospital-acquired pressure injuries are preventable and are identified as a hospital never event. Pressure injuries contribute to longer hospital stays and increased risks for significant patient harm (pain, infection, mortality) and to patient safety. Reducing hospital-acquired pressure injuries is a patient safety priority. Pressure injuries can be prevented through early detection and intervention to significantly reduce incidence and severity

          Key resources

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          Refine local data collection, and review data regularly

          • Review data sources related to pressure injuries to understand your organization’s current state and pressure injury data:
            Ontario Health’s Pressure Injuries Quality Standard (HAPI) eReport; requires a ONEID account – please contact QualityandPatientSafety@ontariohealth.ca for assistance
            Canadian Institute for Health Information (CIHI) Hospital Harm Project data; overview of “pressure ulcer” rates is available
          • Refine local processes related to how data is collected, reported, and actioned:
            Monitor real-time rates and review your local organizational data, electronic medical records (EMRs), skin assessment reports, incident-reporting systems
          • Standardize definitions and documentation by implementing an organization-wide standard to identify, stage, and document pressure injuries. Adopt standard criteria for pressure injury stages, define “hospital-acquired,” and use standardized templates across units:
            RNAO Best Practice Guideline, Pressure injury management: Risk assessment, prevention and treatment

          Build capacity and establish wound care champions to strengthen prevention efforts

          Standardize assessments and focus efforts on early-risk identification and escalation pathways

          Rate of delirium onset during hospitalization
          Sector:
          Hospital
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Rate of delirium onset during hospitalization
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          Delirium affects patient safety, patient experience, alternate level of care (ALC) rates, access, and flow. Delirium is associated with increased mortality in several care settings (emergency department, hospital care, and long-term care (LTC)) and prolonged length of stay in hospital (~8 days) (McCusker et al, 2003). Patients that develop delirium are 2.4 times more likely to be placed in LTC, which leads to longer wait times and a greater number of ALC days. Delirium is only recognized in about one-third of cases, so education and prevention strategies are critical to improving patient outcomes.

          Hospitals interested in this topic are welcome to join the Delirium Aware Safer Healthcare (DASH) campaign. Launched in April 2024, this 3-year provincial campaign promotes awareness and strengthens the ability of hospital teams across Ontario to prevent, identify, and manage hospital-acquired delirium. Join the community of practice on Quorum (linked below), where you can find all previous webinars in support of the change ideas below.

          Key Resources

          Delirium Quality Standard

          Delirium Aware Safer Healthcare (DASH) ‒ Community of Practice

          The Alternate Level of Care (ALC) Leading Practices Guide: Preventing Hospitalization and Extended Stays for Older Adults

          Provincial Geriatrics Leadership Ontario Quality Standard Implementation Guide

          Delirium Senior Friendly Hospital Toolkit

          sfCare E-Learning Series

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          Exercise caution when prescribing certain medications (e.g., sedative-hypnotics, benzodiazepines, opioids)

          Create a sleep-friendly environment

          Address delirium prevention and management strategies daily

          Maintain wellness to prevent deconditioning

          Engage and educate care partners on delirium prevention

          Adopt a diagnostic approach to identifying patients at high risk of acquiring delirium while in hospital

          Typically, delirium is not the main reason for a patient's admission to an inpatient facility. Patients with hip fractures, cardiac disease, and COPD have an increased risk of hospital-acquired delirium.

          References

          1. McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc. 2003 Nov;51(11):1539–46.

          2. Discharge Abstract Database, Fiscal year 2022

          Proportion of patients for whom medication reconciliation was completed at discharge
          Sector:
          Hospital
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Proportion of patients for whom medication reconciliation was completed at discharge
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          Admission into the hospital can result in a patient receiving new medications or having changes made to their existing medications. Medication reconciliation is a systematic and comprehensive review of all the medications a patient is taking, including prescription and non-prescription drugs, to ensure that medications being added, changed or discontinued are carefully evaluated and communicated consistently across transitions of care.

          Click here to visit Ontario Health’s Indicator Library to view how to measure medication reconciliation at discharge.

          Key resources:

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          Conduct medication reconciliation within 24-48 hours of being admitted to hospital

          Define the roles interdisciplinary providers play in medication reconciliation

          Ensure hospital infrastructure supports the process of medication reconciliation

          Planetary health
          Sector:
          Hospital, Primary care, Long-term care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Planetary health
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          Sustainability is a core component of high-quality care, and the need to incorporate a “green lens” and embed environmental sustainability into quality improvement efforts has never been more evident.

          Be it through reducing low-value, carbon-intensive care, selecting more climate-friendly medication options when clinically appropriate, training and educating the workforce toward environmental sustainability and resource stewardship, or adopting reusables in lieu of disposables, there are myriad approaches to advancing high-quality, low-carbon, and sustainable health systems.

          As you work on quality improvement initiatives, it’s important that you integrate a focus on environmental sustainability and climate stewardship in your indicators.

          This tile was developed in collaboration with CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis), PEACH (Partnerships for Environmental Action by Communities within Healthcare systems), and The Canadian Coalition for Green Health Care. CASCADES is a pan-Canadian initiative that strengthens the capacity of the healthcare community across Canada to transition towards, high-quality, low-carbon, sustainable and climate resilient care. CASCADES is funded by funded by Environment and Climate Change Canada. PEACH’s mission is to cultivate and sustain partnerships across health care facilities in Ontario to support climate action. PEACH is supported through Planetary Health and the Department of Family Medicine at McMaster University. The Canadian Coalition for Green Health Care is a national organization that has been working for 25 years on developing green health policies and practices.

          Key Resources:

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          Medication optimization

          • Eliminate use of desflurane as an anesthetic agent
            CASCADES’ playbook: Sustainable Perioperative Care Playbook
            CASCADES’ YouTube video: Sustainable Perioperative Care- Eliminate Desflurane at North York General Hospital
            CASCADES’ project charter: Eliminate desflurane
            Journal article: Developing a quality improvement project to tackle the desflurane problem
            Indicator examples
            % of total anesthetic agents purchased that is sevoflurane (desired direction:↑)
            % of total anesthetic agents purchased that is desflurane (desired direction:↓)
            % of patients who were given a non-desflurane anesthesia (desired direction:↑)
            % of staff educated about environmentally friendly gasses (desired direction:↑)
          • Follow the sustainable prescribing pathway for inhalers
            CASCADES’ playbook: Climate Conscious Inhaler Prescribing in Inpatient Care
            CASCADES’ playbook: Climate Conscious Inhaler Prescribing in Outpatient Care
            CASCADES’ collaborative: Climate Conscious Inhaler Prescribing Collaborative
            CASCADES’ course: Climate Conscious Inhalers Prescribing Course
            PEACH toolkit: Options for sustainable prescribing
            Indicator examples
            # of existing prescriptions that were switched from MDIs to DPIs (per reporting period) (desired direction:↑)
            # of new prescriptions for metered dose inhalers (MDIs) (per reporting period) (desired direction:↓)
            # of new prescriptions for dry powder inhalers (DPIs) (per reporting period) (desired direction:↑)
            Indicator examples
            % of patients using inhalers with a confirmed diagnosis of asthma or chronic obstructive pulmonary disease (COPD) (desired direction:↑)
            % of patients using inhalers with well-controlled disease (desired direction:↑)
            # of existing prescriptions that were switched from MDIs to DPIs (per reporting period) (desired direction:↑)
            # of new prescriptions for metered dose inhalers (MDIs) (per reporting period) (desired direction:↓)
            # of new prescriptions for dry powder inhalers (DPIs) (per reporting period) (desired direction:↑)
            % of patients using inhalers with observed proper technique (desired direction:↑)
            % of patients using inhalers instructed on proper disposal methods (return to pharmacy) (desired direction:↑)
            # of inhalers prescribed per visit (for acute care) (desired direction:↓)

          Food infrastructure

          • Implement plant-forward menus
            CASCADES’ Playbook: Food Infrastructures for Planetary Health
            Journal article: Food is medicine: actions to integrate food and nutrition into healthcare
            The Planetary Health Diet - EAT Forum
            PEACH Guidebook: Sustainable health care food system: Business case and implementation guide
            Coolfood Pledge: resources that help organizations commit and achieve science-based targets to reduce climate impacts of food
            Indicator examples
            % of plant-forward meal options for patients relative to all meal options (desired direction:↑)
            % of plant-forward meal options for visitors and staff relative to all meal options (desired direction:↑)
            % of patients counselled on the health benefits of plant-forward diets (desired direction:↑)

          Health workforce preparedness

          • Build internal capacity
            CASCADES’ course (~20 min- asynchronous): Orientation to Sustainable Health Systems
            CASCADES’ course (~ 90 min- asynchronous): Introduction to Sustainable Health Systems
            CASCADES’ course (4 hours, synchronous course): Fundamentals of Sustainable Health Systems
            CCGHC Green Office Challenge: Comprehensive health care environmental performance benchmarking tool
            CCGHC toolkit: Green Office Toolkit
            CCHGC Green Team Project: How to start a green team
            CCGHC Project: Preparing Canada’s Health Care Buildings for Net-Zero
            CCGHC Environmental Stewardship Guidebooks: Guidebooks for sustainable psychiatry, radiotherapy, rheumatology, cardiology, intensive care and more
            CCGHC and PEACH working groups and networking hubs
            Indicator examples
            % of staff educated on resilient, low carbon and sustainable health systems (desired direction:↑)
            % of staff that completed CASCADES' Introduction to sustainable health systems learning module (desired direction:↑)

          Leadership and governance

          • Engage senior leadership and enable governance structures for sustainability reporting
            CASCADES’ playbook: Organizational Readiness Playbook
            Interior Health’s Roadmap: Climate Change and Sustainability Roadmap 2023–2028
            Vancouver Coastal Health’s Planetary Health Strategy: Vancouver Coastal Health Planetary Health Strategy 2024-2029
            Fraser Health’s Planetary Health Strategy: Fraser Health Planetary Health Strategy 2023-2028
            NHS England’s roadmap: Delivering a net zero health service | National Health Service
            CCGHC Program: Healthy Capital: Sustainable Investment for Hospital Foundations
            PEACH and CCGHC Care Guidebook: Environmental Stewardship: An implementation guide for boards, executive leaders, and clinical staff: Meeting hospital standards and beyond
            Indicator examples
            Has sustainability been formally integrated into one or more leadership roles? (Y/N)
            # of leadership roles with a formal sustainability component (desired direction:↑)
            % increase of leadership roles embedding sustainability as a formal component and responsibility (desired direction:↑)

          Reusables

          Percentage of people who undergo hip fracture surgery within 48 hours of first arrival at any hospital
          Sector:
          Hospital
          Quality Issue:
          Effective transitions
          Status:
          Current
          Search:
          Percentage of people who undergo hip fracture surgery within 48 hours of first arrival at any hospital
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          People with hip fracture requiring surgery should receive surgical intervention as soon as possible, within a maximum of 48 hours of their first presentation to hospital, regardless of whether they are subsequently transferred to another hospital for surgery. Increased time to surgery causes prolongation of pain and extended hospital stays and is associated with increased morbidity and mortality.

          Each year, about 12,000 people in Ontario aged 50 years and older experience a hip fracture. In FY 2022/23, one-quarter (25%) of people with hip fracture waited longer than the recommended 48 hours for surgery. Most people who had hip fracture surgery (85%) were admitted through the ED. However, those admitted through the ED had longer wait times than those admitted directly as an inpatient, with median wait times of 33 hours and 21 hours, respectively.

          Key Resources

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          Standardize and streamline the hip fracture care pathway

          Prioritize surgery for hip fracture patients

          • Prioritize hip fracture cases as B cases and escalate urgency as elapsed time approaches 42 hours
          • Dedicate blocks of operating room time each day for emergency orthopaedic cases
          • National Hip Fracture Toolkit , see Operating Room Priority Management
          • Hip Fracture Quality Standard , see Quality Statement 2: Surgery Within 48 Hours

          Review Hip Fracture Data Regularly

          • Initiate regular interprofessional reviews of data on wait time to surgery for people with hip fracture to identify organizational opportunities for improvement. Potential data sources include:
            Ontario Health’s Hip Fracture eReport
            - For hospitals participating in ONSQIN: Collect targeted hip fracture procedure data via NSQIP to track postoperative outcomes and performance. Please contact ONSQIN@ontariohealth.ca for assistance
            Power BI organizational dashboard

          Build capacity to develop an interdisciplinary approach to hip fracture care quality improvement

          Percentage of non-palliative care patients newly dispensed an opioid
          Sector:
          Primary care
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Percentage of non-palliative care patients newly dispensed an opioid
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          This indicator measures the percentage of non-palliative patients newly dispensed an opioid within a six-month reporting period prescribed by any provider in the health care system.

          The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain and Ontario Health's quality standard for Opioid Prescribing for Chronic Pain both recommend against prescribing opioids for chronic non-cancer pain until non-opioid pharmacotherapy and/or nonpharmacological therapies have been attempted. Avoiding new starts of opioids can help to prevent long-term use, which can lead to significant harm.

          Performance on this indicator is available in Ontario Health's MyPractice Primary Care Report.

          Key resources

          Search:

          Prescription Monitoring Systems

          Resources for Health Care Professionals

          Patient Information on Benefits and Harms of Opioid Use and Shared Decision-Making

          Percentage of LTC residents who fell in the last 30 days
          Sector:
          Long-term care
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Percentage of LTC residents who fell in the last 30 days
          Search:

          Falls are a significant concern among older adults – they can lead to immediate physical injuries and are a leading cause of injury-related emergency department visits and hospital admissions in Canada. For many older adults, a fall can be a critical turning point toward frailty and overall health decline. This can result in the loss of independence, severely impacting quality of life. Furthermore, fall-related injuries place a substantial financial burden on the provincial health care system, making effective prevention strategies essential.

          Key resources

          Search:

          Assess and manage fall risk in residents

          Implement universal fall precautions

          • Complete an environmental safety checklist for each new resident upon move-in
          • Conduct ongoing surveillance of resident spaces to promptly clean up environmental hazards like clutter, spills, and trip hazards
            Appendix to RNAO resource:Components and Example of Universal Falls Precautions
          • Identify and modify equipment and other factors in resident spaces that could contribute to falls (e.g., improve lighting in room, install night lights)
          • Implement the use of devices and equipment (such as low-profile beds, bed and chair alarms, and grab bars) that can help reduce the risk of falling

          Follow best-practice rehabilitation care pathways

          Percentage of LTC residents not living with psychosis who were given antipsychotic medication
          Sector:
          Long-term care
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Percentage of LTC residents not living with psychosis who were given antipsychotic medication
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          In Ontario long-term care homes, antipsychotic medications play a crucial role in treating behavioral symptoms, such as agitation and aggression, that are associated with psychosis or dementia. However, the use of antipsychotic medications has become a subject of controversy, both within the province and globally, due to their potential adverse effects, which include sedation, increased fall risk, and a slightly elevated risk of death. Family members of residents are often concerned when they witness these effects – loved ones struggling to communicate or experiencing prolonged periods of drowsiness – but, for some residents, not taking these medications can lead to behaviours that pose risks to themselves and others around them.

          Key Resources

          Search:

          Collect and monitor current resident medication use data

          • Review medication use data from the home and from pharmacy providers (e.g., indications, new starts, PRNs, administration rates, summary of responsive behaviours, interventions)
          • Sign up for long-term care practice reports for antipsychotics data and change ideas for reducing the use of antipsychotic medications
            Ontario Health MyPractice: Long-Term Care

          Establish a regular medication review process

          • Use a simple, standardized medication review process
            Alberta Health Services: Pharmacologic Restraint Management Worksheet
          • Upon admission of new residents, conduct a comprehensive assessment to determine if antipsychotic medications are being used and whether there is an appropriate diagnosis that justifies their use
          • Consider using an interprofessional approach – involving behaviour support leads, physicians, pharmacists, nurses, and personal support workers – for monthly and quarterly medication reviews
          • Review the charts of residents that trigger the RAI (Resident Assessment Instrument) Indicator Code: DRG01 to assess appropriate use of antipsychotics

          Develop and update individual behaviour care plans

          Collaborate with behavioural support and mental health services

          • Explore opportunities to work with an external behavioural support lead, team or champion
            Consult Behavioural Supports Ontario or consult with a Geriatric Mental Health Outreach Team or a Psychogeriatric Resource Consultant

          Improve staff education and training on dementia

          • Educate staff on antipsychotic medications and the behavioural symptoms of dementia
          • Train staff to use a person-centred, compassionate, gentle approach to responsive behaviours
            Advanced Gerontological Education’s fact sheet on About Gentle Persuasive Approaches in Dementia Care training
          • Train staff to consistently complete necessary care plan documentation
          • Implement protocols and clinical pathways that are in-line with best practice guidelines to clearly guide staff actions
            RNAO Best Practice Guidelines
            RNAO Clinical Pathways

          Percentage of long-term care residents whose stage 2, 3, or 4 pressure ulcer worsened
          Sector:
          Primary care
          Quality Issue:
          Medication safety
          Status:
          Archived
          Search:
          Percentage of long-term care residents whose stage 2, 3, or 4 pressure ulcer worsened
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          Pressure ulcers, also known as pressure injuries, are a serious and often preventable condition that can affect residents in long-term care. Pressure injuries in stages 2, 3, or 4 involve damage that extends beyond the skin surface, ranging from partial-thickness skin loss to deep tissue injury involving muscle or bone. When these injuries worsen, residents may experience significant pain, increased risk of infection, and reduced quality of life. For older adults with limited mobility or chronic health conditions, a worsening pressure injury can signal a decline in overall health and function, often requiring more intensive care and treatment. Preventing progression through early detection, regular skin assessments, and evidence-based interventions is critical to maintaining residents’ comfort, dignity, and overall well-being.

          Key Resources

          Search:

          Deliver staff education and training on early detection and prevention

          • Provide ongoing training on pressure injury prevention, assessment, and staging, using current best practice guidelines
          • Use case studies and visual tools to improve staff recognition of early-stage skin changes
          • Educate all staff, including non-clinical team members, on the importance of repositioning and skin checks

          Conduct comprehensive risk screening and assessment for every resident

          • Screen all new residents for pressure injury risk using validated tools (e.g., Braden Scale) within 24 hours of admission
          • Repeat risk assessments regularly and after significant changes in a resident’s health status
          • Document risk scores and tailor prevention plans accordingly

          Implement the evidence-based SSKIN prevention bundle

          • Adopt and maintain the SSKIN bundle (surface, skin inspection, keep moving, incontinence, nutrition) for all at-risk residents
          • Ensure repositioning schedules are documented and followed
          • Provide high-specification foam mattresses or pressure redistribution surfaces for residents at high risk

          Engage residents and families in prevention

          • Review prevention strategies and care plans with residents and families during care conferences
          • Provide education on early signs of skin breakdown and how to report them promptly
          • Involve residents in setting mobility, nutrition, and hydration goals to support skin health

          Facilitate interprofessional collaboration for wound care planning

          • Involve wound care specialists, nurses, physiotherapists, dietitians, and occupational therapists in prevention and treatment plans

          • Have physiotherapists design mobility programs to reduce prolonged pressure
          • Have dietitians assess nutritional needs and recommend supplements to promote skin healing

          Percentage of long-term care residents in daily physical restraints
          Sector:
          Long-term care
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Percentage of long-term care residents in daily physical restraints
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          The use of physical restraints in long-term care is a significant concern. While restraints are sometimes used with the intention of preventing harm, they can lead to serious physical complications, such as reduced mobility, pressure injuries, and an increased risk of falls. Restraints can also cause psychological harm, including confusion, agitation, and depression. For many residents, restraint use negatively impacts dignity and quality of life. Minimizing restraint use is therefore a key priority in providing safe, resident-centred care and improving overall health outcomes in long-term care settings.

          Key Resources

          Search:

          Train all staff on alternatives to restraint use

          • Deliver mandatory education sessions on evidence-based, non-restraint interventions
          • Use real case scenarios to demonstrate how to de-escalate behaviours without physical restriction
          • Conduct hands-on workshops for staff to practise communication, redirection, and environmental modification strategies

          Enforce a least restraint policy

          • Implement a clear home-wide policy prioritizing alternatives before any restraint use
          • Audit restraint use regularly to ensure compliance with the Fixing Long-Term Care Act and professional standards
          • Require documentation of the rationale for any restraint use, including all attempted alternatives and reassessment plans

          Complete individualized assessments for every resident

          • Assess all residents within 24 hours of admission for fall risk, mobility challenges, and triggers for responsive behaviours
          • Reassess after any significant health, cognitive, or behavioural change
          • Use assessment findings to create tailored safety and mobility plans that avoid restraints

          Apply targeted mobility and environmental strategies

          • Engage physiotherapists to improve mobility, balance, and strength through exercise programs
          • Have occupational therapists adapt the environment with clear signage, grab bars, and low beds to support orientation and reduce wandering risks
          • Adjust lighting, noise levels, and room layouts to prevent confusion and agitation

          Partner with residents and families

          • Discuss restraint policies, risks, and alternatives during care conferences
          • Provide residents and families with information on safe, non-restrictive safety measures
          • Involve residents and families in co-designing mobility and activity plans that maintain dignity and independence

          Percentage of discharge summaries sent from hospital to community care within 48 hours of discharge
          Sector:
          Hospital
          Quality Issue:
          Effective transitions
          Status:
          Current
          Search:
          Percentage of discharge summaries sent from hospital to community care within 48 hours of discharge
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          Discharge summaries should be sent to patients’ primary care providers within 48 hours of their discharge to ensure continuity of care and enable follow-up by the primary care provider in a timely manner (typically within seven days). Doing so can improve patient satisfaction and reduce hospital readmissions and patient complications.

          A good discharge summary should provide relevant information on the patient’s care while in the hospital and describe the next steps for their care, including plans for follow-up appointments, test results to be returned, and other tests required.

          Click here to visit Health Quality Ontario’s Indicator Library to view how to measure this indicator.

          Search:

          Continuity of care and transitions

          Percentage of clinicians within the primary care practice utilizing provincial digital solutions
          Sector:
          Primary care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Percentage of clinicians within the primary care practice utilizing provincial digital solutions
          Search:

          The persistence of paper- and fax-based workflows, as well as suboptimal digital solutions that are implemented inconsistently across the health care system, is a significant contributor to administrative burden. This can lead to:

          • Patient safety risks posed by delays in receiving timely and appropriate care due to faxing errors and illegible information
          • Slower access to care caused by unnecessary waits from slower processing time, fax backlog, and extra follow-ups associated with fax errors and misdirects
          • Privacy breaches, including misdirected faxes, which accounted for 50% of the complaints about health care privacy breaches made to the Information and Privacy Commissioner of Ontario in 2021
          • Patient safety risks posed by delays to receiving timely and appropriate care because of faxing errors and illegible information.

          Key resources

          Search:
          • AI Scribe
            An AI scribe is a digital assistant that uses artificial intelligence to listen to conversations during a patient visit and automatically turn them into clinical notes. This helps reduce the amount of time physicians spend typing or dictating notes after a visit. Some AI scribes can also automate tasks such as booking follow-up appointments or sending reminders using robotic process automation (RPA).
            The Government of Ontario, in partnership with Supply Ontario and OntarioMD, has selected recognized Canadian vendors to offer AI scribe technology that supports family physicians and nurse practitioners. These vendors meet key clinical, privacy and security standards, and offer fair pricing—helping to reduce the time, cost, and effort of finding the right solution. The vendor of record (VOR) list is available on the Supply Ontario website.
            To help physicians and nurse practitioners integrate AI scribes into their practice, OntarioMD will offer complimentary change management support, including training, technical assistance, and workflow guidance. Please email OntarioMD for any questions or requests for information. 
            Additional Resources:
            OntarioMD Report: “AI scribes show promising results in helping family doctors and nurse practitioners spend more time with patients and less time on paperwork”
            OntarioMD Report: “Transforming Primary Care with AI: A Collaborative Implementation Strategy”
          • eConsult
            eConsult is a secure digital health tool that provides family physicians, nurse practitioners, and midwives with timely access to specialist advice that they may need to deliver care to their patients, often eliminating the need for an in-person specialist visit.
          • e-Prescribing
            e-Prescribing enables prescribers and pharmacists to transmit prescriptions electronically and enables prescribers to electronically transmit a prescription directly from an electronic medical record (EMR) to the pharmacy management system (PMS) of a patient’s pharmacy of choice. ePrescribing also enables clinical communications, making it easier for prescribers and pharmacists to clarify questions about a patient’s prescription.
          • eReferral
            eReferral (electronic referral) enables quick and secure referrals between primary care clinicians, specialists, and organizations across the province, reducing administrative burden and allowing clinicians to spend more time delivering patient care.

            To learn more about eReferral and get started with eReferral Ontario, please visit this information page from Ontario Health.

          • Health Report Manager
            Health Report Manager (HRM) facilitates secure electronic transfer of patient records between hospitals, independent health facilities, specialty clinics, and community-based primary care clinicians (such as physicians and nurse practitioners) using an OntarioMD-certified EMR system. It reduces the reliance on paper- and fax-based workflows by adding patient reports, such as narrative, text-based medical records, and diagnostic imaging, directly into a patient’s record within their clinician’s EMR. This provides clinicians with timely access to the clinical reports they need to make informed decisions and empowers care teams to follow up with patients sooner to ensure seamless continuity of care. 
          • Online Appointment Booking
            Online appointment booking solutions enable patients to book in-person, video, or telephone appointments electronically, by choosing a date and time and receiving an automated appointment confirmation, all in a self-serve environment available 24/7. In addition to booking appointments, online appointment booking���solutions offer other beneficial features such as automated email, text message, and voice reminders.
          • Ontario Laboratories Information System (OLIS)
            Ontario Laboratories Information System (OLIS) is a secure digital health tool that provides authorized health care providers with access to patients’ laboratory test orders and results, both past and present, from hospitals and public health and community labs through 1 platform. The centralization of information enables a patient’s results to follow them as they move between different care settings (e.g., from a hospital to long-term care), and enables health care providers to make more informed, timely, and safe care decisions. OLIS also reduces laboratory errors caused by illegibility or misinterpretation of requested lab orders, improves the turnaround time for lab results, and enables patient orders and results to be added directly into an EMR. 

          How to Get Started

          Support is available for primary care practices across all 6 Ontario Health regions. Each region is equipped with a Regional Digital Health Team that can:

          • Answer your questions or requests for information about digital health tools
          • Provide guidance around digital health tools
          • Facilitate connections to enable digital health tool sign-up and onboarding

          To get started, contact your Regional Digital Health Team:

          If you don’t know your Ontario Health region, email the Pb4P Change Management and Adoption Team for assistance.

          Percentage of clients with type 2 diabetes mellitus who are up to date with HbA1c (glycated hemoglobin) blood glucose monitoring
          Sector:
          Primary care
          Quality Issue:
          Medication safety
          Status:
          Current
          Search:
          Percentage of clients with type 2 diabetes mellitus who are up to date with HbA1c (glycated hemoglobin) blood glucose monitoring
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          Diabetes is one of the most common chronic diseases affecting people living in Canada.

          Around 3.7 million people in Canada older than 1 year live with diagnosed diabetes (9.4% of the population).1 In addition, over 6% of adults in Canada live with prediabetes, which gives them a higher chance of developing type 2 diabetes.

          The number of people living with diabetes is expected to continue to increase as the population in Canada ages and grows. This will result in increased costs that affect society, individuals, communities, and health care systems.

          Additionally, Indigenous peoples (First Nations, Inuit, Métis, and Urban Indigenous people) are among the highest-risk populations in Canada for diabetes and related complications. Effective prevention strategies should be grounded in the social, cultural, and health service contexts of a community.

          This indicator was included as a result of work done in partnership with the Indigenous Primary Health Care Council but is applicable to all interprofessional primary care practice models.

          Key resource

          Search:

          Review federal and provincial standards or guidelines on type 2 diabetes

          Utilize your electronic medical record (EMR) system to identify and track patients with type 2 diabetes in your practice to ensure they are up to date with HbA1c blood glucose monitoring

          • Review your most recent MyPractice Primary Care Report to help focus your quality improvement efforts
          • Run a search in your practice’s EMR system using diabetes billing codes to generate a list of patients with diabetes 

          • Utilize community supports for patients

            Improve awareness of and make use of guidelines, education, and prevention resources for Indigenous peoples

            1Reference: 
            • Connect patients with local Diabetes Education Programs
            • In addition to education and support, Diabetes Education Programs teach self-management skills
            • Encourage use of My Diabetes Passport. This tool helps patients set goals, and record past and future HbA1c test results
            • Diabetes Canada clinical practice guidelines
            • Knowledge Department combines “traditional wisdom with current diabetes education, incorporating First Nations, Inuit, Métis and mainstream influences.” This program supports frontline workers in planning, preparing, and presenting relevant information about diabetes and Indigenous perspectives on health and wellness.

          Percentage of clients actively receiving mental health care from a traditional program
          Sector:
          Primary care
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Percentage of clients actively receiving mental health care from a traditional program
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          Indigenous people and communities have a holistic view of mental health and wellness. For Indigenous Peoples, health and wellness is a state of balance with self, family, community, and the land. Traditional healing practices use wholistic approaches that focus on connection with family, community, spirituality, and nature. Traditional healing may include ceremonies, songs, stories, dances, and prayers; traditional medicines; healing circles; talking circles; and connections to Elders, Traditional Healers, Traditional Knowledge Keepers, Medicine People, and other helpers.

          This indicator was included as a result of work done in partnership with the Indigenous Primary Health Care Council (IPHCC), but all models of primary care are encouraged to participate, where applicable.

          Key resources

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          Identify and connect adult patients to Indigenous mental health and wellness supports

          • The Hope for Wellness Helpline provides mental health counselling to address a range of issues, including mental health concerns, anxiety, and coping, and is available to all Indigenous people by telephone and online chat 24/7
          • Aboriginal Health Access Centres (AHACs) provide different types of health and social support services to First Nations, Métis, and Inuit communities. They provide care both on- and off-reserve, in cities, and in rural and northern communities. Services include mental health counselling, traditional healing and addiction programs, and youth empowerment. Patients do not need a referral, and there are no fees
          • Community health centres (CHCs) and nursing stations provide care in different communities. Anishnawbe Health Toronto and Misiway Milopemahtesewin in Timmins are CHCs that serve the Indigenous community exclusively. Many other CHCs in Ontario serve both Indigenous and non-Indigenous communities. Nursing stations provide health services on reserves, but often have fewer services than CHCs in cities. Connect with the health centre in your community
          • The Ontario Federation of Indigenous Friendship Centres (OFIFC) provides 28 Friendship Centres in towns and cities across Ontario that offer various health and social services
          • Métis Nation of Ontario’s mental health services include screening and assessment, intake, early intervention, referrals, case management, and aftercare (post-treatment) support using contemporary and traditional therapeutic interventions, such as healing circles and individual or group counselling. Mental wellness promotion and peer support are also available
          • The Ontario Native Women’s Association offers a variety of programs for Indigenous girls and women and their families in Ontario

          Connect Indigenous children and youth with mental health and wellness services for young people of First Nations, Métis, and Inuit communities

          • OFIFC provides 28 Friendship Centres in towns and cities across Ontario that offer various health and social services. Examples of their services include:
          •  
            • The Children’s Mental Health Project, which has programs at 5 Friendship Centres in Ontario for children aged 7–15 years and their families
            • The Children Who Witness Violence Program for children aged 7–14 years

          Know where to find Indigenous mental health services

          The following directories are available to connect patients to Indigenous mental health care in their communities:

          Patient involvement in decisions about care
          Sector:
          Primary care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Patient involvement in decisions about care
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          Patient involvement in decisions about their care is one aspect of patient engagement and experience. Evidence tells us that supporting patients to be actively involved in their own care, treatment decisions, and support can improve outcomes and experiences and potentially yield efficiency savings for the system.

          Key Resources

          The Primary Care Patient Experience Survey and Primary Care Patient Experience Survey: Support Guide are designed to help primary care practices achieve the goals of improving access to care and the care experiences of their patients. The guide is a handbook for practices planning to survey patients in a primary care setting. The Primary Care Patient Experience Survey contains the specific question related to this indicator

          Shared decision making NICE guideline [NG197] Published: 17 June 2021

          The Ottawa Hospital Research Institute Patient Decision Aids

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          Overall access to preventive care
          Sector:
          Primary care
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Overall access to preventive care
          Search:

          Specific Indicators

          • Percentage of screen-eligible people who are up to date with at least 1 screening HPV test in the past 66 months or cytology (Pap) test in the past 42 months
          • Percentage of screen eligible patients up to date with breast screening
          • Percentage of screen eligible patients up to date with colorectal tests

          Cancer screening is an important component of preventive care and a focus for many primary care teams. According to statistics gathered by Ontario Health, almost a million fewer colorectal, breast, and cervical cancer screenings were conducted between March and December of 2020 than were carried out through the same time period in 2019.

          Key Resources
          Engage your regional primary care lead for support with cancer screening and sign up for the Provincial Primary Care and Cancer Network newsletter for regular cancer screening updates. Contact PrimaryCareInquiries@ontariohealth.ca for more information

          Search:

          Redesign your system, and lever digital health solutions

          Education and Training

          Engage Patients

          • For patients without a primary care provider (unattached), prepare materials at points of entry into the system for self-referrals
            - Health811 (call 811 [TTY: 1-866-797-007] or use the live chat at ontario.ca/health811) to access the free ColonCancerCheck fecal immunochemical test (FIT) kit to screen for colon cancer or to find a clinic that does cervical screening
            - Ontario Breast Screening Program Locations(patients can self-refer)
          • Increase cancer screening participation among First Nations, Inuit, Métis and Urban Indigenous populations
            - The Indigenous Cancer Strategy sets to address and improve cancer care for First Nations, Inuit, and Métis, and Urban Indigenous people in Ontario.
            - Review and incorporate into your practice the First Nations, Inuit, Métis and Urban Indigenous Cancer Screening Resources
            - Review and incorporate into your practice the Cancer 101 Toolkit for First Nations, Inuit, Métis, and Urban Indigenous people
            - Utilize the Indigenous Navigators in your region, who provide support and advocate for First Nations, Inuit, Métis and Urban Indigenous patients and families by:
            - Facilitating and coordinating access to palliative and supportive cancer care services
            - Addressing cultural and spiritual needs
            - Networking with Indigenous and non-Indigenous partners to make the cancer journey culturally safe

          Resources for cervical screening change to HPV testing as of March 2025

          • Consult the Human Papillomavirus (HPV) Testing in Ontario: Implementation Resource Hub, from Ontario Health (Cancer Care Ontario), to explore tools and resources available to primary care providers
          • For easy reference, bookmark or print the Ontario cervical screening guidelines summary flow chart
          • Where relevant, follow Ontario Cervical Screening Program: guidance to support the transition years following the launch of human papillomavirus testing in Ontario: Cervical screening and colposcopy recommendations for people ages 21 to 24
          • Clinicians who are Telus PSS users can use OntarioMD HPV Tools, composed of 4 searches and 2 reminders, to help them identify patients eligible for cervical cancer screening

          Number of patients receiving care in unconventional spaces
          Sector:
          Hospital
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Number of patients receiving care in unconventional spaces
          Search:

          This indicator measures the number of inpatients in unconventional spaces (including hallways and auditoriums).

          Click here to visit Health Quality Ontario’s Indicator Library to view how to measure the number of inpatients receiving care in unconventional spaces.

          Search:

          Optimize patient flow

          Reduce avoidable hospital readmissions to increase bed availability

          Number of new patients/clients/enrolment
          Sector:
          Primary care
          Quality Issue:
          Effective transitions
          Status:
          Current
          Search:
          Number of new patients/clients/enrolment
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          Approximately 2.2 million Ontarians do not have a family physician. Escalating workforce shortages due to fewer graduates choosing family medicine, an aging workforce, and earlier retirement may cause an increase in the number of unattached patients to 3 million by 2025.

          Although initiatives aimed at reducing administrative work for providers are important to support expanded access, access can also be measured at the practice level. The change ideas below present the fundamental principles of understanding patient panels, measuring supply and demand, and other examples of streamlining clinic workflows to expand capacity.

          This indicator is intended to measure the net new number of patients/clients/enrolment, accounting for both patients that have left the practice, as well as newly added or enrolled patients.

          Key resources

          Search:

          Determine ideal panel size based on caseload complexity and roster balance

          Implement key approaches outlined in the Advanced Access and Efficiency Workbook for Primary Care to assist with providing timely access to appointments

          Consider innovative appointment types and approaches to help manage demand for appointments

          Number of faxes sent per 1,000 rostered patients
          Sector:
          Primary care
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Number of faxes sent per 1,000 rostered patients
          Search:

          As part of Your Health: A Plan for Connected and Convenient Care announced in 2023, the Ministry of Health laid out a plan to replace “antiquated fax machines with digital communication alternatives among all Ontario health care providers within the next 5 years.” Eliminating faxing in health care settings will:

          • Promote safer patient care, decreasing risks posed by delays in receiving timely and appropriate care due to faxing errors and illegible information
          • Reduce the risk of delays in diagnosis and treatment caused by unnecessary waits from slower processing time, fax backlog, and unnecessary follow-ups associated with fax errors and misdirects
          • Better protect personal health information (e.g., misdirected faxes accounted for 50% of the complaints about health care privacy breaches made to the Information and Privacy Commissioner of Ontario in 2021)
          • Make it easier and faster for health data to follow the patient wherever they access care

          Key resources

          Search:

          Implement digital health tools

          Ontario Health’s new initiative, Patients Before Paperwork (Pb4P), is supporting innovative and creative digital solutions to make it easier for providers to deliver and connect people to care. Phase one of Pb4P is focused on improving utilization of digital health tools such as:

          • AI scribe is a digital assistant that uses artificial intelligence to listen to conversations during a patient visit and automatically turns them into clinical notes. This helps reduce the amount of time physicians spend typing or dictating notes after a visit. Some AI scribes can also automate tasks such as booking follow-up appointments or sending reminders using robotic process automation (RPA).
          • eConsult is a secure digital health tool that provides family physicians, nurse practitioners, and midwives timely access to specialist advice that they may need to deliver care to their patients, often eliminating the need for an in-person specialist visit. eConsult eliminates the need for a traditional referral to the specialist, which is typically sent by fax.
          • eReferral (electronic referral) enables quick and secure referrals between primary care clinicians, specialists, and organizations across the province, reducing administrative burden and allowing clinicians to spend more time delivering patient care. eReferral removes the need for referrals to be sent via fax.

            To learn more about eReferral and get started with eReferral Ontario, please visit this information page from Ontario Health.

          • Health Report Manager (HRM) facilitates secure electronic transfer of patient records between hospitals, independent health facilities, specialty clinics, and community-based primary care clinicians. It reduces the reliance on paper- and fax-based workflows by adding patient reports, such as narrative, text-based medical records, and diagnostic imaging, directly into a patient’s record within their clinician’s EMR. This allows for timely access to clinical reports and faster patient follow-up.
          • Online appointment booking solutions enable patients to book in-person, video, or telephone appointments electronically, by choosing a date and time and receiving an automated appointment confirmation, all in a self-serve environment available 24/7. Additionally, online appointment booking solutions allow clinicians and administrative staff to set parameters on the types and number of appointments available, and offer other beneficial features such as automated email, text message, and voice reminders.
          • Ontario Laboratories Information System (OLIS) is a secure digital health tool that provides authorized health care providers with access to patients’ laboratory test orders and results, both past and present, from hospitals and public health and community labs through 1 platform. The centralization of information enables a patient’s results to follow them as they move between different care settings, and enables health care providers to make more informed, timely, and safe care decisions. OLIS also reduces laboratory errors caused by illegibility or misinterpretation of requested lab orders, improves the turnaround time for lab results, and enables patient orders and results to be added directly into an EMR. 

          Implementation of 1 or a combination of these tools has the potential to reduce the volume of faxes sent and received in a primary care practice.

          As part of the Pb4P initiative, each Ontario Health region is equipped with a Regional Digital Health Team that can:

          • Answer your questions or requests for information about digital health tools
          • Provide guidance around digital health tools
          • Facilitate connections to enable digital health tool sign-up and onboarding

          To get started, contact your Regional Digital Health Team:

          If you don’t know your Ontario Health region, email the Pb4P Change Management and Adoption Team for assistance.

          Note: The tools mentioned above have been included as optional indicators for primary care on the 2026/27 Quality Improvement Plan (QIP). If your organization chooses to use 1 or a combination of these digital tools as your change idea(s) for reducing faxes, also select the corresponding optional QIP indicator to help create an implementable and measurable plan.

          Number of events and participants for traditional teaching, healing, or ceremony
          Sector:
          Primary care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Number of events and participants for traditional teaching, healing, or ceremony
          Search:

          Traditional healing and wellness play an important role in Indigenous health, though they are often neglected by mainstream health care systems.

          Traditional healing encompasses Indigenous health practices, approaches, knowledge, and beliefs. This includes the use of traditional and cultural ceremonies; medicines derived from plants, animals, or minerals; energetic therapies; and physical techniques.

          The goal of Indigenous healing and wellness is to improve the overall health of Indigenous Peoples. In addition to the longstanding First Nations, Inuit, and Métis knowledge of the benefits of traditional healing practices, research and reports indicate that integrating traditional healing practices into health services for Indigenous Peoples can lead to improved overall health outcomes. A wholistic approach to wellness is thought to yield better long-term results for individuals, families, communities, and nations, as well as for the health system itself.

          This indicator was included as a result of work done in partnership with the Indigenous Primary Health Care Council (IPHCC), but all models of primary care are encouraged to participate, where applicable.

          Key resources

          Additional Resources

          Search:

          Meaningful Engagement

          Standardization and Consistency

          Traditional Healing and Wellness and Cultural Services Training

          Evaluation and Feedback Mechanisms

          • Implement mechanisms to evaluate impact and effectiveness, such as soliciting feedback from Indigenous communities, health care providers, and clients

          Equity, Inclusion, Diversity, and Anti-Racism Education
          Sector:
          Long-term care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Equity, Inclusion, Diversity, and Anti-Racism Education
          Search:

          There is a wide variety of equity, inclusion, diversity, and/or anti-racism (EIDA-R) education such as training courses, online modules, webinars, and information sessions. Organizations are encouraged to provide EIDA-R education for all staff and report on the number of staff engaging in education courses.

          Search:

          All executive-level staff, front-line workers, and health service providers are expected to have some EIDA-R education

          Emergency services indicators in the access and flow theme
          Sector:
          Hospital
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Emergency services indicators in the access and flow theme
          Search:

          Measuring emergency department (ED) length of stay provides information about not only care within hospitals, but also how well other parts of the health system are working. Some patients may spend a long time in the ED because inpatient beds are not available. The lack of available inpatient beds is often a result of other factors in the health system, such as patients not being able to leave the hospital for care in other places.

          Indicator: Percentage of patients who visited the emergency department (ED) and left without being seen (LWBS) by a physician

          This indicator measures the percentage of visits to the ED that result in the patient leaving before being assessed or treated by a physician.

          Indicator: 90th percentile emergency department (ED) length of stay (LOS)

          This indicator measures the total time elapsed between the time of triage or registrations (whichever occurs first) and the time the patient leaves the emergency department.  This indicator will use the 90th percentile ED LOS as its evaluation metric.

          Indicator: 90th percentile ambulance offload time (AOT)

          This indicator measures the total time elapsed between the time of ambulance arrival at the ED and the time of the ambulance transfer of care process. This indicator will use the 90th percentile AOT as its evaluation metric.

          Indicator: 90th percentile emergency department (ED) wait time to inpatient bed

          This indicator measures the time interval between the disposition date/time and the date/time the patient left the ED for admission to an inpatient bed (or operating room).

          This indicator will use the 90th percentile time to physician initial assessment (PIA) as its evaluation metric.

          Key Resources

          Search:

          Improve ED flow

          Improve overall hospital flow

          Avoid unnecessary ED visits

          Do patients/clients feel comfortable and welcome at their primary care office?
          Sector:
          Primary care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Do patients/clients feel comfortable and welcome at their primary care office?
          Search:

          This indicator is based on the Alliance for Healthier Communities Common Indicators but can apply to all interprofessional primary care settings.

          This indicator is measured through a patient survey question and measures patient perception of comfort at their primary care office.

          The data collected for this indicator can be compared to the national data collected through the Canadian Community Health Survey and the Canadian Index of Wellbeing.

          Key resources

          Search:

          Make written material, programs, and services available in the language(s) of your community’s preference

          • Consider using phone and video interpreting services for patients whose preferred language is not English
            Access Remote Interpretation Ontario (R.I.O.), an on-demand and immediate collaboration of Canadian non-profit community interpreting agencies
          • Provide health information in the language of the patient's choice, where possible
            Use Remote Interpretation Ontario's Multilingual Information eXchange to search a repository of translated materials relating to health and community care and support

          Ensure that images and language in public-facing materials and those displayed in the primary care office are inclusive and representative of the population

          Ensure that staff, providers, and board members complete cultural safety training

          Consider virtual care as part of the overall patient experience

          • Ensure clinicians understand their options when it comes to virtual care
            Familiarize yourself with Ontario Health’s Virtual Visits Verification program to expand options for virtual care solutions.
          • Determine how best to implement and use virtual care in your organization
            Review the Clinician Change Virtual Care Toolkit, a general guide to support clinicians with their use and implementation of virtual care
          • Help patients to prepare for their virtual care appointments
            Promote the Canadian Medical Association’s Virtual Care Guide for Patients

          Documented assessment of palliative care needs among patients identified to benefit from palliative care (long-term care sector)
          Sector:
          Long-term care
          Quality Issue:
          Palliative care
          Status:
          Archived
          Search:
          Documented assessment of palliative care needs among patients identified to benefit from palliative care (long-term care sector)
          Search:

          Most patients in our health care system should be receiving a palliative care approach much earlier than they often do. Ultimately, receiving timely palliative care provides benefits for patients, caregivers and the health system, often supporting patients to die in their preferred place of death with the supports they need. Health care providers in all sectors have a role to play in identifying patients who could benefit from a palliative care approach.

          Click here for a visual guide outlining how to measure this indicator.

          Tips

          • You can select one or more of the change ideas or tools below and use this PDSA worksheet to help test your change ideas. You can learn to select the most appropriate process indicators by reading this Measurement Guide.
          • To prioritize a change idea to include in your QIP, consider choosing one that addresses a known gap within your care team (i.e., ensuring care teams have confidence to have difficult conversations); standardizes or enhances an existing process (i.e., choosing an early identification tool and developing a process to identify); and/or provides an opportunity to build greater patient and caregiver engagement (i.e., create a palliative care plan to support patients and caregivers).
          • Email palliative@hqontario.ca to join the mailing list for monthly webinars and other supports.

          Key resources

          Search:

          Select and use tools that support early identification

          • Review the Tools to support Earlier Identification for Palliative Care toolkit, then:
            Engage staff in choosing and testing the tool to ensure uptake
            Embed the chosen tools into your electronic medical record system
            Use flags in EMR when changes in medical or functional status occurs to prompt clinicians to screen or re-screen for palliative care needs

          Ensure patients identified early have a holistic assessment completed

          Documented assessment of palliative care needs among patients identified to benefit from palliative care
          Sector:
          Hospital
          Quality Issue:
          Palliative care
          Status:
          Current
          Search:
          Documented assessment of palliative care needs among patients identified to benefit from palliative care
          Search:

          Most patients in our health care system should be receiving a palliative care approach much earlier than they often do. Ultimately, receiving timely palliative care provides benefits for patients, caregivers and the health system, often supporting patients to die in their preferred place of death with the supports they need. Health care providers in all sectors have a role to play in identifying patients who could benefit from a palliative care approach.

          Click here for a visual guide outlining how to measure this indicator.

          Tips

          • You can select one or more of the change ideas or tools below and use this PDSA worksheet to help test your change ideas. You can learn to select the most appropriate process indicators by reading this Measurement Guide.
          • To prioritize a change idea to include in your QIP, consider choosing one that addresses a known gap within your care team (i.e., ensuring care teams have confidence to have difficult conversations); standardizes or enhances an existing process (i.e., choosing an early identification tool and developing a process to identify); and/or provides an opportunity to build greater patient and caregiver engagement (i.e., create a palliative care plan to support patients and caregivers).
          • Email palliative@hqontario.ca to join the mailing list for monthly webinars and other supports.

          Key resources

          Search:

          Select and use tools that support early identification

          • Review the Tools to support Earlier Identification for Palliative Care toolkit, then:
            Engage staff in choosing and testing the tool to ensure uptake
            Embed the chosen tools into your electronic medical record system
            Use flags in EMR when changes in medical or functional status occurs to prompt clinicians to screen or re-screen for palliative care needs

          Ensure patients identified early have a holistic assessment completed

          Support health care providers in communicating with patients and their families about palliative care

          Foster collaboration and communication internally and across care settings

          • Explore opportunities for digital tools and technology for palliative care planning and referrals
            Ontario Palliative Care Network Resources
          • Explore virtual platforms for connecting with specialists or with patients, especially in remote areas
            The Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs
          • Reach out to your Regional Palliative Care Network to get information on supports and partners in your area
            Contact info@ontariopalliativecarenetwork.ca to get more information
          • Share resources (staff, technology, or training opportunities) amongst partners in your region (i.e., sharing and co-funding an NP amongst partners within a region, holding regional educational events)
          • Create a process or a consult service to enable palliative care and end of life discussions with identified patients

          Ensure providers have the skills and confidence to provide palliative care

          Did patients feel they received adequate information about their health and their care at discharge?
          Sector:
          Hospital
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Did patients feel they received adequate information about their health and their care at discharge?
          Search:

          Ineffective discharge planning without sufficient information and lack of coordination of care can lead to decreased patient satisfaction, adverse events (AEs) and a higher number of hospital readmissions due to complications.

          Key resources

          Search:

          Combine verbal instructions with other modes of communication (e.g., written, visual)

           

          Educate staff about appropriate discharge practices and how to verify that their patients are leaving the hospital with enough information

          Completion of sociodemographic data collection
          Sector:
          Primary care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Completion of sociodemographic data collection
          Search:

          Collecting sociodemographic data can allow primary care organizations to better understand the populations they serve and how health care access and utilization differ across equity-deserving groups. This indicator is a measure of progress on the collection of equity data. Low participation rates may indicate challenges that clients experience in responding to the questions or challenges that primary care organizations experience in collecting the data. Strategies listed below may help to improve participation.

          This indicator references survey methods developed by the Alliance for Healthier Communities and the Association of Family Health Teams of Ontario, but this should not preclude organizations from using other sociodemographic surveys of their choice. This indicator can apply to all primary care settings.

          Key resources

          Search:

          Implement key approaches outlined in the Guide to Demographic Data Collection in Healthcare Settings, developed by Ontario Health (Toronto)

          Review the Resource Package to Support Sociodemographic Collection and Use developed by the Alliance for Healthier Communities

          • Learn how to answer common patient/client questions about collecting sociodemographic data
            Common questions and possible answers from the Alliance for Healthier Communities
            Clinician script (with background information, as well as questions and response options)
            Interactive script (with client questions and staff responses) from the Alliance for Healthier Communities
          • Create print or online resources to educate patients/clients on sociodemographic data collection
            Review this customizable sample brochure developed by the Alliance for Healthier Communities

          Develop an implementation plan specific to your primary care organization that will maximize the possibility of collecting sociodemographic data

          • Develop a workflow diagram outlining the necessary steps
            Review workflow developed by East End CHC that enabled data collection completion rates of greater than 95%
          • Set reminders in the patient’s electronic medical record (EMR) to update or collect demographic information
            How to add a reminder in PS Suites from the Alliance for Healthier Communities
          • Implement the Health Equity Questionnaire custom form for PS Suite into your EMR
            AFHTO members can access this custom form through their member page
            Review Screenshots of the Health Equity Questionnaire from the Alliance for Healthier Communities to preview how the tool will look in PS Suites
          • Review documentation developed by East Wellington FHT
            Including operationalizing the questionnaire and inviting patient participation (AFHTO members only)

          Complaints acknowledged in a timely manner (long-term care sector)
          Sector:
          Long-term care
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Complaints acknowledged in a timely manner (long-term care sector)
          Search:

          Collecting patient feedback, complaints and concerns can be a valuable source of insight and allows health care organizations to track and identify key trends and opportunities for improvement in care.

          Click here to visit Health Quality Ontario's Indicator Library to view how to measure acknowledging complaints in a timely manner in long-term care homes.

          Key resources

          Search:
          • Gather feedback on how well the current process is working. Review data relative to days between receipt and acknowledgement and review client and family feedback to determine opportunities for improvement.
            Process measure: Percent of comments on process that were positive
          • Create a flag to go to senior leadership when a complaint is received
            Process measure: Percent of complaints that are flagged to senior management when received
          • Educate staff on how to manage complaints when expressed and how to mediate situations on the spot. Train staff in customer service and communication frameworks such as LAST (Listen, Apologize, Solve, and Thank)
            Process measure: Percent of staff reporting they are likely to implement one of the ideas shared in the training
          • Create posters to display in the home to indicate the process by which to lodge a complaint. Include the effort to discuss the situation at the time.
          • Use Health Quality Ontario’s Quality Standards so that what quality care looks like is understood by all
          • Health Quality Ontario's Quality Standards

          Complaints acknowledged in a timely manner
          Sector:
          Hospital
          Quality Issue:
          Timely access to care Services
          Status:
          Current
          Search:
          Complaints acknowledged in a timely manner
          Search:

          Collecting patient feedback, complaints and concerns can be a valuable source of insight and allows health care organizations to track and identify key trends and opportunities for improvement in care.

          Click here to visit Health Quality Ontario's Indicator Library to view how to measure acknowledging complaints in a timely manner in hospitals.

          Key resources

          Search:
          • Use Ontario Health's quality standards as a guide to care delivery so that everyone is on the same page about the care patients should receive
          • Gather feedback on how well the current process is working. Review data relative to days between receipt and acknowledgement and review client and family feedback to determine opportunities for improvement.
          • Create a system to track when a complaint is received and when it is acknowledged
          • Create a routinized process to flag senior leadership when a complaint is received
          • Educate staff on how to manage complaints when expressed and how to mediate situations on the spot
          • Provide customer service training and communication skills training such as difficult conversations
          • Use Health Quality Ontario’s Quality Standards so that what quality care looks like is understood by all
            Health Quality Ontario's Quality Standards

          Chronic disease management and prevention (OHT)
          Sector:
          Ontario Health Teams
          Quality Issue:
          Person experience
          Status:
          Current
          Search:
          Chronic disease management and prevention (OHT)
          Search:

          Strengthening proactive management in primary and community care settings is an effective strategy to improve patient outcomes and access to care for people with Heart Failure, Chronic Obstructive Pulmonary Disease or those with other Ambulatory Care Sensitive Conditions. Outcomes can be improved by leveraging existing provincial programs, community supports and primary care-team based care with appropriate pathways for specialty care. 

          Review and analyze data to identify, understand, and explore variation within the patient population

          Search:

          Collaborate with partners on early identification of needs and upstream care activities

           

          Build capability across OHT partners on best practices for care of patients with chronic diseases

           

          • Ensure providers have tools and resources required to promote adoption of structured self-management and action planning for patient, families and caregivers 

          Connect programs and providers to training related to prevention such as motivational interviewing, chronic disease self-management, smoking cessation counselling, physical literacy, nutrition, food insecurity, diabetes management training, health promotion and best practices resources for providers around alcohol use disorder. 

          Heart Failure (HF)

           

          COPD

           

           

          Diabetes

          Palliative care

          Develop and implement a collaborative model for service delivery to patients with chronic diseases

           

           

           

          Leverage digital and virtual solutions to improve processes and workflow

          • Use digital health solutions and technology to support integration, documentation, communication and coordination across different sectors and care settings for the lifetime of a patient’s condition

           

          Cancer screening (OHT)
          Sector:
          Ontario Health Teams
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Cancer screening (OHT)
          Search:

          OHTs can support increased participation in cancer screening and follow-up services in collaboration with their Regional Cancer Programs, especially for patients without access to a primary care provider (unattached patients).

          If you have any questions or require guidance when designing and implementing cancer screening initiatives, please engage with your Regional Cancer Screening Program. For contact information, please see the OHT Regional Contact List.

          Review and analyze data to identify, understand, and explore variation within the patient population

          Search:

          Optimize screening processes and leverage digital health solutions

          • For attached patients, develop electronic medical record(EMR) reminder systems like Ocean to track and contact patients due for cancer screening using reports such as the MyPractice Primary Care Plus report (with Screening Activity Report data). Consider patient preference such as language and method of communication (e.g., email, text, and phone). Add health promotion messages in reminders. Integrate with online appointment booking systems.

          Education and training

          Engage patients

          Alternate level of care (OHT)
          Sector:
          Ontario Health Teams
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Alternate level of care (OHT)
          Search:

          OHTs can improve patient transitions and access to integrated team-based care, including home and community care by supporting the implementation of activities aligned with OH Region ALC planning and by identifying the greatest opportunities for ALC prevention and discharge management.  OHTs should continue to implement the Home First Operational Direction and ALC Leading Practices, working with their OH Region for specific focus areas in alignment with local and regional plans.  

          Review and analyze data to identify, understand, and explore variation within the patient population

          KEY RESOURCES

          Search:

          Conduct asset mapping to understand what services are available for the population and wait times

          Include patients and care partners as part of the care team

          • Develop care plans and goals of care collaboratively with patients and care partners
          • Implement an approach to measuring patient and care partner experiences and outcomes (e.g., using Patient Reported Experience Measures, PGLO Care Partner Experience Survey) 

          Strengthen system capabilities and cross-sector partnerships to support care in the community and improve transitions in care  

          Strategies can be deployed upstream (to prevent hospitalizations/ALC prevention) and/or downstream (to enable discharge/as part of ALC discharge management).  

          Across sectors, support patients with behaviours and those at risk of deconditioning 

          Transition patients requiring palliative care support back to the community

          • Use evidence-based tools to identify individuals who would benefit from palliative care that supports timely identification, needs assessment, and connection to palliative care supports when indicated. 
          • Connect patients with identified palliative care needs, back to their community, should include timely assessment of needs, goals-of-care planning, all aimed to improve the quality of life and reducing crises and avoidable acute-care use as needs become more complex.
            • Step 1: Continue developing relationships with OH regional palliative care teams and regional palliative care clinical leads.
            • Step 2: Use and embed clinical indicators to identify those with palliative care needs.  
              • Palliative Care Toolkit: Best-practice tools that support health care professionals with palliative care delivery, organized into three steps: Identification, Assessment, and Plan and Manage.  
            • Step 3: Once identified, complete a holistic assessment of needs using validated tools and connect with an interdisciplinary palliative care team to support. Based on needs assessment outcomes, consider what, if any, referrals are needed to support the patient’s needs.  

          • Reach out to the ProvincialPalliativeCareProgram@OntarioHealth.ca if you require information on supports and partners in your local area

          Alternate level of care (ALC) throughput ratio
          Sector:
          Hospital
          Quality Issue:
          Access to right level of care
          Status:
          Archived
          Search:
          Alternate level of care (ALC) throughput ratio
          Search:

          Alternate level of care (ALC) refers to a patient who is occupying a bed in hospital and waiting to receive care elsewhere. A designation of ALC can have negative effects on the patient (for example, through risk of hospital-acquired infections and functional decline while in hospital), family, and the health care system (for example, through decreased access to acute-care hospital services for patients who truly require them). The ALC throughput ratio reflects the rate at which patients are being discharged versus designated ALC.  It is important to understand the causes of delayed transitions and discharge for individuals designated as ALC, and work with other partners within the health care system to ensure that improvements support access to care in the right place at the right time.

          In 2023/24, hospitals took an important next step toward better understanding the root causes of delayed transitions in care through completion of the ALC Leading Practices Self-Assessment. This work has helped to identify the current state and has supported organizations to establish a baseline for improvement from which they can plan and implement relevant change concepts and ideas.

          Key Resources

          Search:

          Use data to understand the population most at risk for ALC designation and the care that they require

          • Access Wait Time Information System (WTIS) data, monthly reports, etc.
          • Conduct asset mapping to understand the current- state capacity of services available for the population most at risk

          Include patients and caregivers as part of the care team

          • Develop care plans and goals of care collaboratively with patients and caregivers.
          • Implement an approach to measuring patient and caregiver experience and outcomes.

          Optimize processes for early identification, assessment, and care plan development prior to ALC designation

          Deliver senior-friendly care interventions throughout admission

          Ensure consistent application of the ALC definition

          Transition patients requiring palliative support back to the community

          Transition patients requiring support to age in place back to the community

          Alternate level of care (ALC) days
          Sector:
          Hospital
          Quality Issue:
          Access to right level of care
          Status:
          Current
          Search:
          Alternate level of care (ALC) days
          Search:

          Alternate level of care (ALC) refers to a patient who is occupying a bed in hospital and waiting to receive care elsewhere. A designation of ALC can have negative effects on both the patient (for example, through risk of hospital-acquired infections and functional decline while in hospital) and the health care system (for example, through high costs and decreased access to acute services for patients who truly require them)

          Key resources

          Search:

          Optimize hospital capacity and patient flow

          Follow best-practice rehabilitation care pathways

          Apply behavioural support and preventative deconditioning strategies to patients designated as alternate level of care to optimize health status

          Transition patients requiring palliative support back to the community

          7-day post-hospital discharge follow-up
          Sector:
          Primary care
          Quality Issue:
          Timely access to care Services
          Status:
          Current
          Search:
          7-day post-hospital discharge follow-up
          Search:

          Supporting effective transitions within Ontario’s health care system helps to provide the best outcomes for patients as they move through the different levels of care. Primary care follow-up after a hospitalization has been shown to provide better continuity of care and reduce readmissions to hospitals for patients with multiple conditions or complex needs.

          Visit Health Quality Ontario’s Indicator Library to view how to measure timely access to a primary care provider:

          Click here to view the Indicator Technical Specifications for the 2020/21 QIPs to learn how to measure this indicator.

          Key resources:

          Search:

          Improved communication between hospital and primary care providers

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          Last Updated: August 31, 2026

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