Celebrating Diversity, Equity and Inclusion at Rapelje Lodge Long-Term Care Home
Organization: Douglas H. Rapelje Lodge
Sector: Long Term Care
As part of Niagara Region’s broader commitment to equity, diversity, inclusion and anti-racism
(EDIAR), Rapelje Lodge looks for ways each year to deepen its understanding of residents’
backgrounds, identities, cultures and lived experiences. The home aims to embed equity, diversity,
inclusion, anti-racism and respect into day-to-day work, while building staff capacity through practical
tools, education and resources that support culturally responsive, person-centred care. Working with
the interdisciplinary team, residents and families, the home identified opportunities to strengthen its
diversity, equity and inclusion (DEI) work and focused on four change ideas: more DEI activities on the
recreation calendar, implementing the Registered Nurses’ Association of Ontario (RNAO) DEI Best
Practice Guideline (BPG), reviewing policies to include cultural perspectives at end of life (EOL), and
hosting in-home potlucks. The initiative addressed the Quality Improvement Plan (QIP) priority issue
of equity and was tied to the indicator: percentage of staff (executive-level, management, or all) who
have completed relevant equity, diversity, inclusion and anti-racism education.
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Transforming Patient Flow Through
Southlake’s Integrated
Care Centre (ICC)
Organization: Southlake Regional Health Centre
Sector: Acute Care/Hospital
Southlake Health implemented a major quality improvement initiative titled “Transforming Patient
Flow Through Southlake’s Integrated Care Centre (ICC)” to improve access and flow across the
hospital system. The initiative responded to increasing Emergency Department (ED) demand,
prolonged waits for inpatient beds, and system-wide capacity constraints driven by rising volumes,
ALC pressures, and limited community resources. The core aim was to reduce Time to Inpatient Bed
(TIP) by shifting from a fragmented, department-based model of patient flow to a coordinated,
hospital-wide system supported by real-time data and centralized decision-making. The ICC,
supported by a Distributed Health Network (DHN) model, was established to bring together clinical,
operational, and community partners to improve visibility of demand and capacity, enabling faster
escalation and resolution of flow barriers. The initiative aligns with Southlake’s broader goal of
becoming a high-reliability organization and evolving toward a more integrated, distributed model of
care.
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Reducing Potentially Avoidable Emergency Department Visits
Organization: Cummer Lodge
Sector: Long Term Care
Cummer Lodge’s initiative to reduce potentially avoidable emergency department (ED) transfers
began in 2016 and has grown into a sustained quality improvement effort. It aims to improve
residents’ quality of life and experience during acute changes in health while reducing strain on the
health care system. The home focused on understanding residents’ wishes and treatment
preferences, building the clinical decision-making skills of registered nursing staff, improving
communication and care coordination with physicians and partners, and expanding access to nurse
practitioners and external specialists who can support care in the home. Through these ongoing
efforts, the home reduced potentially avoidable ED visits to 11.56%, down from 19.28% the previous
year. The initiative addressed the Quality Improvement Plan (QIP) priority issue of access and flow
and was tied to the indicator for potentially avoidable ED transfers.
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Implementation of Educational Bundles to
Improve Delirium Screening Compliance
Among Hospitalized Older Adults
Organization: Niagara Health System
Sector: Acute Care/Hospital
Niagara Health’s initiative, Implementation of Educational Bundles to Improve Delirium Screening
Compliance Among Hospitalized Older Adults, focused on increasing consistent use of the Confusion
Assessment Method (CAM) screening tool. Aligned with the organization’s Care for Older Persons
Strategy, the project formed part of broader efforts to improve delirium care and reduce hospitalacquired delirium (HAD). It aimed to strengthen staff comfort with screening, support earlier
identification and management of delirium, and improve patient safety, patient experience and
provider experience. The initiative was linked to the indicator measuring the percentage of
hospitalized patients aged 65 and older with reported HAD. The results reported in this story
demonstrate improvements in screening compliance and staff-reported comfort, rather than a
measured reduction in HAD.
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Ambulance Offload Time (AOT)
Optimization
Organization: William Osler Health System
Sector: Acute Care/Hospital
William Osler Health System (Osler) implemented a quality improvement initiative focused on
optimizing Ambulance Offload Time (AOT). This is a 2025/26 Quality Improvement Plan priority
indicator linked to access, flow, patient safety, emergency department (ED) capacity, and emergency
medical services (EMS) availability. The initiative aimed to reduce delays between ambulance arrival
and transfer of care to hospital teams by identifying process barriers, improving offload capacity, and
strengthening collaboration between EMS and emergency department partners. Using Lean methods,
process mapping, time studies, environmental assessments, operational data review, and Plan-DoStudy-Act cycles, the team tested and refined changes such as standardized offload processes,
designated transition-of-care spaces, rapid nursing assessment, streamlined transfer workflows, and
daily operational reviews. The project led to measurable improvement in AOT, including a reduction
in the 90th percentile AOT from 38 minutes in FY24/25 to 36 minutes in FY25/26.
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Delirium Risk Identification and
Prevention Across Sunnybrook
Showcase Units
Organization: Sunnybrook Health Sciences Centre
Sector: Acute Care/Hospital
Sunnybrook Health Sciences Centre launched a quality improvement initiative across four acute
medicine and transitional care showcase units to strengthen delirium prevention for older adults. The
project combines standardized risk identification, early screening, individualized prevention bundles,
Healthy Stay Volunteer visits and preoperative education. Beginning in December 2026, two units will
also pilot the GEMINI-developed artificial intelligence model to identify patients at highest risk and
target prevention efforts. The initiative addresses safety, access and flow, patient and caregiver
experience, and provider experience, with the primary outcome focused on reducing hospitalacquired delirium among patients aged 65 and older.
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Reducing Potentially Avoidable Emergency Department Visits by Treating Residents in the Home
Organization: The District Municipality of Muskoka – The Pines Long Term Care Home
Sector: Long Term Care
The Pines Long-Term Care (LTC) Home launched a multifaceted initiative to reduce potentially
avoidable emergency department (ED) visits by building the home’s capacity to assess and treat
residents in place. The work focused on introducing new clinical technologies, upgrading nursing
equipment and systematically reviewing ED transfer data through interdisciplinary committees. Key
interventions included Jubo vital sign integration with PointClickCare, bladder scanning, computerized
ambulatory drug delivery (CADD) pumps, telemedicine, portable diagnostics and enhanced nursing
equipment, supported by stronger interdisciplinary review through the home’s CORE Committee and
collaboration with physicians and health care partners. These efforts reflect the home’s philosophy of
providing the right care, at the right time, in the right place, so residents can stay in familiar
surroundings whenever clinically appropriate. The initiative addressed the Quality Improvement Plan
(QIP) priority issues of access and flow, resident safety and quality of care, and was tied to the
indicator: rate of ED visits for a modified list of ambulatory care-sensitive conditions per 100 LTC
residents. The home’s rate fell from 26.47 to 19.40 visits per 100 residents.
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Enhancing Emergency Department Care
for Adults Living with Sickle Cell Disease
Organization: Humber River Health
Sector: Acute Care/Hospital
Humber River Health’s Hennick Humber Hospital launched Enhancing Emergency Department Care
for Adults Living with Sickle Cell Disease to address delays and improve the consistency, equity and
quality of emergency department (ED) care. The initiative focuses on adults presenting with vasoocclusive pain episodes, using a standardized sickle cell disease (SCD) pathway, physician order sets,
staff education and workflow improvements to support timely assessment and pain management.
The work addresses equity, access and flow, patient and provider experience, and safety. The
organization reports reductions in time to physician initial assessment and pain intervention;
however, numerical results were not provided, and improvement targets have not yet been achieved.
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Supported Attachment Clinics
Organization: City of Lakes FHT
Sector: Primary Care
City of Lakes Family Health Team developed Supported Attachment Clinics to improve access to
primary care for unattached patients. The initiative redesigned the traditional intake process, which
was often time-intensive, administratively burdensome, and disconnected from immediate patient
needs. Instead, the team created a clinic model that uses interprofessional providers to complete
histories, build patient records, support documentation, and introduce patients to team-based care
before or alongside physician assessment. This allows physicians to focus on understanding patient
needs and developing care plans from the first encounter. The model has increased attachment
capacity, reduced administrative burden, and helped patients leave their first visit feeling informed,
connected, and supported by their care team.
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Improving access to timely cancer screening to reduce disparities in cancer screening rates between IPHCO clients and provincial benchmarks.
Organization: Misiway Milopemahtesewin CHC
Sector: Primary Care
Misiway Milopemahtesewin Health Centre’s quality improvement initiative aims to increase completion of recommended cancer screening among eligible Indigenous clients. Following its transition from a Community Health Centre to an Indigenous Primary Health Care Organization on April 1, 2026, the organization identified the need to update EMR fields, improve data collection and strengthen reporting to accurately track screening offers and completion rates. The initiative focuses on improving access to timely, culturally safe cancer screening, reducing disparities between organizational screening rates and provincial benchmarks, and supporting clients through proactive follow-up, navigation, respectful conversations and innovative screening delivery approaches.
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Improving Equitable Access to Primary
Care Through Priority Attachment
Pathways for Marginalized Populations
and Children
Organization: Ottawa NPLC
Sector: Primary Care
The Ottawa Nurse Practitioner Led Clinic (ONPLC) introduced an equity-focused intake and referral
model to improve access to comprehensive primary care for people in Vanier and Overbrook who
face barriers to attachment. The initiative replaces a first-come, first-served approach with
transparent priority pathways based on health equity and clinical need. It focuses on children and
families, newcomers, people experiencing material deprivation or housing instability, people with
complex mental health or substance-use concerns, community-partner referrals, and people without
primary care.
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Right Place, Right Time
Organization: The Red Lake Margaret Cochenour Memorial Hospital
Sector: Acute Care/Hospital
Red Lake Margaret Cochenour Memorial Hospital launched the “Right Place, Right Time” quality
improvement initiative to better understand and improve emergency department length of stay for
high-acuity, non-admitted patients. As a small rural acute care hospital located more than 200 km
from the nearest hospital, the organization often keeps patients in the emergency department for
extended periods while awaiting external resources, diagnostic testing, or transfer. After the
hospital’s 2025/26 QIP data showed a 90th percentile emergency department length of stay of 16.67
hours for high-acuity, non-admitted patients, the team reassessed whether patients nearing or
exceeding 24 hours in the ED were still in the most appropriate care setting. The initiative focused on
reviewing outlier data, identifying patient and diagnostic themes, improving data quality, and
implementing a standardized review process led by the Nurse Manager to ensure patients received
care in the right place at the right time.
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Becoming a Trauma-Informed Clinic: Embedding
Sociodemographic Data Collection Within the
Mental Health Pathway
Organization: Plantagenet FHT
Sector: Primary Care
Plantagenet Family Health Team redesigned its Mental Health Program pathway as part of a longterm organizational commitment to becoming trauma-informed. The initiative introduced a
structured social worker-led telephone screening and triage process that embeds sociodemographic
and socioeconomic data collection into mental health intake. Previously, patients were referred
directly to mental health clinicians without a consistent process to assess urgency, barriers to care,
safety concerns or the most appropriate service. The revised pathway helps the team understand
each patient’s clinical needs, lived experience, strengths and social context, including factors such as
poverty, food insecurity, housing instability, transportation barriers, social isolation, language barriers
and trauma history. By identifying these needs early, the clinic can match patients to the right
clinician, service or community support, reduce repeated storytelling and delays, improve equitable
access, and support both patient and provider well-being.
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Transforming Children Vaccination
Reporting Between Primary Care and
Public Health: A Scalable, Secure Model to
Reduce Administrative Burden and Faxes,
and Improve Patient and Provider
Experience
Organization: Maple FHT
Sector: Primary Care
Primary care organizations in the Frontenac, Lennox & Addington region, in collaboration with
Southeast Public Health, implemented a secure and scalable way to improve the sharing of childhood
immunization records between primary care and public health. The initiative aimed to reduce reliance
on faxing, decrease administrative burden, improve the completeness and timeliness of immunization
reporting, improve patient and provider experience and reduce privacy risks associated with faxes.
By enabling monthly bulk electronic sharing of immunization records, the project sought to improve
the experience of families by reducing the need for parents and caregivers to submit their children’s
records to the public health unit themselves and to help prevent unnecessary school and daycare
suspensions related to missing records.
The work is tied to the QIP indicator focused on the number of faxes sent per 1,000 rostered patients
and reflects a safety-focused improvement effort that benefits patients, primary care teams, public
health units, schools and the province.
Click here to learn more about the initiative
Corporate Delirium Steering Committee at
Queensway Carleton Hospital
Organization: Queensway-Carleton Hospital
Sector: Acute Care/Hospital
The Queensway Carleton Hospital (QCH) launched a Corporate Delirium Steering Committee to
oversee and guide its delirium-related quality improvement efforts. This advisory group was tasked
with aligning initiatives to QCH’s strategic goals, ensuring timely and budget-conscious delivery, and
resolving complex issues around delirium prevention and management. Using structured problemsolving
and evidence-based practices, the committee aimed to reduce hospital-acquired delirium and
enhance both patient and staff experiences. The initiative focused on improving patient safety, staff
experience, and overall quality of care. Key indicators included the rate of delirium onset during
hospitalization, compliance with Confusion Assessment Method (CAM) documentation, staff training
rates, and patient/family satisfaction with delirium education.
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Right Care, Right Place: Reducing ED Transfers from LTC at Newmarket Health Centre
Organization: York Region Newmarket Health Centre
Sector: Long Term Care
Newmarket Health Centre launched Right Care, Right Place: Reducing ED Transfers from LTC to lower avoidable emergency department (ED) visits for ambulatory care-sensitive conditions. Baseline performance was 28.57 ED visits per 100 residents from October 1, 2022 to September 30, 2023. The 2024–2025 plan set an improvement target of 27.00, focusing on earlier detection of health changes, rapid in-home interventions, and stronger collaboration among clinicians, residents, families, and external partners. The approach blends proactive assessment, palliative and pain expertise, and structured communication so residents receive timely, person-centered care within the home whenever safe and appropriate.
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Improving Patient Satisfaction at
Discharge at West Parry Sound Health
Centre
Organization: West Parry Sound Health Centre
Sector: Acute Care/Hospital
The initiative, titled “Improving Patient Satisfaction at Discharge,” was launched with the primary
objective of enhancing patient satisfaction and ensuring that individuals felt adequately supported
with the necessary resources at the time of discharge. The project focused on a thorough review of
discharge documentation and strengthening data collection processes to inform practice. Staff
engagement was central, with a strong commitment to preparing patients for their transition from
hospital to home. The introduction of the Patient Navigator role proved especially impactful, patients
appreciated the human engagement and the interaction allowed for candid, robust feedback from
patients to drive improvement efforts. The initiative is ongoing, with continuous efforts to identify
and implement further improvements for sustained positive outcomes. The priority issue addressed
was patient experience, measured by the percentage of respondents who felt they received enough
information about post-discharge concerns.
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Medication Reconciliation at Discharge at
Queensway Carleton Hospital
Organization: Queensway-Carleton Hospital
Sector: Acute Care/Hospital
Over the past few years, Queensway Carleton Hospital (QCH) has focused on enhancing its medication
reconciliation processes at both admission and discharge. While admission improvements involved
prioritising patients for Best Possible Medication Histories (BPMH), standardising documentation, and
improving communication to physicians, this initiative spotlights the discharge process. The project
aims to increase the completion rate of discharge medication reconciliation and improve the quality
of information provided to patients and primary care providers. The priority issues addressed are
patient safety and patient experience, with indicators including the proportion of discharged patients
receiving a Best Possible Medication Discharge Plan and feedback from patients and primary care
providers.
Click here to learn more about the initiative
Fall Prevention at Extendicare Elginwood Long-Term Care
Organization: Extendicare Elginwood
Sector: Long Term Care
Extendicare Elginwood implemented a home-wide fall-prevention initiative to reduce resident harm and improve safety. In 2023 the home recorded 267 falls. By 2024, with standardized rapid post-fall reviews, biweekly data huddles, targeted care plan audits, environmental checks, and stronger interdisciplinary communication, total falls declined to 189. The approach emphasizes real-time root-cause analysis, timely care plan updates, identification of high-risk residents and peak-risk times, and resident engagement during known risk periods. Progress is tracked through biweekly and quarterly reviews, audit compliance, and year-over-year comparisons.
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Reducing Emergency Department Visits for Care-Sensitive Conditions in Long-Term Care Residents at Norwood Nursing Home
Organization: Norwood Nursing Home
Sector: Long Term Care
Norwood Nursing Home implemented a Quality Improvement initiative titled “Reducing Emergency Department Visits for Care-Sensitive Conditions in Long-Term Care Residents.” The goal was to lower avoidable hospital transfers by addressing root causes such as infections, chronic disease flare-ups, and falls. Frequent emergency visits were recognized as missed opportunities for early intervention. To address this, the home partnered with the Unity Health Toronto Nurse Lead Outreach Team (NLOT) to enhance early detection, strengthen communication, and improve care coordination.
The initiative focused on proactive, resident-centered strategies such as routine on-site assessments, standardized infection management protocols, and timely access to diagnostics and medications. This work supported the Access and Flow priority area within Ontario Health’s Quality Improvement Plan, specifically targeting the rate of emergency department visits for ambulatory care–sensitive conditions per 100 long-term care residents.
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Enhancing Emergency Department Care
for Adults Living with Sickle Cell Disease
Organization: Humber River Health
Sector: Acute Care/Hospital
The project, titled “Enhancing Emergency Department Care for Adults Living with Sickle Cell Disease,”
was launched to address disparities in emergency department (ED) care for adult patients with Sickle
Cell Disease (SCD). These patients often present during vaso-occlusive crises and experience delays in
pain management and inconsistent care. The multi-phase quality improvement (QI) initiative focused
on improving timely access to evidence-based pain management, standardising triage and care
protocols, and enhancing staff education on SCD. The primary aim was to reduce the time to firstdose
analgesia, ensure more consistent and compassionate care, and improve patient satisfaction and
clinical outcomes. The initiative aligns with provincial and organisational commitments to equity,
patient-centred care, and timely access.
Click here to learn more about the initiative
Reducing the 90th Percentile Time to Inpatient Bed:
A Collaborative Approach
Organization: Humber River Health
Sector: Acute Care/Hospital
Humber River Health identified extended stays for admitted patients in the Emergency Department
(ED) as a growing challenge, particularly as patient volumes increased. Historically, the hospital
maintained relatively low numbers of admitted patients boarding in the ED, but recent pressures
necessitated targeted interventions. The project, titled “Reducing the 90th Percentile Time to
Inpatient Bed: A Collaborative Approach,” aimed to improve operational flow and patient experience
by reducing the time from ED arrival to inpatient bed. The initiative focused on culture change,
standardized workflows, command center insights, and frontline empowerment. Key strategies
included daily flow huddles, real-time dashboards, proactive discharge planning, and embedded
education, all designed to address access and flow, safety, and patient experience, with the primary
indicator being the 90th percentile time to inpatient bed.
Click here to learn more about the initiative
Workplace Violence Prevention
Organization: Mackenzie Health
Sector: Acute Care/Hospital
Mackenzie Health launched a Workplace Violence Prevention initiative aimed at automating and
enhancing their workplace violence risk assessment tool. The project’s primary goal was to improve
accessibility and utilisation of the risk assessment process across various areas of the organisation. By
focusing on the indicator of workplace violence incidents resulting in harm rate, the initiative sought
to streamline data collection and submission, making it easier for leaders to assess and manage risks
effectively.
Click here to learn more about the initiative
Improving Access to Care at Amherstburg Family Health Team
Organization: Amherstburg FHT
Sector: Primary Care
The Amherstburg Family Health Team (AFHT) recognized that access to primary care is a persistent challenge, especially highlighted during the COVID-19 pandemic. In response, AFHT collaborated closely with patients to develop access methods tailored to their needs, including an After-Hours physician line operating four evenings per week. As the pandemic subsided, the team realized the importance of frequently reviewing data on patient demand and shifting between virtual and in-person care. To support this, AFHT developed an Access Dashboard, which evolved to encompass all aspects of physician access, including where patients seek care (e.g., ER, outside use), third next available appointments (virtual and in-office), and reasons for urgent appointments. The dashboard integrates quantitative EMR data and qualitative patient satisfaction survey results, empowering physicians to adjust their practices in line with patient needs and preferences. The overarching goal is to continually refine access to care based on patient feedback and data.
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Staff Technology Training at Langs Community Health Centre
Organization: Langs
Sector: Primary Care
Langs Community Health Centre launched the “Staff Technology Training” initiative to help staff become more comfortable and confident with the technology they use daily. The project involved creating a SharePoint page where staff could easily access training tools and resources, building a peer support network for technology help, and testing Microsoft tools like Power Automate for support requests. AI tools such as Copilot Agents were introduced to make it easier for staff to find policies and internal information. The initiative focused on improving provider experience and efficiency, with a custom indicator tracking the percentage of staff reporting satisfaction with technology training and resource access.
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Decreasing Emergency Department (ED) Visits Among Residents at Northwood Lodge
Organization: Northwood Lodge
Sector: Long Term Care
Northwood Lodge is implementing a coordinated effort to decrease emergency department (ED) visits for ambulatory care–sensitive conditions among all residents. The strategy combines stronger external partnerships, expanded in-home clinical capacity, and clearer shared routines so timely assessment and treatment can occur in the home whenever safe and appropriate. Priority is placed on reliable communication with the local hospital and Family Health Team, consistent onboarding of new community physicians, and increasing nurse practitioner (NP) availability to manage life-limiting conditions and avert transfers. Progress is tracked through counts of ED visits alongside qualitative assessment of each initiative’s impact on resident and family experience.
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Reducing Fax Use at Langs Community Health Centre
Organization: Langs
Sector: Primary Care
Langs Community Health Centre has begun a quality improvement initiative titled “Reducing Fax Use” to explore opportunities to modernize communication practices and gradually transition from traditional faxing to more digital solutions such as eFaxing and Ocean eReferral. Early work has focused on gathering baseline data from electronic medical records (EMR) and physical fax machines to better understand current usage patterns, though data collection has been somewhat inconsistent across areas. The team has started reviewing commonly faxed forms to determine whether Ocean referral versions exist and, where possible, encouraging the use of these digital alternatives. The initiative is being led by the Digital Health and Telemedicine Coordinator, a Registered Practical Nurse (RPN), who is supporting staff in testing and adopting new workflows. While still in progress, the project is expected to inform future improvements related to efficiency, provider experience, safety, and access, and aligns with Quality Improvement Plan (QIP) indicators such as reducing faxes sent per 1,000 rostered patients and increasing eReferral use
Click here to learn more about the initiative