Accountability & Public Reporting

This year, we laid the foundation for our next chapter, one that focuses on our SPARQ: Sustainability, People, Access, Research and Quality.

Past annual reports

• 2023-2024
• 2022-2023
• 2021-2022
• 2020-2021

Research at The Royal is driven by the goal to get people living with mental illness and addiction better, faster.

Our Research Annual Reports outline how we are working to achieve this goal, through collaborative and interdisciplinary discoveries and innovation in research.

Past Reports:

• • 2023-2024
  • 2022-2023
  • 2021-2022
  • 2018-2019

Every donation to The Royal makes a difference in the lives of those we serve—now and in the future. Read more about how your support helps patients reclaim their lives in the Foundation’s annual impact report.

Past Reports:

• 2023-2024
• 2022-2023

People using assistive devices, service animals, and support people are welcomed and accommodated in our environment. All staff at The Royal receive training on how to interact with individuals with disabilities who use an assistive device or require the assistance of a service animal or a support person. In addition, patients admitted to The Royal’s inpatient programs/units will be assessed to determine if there is a need for additional equipment, aids and/or support requirements.

The Royal is committed to providing documents in the preferred accessible formats for persons with disabilities and will respond to requests for accessible formats promptly and to the best of our abilities. A formal request for any document in a particular accessible format or other communication supports (such as sign language interpretation) can be made by or to any staff member.

All of The Royal’s facilities are fully accessible with accessible entrances, washrooms, elevators and parking that are clearly marked.

Any pre-planned interruptions to entrances, access roads, elevating devices or accessible washrooms will be posted on The Royal’s website to provide public notification. Signs will be placed at the interruption site indicating alternate accessible options.

Unexpected disruptions, or disruptions where it is too difficult to post a notice on the website, will be handled with signs and/or The Royal staff or volunteers who will provide alternate directions as required. The person providing the alternate directions should be able to communicate the nature of the outage and expected duration, whenever possible. The Royal will try to ensure that multiple accessible service disruptions do not occur at the same time.

Review The Royal’s audited financial statements.

Review the foundation’s audited financial statements.

What is C. difficile?
C. difficile (Clostridium difficile) is a spore-forming bacterium that can be part of the normal bacteria found in the large intestine. A C. difficile infection occurs when other good bacteria in the bowel are eliminated or decreased allowing the C. difficile bacteria to grow and produce toxin. The toxin produced can damage the bowel and cause diarrhea.

What is The Royal doing to minimize the risk of patients contracting C. difficile at their facilities?
Good hand hygiene—cleaning hands thoroughly and often—is the single-most effective way to prevent the spread of infectious diseases like C. difficile. The Royal is committed to promoting hand hygiene for patient care. We provide access to alcohol-based hand products as well as soap and water throughout the facility for staff, patients and visitors to use. We also follow the advice of the Ontario “Just Clean Your Hands” including providing education to staff and auditing our hand-hygiene practices.

Any patient with C. difficile diarrhea will be isolated until free of the symptoms for at least two days. All healthcare staff that enters the patient’s room will wear a gown and gloves, and will clean their hands when leaving the room.

The Royal also works with its housekeeping team to ensure a clean hospital environment and that best practices are followed for cleaning in situations where patients are identified with C. difficile.

For further information, please view the C. difficile Patient Information Sheet.

The Royal posts its C. difficile infection rates online on a monthly basis. On this website, you can find information about hospital-acquired infection rates for C. difficile.

What is Methicillin-resistant Staphylococcus aureus (MRSA)?
MRSA is a type of staphylococcus bacterium (a germ) that is resistant to many common antibiotics. It is not resistant to all antibiotics, however. Staphylococcus bacteria (or ‘staph’) often live on the skin or in the nose, without causing any health problems (this is called colonization). Most people who carry MRSA on their skin or in their nose do not get an infection or get sick from it.

What is The Royal doing to minimize the risk of patients contracting MRSA at their facilities?
Good hand hygiene—cleaning hands thoroughly and often—is the single-most effective way to prevent the spread of infectious diseases. The Royal is committed to promoting hand hygiene for patient care. We provide access to alcohol-based hand products as well as soap and water throughout the facility for staff, patients and visitors to use. We also follow the advice of the Ontario “Just Clean Your Hands” including providing education to staff and auditing our hand-hygiene practices.

For further information, please view the MRSA Patient Information Sheet.

What is Vancomycin-Resistant Enterococci (VRE)?
Enterococci are bacteria normally found in a person’s bowels. These bacteria can sometimes cause infection. Vancomycin is an antibiotic used to treat infection caused by enterococci. One strain of Enterococcus bacteria known as Vancomycin Resistant Enterococcus (VRE) has developed resistance to vancomycin.

What is The Royal doing to minimize the risk of patients contracting VRE at their facilities?
"Just Clean Your Hands" including providing education to staff and auditing our hand-hygiene practices.

For more information, please view the VRE Patient Information Sheet

Why is hand hygiene so important?
Hand hygiene is an important practice for healthcare providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients, visitors and healthcare providers.

We have a number of practices in place to help prevent and control infections, including a comprehensive hand hygiene program. All Ontario hospitals are required to annually post their hand hygiene compliance rates to further promote accountability and transparency within the health system.

What is The Royal doing to improve hand hygiene practices?
Hand hygiene involves everyone in the hospital, including patients. Hand cleaning is one of the best ways you and your healthcare team can prevent the spread of many infections. Patients and their visitors should also practice good hand hygiene before and after entering patient rooms.

Alcohol based hand rub (ABHR) is placed in strategic locations within our facilities and education is provided to all staff with the "Just Clean Your Hands" training module from the Ministry of Health and Long Term Care. We are offering small portable ABHR for staff to carry to ensure they will be able to clean their hands at any given time, in any given place.

Past and present clients of The Royal have a right to access their personal health information at any time during or after their care.

For full details on how to access your information, visit the page linked below.

Key Principle
When collecting, using or disclosing an individual’s personal health information, a key principle is that the patient’s consent is required.

Consent
Consent to the collection and use of personal health information about a patient may be:

• Express or
• Implied.

In order to be valid, the consent must be:

• Be the consent of the patient.
• Be knowledgeable (reasonable to believe the patient knows the purpose of the collection or use and knows that consent can be withheld).
• Relate to the information.
• Not be obtained through deception or coercion.
• Withdrawal of consent shall not have a retroactive effect.

Capacity to Consent
A patient is capable of consenting if the patient is able to:

• Understand the information that is relevant to the decision to consent to the collection, use or disclosure and
• Appreciate the reasonably foreseeable consequences of giving, not giving, withholding or withdrawing the consent.

The patient may be capable of consent with respect to consenting to the collection, use or disclosure of some parts of personal health information, but incapable with respect to other parts, or capable at one time, but not another time.

• The default position is that there is a presumption of capacity.

Determination of Incapacity
The hospital (a health information custodian) may rely on the “presumption of capacity” unless the hospital has reasonable grounds to believe that the patient is incapable of consenting to the collection, use or disclosure of personal health information.

• If found incapable, the patient has an opportunity to apply to the Consent and Capacity Board for a review of the determination.

Direct Collection
Collection of personal health information directly from the patient requires consent, however, the hospital may collect personal health information about a patient indirectly even if the patient is incapable of consenting, if the collection is necessary for the provision of treatment and it’s not reasonable to obtain consent in a timely manner.

Indirect Collection
The hospital may collect personal health information indirectly if:

• The patient consents.
• Reasonably necessary for providing healthcare and it’s not possible for the hospital to collect it directly from the patient accurately or in a timely fashion.
• The hospital collects it from a non-health information custodian for research purposes (with Research Ethics Board approval).
• The Commissioner authorizes the collection.
• Permitted or required by law, treaty or agreement under an Act.
• Permitted under FIPPA or MFIPPA (Freedom of Information and Protection of Privacy Acts).
• Investigating a breach or contravention of a law.
• Conducting a proceeding or possible proceeding.
• Compiling statistics for the planning and management of the healthcare system.

Permitted Uses
Unless a patient expressly instructs otherwise, the hospital may use personal health information about the patient:

• For the purposes for which the information was collected or created.
• For planning or delivering programs or services, allocating resources, monitoring or preventing fraud regarding services or benefits.
• For risk or error management, to maintain quality of care.
• Educating agents to provide healthcare.
• To seek the patient’s consent (only name and contact information).
• In a proceeding or contemplated proceeding.
• To obtain payment, processing, monitoring, verifying or reimbursing claims for payment.
• For research with Research Ethics Board approval.
• To comply with a legal requirement in this Act or another Act.

Agents
The hospital permitted to use personal health information may provide it to an “agent” who may use it for that purpose on behalf of the custodian. This is not considered a “disclosure” by the hospital to the agent, but rather a “use.”

An “agent” means a person that with the authorization of the hospital acts for or on behalf of the hospital not for the agent’s own purposes with respect to personal health information whether or not:

• The agent has the authority to bind the hospital.
• The agent is employed by the hospital.
• The agent is being remunerated.

Permitted Disclosures

The hospital may disclose personal health information about the patient as follows:

Disclosure related to providing healthcare

• To another health information custodian if the disclosure is reasonably necessary for the provision of healthcare and it’s not reasonable to obtain the patient’s consent in a timely manner, unless the patient has expressly instructed the hospital not to make the disclosure (effective November 1, 2005).
• If a patient’s instruction prevents the hospital from disclosing all the personal health information necessary for the provision of healthcare to the patient, the hospital must make the recipient of the information aware of that fact.

For funding or payment

• For the Minister or another health information custodian to determine or provide funding of payment to the hospital for the provision of healthcare.

Contacting a relative, friend, or substitute decision maker

• For contacting a relative, friend or potential substitute decision maker if the patient is injured, incapacitated or ill and unable to give consent personally.

Facilities that provide healthcare
Providing the hospital offers the patient the option to object to the disclosure and the patient does not do so, the hospital may disclose.

• The fact that the patient is a patient or resident in the facility.
• The patient’s general health status—i.e. critical, poor, fair, stable or satisfactory.
• The location of the patient in the facility.

Deceased individual (or presumed deceased)

• For identifying the patient.
• For informing any person about the death of the patient and circumstances where appropriate.
• To the recipient i.e. spouse, partner, sibling or child of the patient who may require the information to make decisions about their own or their children’s healthcare.

For health or other programs

• For determining or verifying eligibility to receive healthcare.
• To a person conducting an audit or accreditation.
• To a person who compiles or maintains a registry relating to the storage or donation of body parts or bodily substances.
• To the Chief Medical Officer of Health or public health authority.

Disclosures related to risks

• For eliminating or reducing significant risk or serious bodily harm to a person or group of persons.

Disclosure related to care or custody

• To the head of a penal or other custodial institution in which the patient is being lawfully detained.
• To the officer in charge of a psychiatric facility in which the patient is being detained for the purposes of assisting in making decisions concerning arrangements for the provision of healthcare to the patient or the placement of the patient into custody, detention, release, conditional release, discharge or conditional discharge.

For a proceeding

• For a proceeding that in which the hospital or the agent or former agent of the hospital is a party or witness if the information relates to the proceeding or contemplated proceeding.
• To a proposed litigation guarding or legal representative for the purposes of having the person appointed as such or to commence, defend or continue a proceeding on behalf of the patient.
• To comply with a court order, summons etc. issued by an Ontario court.
• To comply with a procedural rule compelling the production of information.
• To the agent or former agent’s professional advisor for the purpose of providing advice or representation if the advisor is under a professional duty of confidentiality.

To a successor

• To allow a potential successor to assess and evaluate the operation of the health information custodian but only if the successor enters into an agreement with the health information custodian to keep the information confidential and not retain it for longer than is necessary to carry out the assessment or evaluation.
• To transfer the hospitals records to the hospitals successor after giving notice to the patient before transferring the records or if not reasonably practical than as soon as possible after the transfer took place.
• To the Archives of Ontario.

Disclosure related to this act or other acts

• For determining, assessing or confirming capacity under the Healthcare Consent Act, The Substitute Decisions Act of this Act.
• To a college within the meaning of the Regulated Health Professions Act for the purposes of administration or enforcement of the Drug and Pharmacies Act or the RHPA.
• To the Board of Regents under the Drugless Practitioners Act for administration or enforcement.
• To the Ontario College of Social Workers for administration or enforcement.
• To the Public Guardian and Trustee, The Children’s Lawyer, a children’s aid society, a Residential Placement Advisory Committee under the Child and Family Services Act or the Registrar of Adoption Information to carry out their statutory functions.

For research

Refer to policy “Disclosure of Personal Health Information for Research”.

• If the researcher submits a written application and research plan to the hospital.
• The research plan meets certain requirements and is approved by the Research Ethics Board of the hospital.
• The researcher enters into an agreement with the hospital about the research plan.

Mandatory disclosures

• Aviation Medical Advisor (Aeronautics Act) if condition impacts the patient’s ability to perform job safely (flight crew, air traffic controllers, etc).
• Children’s Aid Society (Child and Family Services Act) if child needs protection.
• Coroner or Police Officer (Coroner’s Act) for facts surrounding a death of a patient as a result of violence, negligence, malpractice or to a coroner if a patient dies while in hospital.
• Medical Officer of Health (Health Protection and Promotion Act) for communicable diseases.
• Registrar of Motor Vehicles (Highway Act) if condition may make it unsafe to drive.
• Registrar General (Vital Statistics Act) for births and deaths.

To the Minister of Health and Long-Term Care

• To any person appointed by the Minister for research purposes.
• For purposes requested and approved by the Minister for centralized control of computerized health record.
• To a Minister inspector.

To employees of a hospital

• To fulfill their duties or functions.

To a psychiatric facility

• To assess, observe, examine or detain the patient in accordance with the MHA.
• To comply with Part 21 (Mental Disorder) or an order under that part.
• To the Consent and Capacity Board for a proceeding.
• To a physician issuing or renewing a community treatment order (CTO) or for consulting others concerning a CTO.
• To a person named in the CTO plan providing the treatment (upon written request of the physician or other named person).
• To a person providing advocacy services in “prescribed” circumstances.
• To the Public Guardian and Trustee to enable investigations.
• To respond to a summons, order, subpoena or similar legal requirement.

Disclosures outside of Ontario

• With patient consent.
• If the Act permits the disclosure.
• The recipient performs functions comparable to the functions performed by a person within Ontario.
• The disclosure is for the purposes of providing healthcare and the patient does not object.
• The disclosure is required for payment or healthcare purposes.

To the Quality Care Committee of a hospital

• To carry out the committee’s duties and responsibilities

• Research Plan Checklist
• Research Ethics Board Approval Checklist
• Research Ethics Board Decisions Checklist
• Agreement between the Hospital and the Researcher Checklist

The Rule: Collection, Use and Disclosure of Personal Health Information for Research

Purposes:

• Nothing in the Act prevents the hospital or researchers from collecting, using or disclosing personal health information for research purposes with the express consent of the patient. The hospital or researchers may not rely on implied consent.
• The hospital or researchers may collect personal health information for research purposes without patient consent, providing the collection is in compliance with the Act.
• The hospital or researchers may use personal health information for research purposes without patient consent, providing the requirements concerning research plans and Research Ethics Board approval are met.
• The hospital may disclose personal health information to a researcher without patient consent, if a written agreement with the researcher to protect the information is in place. The researcher must also provide the hospital with the written application, the written research plan and a copy of the Research Ethics Board approval of the research plan.

Research Plan

The research plan must be in writing and set out the following:

• The affiliation of each person involved in the research.
• The objectives of the research and the anticipated public or scientific benefits.
• A description of the proposed research and the duration.
• A description of the personal health information required and potential sources.
• A description of how the personal health information will be used and if linked to other information – a description of the other information and how the linkages will be done.
• An explanation of why the personal health information is necessary and if linked to other information why it’s required.
• An explanation as to why “consent” of the individual to whom the information relates is not being sought.
• A description of the foreseeable harms and benefits that may arise from the “use” of the personal health information and how the researcher intends to address the harm.
• A description of all persons having access to the personal health information, why their access in necessary, their roles relative to the research and their qualifications.
• The safeguards to protect the confidentiality and security of the personal health information.
• An estimate of how long the information will be retained in an identifiable form and why.
• An explanation of how the personal health information will be disposed of or returned to the hospital.
• The funding source of the research.
• Whether the researcher has applied to another Research Ethics Board and if so the status of the application.
• Whether the researcher’s interest or performance of the research would result in an actual, perceived or potential conflict of interest with other duties of the researcher.

Research Ethics Board Composition

A research ethics board must be composed of at least five members including:

• An independent community member.
• A member with experience in research ethics.
• Two members with relevant expertise in research.
• A member with expertise in health privacy.

Research Ethics Board Duties

In order to approve a research plan, the Research Ethics Board must consider:

• Whether the objectives of the research can be accomplished without using personal health information.
• Whether there are adequate safeguards in place to protect the privacy of the individuals whose personal health information is being disclosed and the confidentiality of the information.
• The public interest in conducting the research and the public interest in protecting the personal health information.
• Whether obtaining the consent of the individual would be impractical.
• Whether all matters listed on the Research Approval Checklist have been met.

Research Ethics Board Decisions

The Research Ethics Board must:

• Notify the researcher of its decision in writing with reasons, setting out whether the Board approves the plan.
• Whether the approval is subject to any conditions.
• Specify the conditions, if any.

Researcher Duties

A researcher who receives personal health information about an individual from the hospital shall:

• Comply with the conditions specified by the Research Ethics Board regarding the plan.
• Use the personal health information only for the purposes set out in the plan as approved.
• Not publish the information in a form that could lead to the identification of the individual.
• Not disclose the information, unless required by law.
• Not make or attempt to contact the individual directly or indirectly unless the hospital first obtains the individual’s consent to being contacted.
• Notify the hospital immediately in writing of any breach.
• Comply with the “agreement” between the hospital and the researcher.

Agreement between the Hospital and the Researcher

Before the hospital discloses personal health information to a researcher:

• The Researcher must enter into an agreement with the hospital and agree to comply with any conditions and restrictions that the hospital imposes relating to the use, security, disclosure, return or disposal of the information.

Transition

A hospital that “used” or disclosed personal health information for the purpose of conducting research in the three-year period before November 1, 2004 may continue to disclose personal health information to the researcher for the purposes of that research for a period of three years after November 1, 2004 (i.e. November 1, 2007).

Last updated: October 28, 2004

Policy: Correction to Personal Health Information (Patient)

An individual having been granted access to a record of personal health information (health record) about the individual in the custody or under the control of a health information custodian may make an informal request (oral) or a request in writing a correction to that record, if the individual believes the record is inaccurate or incomplete for the purposes the record was collected or used.

The following are the obligations placed on Health Records when responding to an individual’s request for access to a record of his or her personal health information.

Request Process: Patient

• If the patient makes an informal (oral) or written request to the health information custodian who has custody or control of the individual’s record of personal health information for a correction to his or record, and
• Gives the custodian the information necessary to enable the custodian to correct the record.

Time Frame

Health Records must:

• Respond to the request within 30 days from the date of receipt of the request to a maximum of 60 days after receiving the request if an extension is required.
• Provide the individual with a written notice if extending the time frame, setting out the length and the reasons for the extension.
• Be deemed non-compliant or have refused the request if the custodian does not respond within the time limit or before the extension expires.

Approval Process

Health Records must:

• Determine the validity of the requested correction by consulting with the persons or professionals responsible for the entry in the record if required, or examining the information that the individual provides to the custodian.
• Assess whether the request is frivolous, vexatious or made in bad faith.

Correction Granted

The “Author” of incorrect or incomplete information will:

• Make the correction in the record by: striking out the incorrect information in a way that does not obliterate it; or if not possible;
• Label the information as incorrect, advise Health Records of the change and send the record to Health Records. Health Records will sever the incorrect information from the record, and store it separately, while maintaining a link in the record to trace the incorrect information;
• If it’s not possible to correct the record (i.e. an electronic record) then direct a person who accesses the record to the amended record with the correct information.

Notice of Corrected Record

Health Records must:

• Give notice to the individual of what was done in writing.
• Give written notice to persons to whom the custodian has disclosed the information with respect to the correction unless the correction cannot reasonably be expected to have an effect on the ongoing provision of healthcare or other benefits to the individual.

Reasons for Refusing To Correct Personal Health Information

The hospital is not required to correct a record:

• If it is a professional opinion or observation about a patient made in good faith.
• If it was not made by an employee or agent of the hospital.
• Where there is insufficient knowledge, expertise and authority to correct the record.
• Where there is no ability to validate the new information provided.
• Where the patient has been unable to demonstrate that the record is incorrect or incomplete or has not given you the information to make the correction.

Correction Refused

Health Records must:

• Notify the individual in writing that the request for correction has been denied and the reasons for the refusal.
• Inform the individual of his/her right to attach a “statement of disagreement” that sets out the corrections that were requested but refused.
• Disclose the “statement of disagreement” whenever the custodian discloses the information to which the statement relates.
• Make all reasonable efforts to disclose the “statement of disagreement” to any person who had received information to which the statement relates.
• Inform the individual that he/she is entitled to make a complaint about the refusal to the “Commissioner.”

Consent for Fundraising

The hospital may only collect, use or disclose personal health information about a patient for the purposes of fundraising if:

• The patient gives express consent or consent is implied and the information consists only of the patient’s name and contact information.
• Consent may be implied only if the hospital had at the time of providing service to the patient posted or made available a notice of information practices that describes that unless the patient requests otherwise – name and contact information may be disclosed for fundraising purposes, together with information on how the patient can easily “opt out” from receiving any future solicitations, and
• The patient has not opted out.

Contact Information

Means the patient’s name and mailing address only.

• When contacting or attempting to contact the patient, the hospital or a person conducting the fundraising on behalf of the hospital, must not reveal any information about the patient’s healthcare or state of health.

Solicitations and Opt-out Option

All solicitations for fundraising must provide the patient with an easy way to opt-out from receiving any future solicitations.

Transfer of Personal Health Information to Others

Service providers, for example mail service providers, must comply with the rules in the Act that apply to them. They must only use the information for the stated purpose and no other purpose. They must notify the hospital if the information they handle is stolen, lost or accessed by unauthorized persons or used, disclosed or disposed of in an unauthorized manner.

Biddingo.com is an online portal that connects vendors providing various goods and services to buyers from the Provincial, Municipal, Education, Crown Corporation, Housing, Construction, Healthcare and Private sectors from across Canada. All current bids for The Royal Ottawa Healthcare Group can be found on-line at Biddingo. The hospital will post any and all competitive bid documents on this site for Vendors to have the opportunity to submit a proposal.

The St. Joseph’s Health System, Group Purchasing Organization (SJHS-GPO), which originated in 1992, has grown to become a national group that works together with healthcare facilities, manufacturers and distributors to create effective purchasing opportunities. The St. Joseph's Health System Group Purchasing Organization consists of a Capital Group and Food & Nutrition Group. The Capital Group includes membership of over 160 healthcare facilities across Canada, including British Columbia, Ontario and Nova Scotia. The membership is comprised of academic health centres, community hospitals and long-term care facilities. Of these, 131 facilities are located throughout the Province of Ontario. With the adoption of integrated supply-chain management the SJHS-GPO has been approached to deliver customized Capital acquisition processes to a wide variety of member organizations and externally to organizations ranging from government bodies (federal and provincial) to large academic health centres, rural community hospitals and long-term care facilities, which have resulted in overall success.

HealthPRO is Canada’s healthcare group purchasing organization. Founded in 1996, HealthPRO is invested in Canada’s healthcare system by advancing the purchasing interests of hospitals, provincial and shared service organizations (SSOs) from coast to coast to coast. With more than 260 members representing over 800 healthcare facilities across seven provinces and the territories, HealthPRO brings together the most significant purchasing power ever assembled within Canada’s healthcare system. Together, these national collective efforts save members hundreds of millions of dollars that can be directed where it is needed most – to frontline patient care.

With offices in Vancouver, Edmonton, Regina, Mississauga and Halifax, HealthPRO provides member support and knowledge sharing across the broadest possible range of operational areas including: Pharmacy, Clinical, Nutritional & Food and Support Services as well as Clinical Specialties, Energy Management and On-site Managed Services.

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