Accountability and public reporting

Being one of Canada’s foremost mental health care and academic health science centres means ensuring that each patient receives the highest quality and safest care possible. Explore the ways we pursue quality, and learn more about our accountability to those we serve. 


Accessibility plan 

In keeping with the Mission, Vision and Value statements, The Royal recognizes and respects the diversity of our patients, visitors and staff. We serve a diverse community and welcome the involvement of all individuals in our organization. Our leadership, our patient services and our employment practices demonstrate respect of diversity.

The Royal will, whenever possible, implement measures for the identification and removal of barriers with respect to goods, services, facilities, accommodation, employment, buildings, structures, premises or other such things.

The Royal’s Accessibility Plan outlines the organization’s commitment to these standards and planned actions to improve accessibility in line with the Accessibility for Ontarians with Disabilities Act.

Accreditation Canada

Accreditation with Exemplary Standing

The Royal has been accredited with Accreditation Canada for over 60 years. Accreditation Canada is a not-for-profit, independent organization that provides health organizations with an external peer review to assess the quality of their services based on standards of excellence. As an academic teaching hospital for postgraduate medical education, The Royal must undergo this evaluation process every four years.

Our last accreditation was in 2015, when The Royal received the “Accredited with Exemplary Standing” designation. This is the highest level that can be attained and is a testament to the quality and safety of services The Royal offers to clients, families and the community.


Audited financial statements

Independent auditors' report: Years ended March 31, 2013 and 2012

To the Board of Trustees of Royal Ottawa Health Care Group:

We have audited the accompanying financial statements of Royal Ottawa Health Care Group, which comprise the statements of financial position as at March 31, 2013, March 31, 2012 and April 1, 2011, the statements of operations, changes in fund balances and cash flows for the years ended March 31, 2013 and March 31, 2012, the statement of remeasurement gains and losses for the year ended March 31, 2013, and notes, comprising a summary of significant accounting policies and other explanatory information.


Management's Responsibility for the Financial Statements

Management is responsible for the preparation and fair presentation of these financial statements in accordance with Canadian public sector accounting standards, and for such internal control as management determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error.

Auditors' Responsibility
Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with Canadian generally accepted auditing standards. Those standards require that we comply with ethical requirements and plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial statements. The procedures selected depend on our judgement, including assessment of the risks of material misstatement of the financial statements, whether due to fraud or preparation and fair presentation of the financial statements in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the entity's internal control. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of accounting estimates made by management, as well as evaluating the overall presentation of the financial statements.

We believe that the audit evidence we have obtained in our audits is sufficient and appropriate to provide a basis for our audit opinion.


In our opinion, the financial statements present fairly, in all material respects, the financial position of Royal Ottawa Health Care Group as at March 31, 2013, March 31, 2012 and April 1, 2011, its results of operations, changes in fund balances and its cash flows for the years ended March 31, 2013 and March 31, 2012 and its remeasurement gains and losses for the year ended March 31, 2013 in accordance with Canadian public sector accounting standards.

Board and executive expense claims

In 2010, the government passed the Broader Public Sector Accountability Act, which requires hospitals to publicly post any expense claims made by hospital executives and board members, effective Nov. 30, 2011.

The Royal embraces this requirement as a reasonable way to promote public confidence in our management of taxpayer money. It is consistent with policies that apply to senior leaders in government and other broader public sector organizations.

Hospitals, like many other complex businesses, may have executives who incur business-related expenses from time to time that are permissible and should be reimbursed. Business-related expenses identified by the government for public reporting typically fall under three categories: meals, travel, and hospitality.

Corporate Policies
  • Accessible formats
  • Conflict of interest
  • Expense claims
  • Infection control
  • Prevention management of violence in the workplace
  • Providing a barrier-free environment
  • Respectful workplace
  • Scent-free
  • Smoke-free environment
  • Visiting
  • Whistleblower
Executive compensation

The Royal has a comprehensive performance management program in place for its executive team, consisting of:


The President and Chief Executive Officer (CEO) compensation and contract details are negotiated by a sub­committee of the Board of Trustees and approved by the Board.

Vice presidents’ compensation is approved by the President and CEO under guidelines approved by the Board of Trustees.


Performance Reviews

Each year the CEO and vice presidents set goals against which the incentive component is determined.

The CEO’s goals and incentive is evaluated by a subcommittee of the Board of Trustees and approved by the Board. Vice presidents are evaluated by the CEO based on goals that are cascaded from the CEO’s.

Vice presidents’ performance reviews are presented to a Board sub­committee as part of the overall talent review and succession planning process.


Performance Development Program

The CEO and the vice presidents completed a 360 evaluation in 2011. The results are used as an opportunity for growth and development.


Quality Improvement Plan
Consistent with government legislation, a percentage of the incentive pay is linked to the organization’s Quality Improvement Plan.

Hospital Service Accountability Agreement

Hospital Service Accountability Agreements (H-SAAs) are tools to help clarify expectations, facilitate the assessment of performance and improve processes and policies in both hospitals and the Ministry of Health and Long-Term Care.

The H-SAA reflects a commitment to joint planning and negotiation, collaborative problem-solving and continuous improvement. It is a flexible document that will adjust as hospitals and the health care system change.

Infection prevention and control

The Infection Prevention and Control Program at The Royal is based on evidence based practices and procedures. It involves many aspects of keeping patients, staff and visitors safe, including surveillance for infectious diseases, hand hygiene, education, communication, and monitoring outbreaks. We strive to prevent and reduce the spread of infections between health care workers, patients, and visitors.

In May 2008, the Ministry of Health and Long Term Care announced that all funded hospitals in the province were being provided an opportunity to join in public reporting of a number of patient safety indicators. The rates of C difficile are the first of the eight indicators that were selected for this initiative. Further information on the public reporting plan can be found on the Ministry of Health and Long Term care website.



At the Royal Ottawa Mental Health Centre, Brockville Mental Health Centre, and in our region, the rate of C difficile infection is low, but we recognize that there always remains work to be done to make sure that no preventable infection occurs in our patients. Patient safety is a priority at our centres. Hospital-acquired infections do sometimes occur, but we are constantly striving to identify risks to our patients and ensure our staff have all the tools they need to avoid infection in their patients.

Our infection control staff are active in programs to improve hand hygiene and to provide education to staff, visitors, and patients. To make sure we keep track of infections and to ensure our rates of infection stay low, we have a program to monitor infection rates. Our ultimate goal is to keep our patients safe, and provide excellent care to all who need our services.

Mental Health and Addictions Quality Initiative
Ontario’s four specialty mental health hospitals have developed an innovative and standardized approach to measure critical performance indicators of mental health care. The mental health indicators represent performance in key areas including client complexity, client outcomes, client access, staff safety, human resources, fiscal responsibility and client safety.

This common approach allows each organization to measure its outcomes, quality, safety and fiscal responsibilities as a public hospital and share this information with the community in a way that is consistent for all mental health care facilities in Ontario.

Participating organizations are: The Centre for Addiction and Mental Health (CAMH), Ontario Shores Centre for Mental Health Sciences (Ontario Shores), Royal Ottawa Mental Health Group (The Royal) and Waypoint Centre for Mental Health Care (Waypoint).

Privacy and information practices

The Royal places a high value on the privacy, confidentiality and security of each patient’s personal health information.

With this in mind, we follow the Government of Ontario’s Health Information Protection Act as well as follow our own strict policies regarding the collection, use and disclosure of information about our patients.


View the Royal Ottawa Health Care Group procurement process.

Public Sector Salary Disclosure (PSSD)

View The Royal's 2019 PSSD.

Quality Improvement Plan

The Excellent Care for All Act, which came into effect in June of 2010, included a requirement that all hospitals create and make public annual Quality Improvement Plans. All hospitals in Ontario are now required to develop quality initiatives and make measurable improvements in the areas of safety, effectiveness, access and patient-centredness.

We take quality improvement very seriously and are committed to achieving the targets that we set for our organization based on our mission of delivering excellence in specialized mental health care, advocacy, research, and education. Reporting on our progress is one the ways that we hold ourselves accountable to our stakeholders and acknowledge our progress as we continue on our quality improvement journey.