Regulation - LGIC

Public Hospitals Act, Ontario Regulation 965, Hospital Management

Regulation Number(s):
Regulation 965
Instrument Type:
Regulation - LGIC
Bill or Act:
Public Hospitals Act
Summary of Decision:
Ontario Regulation 448/10 under the Public Hospitals Act (PHA) was filed on December 2, 2010. This regulation amended Regulation 965 under the PHA, effective January 1, 2011, to support the Excellent Care for All Act, 2010.

These amendments to Regulation 965 under the PHA require aggregate critical incident reporting to the quality committee at least two times per year. They establish reporting relationships between the medical advisory committee (MAC) and quality committee and change requirements related to MAC reporting on the quality of care provided by extended class nurses who are hospital employees.
In addition, the administrator, the president of the medical staff, the chief of staff or chair of the MAC, and the chief nursing executive are required to sit on the board as non-voting members. These changes to hospital boards promote a more collaborative environment and ensure each board benefits from clear and direct access to clinical and management expertise through adherence to a common set of membership standards.
Further Information:
Proposal Number:
Posting Date:
October 28, 2010
Summary of Proposal:

On June 8th, 2010, the Excellent Care for All Act, 2010 (ECFAA) received Royal Assent. Beginning with hospitals, the Act requires health care organizations to:
• Develop and post annual quality improvement plans.
• Implement patient and employee satisfaction surveys and a patient relations process.
• Link executive compensation to achievement of quality plan performance improvement targets.
• Develop declarations of values after public consultation.
• Create quality committees to report to each hospital board on quality related issues.

Related amendments to Regulation 965 under the Public Hospitals Act (PHA) were made and filed to support ECFAA. Effective July 1, 2010, critical incident reporting was strengthened to require that critical incidents in hospitals be reported to the Medical Advisory Committee and the hospital administrator, in addition to the affected patient. Action plans are required for every critical incident.

Also, amendments were made to provisions of Regulation 965 concerning hospital board membership, which will be effective as of January 1, 2011.

Overview of Proposed Regulations

Amendments to Regulation 965 under the PHA are proposed to support ECFAA. These include amendments to support quality committees established under ECFAA that were not proclaimed upon Royal Assent, should these requirements in ECFAA come into force.
Contact Address:
Sylvia Moustacalis
Manager, System Productivity and Governance Unit
Ministry of Health and Long-Term Care
Health System Strategy Division
80 Grosvenor Street, 8th Floor, Hepburn
Toronto ON M7A 1R3
Fax: (416) 212-2092
Effective Date:
January 1, 2011