Performance Reporting

Why is it important to publish performance reports?

Bluewater Health is pleased to share reports of our performance not only as a means of communicating and demonstrating the quality of care provided at our hospital and our plans to improve healthcare experiences, but also as an indication of our commitment to accountability and transparency to our community, patients, and staff.

Performance Measures

What is the purpose of measuring and reporting our performance?

Bluewater Health measures and reports performance for many reasons:

  1. To monitor our progress in achieving the desired outcomes of our strategic plan.
  2. To check that our efforts to improve the quality of care at Bluewater Health, as outlined in our Quality Improvement Plan (QIP), are truly resulting in better and safer care.
  3. To comply with Local Health Integration Network (LHIN) and Ministry of Health and Long-Term Care (MOHLTC) requirements for publicly reported patient safety measures as a condition of receiving funding for the care and services we deliver.

Learn more about Bluewater Health’s performance for a single measure aligned with our strategic plan, QIP, or a publicly reported patient safety measure by clicking on it in the list below. Note that in many cases, a measure may align with more than one reason to report performance. Or, review the full report of all 20 measures together by clicking here.

Performance Measure

Last Updated

Strategic Plan

  Quality Care        
  Safe & Effective        
Hospital Standardized Mortality Ratio (HSMR) X   X 12/30/2015
Hand Hygiene X X X 7/10/2019
Clostridium Difficile Infection (CDI) X   X 10/30/2019
Central Line Infection (CLI) X   X 10/30/2019
Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection X   X 10/30/2019
Surgical Safety Checklist Compliance X   X 11/26/2018
Surgical Site Infection Prevention X   X


Vancomycin-Resistant-Enterococcus (VRE) Infection X   X 10/30/2019
Ventilator-Associated Pneumonia (VAP) X   X 10/30/2019
Falls X     1/31/2019
Medication Reconciliation X X   9/29/2016
  Accessible & Equitable        
Surgery, Magnetic Resonance Imaging (MRI), and
Computed Tomography (CT) Wait Times
X     11/30/2015
Emergency Department Wait Times for Admitted Patients X X   11/30/2015
Cancer Surgery Wait Times X     2/29/2016
Readmissions to Hospital X X   5/31/2016
  Exceptional Relationships        
  Patient & Family-Centred Care        
Would Definitely Recommend Bluewater Health     X 8/08/2017
Respect for Patient Preferences        12/31/2015
  Outstanding Performance        
Cost per Weighted Case X     7/31/2015
Total Margin X     2/29/2016
  Inspired People        
Employee Rating of Bluewater Health as a Place to Work X     2/28/2013


How often are performance reports updated?

Different measures of performance are monitored at different frequencies depending on how often new information is available; some are reviewed daily while others may be reviewed weekly, monthly, or quarterly by staff, physicians, managers, executives, and Board members. The performance reports published here will be updated as new information is available (refer to Last Updated column of chart).

In what other ways does Bluewater Health measure performance and demonstrate accountability?

  • Our Quality Improvement Plan (QIP)
  • H-SAA (Hospital Service Accountability Agreement)
  • Accreditation
  • Financial Statements
  • Expense Reporting

Where can I learn more about Bluewater Health’s performance?

Maps & Directions

Bluewater Health’s programs and services are distributed across two locations, Bluewater Health in Sarnia and Charlotte Eleanor Englehart Hospital of Bluewater Health in Petrolia. 

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Emergency Care

Bluewater Health’s Emergency Department (ED) provides safe, quality emergency nursing and medical care to patients.

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Patient Virtual Visit

Due to COVID-19, Bluewater Health currently has restrictions in place limiting family support and visiting in the hospital – but that doesn't mean you can't connect with your loved ones. Please let us know if you would like to schedule a 15-minute virtual visit with a loved one in hospital.

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Locate a Patient

Find or contact a patient by telephone, email or e-card.

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Compliments & Concerns

We are always looking for ways to improve, and welcome your questions, comments, suggestions and concerns. If you’re in hospital, please speak to the hospital staff.

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