Safety & Quality
The enhancement of patient care safety and quality is a top priority in accordance with the hospital’s corporate strategy.
WELCOME MESSAGE
The Division of Orthopaedic Surgery is dedicated to continually enhancing the quality and safety of patient care through our Patient Safety and Continuous Quality Improvement (PS & CQI) initiatives. Our mission is to achieve the best possible surgical outcomes and patient experiences while minimizing complications and adverse events.
Through ongoing monitoring and detailed analysis of surgical outcomes, we identify opportunities for improvement and implement system-wide changes that lead to measurable, lasting advancements in care. This work is guided by our multidisciplinary Quality Improvement Committee—comprising surgeons, nurses, residents, physician assistants, patient relations specialists, and research experts, who meet regularly to review data, share insights, and develop targeted improvement initiatives.
Collaboration is at the heart of our process. The committee works closely with other hospital departments and divisions to align efforts, share best practices, and ensure that our quality and safety initiatives meet—and strive to exceed—provincial, national, and international standards.
Dr. Peter Lapner, MD FRCSC
Committee Chair
Safety & Quality Committee Members
- Peter Lapner MD FRCSC: Committee Chair
- Natasha Casey: Physician Assistant
- Alexandra Craig: Clinical Manager, Ambulatory Care, General/Civic Campuses
- Savannah Davis Rph ACPR: Pharmacist
- Johanna Dobransky MD MHK BSc: Resident Representative
- Kimberly Jemmott RN: Clinical Manager 6NE, General Campus
- Stephen Kingwell MD FRCSC: Integrated Spine CQI
- Stephanie Kusiak: Patient Relations Specialist
- Rosa Lamothe RN BScN: Clinical Manager D7, Civic Campus
- Katie McIlquham HBScHK RKin: Quality Improvement Coordinator
- Steven Papp MD MSc FRCSC: Division Chair
- Johanne Samson: Executive Administrator
- Andrew Tice MD FRCSC: Lead, Quality Improvement CHEO
- Mazen Younes MD: Hospitalist
From the Beginning
This publication highlights the structure of our CQI program.
Current Program
Below you’ll see this year’s Division focus on Patient Safety and Quality Improvement, highlighting key initiatives that enhance outcomes, streamline care, and elevate the overall patient experience.
Division of Orthopaedic Surgery Annual Highlights 2025-2026
The Division of Orthopaedic Surgery continues to strive to improve the quality of patient care with a strong focus on Patient Safety and Quality Improvement. According to Qualtrics data, our overall rating of care for day surgery was 90.5% for the 2024/2025 fiscal year. We hold ourselves to a high standard, and strive to improve the patient experience in both outpatient and inpatient care. Below are some examples of our current initiatives.
Performance Scorecards
During the 2025 year, we continued to build on the previous years’ initiatives. As per the previous two years, we continue to provide the surgeons in each Clinical Practice Unit (CPU) within the Division with individual performance metrics via scorecards. Scorecards are comprised of information relating to primary elective procedures at the inpatient campuses and our satellite sites including Kemptville District Hospital (KDH) and Hawkesbury General Hospital (HGH).
The following variables were provided to each surgeon for all primary cases:
- 7-day post-operative Emergency Department visits
- 30- and 90-day post-operative readmission rates
- Superficial and deep infection rates
- Revision and reoperation rates
Patient-Reported Outcome Measures (PROMs) + ConEHR
Our division closely tracks patient-reported outcome measures (PROMS) in all clinical practice units using a prospective Quality database, ConEHR. These measures are monitored to allow for the provision of excellence in care in all services we provide.
Patient Feedback Letters
We receive a number of patient feedback letters. A majority of our patient experience letters are extremely positive. We take negative feedback very seriously and always seek to improve.
Ongoing Key Initiatives
- Hip Fracture Care
Time-to-OR
During the 2022 year, the Canadian Institute for Health Information published metrics for timing of hip fracture care once admitted to hospital. Only 75% of patients had surgery within 48 hours from the time of admission. A new initiative to prioritize hip fracture cases led to dramatic improvement in this metric, now at 89.1%. Upgrading surgical booking the morning following admission significantly improved access to OR time, with a marked improvement in secondary health metrics.
Delirium
Delirium rates in the hip fracture population were flagged through NSQIP as an area for improvement as the incidence at TOH was higher than expected. Various measures have been enacted to address this and the incidence of delirium in hip fractures continues to improve.
Venous Thromboembolism (VTE) Prophylaxis
Inconsistent VTE prophylaxis dosing was identified as a possible risk factor for post-operative deep vein thrombosis (DVT) following hip fractures. We continue close collaborations with Pharmacy and Thrombosis, after creating a Divisional Standardized Operating Procedure (SOP) for VTE prophylaxis in hip fracture patients.
2. Streamline Stable Non-Operative Pelvic Fractures to Rehabilitation
We are actively working with one of partner institutions, Bruyère, to streamline patients transfers via expedited referrals to a rehabilitation program. This benefits all patients by creating an efficient pathway to get patients the best care possible for their needs while creating additional room for acute in-patient care.
3. Prosthetic Joint Infection (PJI) Care and Prevention
All infections in joint replacement are carefully tracked. These ongoing evaluations have led to early pre-operative optimization for patients to mitigate infection risk amongst various other measures.
In summary, our goal is to provide the highest quality care for orthopedic patients in Canada. Our robust quality program continues to serve to allow us to achieve this.
