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HPA-OHT Accreditation Collaborative Shares Policies

With great pride, we update you on the remarkable progress made by the HPA-OHT Accreditation Collaborative. This initiative is a shining example of our commitment to enhancing healthcare standards through collaboration and shared learning.


Since the collaboration’s inception in 2019, we have witnessed inspiring growth in our collective efforts. From just four policies in 2019, we have expanded to 20 comprehensive policies by 2024. This increase is not just a number—it’s a testament to all participating organizations’ dedication and collaborative spirit.


Our diverse team, encompassing hospitals, long-term care, community support services, home care, primary care, and sectors focused on intellectual and developmental disabilities, has harmonized policies across various domains. The harmonization covers governance, leadership, medication management and infection prevention and control, among other areas. This collaboration ensures that our policies are rooted in shared purposes and processes, tailored to meet the specific needs of each participating organization.


One of the critical outcomes of this collaboration is the creation of standardized evaluations for board members and board meetings, reflecting our commitment to consistent governance and leadership quality. Moreover, our sub-committees, including governance, IPAC, and medication management, have been diligently working on reviewing and creating policies and incorporating site visits to ensure practical implementation.


As we march towards the 2024 Accreditation Canada survey, it’s clear that our collective efforts are reshaping the landscape of integrated healthcare in our community.


Call to Action:


We strongly encourage all member organizations to review and adopt the collaborative policies available on the HPA-OHT website. For further inquiries or guidance, please get in touch with our HPA-OHT Project Coordinator, Kim Van Wyk. Your active participation and feedback are vital to the success of this initiative.


Additionally, we are excited to inform you that we are developing an Equity, Inclusion, Diversity, and Anti-Racism (EID-AR) plan. This plan is designed to align with the Ontario Health Equity Framework and will include educational resources to implement it. Stay tuned for more details on this transformative initiative.


Together, we are not just preparing for accreditation; we are forging a path toward a more integrated, equitable, and high-quality healthcare system. Thank you for being a part of this transformative journey!

Harmonized Policies Huron Perth & Area Ontario Health Team Accreditation Collaborative

Just Culture (pdf)

This policy outlines the principles of a ‘Just Culture’ within the Huron Perth & Area – Ontario Health Team, emphasizing the importance of a fair and just process in assessing accountability and handling healthcare providers involved in adverse events. It highlights the goal of creating a transparent, supportive environment that prioritizes safety, learning from incidents, and avoiding blame while maintaining responsibility and ethical conduct.

Equity Framework Ontario Health Quality (pdf)

This policy presents Ontario Health’s Equity, Inclusion, Diversity, and Anti-Racism Framework, focusing on addressing systemic issues like anti-Indigenous and anti-Black racism. It outlines 11 areas of action, including collecting and using equity data, embedding these goals in strategic plans, and partnering to advance Indigenous health equity, aiming to foster an equitable and inclusive health system in Ontario.

Risk Management Policy (pdf)

This policy outlines a comprehensive approach to risk management, aiming to safeguard fiscal integrity and ensure safety and care. It encompasses continuous assessment, mitigation, implementation, and evaluation of management strategies in collaboration with regional and provincial partners, applicable to all HPA-OHT Accreditation Collaborative member organizations.

2024 01 03 Board self evaluation (pdf)

A comprehensive tool designed for annual self-assessment by Board Directors. It covers various aspects of board performance, governance, financial oversight, stakeholder relations, and individual director contributions, helping to ensure accountability and effectiveness in their roles.

2023 Medication Sample Management (pdf)

Details guidelines for managing medication samples in compliance with regulatory requirements. It focuses on ensuring safety and quality through clear documentation, proper labelling, and patient education, while outlining specific procedures for handling, dispensing, and monitoring medication samples within healthcare settings.

2023 Medication Recording Policy (pdf)

Provides comprehensive guidelines for medication administration, emphasizing adherence to the ’10 Rights of Drug Administration’. It aims to reduce medication errors by ensuring correct drug, dose, patient, route, time, documentation, assessment, drug interactions, and patient education, enhancing safety and quality of care in healthcare settings.

2023 Executive Leader Succession Planning Policy (pdf)

Outlines a policy for ensuring organizational stability and effectiveness through a structured succession plan for executive leaders. This plan addresses both unexpected temporary vacancies and planned transitions, focusing on continuity of leadership, encouraging internal leadership development, and guiding recruitment strategies.

2023 Do Not Use Abbreviations Policy (pdf)

Aims to promote safe and clear communication in healthcare settings. It prohibits using specific abbreviations, acronyms, and symbols in documentation to prevent misinterpretation and reduce the risk of medication errors, focusing on accuracy in medical orders and patient records.

2023 Code of Conduct Policy (pdf)

Establishes ethical guidelines and standards for Board Directors, including managing conflicts of interest, maintaining confidentiality, and adhering to legal and organizational policies. It is applicable to all directors and non-director board committee members, emphasizing the importance of integrity, transparency, and commitment to the organization’s values and responsibilities.

2023 Board_Effectiveness Policy (pdf)

Outlines a policy for continuous monitoring and improvement of board performance. It emphasizes regular evaluation of both the board as a whole and individual members, focusing on a range of factors including skills, risk management, leadership, succession planning, and stakeholder communication, to enhance overall governance effectiveness.

2023 07 24 Client Flow overview (pdf)

The policy provides a comprehensive overview of the Huron Perth and Area Ontario Health Team’s (HPA-OHT) approach to fostering a sustainable, people-driven healthcare system, detailing its commitment to evidence-based care, cross-sector collaboration, and the specific working groups and initiatives aimed at improving health outcomes and patient experiences across the region.

2023 11 01 Health and Safety Policy (pdf)

The policy emphasizing the commitment to creating and sustaining safe, healthy workplaces by adhering to all applicable laws and regulations, with specific strategies for preventing workplace injuries and illnesses.

2023 12 06 Board of Directors Nomination Policy (pdf)

The policy focuses on creating a transparent, equitable process for board nomination that ensures a diverse, skilled, and community-representative board membership, in alignment with organizational by-laws and strategic leadership goals.

2023 11 01 Workplace Violence & Harassment & discrimination policy (pdf)

The policy details our commitment to preventing workplace violence, harassment, and discrimination, outlining responsibilities and procedures for reporting and addressing incidents, and emphasizing a zero-tolerance approach to ensure a safe and respectful working environment.

2023 11 01 Ethics Policy (pdf)

This policy emphasizes a standardized, fair approach to ethical issues in healthcare. It outlines ethical principles such as autonomy, beneficence, confidentiality, and justice, aiming to guide decision-making and actions while ensuring ethical practice across all levels of the organization.

2023 11 01 Safety Incident Management HPA OHT (pdf)

This policy focuses on a harmonized approach for managing safety incidents involving staff, patients, and others within the healthcare setting. It emphasizes timely incident reporting, learning from incidents to foster a safety culture, and implementing system improvements to minimize risk, ensuring a safe environment for both healthcare recipients and providers.

2023 12 06 Board of Directors Meeting Evaluation (pdf)

The document is an evaluation form designed for the Huron Perth & Area Ontario Health Team’s Board of Directors to assess the effectiveness of board meetings and member contributions, aiming to enhance future meetings and ensure productive, engaged participation.

2024 01 03 Board self evaluation (pdf)

The document is a comprehensive Board Self-Evaluation Questionnaire designed to annually assess board performance, effectiveness in governance, financial oversight, stakeholder relations, and individual director contributions, fostering continuous improvement and strategic alignment within the organization.