Hospital Patient Relations Regulations in Force September 1, 2015

August 27, 2015 | Kathryn M. Frelick

Two new regulations under Ontario’s Excellent Care for All Act, 2010 (“ECFAA”) have been filed by the Ministry of Health and Long-Term Care and are coming into force on September 1, 2015.  These regulations set out requirements for hospital patient relations processes as well as requirements for patient engagement in annual hospital quality improvement plans.

Consultations on the draft regulations were held in the spring of 2014.

Patient Relations Process Regulation

Section 6 of ECFAA requires every healthcare organization to have a patient relations process in place.  The patient relations process must reflect the content of the organization’s patient declaration of values, and information about the process must be available to the public.  “Healthcare organization” is currently defined as a public hospital, however other health sector organizations could potentially be added by regulation.

The Patient Relations Process Regulation (the “Regulation”) sets out minimum requirements for a hospital complaint process.  It also addresses communication with complainants and the designation of a “patient relations process delegate” who is responsible for overseeing the hospital’s patient relations process.

Complaint Process

Under the Regulation, hospitals are required to have a process in place for “receiving, reviewing and attempting to resolve expeditiously complaints from patients and caregivers of patients.”  To this end, hospitals are required to engage patients and their caregivers in designing, reviewing and maintaining their complaint processes.

“Patient” is defined broadly to include a patient, former patient, or individual who is or has acted as the patient’s substitute decision maker under the Health Care Consent Act, 1996.  The Regulation also provides a role for a patient’s “caregiver” in this process.  In this context, “caregiver” refers to an individual who “provides or has provided sustained care or support to a patient or former patient.”

Hospitals will be required to record, monitor and analyze data relating to complaints.  At a minimum they must track:

  • the name of the complainant and, where the complainant is a caregiver, the name of the patient and the caregiver’s relationship to the patient (except in the case of an anonymous complaint);
  • the subject matter of the complaint;
  • the date when the complaint was received; and
  • whether the complaint is resolved to the satisfaction of the patient or caregiver and if so, how and on what date.  If the complaint is not resolved, the hospital must identify the manner and date that it forms the view that it has exhausted all options under its complaint resolution process.

Communication with Complainant

The Regulation requires a hospital to ensure that a complainant is informed of the status of the review of the complaint.  Initial communication must take place within five days from the day the complaint is received and, thereafter, whenever the complainant reasonably requests further information.  Given the short time frame, it is extremely important to ensure that there is a streamlined intake process which enables the hospital to determine the manner in which the review ought to be handled, and to ensure timely communication with the complainant.

Patient Relations Contact Person

The Regulation requires every hospital to designate an individual as its “Patient Relations Process Delegate,” who is responsible for overseeing the organization’s patient relations process.  The individual’s contact information must be made available to the public and, at least twice a year, the Delegate must present aggregate data relating to the patient relations process at meetings of the hospital’s quality committee.  This must be built into the organization’s processes and procedures.  Aggregate patient relations process data must also feed into the hospital’s quality improvement plan.

It is up to each hospital to determine how best to structure its patient relations process, recognizing that this will differ depending on the size of the organization and available resources.  For smaller organizations, the patient relations process delegate may have multiple areas of responsibility.  For larger hospitals, there may be a patient relations department within the organization.


The patient relations process is the responsibility of all staff and physicians in the hospital.  Wherever possible the concerns of patients and their families should be addressed at the point of contact and dealt with accordingly.  Where it is not possible to resolve concerns, individuals ought to be made aware that the hospital has a patient relations process and how to access it.

Many hospitals are already meeting the requirements of the Regulation and have well-developed patient relations processes in place.  When used effectively, such processes can provide opportunities for process and system improvements.  Valuable insights can be gained through this process to identify areas of service excellence as well as opportunities for improvement.  To this end, it is essential for the patient relations process to be linked to other hospital processes to ensure that quality and risk issues, including potential performance issues, are promptly identified and addressed.

Quality Improvement Plan Regulation

A new Annual Quality Improvement Plan Regulation will also be in force as of September 1, 2015.

Under ECFAA, hospitals are required to develop a quality improvement plan or QIP, which is a documented set of quality commitments that a hospital makes to its patients to improve quality through focused targets and actions.  The new Annual QIP Regulation requires hospitals to engage patients, former patients and their caregivers in the development of their annual QIP.  The publicly available version of the QIP must contain a description of the patient engagement activities of the hospital and how these activities informed the development of the QIP.

There are a number of resources available through the Ministry of Health and Long-Term Care to assist hospitals to meet the requirements of the new regulations.  Miller Thomson would be pleased to provide assistance with the development and structuring or review of your patient relations process.


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