Back to Top Committees Terms of Reference - The Ottawa Hospital


Development Committee

To advise and make recommendations for approval to the Board of Governors on matters relating to the Master Plan of The Ottawa Hospital. Planning will align with the Hospital’s academic and research mandate and encompass program requirements and development plans for the Hospital’s clinical, corporate and research services, offered at all campuses and other satellite locations.

Finance and Audit Committee

The Finance and Audit Committee, unless otherwise designated by resolution of the Board, shall:


  • Review and recommend to the Board for approval a detailed annual operating budget and capital budget for the ensuing fiscal year;
  • Oversee the implementation of the annual Operating Plan ;
  • Review and recommend procedures relating to the control of the operational and capital expenditures of the Hospital;
  • Examine the financial strategies of the Hospital and their relationship to the priorities established by the Board;
  • Review and evaluate long-range revenue and expenditure projections;
  • Review the detailed financial statements on an as-needed basis but at least once every three months and advise the Board of issues as required;
  • Review annually Management’s recommendations on the types and amounts of insurance to be carried by the Corporation;
  • Review and recommend the Board regarding donations, bequests, endowments, investments and debts;
  • Review claims and possible claims including civil litigation or regulatory proceedings to which the organization is a party;
  • Review and assess the integrity and monitor the performance of the system of internal controls; and
  • Advise the Board on other financial matters as required.


External Audit

  • Review and recommend all audit and non-audit engagements by the external auditor including fees and terms, in accordance with the Auditors Independence Policy.
  • Review the Hospital’s audited annual financial statements and recommend to the Board accordingly. Prior to commencement of the annual audit, review with the external auditor the proposed audit plan and scope of work.
  • Review issues and make recommendations that affect the financial management, financial viability and internal control systems of the Hospital; and
  • Advise on the selection of the external auditor, as required by the By-law of the Corporation.

Internal Audit

  • Oversee and advise the chief internal auditor with respect to Internal Audit (‘IA’) operations and functions including:
    • Review, recommend and approve TOH’s IA charter at least every second year or more frequently, if necessary;
    • Review, recommend and monitor the multi-year IA plan prepared by the chief internal auditor and make recommendations for in-year changes in the plan as the Committee deems necessary;
    • Receive and review IA reports including management’s progress on action plans advise the Board accordingly;
    • Review Management’s policies and processes relating to compliance with laws and regulations, ethics, conflicts of interest, and the investigation of misconduct and fraud; and
    • Advise, jointly with the CFO, on the appointment, removal and performance review of the Internal Auditor.

Information Technology

  • Review and recommend the Digital Solutions Plan;
  • Report on all aspects of the implementation, costs, and efficacy of the of the strategy and plan, both for the Hospital and as a resource to the region; and
  • Monitoring program management for the Hospital Information System (HIS) implementation.

Planning and Facilities

  • Review and recommend the Capital Development and Facility Renewal Plan;
  • Report on the implementation of the Ministry of Health and Long-term Care approved redevelopment plan of the Hospital and any other physical facilities and capital expenditures planned for the Hospital;
  • Report on the development and implementation of the Hospital Planning and Facility Plan; and
  • Report on the land usage and requirements of the Corporation and all important construction and renovation proposals relating to the Hospital.


  • Receive and review semi-annual reports from Management regarding the Hospital’s privacy controls.

Governance Committee

The Governance Committee, unless otherwise designated by resolution of the Board, shall:


  • Review and recommend to the Board amendments to the By-laws, Committee structure and board policies;
  • Implement and monitor processes for the orientation, development, and evaluation of the effectiveness of the Board;
  • Oversee Board accountability in accordance with the University of Ottawa Heart Institute Service Agreement and the Ottawa Hospital Research Institute Relationship and Services Agreement;
  • Establish and recommend Committee composition;
  • Establish and recommend Committees Terms of Reference;
  • Act as Nominating Committee;
  • Review governance issues as requested by the Board of Governors.

Performance Management

  • Review and recommend annually the performance objectives of the President and Chief Executive Officer and the Chief of Staff;
  • Evaluate the performance of the Chief Executive Officer and the Chief of Staff based on agreed-upon annual objectives;
  • Establish annually the compensation of the Chief Executive Officer and the Chief of Staff, including the philosophy and policy underlying that compensation, the level of incentive compensation and the amount of the incentive compensation tied to quality plan targets pursuant to the provisions of the Excellent Care for All Act, 2010;
  • Participate in the development of learning plans and activities for the Chief Executive Officer and the Chief of Staff; and
  • Oversee and assume responsibility for the succession planning process for the Chief Executive Officer and the Chief of Staff.

Quality Committee

The Ottawa Hospital Quality Committee performs the functions of the Quality Committee under the Excellent Care for All Act, 2010, (the “Act”) and assists the Board of Governors in the performance of its governance role for the quality of patient care and services.

A. Legislative Requirements

Excellent Care for All Act, 2010

  1. Monitor and report to the Board on quality issues and on the overall quality of services provided in the Hospital, with reference to appropriate data including:
    1. Performance indicators used to measure quality of care and services and patient safety;
    2. Reports from the Medical Advisory Committee identifying and making recommendations regarding systemic or recurring quality of care issues at the Hospital; and
    3. Publicly Reported Patient Safety Indicators.
  2. Consider and make recommendations to the responsible body regarding quality improvement initiatives and policies.
  3. Ensure that best practices information supported by available scientific evidence is translated into materials that are distributed to employees and persons providing services within the Hospital, and to subsequently monitor the use of these materials by these people.
  4. To oversee the preparation of annual quality improvement plans.
  5. To carry out any other responsibilities provided for in the regulations under the Act.

Public Hospitals Act and Regulation 965

  1. Receive from the Chief Executive Officer, at least twice a year, aggregate critical incident data related to critical incidents occurring at the Hospital since the previous aggregate data was provided to the Committee.
  2. Annually review and report to the Board on the Hospital’s system for ensuring that, at an appropriate time following disclosure of a critical incident, there be disclosure as required of systemic steps, if any, the Hospital is taking or has taken to avoid or reduce the risk of further similar critical incidents. The Committee shall review reports of sentinel events and oversee any plans developed to address, prevent or remediate such events.

B. Additional Requirements

Patient Relations

  1. Receive and consider semi-annual reports from Patient Relations including an analysis of high/low performing units, performance compared to leading benchmarks and progress towards management’s goals.

Quality and Cost

  1. Oversee the hospital’s quality assurance program, including:  its system of performance measurement, incident management, document control, audit program and accreditation programs.
  2. Monitor and evaluate pertinent Corporate Scorecard / Quality Improvement Plan indicators on a quarterly basis and receive reports from Senior Management and other stakeholders, as required.
  3. Receive reports from Senior Management regarding plans addressing performance issues as requested by the committee.
  4. Receive reports from Senior Management demonstrating that best practices information, based on available scientific evidence, is translated into the materials distributed to employees and persons providing services within the Hospital, and that monitoring processes are in place.
  5. Receive reports from Service Line Leadership highlighting issues of patient safety, quality, patient experience, clinical outcomes and employee engagement. Provide feedback on the effectiveness of safety programs, employee engagement initiatives, and clinical quality initiatives outlined in these reports.
  6. If requested by the Board, provide advice to the Board on the implications of budget proposals on the quality of care and services.

Hospital Services Accountability Agreement and Hospital Annual Planning Submission (HAPS)

  1. If requested by the Board, provide advice to the Board on the quality and safety implications of the HAPS and the quality indicators proposed for inclusion in the Hospital’s service accountability agreement or in any other funding agreement.

Risk Management

Review and make recommendations with respect to:

  1. the Hospital’s standards on emergency preparedness;
  2. Management’s plans and policies for risk management related to quality of patient care and safety; and


  1. Ensure the Hospital has a process to address bioethics related issues
  2. Receive Management reports on the Hospital’s policies on bioethics related issues

Last updated on: June 22nd, 2023