Shared on behalf of Quality and Risk Management

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Please be advised that the Hospital’s Integrated Risk Management policy (QM-180) has been revised. 

Actions Required

• All – Review the updated policy to familiarize yourself with key policy changes and as a refresher on procedural steps. The approved updated policy is attached for reference and is now available on the iNtranet .
• Managers – Review this memo and the attached poster with your staff during Safety/Quality Huddles and post in your department.

Policy Changes

• Policy Statement:

The Hospital is committed to high standards of care and patient safety. Risk management is embedded within day-to-day business, in addition to informing strategic and operational planning. Integrated Risk Management (IRM) at the Hospital is a coordinated, organization-wide approach to identifying, assessing, mitigating and monitoring risks that could impact patient safety, clinical outcomes, staff well-being, finances, reputation and compliance.   

• Scope Change:

Contract employees added. 

• Definitions:

Definitions have been refreshed.

• Roles and Responsibilities Updated:

5.6 All Workers (staff, professional staff, learners, volunteers and contract employees) will:

• identify actual or potential risks and report them to their manager/leader;
• safely conduct work and make daily decisions using the Risk Assessment Tool (Appendix B) and Risk Impact/Likelihood Matrix (Appendix C);
• conduct Occupational Health and Safety (OHS) risk assessments in accordance with policy OHS-os-251 Risk Assessments; and,
• report Patient Safety Incidents via the Incident Learning System (ILS) as per policy QM-60 Incident Learning System: Reporting, Investigation, and Trending of Incidents and Near Misses (excluding volunteers and security staff who will bring the information to their manager).
  
• Procedure Updated:

6.1 All Department/Program Leaders will:

• incorporate discussions on quality and IRM in team meetings and Director/VP meetings on a regular basis 
• Appendix B Updated:Risk Assessment Tool updated to the most recent version provided by HIROC (see updated policy/attached poster).

• Appendix C New:Added TBRHSC Risk Impact/Likelihood Matrix (see updated policy/attached poster).

Process Reminders

• Please see the attached poster.  

 If you have any questions, please email: TBRHSC.QualityandRiskManagement@tbh.net For more resources related to risk management (including Risk Register and Risk Assessment Checklist), please visit the Risk Management tab on the iNtranet:  

Ribbon Skirts are a meaningful expression of culture, identity, and resilience. Worn by Indigenous women, girls, and two-spirit people across North America, they carry deep cultural and spiritual significance, reflecting connections to the land, ancestors, and community. Each ribbon skirt is unique. The colours, fabrics, and designs often hold personal meaning, honouring family, Clan, and individual stories. Whether worn during ceremonies, at pow-wows, or in everyday life, Ribbon Skirts are a visible expression of pride, strength, and belonging.

The priority of Equity, Diversity, and Inclusion identified in Strategic Plan 2026 ensures that the Thunder Bay Regional Health Sciences Centre embeds equity, diversity, and inclusion in all aspects of its operations, providing a culturally safe experience for all patients and staff.

Throughout April, we invite staff to wear their Ribbon Skirts in recognition of Ribbon Skirt Month and to celebrate the strength and beauty of Indigenous cultures.

As shared by Myra Laramee, Grandmother of Fisher River Cree Nation: “When you put on your skirt, you are showing Mother Earth who you are.” Click here to learn more.

For more information on Ribbon Skirts, click here.

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April marks Be A Donor Month in Ontario, a time dedicated to encouraging individuals who haven’t yet signed up to consider organ and tissue donation. In Ontario, 1,400 people on average are waiting for a lifesaving organ while thousands more are in need of a transformative tissue donation. Increasing the number of registered donors enhances the likelihood of saving lives for those needing transplants. It takes two minutes to register at beadonor.ca, and by doing so, you can offer hope to those who are waiting for a critical transplant.

Thank you to all staff who completed the 2025–2026 Annual Corporate LMS modules through Dual Code by the March 31 deadline. Your commitment to mandatory learning supports a safe, knowledgeable, and compliant workplace.

The LMS is currently in a short blackout period while course content is being updated and refreshed for the 2026–2027 learning cycle.

We will share an update once the new modules are available.

Shared on behalf of Rae-Anne Robinson, Lead, Equity, Diversity, and Inclusion

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April is Diversity Month — a time to recognize, celebrate, and honor the wide range of backgrounds, perspectives, and experiences that make up our workforce and the communities we serve.

Diversity includes differences across many dimensions, such as race, ethnicity, gender, age, disability status, religion, sexual orientation, and life experiences — all of which shape who we are.

In health care, embracing diversity is essential to providing respectful, patient centred care. When employees feel respected and included, they are more engaged, collaborative, and better able to provide high-quality care.

How We Can Celebrate Diversity Month

• Take time to learn more about cultures, traditions, and perspectives different from your own.
• Foster respectful dialogue with colleagues and patients, and be mindful of how language, behaviors, and unconscious biases affect others.
• Encourage an environment where everyone feels heard and valued.

Moving Forward Together

Diversity Month reminds us that our differences are not barriers—they are strengths. By embracing diversity and practicing inclusion every day, we create a healthier workplace and provide better care for the communities we serve.

Let this month serve as a starting point for continued learning, compassion, and connection. Together, we can build a culture where everyone — staff and patients alike — feels respected, supported, and valued.

You can learn more about Celebrating Diversity Month here: https://www.stompoutbullying.org/blog/diversity-month

Shared on behalf of Dr. Rhonda Crocker Ellacott, President and CEO, TBRHSC, and CEO, TBRHRI

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Hello, Boozhoo, Bonjour.

March has been a busy month as we have seen a steady increase in activity across our organization and the broader health care system. We are welcoming more students into the building, monitoring developments related to the provincial budget at Queen’s Park, and preparing for several important initiatives in the weeks ahead. I also want to acknowledge the various construction projects happening around our Hospital. I recognize the added strain this can create in an already demanding environment, and I appreciate your continued patience as this work progresses. Recognizing how busy everyone is, below you will find a brief update on what is top of mind this month.

I would like to begin with last week’s provincial budget. You have likely seen the headlines, but I want to share my perspective directly. There is meaningful investment in health care infrastructure, which is important for our organization. At the same time, there is continued emphasis on hospitals operating more efficiently. While this is not new, I feel it is important that you know: The Ministry expects us to identify and implement efficiencies, and we will be held accountable.

That said, our Hospital has consistently outperformed provincial efficiency benchmarks. This positions us more strongly than other organizations as we navigate expectations. While it does not eliminate the pressure, it does mean that we are better positioned to manage it.  This also creates an opportunity for us to better navigate our reality, and our role as the only regional tertiary academic centre in Northwestern Ontario. To this end, we continue to advocate with the Ministry of Health, Ontario Health, and our local and regional MPPs to ensure our context and needs are clearly understood.

As mentioned, you will notice an increase in students and new graduates in the building over the next few weeks. As preceptorships and residencies conclude, some of those people will be making decisions about where they want to begin to build their careers. The fact that they have chosen to train here and are continuing to stay here reflects positively on our organization. I encourage you to welcome them and share your experiences, helping them understand what makes this a great place to work. 

I would also like to highlight that April is Be A Donor month. I encourage you to take a few moments to reflect on this initiative, both personally and where appropriate with patients and families. It is one of those areas where what we do in this building connects directly to something with a much broader impact.

Finally, the month of April includes National Volunteer Week (April 19-25). Our volunteers contribute their time and energy in so many invaluable ways – supporting patients, guiding families, staffing our gift shop, supporting events, and serving on our board, to name a few. The range of what volunteers contribute is easy to take for granted because they make it look seamless, but it is anything but. I encourage you to take a moment this month to express your appreciation. A brief, sincere conversation can be more meaningful than any form of recognition.

As always, thank you for taking the time to read this update and staying informed on matters that affect us all. I welcome any feedback about this blog or any other topics you would like to discuss. You can reach me at rhonda.ellacott@tbh.net. I appreciate hearing from you.

A decade after it first launched to raise awareness about cervical cancer, Northwestern Ontario’s annual cervical screening campaign is returning this month with a new name and a renewed call to action.

Formerly known as ‘Pap-A-Palooza’, the month-long initiative has been renamed ‘Cervical Screen-a-Thon’ to reflect recent changes to the Ontario Cervical Screening Program. In 2025, Ontario replaced the traditional Pap test with a new cervical screening test that checks for certain types of human papillomavirus (HPV) that can lead to cervical cancer.

Thunder Bay Regional Health Sciences Centre (TBRHSC) is leading the 10th annual campaign in partnership with more than 40 clinics and health centres across Northwestern Ontario. From April 1 to 30, participating sites are encouraging eligible individuals to book their cervical screening test as part of a regional effort to increase screening rates.

“This 10^th anniversary milestone reflects the strength of our community partnerships and a decade of commitment to cervical cancer screening across Northwestern Ontario,” said Tarja Heiskanen, Manager, Prevention and Screening Clinical Services at TBRHSC. “Cervical Screen-a-Thon is about turning awareness into action and encouraging more people to take that important step for their health.”

Northwestern Ontario screening numbers are below provincial targets and we are hopeful the campaign will increase screening participation across the region.

“Only about half of eligible individuals in Northwestern Ontario are up to date with cervical screening,” said Dr. Naana Jumah, Ontario Health – Cancer Care Ontario Regional Colposcopy and Cervical Screening Lead for the northwest region. “We continue to diagnose cervical cancer in people who were overdue for testing. Regular screening allows us to detect changes earlier and significantly improve outcomes.”

The Ontario Cervical Screening Program recommends screening for individuals who:

• Are at least 25 years old.
• Are a woman, Two-Spirit person, transmasculine person, or non-binary person with a cervix.
• Have ever had sexual contact with another person.
• Do not currently have symptoms such as unusual bleeding or discharge.
• Are due for screening based on program guidelines.

To find a participating clinic near you and to learn more about Cervical Screen-a-Thon, visit tbrhsc.net/screenathon.

National Indigenous Languages Day, celebrated on March 31, is an opportunity to appreciate the linguistic diversity within Indigenous cultures. This day emphasizes the importance of revitalizing and preserving Indigenous languages, which are vital to cultural identity and community connections.

In Canada, languages like Anishinabek (Ojibwe), Mushkegowuk (Cree), and Anisininew (Oji-Cree) demonstrate unique vocabulary and grammar, reflecting the rich histories and cultures of their communities.

Within the Ojibwe community, there are some common words that showcase the beauty and significance of the language. Here are a few:

To learn more:

The Ojibwe People’s Dictionary – https://ojibwe.lib.umn.edu/

James Vukelich Kaagegaawaw – https://www.youtube.com/@james.vukelich/featured

Recommended Reading: Vukelich Kaagegaawaw, James. The Seven Generations and The Seven Grandfather Teachings. James Vukelich, 2023           

Shared on behalf of Infection Prevention and Control

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An RSV outbreak has been declared on 1A Medical /Oncology inpatient unit as of today Tuesday, March 31, 2026. Outbreak #2262-2026-00038 

All restrictions are in place. 

Please share this information with the appropriate staff. 

As always, our number one priority is the safety of patients and their families, staff and visitors. All patients identified as having an exposure to this outbreak will require isolation with appropriate additional precautions. 

The department of Infection Prevention and Control encourages everyone to keep applying the routine practices of hand hygiene, proper use of PPE, equipment cleaning, and the appropriate admission screening of all patients. Please set an example for staff and students and assist us by maintaining compliance and due diligence. 

For more information, contact:

Infection Prevention and Control

Thunder Bay Regional Health Sciences Centre

807-684-6094