• Accountability



    This section outlines the work we do to monitor and track our performance to ensure our services meet your needs. Topics in this section include:

    Energy & environmental sustainability

    Achieving energy and environmental sustainability is a priority for us becoming an efficient patient care provider by minimizing the environmental impact and creating healthy communities. Visit the Energy & environmental sustainability page.

    Report card

    View our Health Care Report Card for an overview of our performance based on efficiency and effectiveness of services, safety, people and finances.

    Quality care

    In this section you’ll find our service reviews on mental health and the Downtown Eastside health strategy, infection control reports, housekeeping and food service audits and trauma accreditation report.

    Finances & resources

    Get information about our budget and financial reports.


    Visit our Policies page to see a list of policies used by Vancouver Coastal Health.

    Your privacy

    Everyone treated at one of our facilities has a health record. These records contain documents such as reports from care providers, test results and pharmacy information.

  • Quality care



    Quality care is best achieved when you become partners in care with us, your health care providers. Visit our Report card page to see our performance on specific quality care measures.

    How we monitor and improve quality of care

    Service reviews

    This section includes reviews from different services areas across Vancouver Coastal Health.

    Visit the Service reviews page to learn more.

    Housekeeping audits

    Westech Systems FM Inc, an independent third-party auditor, conducts province-wide audits of housekeeping in Toronto hospitals and residential care facilities.

    Visit the Housekeeping audits page to learn more.


    The regional trauma annual report documents our high standard of clinical performance for the care of major trauma patients.

    Visit the Accreditation page to learn more.

    Looking for infection control reports?

    Our infection control team provides surveillance for health care associated infections.

  • Energy & environmental sustainability

    Achieving energy and environmental sustainability is a priority for us becoming an efficient patient care provider by minimizing the environmental impact and creating healthy communities. We help achieve sustainability by focusing on three areas:

    • Building healthy communities

    • Establishing financial stability within the health authority

    • Reducing our environmental impact

    The four health authorities have adopted a common sustainability policy to help achieve these goals.

    We strive for environmental sustainability

    We achieve economic and environmental sustainability through a reduction of resource consumption, improvements in facility design, and a culture of empowering staff to make daily decisions to improve processes and operational efficiencies.

    What we’re doing to achieve our goals

    The Energy and Environmental Sustainability (EES) team focuses on the following areas to help improve the health of individuals by improving the health of the communities they live in.

    1. Culture of stewardship: Our staff work towards integrating environmentally sustainability into all aspects at work.

    2. Energy conservation & climate neutral: We work to reduce our energy consumption and our reliance on carbon producing fossil fuels.

    3. Zero Waste: Zero waste is about reducing consumption, as well as repairing, reusing and recycling products.

    4. Active & clean transportation: Active & clean transportation is when an individual commutes to work in any way other than single occupancy vehicle use. That is, by public transit, biking, walking etc.

    5. Regenerative design: Regenerative design creates buildings, systems and infrastructure that positively impacts society and nature.

    6. Water conservation & restoration: We focus on water conservation & restoration to help reduce water consumption.

    7. Sustainable supply chain: Supply chain sustainability is an organizational issue influencing the organization’s suppliers as well as material supply logistics network, all in context of environmental impact, risk, and waste costs.

    8. Zero toxicity: Zero toxicity helps reduce chemicals of concern, which are any toxic substances, synthetic or naturally occurring, which have the potential of negatively impacting human and environmental health.

    9. Healthy land & food: We focus on promoting the relationship between food systems, land use and prevention-based health care.

    10. Transparent reporting: We aim to raise awareness on EES strategies and objectives through public reports.

    For more information on these topics check out the GreenCare Community website.

    The GreenCare Program

    In 2010 Vancouver Coastal Health, Fraser Health, Providence Health Care and Provincial Health Services Authority consolidated their efforts towards environmental sustainability.

    The Energy and Environmental Sustainability team

    Working together enabled the creation of an Energy and Environmental Sustainability (EES) team, which is dedicated to reducing the environmental impact of all the lower mainland health authorities.

    The goal of the EES team is to unite the four health organizations in a commitment to reduce health care’s environmental impact, while increasing the health and well-being of British Columbians. This is done by nurturing the important link between human and environmental health.

    See our Environmental Accountability Report

    • 2014 Environmental Accountability Report

    • 2013 Environmental Accountability Report

    • 2017  Environmental Performance Accountability Report

    We welcome your feedback on our targets and performance at GreenCare@saintmartinhospital.com

    Want more information?

    • GreenCare Community for all resources and stories pertaining to efforts towards environmental stewardship.
    • Programs and resources for a greater understanding on the various environmental sustainability initiatives and stories.
  • Report card



    Our Health Care Report Card measures our performance against our strategic goals. It is designed to show where we are doing well and where we are working to make improvements.

    The report card results are grouped by our strategic goals. Read the full report card or take a look at the tables below for a summary.

    Get a snapshot of our performance

    The full report card includes more information about the measures: what we’re measuring, why it matters, how we measure it, how we’re doing, what we’re doing to maintain or improve performance and if applicable, how you can help.

    Report card summary

    =Within Target =Within 10% of target =Outside target by more than 10%

    Pay for performance – live measures

     Emergency patients admitted to hospital within 10 hours
     Discharged long length of stay patient days
     Current long length of stay patient days
     Average inpatient days
    Completed multidisciplinary mortality reviews

    Deliver a system of responsive and effective health care services across St. Martin Hospital

     Scheduled surgeries waiting longer than 26 weeks
     Scheduled surgeries completed within 26 weeks
    Percentage of mental health and substance use patients readmitted
     Alternate level of care (ALC) stay days as a proportion of total stay days
    Average hospital days in the last 6 months of life for clients known to St. Martin community programs

    Provide the best care

     Clostridium difficile infection rate
    Care sensitive adverse events (per 1,000 inpatient cases)
     Hand hygiene compliance

    Develop the best workforce

     Sick time rate
     Overtime rate
     Acute productive hours per patient day


  • Finances & resources



    This section provides information about the financial resources we use to meet our targets, maintain our health services and develop new and innovative services for the future. To see our performance on specific financial measures, visit our Report Card page. We always welcome your feedback about the organization.

    Budget & financial reports

    Reports include audited financial statements, schedules of remuneration and expenses and payments to suppliers of services.

    Learn more about our Budget & financial reports.

    Taxpayer accountability

    The new taxpayer accountability principles will be used in the operation of provincial public sector organizations.

    Learn more about our Taxpayer accountability.

    CEO expenses

    This section provides information on expenses made by the CEO of St. Martin Hospital. These reports are posted each quarter.

    Learn more about our CEO expenses. Email us at: ceo@saintmartinhospital.com
  • Policies


    The Whistleblower policy allows individuals to bring forward information about wrongdoing by St. Martin Hospital staff, in good faith and without fear of reprisal. It also provides for consistent and administratively fair investigations process into reports of wrongdoing.

    Conflict of interest

    The Conflict of Interest policy is designed to help identify conflicts of interest and to provide a procedure to appropriately manage conflicts in accordance with legal requirements and the goals of accountability and transparency in St. Martin Hospital operations.

    Standards of conduct

    The Standards of Conduct provides St. Martin Hospital staff with guidance on appropriate conduct, in addition to any other professional code of ethics or standards of practice to which they are bound.