Accessibility for people with disabilities

Policies and Procedures No. ADMIN 010

  • Titre: Accessibility for people with disabilities  
  • Effective: March 2010
  • Last revision: December 2017
  • Category: Administrative
  • Source: Organizational Development 
  • Other References
    • Admin 015 : Emergency measures
    • DOCOM 105: Interpreting service (cultural, hearing-impaired and deaf)
    • PREVINF 220: Presence of animals in the hospital
    • RH-DOT 005: Recruitment and selection of Montfort employees and contract staff 
    • RH-DOT 010: Employment orientation 
    • RH-DOT 030: Induction integration and departure of an employee – Roles and responsibilities
    • RH-SST 080: Adapted work and permanent accommodation
  • Approved by (date) : Vice-President, Transformation, Organizational Development and Human Resources  (13/12/2017)

1.    Policy


Hôpital Montfort (HM) is committed to treating people with disabilities equally with regard to the use of and access to its services, programs, goods and facilities. HM is committed to providing people with disabilities the same opportunities to access its services and allow them to receive the same services as other people, at the same location and in a similar manner. This commitment applies to patients, families, visitors and staff who have visible and non-visible disabilities.


HM adheres to the Accessibility for Ontarians with Disabilities Act, 2005 (AODA). Under the present policy, HM combines the requirements of the Regulation on the Accessibility Standard for Customer Service and the Regulation on Integrated Accessibility Standards established under the AODA.


HM establishes policies, practices and procedures for removing barriers, providing services and supporting people with disabilities. These policies, practices and procedures respect the basic principles of autonomy, dignity, integration and equal opportunity. 


HM delivers training to all its staff and members of its Board of Directors on the OADA and its accessibility standards, as well as the Human Rights Code (in relation to accessibility). HM keeps an up-to-date record of the individuals who received this mandatory training. 



HM provides documentation on this policy and each of its requirements on its website and provides it upon request in an accessible format or with the appropriate communication supports.


HM establishes a multi-year accessibility plan in consultation with people with disabilities. The plan is posted on the Hospital’s website and is provided in an accessible format or, by request, with the appropriate communication supports. HM reports on the progress made in responding to the needs determined in the plan based on the schedule established in the AODA. The accessibility plan and related progress reports are approved by senior management and presented to the board of directors.


HM develops and keeps up-to-date policies governing how HM meets the requirements under the AODA and provides these policies in an accessible format, on request.


The Hospital considers accessibility criteria and options when procuring or acquiring goods, services, self-serve kiosks or facilities, unless this is not materially possible. If it is not materially possible to consider accessibility criteria and options, the Hospital provides an explanation for this on request.


2.1 Communication supports:

include, but are not limited to, captioning, alternative and augmentative communication supports, plain language, sign language and other supports that facilitate effective communications.

2.2 Service animal:    

Service animal: under section 4(9) of the Accessibility Standards for Customer Service, an animal is a service animal for a person with a disability in one of the following situations: 


 if it is readily apparent that the animal is used by the person for reasons relating to his or her disability;


if the person provides a letter from a physician or nurse confirming that the person requires the animal for reasons relating to the disability. 

2.3 Guide dog:    

under section 1 of the Blind Persons’ Rights Act, “a dog trained as a guide for a blind person and having the qualifications prescribed by the regulations.”

2.4 Accessible format:    

means a format in large characters, audio or electronically recorded format, Braille and other formats that can be used by persons with disabilities.

2.5 Kiosk:    

means an interactive electronic terminal, including a point-of-sale device, intended for public use that allows users to access one or more services or products or both.

2.6 Disability:    


Any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness and, without limiting the generality of the foregoing, includes diabetes mellitus, epilepsy, a brain injury, any degree of paralysis, amputation, lack of physical co-ordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment, or physical reliance on a guide dog or other animal or on a wheelchair or other remedial appliance or device;


a condition of mental impairment or a developmental disability; 


a learning disability, or a dysfunction in one or more of the processes involved in understanding or using symbols or spoken language; 


a mental disorder; 


an injury or disability for which benefits were claimed or received under the insurance plan established under the Workplace Safety and Insurance Act, 1997.

2.7 Staff:    

employees, physicians, volunteers, researchers, students, residents and interns, as well as their supervisors, contract staff, midwives and other independent practitioners.

2.8 Barrier:    

anything that prevents a person with a disability from fully participating in all aspects of society because of his or her disability, including a physical barrier, an architectural barrier, an information or communications barrier, an attitudinal barrier, a technological barrier, a policy or a practice.

2.9 Support person:    

a person who accompanies a person with a disability to help with communication, mobility, personal care or medical needs or with access to goods or services. 

3. Procedures

3.1 Accessibility standards for customer services:     

3.1.1 Communication:    

  • HM communicates with persons with disabilities in a manner that considers their disability. 
  • Telephone services: HM commits to offering telephone services that are fully accessible to its patients and clients. 
  • HM gives its patients and clients the possibility of communicating by email, using teletypewriters (TTY) or relay service if telephone communication does not meet their needs or is not available. 
  • HM provides invoices that are accessible to all its clientele. For this reason, invoices are issued in the following formats on demand: printed copy, large characters or email. HM answers all of its clientele’s questions regarding the content of an invoice in person, by telephone or by email. 
  • Information on HM’s feedback process is accessible to the public. Comments regarding the manner in which HM provides services to persons with disabilities can be transmitted by email, verbally or on a comment card. HM will respond to these comments and take appropriate measures. 
  • To ensure the necessary follow-up, formal complaints will be transmitted to the Department of Quality and Risk Management Office in writing (e.g., email, letter), verbally or in person.

3.1.2 Assistance:    

  • Persons with disabilities can enter sectors of the HM accessible to the public with their guide dog or service animal, according to its procedures for infection prevention, the PREVINF 220 policy (Présence d’animaux dans l’hôpital), unless a law prohibits them from doing so. If this is the case, HM will take other measures to offer services to these persons. 
  • If a person with a disability is accompanied by a support person, HM will ensure that both may enter the premises together, and that the person with a disability is permitted access to the support person at all times while such person is on the premises.
  • HM may require that a person with a disability be accompanied by a support person while on the premises, but only if it determines, after consulting the person with the disability and considering any supporting information available to it, that:
    • The support person’s presence is necessary to protect the health or safety of the person with a disability or other persons on the premises;
    • There is no other reasonable means of protecting the health or safety of the person with a disability or other persons at the premises.

3.1.3 Notice of service disruption:

  • HM notifies its clientele, whenever possible, in the event of a disruption to its facilities or services that are essential to persons with disabilities. This notice indicates the reasons for the disruption and the estimated duration, and describes available replacement facilities or services, if applicable. The notice is posted in public entrances, at HM service counters, and on its web site.

3.2 Accessibility standards for information and communication:

3.2.1 Accessible formats and communication supports:

  • Unless otherwise set out in the AODA, the Hospital provides or ensures that persons with disabilities are provided with accessible formats and communication supports based on the schedule set out in the Regulation on Integrated Accessibility Standards, established under the AODA. The accessible formats and communication supports are provided in a timely fashion and in a manner that takes into account the needs of the person with respect to accessibility and at a cost that is not greater than the usual cost applied to other people.

3.2.2 Accessible websites and web content: 

  • The HM website was published prior to January 2014. Based on the schedule set out in the Integration Accessibility Standards established under the AODA, it is required to comply with level A and Level AA of the Web Content Accessibility Guidelines (WCAG) 2.0 standards developed by the World Wide Web Consortium, by January 2021.

3.2.3 Information on emergency measures or plans:

  • Upon request, HM provides existing information on emergency measures and plans or on public security in an accessible format or with appropriate communication supports, in a timely fashion. 

3.3 Employment accessibility standards:

3.3.1 Recruitment and orientation of new employees:

  • During its recruitment process, HM makes the necessary accommodation for candidates with disabilities. 
  • Orientation of new employees: when selected candidates begin their functions, HM informs them of its policies regarding accommodation for employees with disabilities.

3.3.2 Employee support measures:

  • HM informs its employees of its policies regarding support to employees with disabilities, namely, those that relate to workplace accommodation that take into account the accessibility needs resulting from the person’s disability. HM provides this information to new employees as soon as it is materially possible after they have commenced employment and provides up-to-date information to all employees whenever changes are made to its existing policies regarding adaptation to the workplace that take into account the accessibility needs resulting from the employee’s disability.  

3.3.3 Accessible formats and communication supports for employees:

  • Upon request by the employee, HM consults the employee with a disability to provide him or her with accessible formats and communication support, or sees that he or she receives them, with regard to:
    • information required to perform his or her work;
    • information generally made available to employees in the workplace. 
  • HM consults the employee who makes the request when the relevance of an accessible format or communication support is determined.

3.3.4 Workplace emergency response information:

  • All staff members must be familiar with their respective department’s procedures (ref. ADMIN 015), particularly evacuation procedures in case of an emergency situation.
  • HM provides workplace emergency response information to employees with disabilities, if the disability is such that individualized information is necessary and HM is aware of the need for accommodation due the employee’s disability.

3.3.5 Documented individual accommodation plans: 

  • The Hospital develops a written process for the development and maintenance of documented individual accommodation plans for employees with disabilities. On request, these plans include individualized workplace emergency response information. 

3.3.6 Return-to-work process:

  • HM has in place a documented return to work process for its employees who have been absent due to a disability and require accommodations related to their disability in order to resume their work. This return to work process outlines the steps the Hospital will take to facilitate the return to work.

3.4 Accessibility standards for transportation:

  • Parking off the site is never assigned to a person with a disability. Therefore, these persons do not have to use the shuttle service.

3.5 Responsibility and monitoring:


The Department of Planning and Transformation is responsible for reviewing this policy on a yearly basis and recommending modifications to ensure continuous adherence to the regulations on accessibility standards and obligations set out in the law. 

  • The Director of Planning and Transformation provides advice and guidelines on the implementation of this policy. 
  • The managers and directors at Hôpital Montfort ensure that they and their staff are familiar with this policy and comply with it.


Non-compliance with the regulations established under the AODA may lead to measures to enforce them and to financial penalties imposed by the Government of Ontario. Managers and directors must monitor current practices to ensure compliance.

4. References and related regulations

Accessibility for Ontarians with Disabilities Act, 2005 (AODA)

S.O. 2005, CHAPTER 11 

Accessibility Standard for Customer Service (2008), Ontario Regulation 429/07 pursuant to the AODA 

Blind Persons’ Rights Act

Human Rights Code, R.S.O. 1990, CHAPTER H.19

Training Resource: Accessibility Standards for Customer Service, Ontario Regulation 429/07

Integrated Accessibility Standards (2011), Ontario Regulation 191/11 pursuant to the AODA

Occupational Health and Safety Act of Ontario 

Ontarians with Disabilities Act, September 2002 

The Ottawa Hospital, ADM VIII 640: Accessibility Policy, December 2012


The printed version of this document does not necessarily correspond to the up-to-date electronic version on Hôpital Montfort’s (HM) Employee Portal. This document was prepared for HM’s sole use. HM is not responsible for the use of this document by an individual or organization that has no connection to the HM. No portion of this document may be used in any form without the permission of HM.