Introduction

Since 1987, the hospital has been promoting healthcare quality management through the establishment of the Medical Quality Review Committee. In 1993, a dedicated office was set up to oversee quality management operations. In 2002, the Center for Quality Management and the Patient Safety Committee were formally established to integrate hospital-wide resources for advancing patient safety and quality improvement. In 2005, the Patient Safety Committee was consolidated into the Quality and Patient Safety Committee. Over the years, successive leadership teams have driven numerous key reforms, solidifying the hospital’s position as a leader in healthcare quality and patient safety, and earning a distinguished reputation both nationally and internationally.

The Center for Quality Management is dedicated to integrating the hospital’s healthcare quality management and patient safety efforts. Through mechanisms such as continuous quality improvement initiatives and clinical audits, the center actively promotes and embeds total quality management practices. Its mission is to ensure and enhance the quality of care and services, foster a culture of ongoing quality improvement, minimize medical risks, and strengthen patient safety.

The scope of work of our hospital’s Center for Quality Management is illustrated in the chart and includes the following domains: Quality and Performance Indicator Management, Patient Safety Monitoring and Improvement, Customer Relations Management, Education, Research, and Promotion, and Accreditation and Audit.

Detailed descriptions are as follows:

1. Quality and Performance Indicator Management

• The Center for Quality Management regularly monitors various quality and operational performance indicators. External indicators include those required for hospital accreditation (continuous monitoring indicators), Taiwan Clinical Performance Indicators (TCPI), Disease-Specific Care Certification indicators, and medical center mission indicators. Internal indicators focus on tracking, analyzing, and improving quality measures for each department. The center also analyzes and provides key operational management indicators across the hospital system to support data-driven decision-making by senior management at both the main and branch hospitals.
• The center also works to optimize the hospital’s Clinical Intelligence Decision Support System, offering unit supervisors a real-time, visualized data analytics platform to support informed managerial decisions.

2. Patient Safety Monitoring and Improvement

• An integrated, multi-channel, and digitalized patient safety and incident reporting system has been established. For significant cases, the center assists departments in conducting root cause analyses and applies creative, design-thinking approaches to develop systematic improvement strategies aimed at reducing the occurrence of potential patient safety threats.
• The center analyzes potential failure modes within the medical environment and systems, categorizes them by severity, and identifies their impact on patients and staff. Proactive measures are then formulated to prevent adverse outcomes.
• A proposal system promoting patient safety has been implemented to encourage staff to proactively suggest improvements whenever potential safety concerns are identified in clinical processes or environmental facilities. This supports the development of a strong patient safety culture.
• Information technology and human factors engineering are incorporated and promoted across all departments to support the continuous enhancement of healthcare quality and patient safety.

3. Customer Relations Management

• The hospital places great importance on patients’ care experiences and feedback. Beyond providing empathetic and patient-centered communication, the center conducts in-depth analysis of patient concerns and proposes effective solutions to deliver compassionate and impactful healthcare services.
• It coordinates system-wide surveys covering outpatient, inpatient, emergency, and other clinical units to assess patient experiences and satisfaction. Survey results are analyzed and shared with relevant departments for quality improvement. The center also assists departments and disease care teams in designing customized surveys, managing data, and conducting analysis to ensure results accurately reflect the needs and experiences of different patient populations, thereby informing targeted improvements.
• Shared decision-making between healthcare providers and patients is actively promoted to enhance patients’ understanding of their conditions and treatment options. This helps reduce information gaps, alleviate patient anxiety regarding major treatments, and foster greater trust and satisfaction with the healthcare system.

4. Education and Research Activities

• The center regularly organizes educational programs and symposiums on healthcare quality and patient safety. It collaborates with academic institutions nationwide to guide students during their internships, allowing them to engage in practical quality management tasks and complete research projects and reports.
• Staff members are encouraged to actively participate in national and international conferences related to healthcare quality and patient safety, facilitating global exchange and showcasing the hospital’s quality improvement achievements.
• Patient safety culture surveys are conducted to promote and strengthen a positive safety culture within the organization.
• Problem-solving-oriented medical design thinking courses are developed, and research related to patient safety and healthcare quality is conducted. The results are translated into practical applications for patient care and clinical process improvement.

5. Accreditation and Audit

• A clinical audit system has been established, along with the formation of a dedicated Clinical Audit Team. The team conducts routine patient flow reviews and systematic verifications within the hospital to ensure that quality and safety standards are effectively implemented in daily patient care.
• The center also supports the hospital and its teams in preparing for and successfully completing various accreditations, certifications, inspections, and evaluations.

Contact Us

Address:No.7, Chung Shan S. Rd. (Zhongshan S. Rd.) , Zhongzheng Dist., Taipei City 100, Taiwan (R.O.C.)

Tel｜(02)23123456 ext 261060, 265859 

Fax｜(02)23945063