4.4 Medical Quality and Patient Safety
Medical Quality and Patient Safety Committee
To effectively oversee medical quality and patient safety, the Hospital has established the Medical Quality and Patient Safety Committee (referred to as the “MQPS Committee”). The MQPS Committee convenes quarterly and is chaired by the Superintendent. A Root Cause Analysis (RCA) Task Force operates under the MQPS Committee to conduct in-depth investigations of various issues in the medical process, ensuring timely corrections and continuous improvement. The MQPS Committee members consist of department heads from various departments, and 11 subcommittees have been formed based on specialized fields to facilitate regular discussions and coordination across departments.
Enhancing Medical Quality
To align with the 9 major goals for medical quality and patient safety proposed by the Joint Commission of Taiwan (JCT), our Hospital actively promotes a comprehensive medical quality management system. By establishing a robust set of monitoring indicators for medical quality and patient safety, we implement PDCA (Plan-Do-Check-Act) cycles that include indicator monitoring, regular education and training programs, critical incident audits, incident reviews, and follow-up actions. These efforts aim to foster a patient-centered and safe healthcare environment. We assess 100% of our medical services for their impact on patient safety, ensuring that every patient receives high-quality and worry-free care.
Safeguarding Patient Safety
To ensure patient safety, our Hospital continuously strengthens healthcare quality management measures while also conducting regular patient safety culture surveys and Patient Safety Week events each year. These initiatives proactively promote information related to patient safety. In terms of medication safety, we maintain 100% compliance with the Pharmacists Act and relevant regulations, ensuring that all prescription labels fully meet the 13 required items stipulated by the Ministry of Health and Welfare. Through these efforts, we aim to prevent and mitigate potential risks and adverse impacts, providing patients with a safer and more trustworthy healthcare environment.
To assess patient safety culture, the Hospital conducts comprehensive surveys covering 8 key dimensions across 15 units, encompassing both administrative and clinical departments. This structured approach captures staff perceptions and understanding of patient safety, reflecting shared attitudes across all organizational levels. The findings provide valuable feedback on current practices and serve as a foundation for the ongoing enhancement of our safety culture.
Patient Safety Incident Reporting
The Hospital has established the Patient Safety Incident Reporting System Guidelines. When an incident occurs, the reporting staff must promptly log the details in the Hospital’s patient safety reporting system. The patient safety officer from the Medical Services Section reviews the report and determines whether it constitutes a major patient safety event based on applicable regulations. If confirmed, a formal incident report is drafted and approved by the Hospital Superintendent, then submitted to the Joint Commission of Taiwan’s Major Medical Accident Reporting Platform within 7 days. Subsequent handling includes a care meeting involving representatives from relevant departments, the patient, and their family. The Hospital’s Deputy Superintendent leads a Root Cause Analysis (RCA) Task Force to investigate the underlying causes and develop concrete corrective actions.
In 2024, our Hospital reported a total of 1,034 patient safety incidents through its internal system. Following comprehensive review and improvement efforts, PDCA or RCA project reports were conducted for 8 cases involving severity levels 1–2, systemic issues, or cases with significant clinical learning value. In accordance with the Medical Accident Prevention and Dispute Resolution Act, 1 incident was proactively identified by the Hospital as a major patient safety event, for which a root cause analysis was conducted and relevant standard operating procedures were refined.
Physician–Patient Relationship
Medical Ethics
To promote clinical ethics education, implement holistic care, enhance medical quality, and strengthen physician–patient relationships, the Hospital has established a Clinical Ethics Committee committed to safeguarding the rights and dignity of patients and their families. The committee convenes biannual meetings and includes an Executive Steering Group, chaired by the Hospital’s Superintendent, as well as external members made up of professionals outside the Hospital. The Executive Steering Group leads the Medical Quality Team, Clinical Research Team, and Education and Training Team, working collaboratively to implement clinical ethics initiatives and improve the overall quality of healthcare services.
To enhance medical service quality and safeguard patient well-being, the Hospital has established a Code of Professional Ethics for Healthcare Personnel and a clearly defined Patient Rights Policy. Clinical ethics are promoted through practical case discussions, interactive teaching sessions, reading of ethics-related literature, and participation in seminars. These initiatives not only help patients understand their rights but also reinforce ethical awareness among healthcare professionals in their daily practice. In 2024, the Hospital held 2 clinical case discussions and 1 medical ethics course, continuing to strengthen the understanding and application of clinical ethics among staff.
Shared Decision Making
The Hospital actively promotes the Shared Decision-Making (SDM) model to enhance patient engagement and autonomy throughout the medical process. By involving patients in managing their own health and making care decisions, SDM enables choices that better reflect individual needs and preferences. Internally, the Hospital has established an SDM platform that allows physicians to issue SDM orders. Physician–patient communication training sessions are also conducted to strengthen the interpersonal and communication skills of medical staff. For patients, we encourage two-way communication using question prompt sheets during consultations and regularly promote the concept of SDM through monthly group health education sessions. In 2024, the Hospital developed 20 SDM topics, implemented 318 SDM cases, and held 17 SDM-focused health education events.
Fostering Positive Physician–Patient Communication
The Hospital conducts patient satisfaction surveys every 6 months to guide continuous improvement. In 2024, satisfaction rates were 77.6% for outpatient services, 82.9% for emergency care, and 80.2% for inpatient services. The lower outpatient satisfaction score was primarily due to concerns over cleanliness in the care environment. In response, the Hospital has implemented targeted improvements to address this issue. These survey results not only reflect our efforts in delivering quality medical services but also provide valuable insights for identifying and addressing areas for enhancement.
In handling medical disputes, the Hospital adheres to the Guidelines for Managing Medical Dispute Complaints. When a dispute arises, the involved personnel must immediately report to their direct supervisor and notify the Care Task Force simultaneously. Upon receiving a report, the Care Task Force assigns a dedicated staff to assess the situation, assist in communication, and actively resolve any issues. If necessary, a holistic care meeting is convened to review the patient’s medical records and formulate an appropriate follow-up treatment plan.
For cases that meet the definition of a major medical accident reporting, the Care Task Force will proactively inform the patient, their family, or legal representative within 5 days, explaining the incident and offering relevant support and care services. We believe that early, empathetic intervention and timely internal communication can foster mutual understanding and trust between patients and medical professionals, ultimately improving both the quality and experience of healthcare services.
