INTRODUCTION

Each year, we hold a consensus meeting with the first and second level directors of the institution.

The purpose of the meeting is to gather the consensus of the entire institution, to explain the decision making tasks, and to review the promotion policy as the basis for the medium and long term plan, so as to achieve the realization of the vision of "Excellence and High Honor, and the world's fame".

Aim

In 2015, the Hospital proposed six major tasks for future development: "improving the quality of teaching and research", "developing medical specialties", "cultivating excellent talents", "providing a friendly service environment", "planning medical land", and "refining medical management".

METHOD

The Quality Management Center implements the implementation and promotion policy according to the decision of the hospital, and prepares the annual implementation target and promotion plan of "Total Quality Management" with 9 major objectives of medical quality and patient safety.

RESULTS

Continuous Improvement

Participating in QCC team activities and QCC publication each year to encourage each unit to set up QCC teams (quality control circle (QCC)), the entire hospital level 1 units are required to propose at least one QCC team improvement project, the number of QCC circles from 2013 to 2020 grew year by year, from 10 to 21; among them, the participation rate of physicians and administrative staff grew the most (physician participation rate increased from 10.5% to 23.7%, medical technology (from 10.5% to 23.7% for physicians and from 4.6% to 34.1% for medical and technical staff).

Every year, the team actively participates in cross-team collaborative improvement efforts and contributes to the development or modification of standard operating procedures. This is aimed at enhancing service quality and ensuring patient safety.

Regular monitoring and review of key indicators of medical quality

Our quality management team monitors 308 indicators of TCPI, 41 indicators of hospital assessment continuity, and 45 indicators of hospital performance measurement (P4P). The above indicators are reported monthly by the clinical units, and are tracked and reviewed quarterly in the relevant quality management meetings.

Emphasis on quality, implementation of the establishment of a disease safety culture

Our hospital participates in the nationwide Patient Safety Culture Survey (PSCs) organized by the Health Policy Commission each year. The response rate of our hospital's staff to the questionnaire has been increasing annually from 2016 to 2020. The response rate for each year has consistently exceeded 80%, indicating our hospital's commitment to establishing a patient safety culture.

Standardization System and Implementation

Since the introduction of the ISO 9001 quality management system in 2004, the hospital has completed 1,206 standardized operations. Through the ISO 9001 management cycle of planning, execution, checking and disposal, the hospital has strengthened its management capabilities and provided excellent services, which have not only increased customer satisfaction and loyalty, but also created a win-win situation for both the hospital and the patients.

CONCLUSIONS

Award-winning and positive image

In addition to promoting quality improvement within the hospital, the hospital has won numerous quality-related competitions both domestically and internationally, and the number of external awards has been increasing year by year, which has not only won the praise of the public and patients, but has also often been the target of peer-to-peer or cross-industry benchmarking.

ACKNOWLEDGEMENTS

Thanks to all colleagues

Thank you for the strong support from the hospital management in promoting patient safety initiatives.

We appreciate the participation of the medical team in implementing patient safety goals in their daily practices and proactively preventing medical incidents.

Thanks to the dedicated efforts of all staff in the hospital, we continuously improve medical techniques and prioritize patient safety.