-Safe and Reassurance-Based Medical Environment-

National Cheng Kung University Hospital’s pursuit of healthcare quality does not stop at indicator improvements or award achievements, but encompasses the complete journey of patients from seeking medical care, diagnosis and treatment, and transitional care, to major medical decisions and end-of-life care. The Hospital continuously establishes a medical service model that makes the public feel at ease, understood, and respected.

Through data-driven quality management, combined with the promotion of a patient safety culture and reporting improvement mechanisms, the Hospital continuously grasps care risks and refines medical processes. Meanwhile, it values feedback from patients and their families, incorporating public needs into service improvement and care decision-making processes, thereby deepening medical services from "providing treatment" to "jointly participating in care." In the future, National Cheng Kung University Hospital will continue to combine professional quality management with humanistic care, ensuring that healthcare not only pursues safety and efficiency but also responds to patients' value choices, family needs, and life dignity.

Safe and Reassurance-Based Medical Environment

The elevation of healthcare quality must take "Patient-Centered Care" as its core. As the driving hub of medical services, National Cheng Kung University Hospital continuously starts from the medical experiences of patients and their families to examine various service processes and care links, dedicating itself to building a safe, friendly, and trustworthy medical environment. Through public feedback, cross-functional collaboration, and quality improvement mechanisms, actual needs are transformed into service optimization actions, continuously enhancing patient safety, medical quality, and the medical experience, ensuring that patients receive more reassuring, smooth, and warm care during the diagnostic and treatment process.

• Healthcare Quality and Patient Safety Management System

Innovative Quality Management Models

National Cheng Kung University Hospital has deeply cultivated its healthcare quality culture for over a quarter of a century. Since promoting Healthcare Quality Circles (HQC) in 2000 and being honored with the National Quality Award in 2007, the Hospital has officially entered a new era of "data-driven" smart healthcare. The Hospital constructs a rigorous Total Quality Management (TQM) system, ensuring the precise implementation of policies through a two-way management model.  Furthermore, the Hospital designates a "Quality Indicator Reporter" and a physician-background "Quality Indicator Leader" within each clinical unit, supplemented by a clinically experienced "Quality Consultant Physician System." Together, they build a medical safety net woven from intelligent and digital monitoring. When indicators show abnormalities or warning signs, they are reported to the Healthcare Quality Indicator Working Group, and quality consultant physicians jointly conduct strategic reviews to ensure comprehensive quality improvement, establishing a solid shield for patients' rights and interests. In 2025, a total of 828 healthcare quality and patient safety indicators were monitored.

This profound foundation of quality was transformed into fruitful achievements in 2025. The Hospital won the Double Gold Awards in both the "Outstanding Healthcare" and "Topic" categories at the National Healthcare Quality Awards (NHQA); the Department of Pharmacy was honored as a "Center of Excellence," and the Hospital secured 12 Smart Healthcare Labels, highlighting the remarkable effectiveness of technology-driven quality.

Moreover, under the validation of the Symbol of National Quality (SNQ), the Hospital combines "patient-centered" care philosophies with digital technology. From integrated chewing and swallowing care, the new Hybrid OR trauma resuscitation model, to the digital human subject protection platform (InsideOne™), these achievements all demonstrate the abundant energy of digital transformation and process reshaping.

 

• 2025 Annual Execution Results of Strategic Objectives

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I1-2 Training for Supervisors at All Levels in Team Resource Management (TRM), Resilience,Quality Indicator Management, and Root Cause Analysis
Annual Goals	Implementation Status	Target Achievement
90% of all first-level supervisors must receive at least one of the following trainings per year:TRM, resilience, indicator management, or quality improvement methodology	98% of all first-level supervisors completed the training	〇
I1-3 Cultivation of Mid- to High-Level Leaders in Medical Quality and Patient Safety
Annual Goals	Implementation Status	Target Achievement
At least 2 mid- to high-level supervisors receive training in the field of medical quality and patient safety	7 mid- to high-level supervisors receive training in the field of medical quality and patient safety	〇
I1-4 Cultivation of Educators in Medical Quality and Patient Safety
Annual Goals	Implementation Status	Target Achievement
At least 2 educators trained annually in medical quality and patient safety	2 educators trained in medical quality and patient safety throughout the year	〇

Deeply Cultivating a Patient Safety Culture

National Cheng Kung University Hospital enhances the organizational safety climate by introducing Team Resource Management (TRM), regularly organizing training courses such as Team Resource Management (TRM) and Resilience. These efforts promote effective collaboration, communication, and response capabilities among interprofessional teams, fostering a team atmosphere that values patient safety while incorporating mutual care and support among colleagues, and encouraging various departments to actively implement internal intervention and improvement programs, thereby strengthening the resilience of healthcare personnel and the organization when facing challenges.

In 2025, the Patient Safety Culture Survey was completed across 27 departments. To strengthen the awareness of all personnel, an identical 1-hour "Healthcare Quality and Patient Safety Educational Training" was simultaneously provided to all colleagues participating in the survey, implementing the effectiveness of "promoting learning through assessment." As of October 20, 2025, the overall completion rate reached 81.7%, with 2,478 individuals having completed the questionnaire out of a total of 3,035 required respondents.

 

To deepen the in-hospital practical execution and succession capabilities of Root Cause Analysis (RCA), the Hospital actively promotes case optimization. In 2025, the project titled "Flipping Concepts: From Arteriovenous Graft (AVG) Bleeding Resuscitation Incidents to Mindset Change" was honored with the "Excellent Poster Award" at the RCA Competition organized by the Joint Commission Taiwan (JCT). Furthermore, two poster authors of this case presented a public poster presentation at the "RCA Benchmarking Sharing Forum," successfully externalizing internal patient safety improvement experiences and demonstrating the Hospital's brilliant results in cultivating professional healthcare quality management talents. In addition, to comprehensively strengthen the patient safety leadership of the management tier and deepen cross-functional consensus, the Quality Center spearheaded a delegation in 2025, accompanying a total of 6 supervisors and physicians from the Department of Orthopedics, the Department of Nursing, the Department of Pathology, and the Department of Pharmacy, to jointly attend the "Promoting Positive Patient Safety Culture Sharing Forum" organized by the JCT. Through practical experience exchanges with external medical institutions, this initiative demonstrated the Hospital's determination for cross-functional continuous advancement and the pursuit of excellence.

• 2025 Annual Execution Results of Strategic Objectives

I2-1 Promotion of Quality Improvement Activities
Annual Goals	Implementation Status	Target Achievement
Each department/unit completed at least one quality improvement activity, achieving a 100% completion rate	Each department/unit completed at least one quality improvement activity, achieving a 100% completion rate	〇
I3-1 Development of Patient Information Security
Annual Goals	Implementation Status	Target Achievement
Participate annually in the ITPS project by the Joint Commission of Taiwan (JCT)	Participated in the ITPS project by JCT and completed the related educational training programs.	〇

E-Platform for Care Management

To ensure patients receive safer and more stable care, National Cheng Kung University Hospital has established the "E-Platform for Indicator Management." By integrating outpatient, emergency, and inpatient systems, data that previously required manual compilation is now automatically aggregated by the medical information system and presented through clear, easy-to-understand charts. This assists medical teams in grasping the shifting trends of overall care quality, enabling physicians and management personnel to more rapidly discover whether workflows are smooth and whether care is properly implemented, allowing for early adjustments to ensure that the medical services received by patients are more immediate and reliable.

When the performance of quality indicators does not meet set thresholds or falls inferior to medical center peers, relevant teams will conduct reviews within the Healthcare Indicator Working Group managed by the Quality Center or during departmental quality meetings, utilizing system analysis functions to formulate improvement strategies to strengthen indicator management effectiveness.

Additionally, the Hospital has established the Disease-Specific Registry and Case Enrollment System. This system automatically aggregates data such as baseline demographics, medications, interventions and treatments, nursing instructions, and discharge follow-up management for patients with specific diseases. It assists physicians and case managers in grasping the progress of case care; when certain necessary examinations, treatments, or follow-ups have not yet been completed, the system actively issues reminders to reduce the risk of omission and ensure uninterrupted continuum of care. This care information is simultaneously reflected in quality indicators, ensuring that through continuous feedback and adjustments, medical services more precisely align with patients' actual needs and expectations.

• 2025 Annual Execution Results of Strategic Objectives

F2-2 Outpatient Surgery Volume Growth Rate
Annual Goals	Implementation Status	Target Achievement
F2-2 Outpatient Surgery Volume Growth Rate ≥ 2.41%	Q1：6.58% Q2：5.82% Q3：5.03% Q4：-7.47% Since the implementation of operating room load reduction measures in March 2024, the outpatient surgery volume growth rate, excluding labor and delivery and outpatient surgeries, was 5.81%.	X
F2-3 Ratio of Outpatient to Inpatient Chemotherapy Visits
Annual Goals	Implementation Status	Target Achievement
Ratio of outpatient to inpatient chemotherapy visits Q1≧1.92 Q2≧1.81 Q3≧1.93 Q4≧1.74	Q1：1.71 Q2：1.66 Q3：1.69 Q4：1.95 In the fourth quarter, inpatient chemotherapy visits increased compared to the first three quarters; the average ratio for the full year of 2024 was 1.75.	〇
F3-1 Outpatient Repeat Test Rate Within 28 Days
Annual Goals	Implementation Status	Target Achievement
Maintain a low repeat test rate to avoid resource waste Q1 less than 11.0% Q2 less than 16.4% Q3 less than 16.5% Q4 less than 16.4%	Q1：9.84% Q2：15.30% Q3：15.10% Q4：14.50%	〇
F3-2 Outpatient Duplicate Medication Days
Annual Goals	Implementation Status	Target Achievement
Q1: less than 1,334 days Q2: less than 1,034 days Q3: less than 1,225 days Q4: less than 1,010 days	Q1：1,122 days Q2：1,182 days Q3：1,048 days Q4：1,218 days Reasons for Unmet Target: The Hospital maintained monthly manual tracking and reporting of the reasons for duplicated medications and the appropriateness of delayed follow-up visits, while simultaneously reminding clinical units through memo alerts. However, due to the addition of national holidays this year, coupled with the Mid-Autumn Festival consecutive holidays in early October, the instances of patients seeking medical consultations in advance increased, leading to a rise in the number of duplicated medication cases.	X

Authority and Professionalism

National Cheng Kung University Hospital has always taken the treatment of "acute, critical, difficult, and rare" diseases as its core mission. The Hospital not only actively dedicates itself to social public welfare, but also closely cooperates with government health policies. By integrating medical energies across various departments, it develops high-level technologies with international competitiveness. In 2025, the Hospital successfully obtained the Disease-Specific Care Certification from the Joint Commission Taiwan (JCT) in four major fields: breast cancer, head and neck cancer, joint replacement, and dementia, deeply winning the trust of the public.

In terms of medical technology tiers, the Hospital demonstrates proud research and development (R&D) as well as clinical strength:

Technical Level	Medical Services (Defined According to Task Two of the Medical Center Mission)
World-Class Level	Pulmonary hypertension treatment, pancreatic cancer treatment and multinational new drug development teams, chronic hepatitis prevention and treatment
Asia-Level	Designated hospital for Helicobacter pylori antibiotic resistance and carcinogenic gene analysis, care team for epidermolysis bullosa (EB)
National-Level	Acute stroke treatment, upper gastrointestinal laparoscopic surgery and gastric tumor surgery and research, neonatal care for premature infants, multidisciplinary integrative cancer care, multiple organ transplantation, occupational disease diagnosis and treatment

At the 26th National Healthcare Quality Awards (NHQA) ceremony hosted by the Joint Commission Taiwan (JCT) in 2025, National Cheng Kung University Hospital won a total of 36 awards and labels across the "Thematic Category," "Outstanding Healthcare Category," "System Category," "Smart Healthcare Category," and the "Intelligent Building Label.”  Furthermore, in the Taiwan Healthcare Quality Management Competition, the Hospital was honored with the Gold Award and Silver Award respectively for two projects: "The Comprehensive Practice from Zero Surgery Rate to 100% Health Education Rate" and "Large Vessel Occlusion (LVO) Stroke Triage Paging to Accelerate Intracranial Artery Patient Screening and Door-to-Endovascular Thrombectomy Workflow.”  While pursuing medical excellence, the Hospital demonstrated profound governance strength in the field of health sustainability in 2025. Leveraging forward-looking smart management, the Hospital first received the "ESG Sustainable Potential Development Award" in the "Health Sustainability ESG Selection."In addition, the Sustainability Report published in 2025 also delivered an extraordinary performance. It not only clinched the highest honor of "Sustainability Report - Platinum Award" at the 2nd Taiwan Health Sustainability Awards, but was also honored with the "Model Award" in the Talent Development Category at the Global Views Medical ESG Awards. This further embodies the Hospital's prominent performance in aspects such as hospital-wide quality elevation, quality policy promotion, quality control activity integration, and process management optimization, reflecting National Cheng Kung University Hospital's establishment of a national benchmark position in patient safety, healthcare quality, and smart governance.

Showcase of Achievements

The nursing team has long deeply cultivated clinical care, educational promotion, and the elevation of care quality, repeatedly winning affirmation from the Nightingale Award. Over the years, the 6 award-winning nursing professionals have continuously dedicated themselves to fields such as maternal and child care, pediatric oncology care, rural services, smart healthcare, and assistive technology innovation. This demonstrates the nursing team's professionalism, creativity, and warmth, while reflecting the achievements of all nursing personnel in jointly safeguarding patients and continuously striving for excellence.

Meanwhile, to express appreciation and gratitude to nursing personnel, National Cheng Kung University Hospital hosts a celebration ceremony on Nurses International Day to extend respect and thanks to front-line nursing staff. The event commences with the "Light-Passing Ceremony," where Director Jui-Ying Feng of the Department of Nursing lights the candle, symbolizing the succession and continuity of the nursing spirit.

• 2025 Annual Execution Results of Strategic Objectives

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C1-2 Participation in External Presentations Related to Medical Quality and Patient Safety (Including Academic Journal Publications, SNQ,JCT, Certifications, etc.)
Annual Goals	Implementation Status	Target Achievement
Hospital-wide departmental publication achievement rate ≥ 60%	Departmental external publication achievement rate reached 82.1%	〇

Diverse Grievance and Feedback Channels

National Cheng Kung University Hospital is dedicated to constructing open and transparent feedback, grievance, and remedy mechanisms. For different stakeholders, the Hospital provides diversified two-way communication platforms to ensure that all types of major incidents, unlawful acts, or medical disputes receive immediate and impartial handling.

Regarding external and patient feedback mechanisms, the Hospital provides diverse channels, including the "Superintendent’s Mailbox," official website messaging system, hardcopy feedback forms, and dedicated hotlines, to ensure seamless communication. In the case of formal complaint grievances, the designated department actively contacts the informant on the very day the complaint is accepted; all cases are documented and integrated into a tracking mechanism. Following investigation, response, and improvement by the primary responsible department, the case is submitted to the Superintendent's Office for final review and approval, ensuring that processing progress is well-defined and transparent. The processing results and statistical analysis of customer feedback cases are submitted quarterly to the Healthcare Quality and Patient Safety Committee to facilitate continuous improvement and quality elevation.

Feedback and Grievance Channels for Patients and Visitors
Receiving Unit		Quality Center
Service Address		National Cheng Kung University Hospital, No. 138, Shengli Road, North District, Tainan City
Complaint Method	Telephone:	(06)2766668
	Fax:	(06)2750381
	Email:	hospital@mail.hosp.ncku.edu.tw

To continuously elevate the quality of medical care, the Hospital conducts a Patient Experience Survey in April and October each year, serving as a baseline to understand the current status of services and evaluate improvement effectiveness. The questionnaire design encompasses five major dimensions: "Professionalism and Care," "Environmental Facilities," "Waiting Time," "Service Attitude," and "Service Outcomes." The survey results indicate that the satisfaction levels across various patient experiences exhibit a positive trend of steady and robust growth year by year.

• 2025 Annual Execution Results of Strategic Objectives

C2-2 Percentage of Patient Experience Survey
Annual Goals	Implementation Status	Target Achievement
Percentage of satisfaction achieved Emergency: 85% Outpatient: 90% Hospitalization: 90%	Emergency: 93% Outpatient: 93% Hospitalization: 95%	〇
C2-3 Immediate Response Rate for Customer Complaints
Annual Goals	Implementation Status	Target Achievement
Customer complaint one-day response rate 65%	Average one-day response rate achieved throughout the year: 67%	〇
C3-2 Completion Rate of Preliminary Response to Employee Suggestions Within the Timeliness (Within 4 Hours)
Annual Goals	Implementation Status	Target Achievement
After the " Cheng Kung Window " receives an employee suggestion, it immediately notifies the case acceptance and submission to the responsible unit supervisor via email or phone. The unit provides an explanation or preliminary response within 4 hours reached 80%.	96%	〇

Optimization of Reporting Mechanisms

To build a transparent and safe medical environment and eliminate concerns among colleagues when filing reports, the Hospital has established a protective mechanism for anonymous reporting within the "Patient Safety Reporting SOP," paired with substantial incentive measures: for any report whose content possesses educational value or can yield a positive contribution to medical quality and environmental safety, the Hospital will provide an incentive bonus of NT$500. This non-punitive organizational culture aims to encourage every colleague to proactively discover potential risks, transforming abnormal incidents into nutrients for the collective growth of the entire Hospital, thereby elevating the overall standard of care.

Regarding reported incidents, the Severity Assessment Code (SAC) is adopted for stratification. SAC Level 3–4 incidents are reviewed and improved by their respective clinical departments. Sentinel events classified as SAC Level 1–2, on the other hand, are evaluated using a Decision Tree; if it is determined that the root cause of the incident involves "systemic factors," a Root Cause Analysis (RCA) will be further executed, and corresponding improvement strategies will be formulated accordingly.

• 2025 Annual Execution Results of Strategic Objectives

I1-1 Achievement Rate of Root Cause Analysis for Patient Safety Reporting Events
Annual Goals	Implementation Status	Target Achievement
All adverse events to complete Root Cause Analysis (RCA) and formulate specific improvement plans within 45 days	A total of 4 RCA cases completed throughout the year, with 100% completion rate within 45 days	〇
I1-5 Achievement Rate for Timeliness of Care by Medical Incident Support Team
Annual Goals	Implementation Status	Target Achievement
Complete care communication within 5 working days with 100% achievement rate	No cases throughout the year	〇