Pergamon
IntcmationalJoumal for Quality in Health Cart, Vol. 8, No. 1, pp. 75-82, 1996
Copyright © 1996 Elsevier Science Ud. All rights reserved
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Quality Assurance in Taiwan, the Republic of China
plasm, cerebrovascular disease, accidents and
adverse effects, heart disease, diabetes melliSecretary-General, The Association of Healthcare tus, chronic liver disease and cirrhosis, nephriQuality, Republic of China, c/o Taipei Veterans' tis, nephrotic syndrome and nephrosis, pneuGeneral Hospital, 201 Shih-Pai Road, Sec. 2, Taipei
monia, hypertensive disease and bronchitis,
112, Taiwan, Republic of China.
emphysema and asthma.
Article 157 of the Constitution of the RepubINTRODUCTION
lic of China stipulates that "the state, in order to
This paper describes and examines the improve national health, shall establish extencurrent status of quality assurance in Taiwan, sive services for sanitation and health protecthe Republic of China (ROC). It includes tion, and a system for public medical service".
general information about Taiwan and its To meet the needs of the changing society, the
health care delivery and financing system, the National Assembly, at its recent meeting in
historical evolution of QA in Taiwan, system 1992, amended the Constitution to include as
approaches and issues and problems in QA, and Article 18 of the Amendments: "The state shall
future developments and challenges.
implement a national health insurance program
and promote research and development on
modern and traditional medicines".
GENERAL INFORMATION
PING HUANG
The Republic of China, the first republic in
Asia, was founded in 1912. At present, the
ROC of Taiwan includes two municipal cities,
Taipei and Kaohsiung and the Province of
Taiwan [1]. The Taiwan Area of the ROC is
located in the south-eastern China sea, with a
land size of 36,000 km2 and a population size of
20,802,622 persons in 1992. The crude birth rate
of the Taiwan Area was 15.53 per 1000; the
crude death rate 5.34 per 1000; and the natural
increase rate of population was 10.20 per 1000.
At current prices, the per capita national
income in 1992 was US$9329. The total health
and medical care expenditure of the government in the Fiscal Year 1992 was approximately
US$ 2 billion. At the end of 1992, the life
expectancy of people in the Taiwan Area was
71.79 years for males and 77.22 years for females. In 1992, the infant mortality rate was
5.18 per 1000 live births; the maternal mortality
rate was 6.85 per 100,000 live births. The 10
major causes of death were malignant neo-
HEALTH CARE DELIVERY AND
FINANCING SYSTEM
Taiwan's health care delivery system has
evolved over 120 years [2]. It is a mixture of
public and private sectors, a structure dominated by modern Western medicine, coexisting
with Chinese medicine [7,12]. It provides integrated hospital services and primary health care
[15]. Care-seeking behavior among the general
population in Taiwan is varied [9,10]. Public
health agencies are organized at four levels:
national, municipal city and province, county
and city, and townships. The Department of
Health (DOH) of the Executive Yuan (the
Cabinet) determines national health policies,
formulates health programs and coordinates
and supervises health services at all levels [1].
Generally, the public sector is centrally funded;
programs are mostly implemented by provincial
and municipal health departments and by local
Submitted 17 October 1994; accepted 25 October 1994.
Correspondence: Ping Huang, Secretary-General, The Association for Healthcare Quality, Republic of China, c/o Taipei
Veterans' General Hospital, 201 Shih-Pai Road, Sec. 2, Taipei 112, Taiwan, Republic of China.
75
76
and regional hospitals, with the exception of
major teaching hospitals of national medical
schools, military and veteran's medical institutions. For the public health services, there are
two municipal and one provincial health departments.
Private sector health care services are delivered by private hospitals or independently
practising practitioners. Prior to stepped-up
government efforts during the expansion period
of the 1970s, private hospitals were the mainstay of medical care in Taiwan [22]. At the end
of 1992, there were in the Taiwan Area 14,471
public and private medical institutions. The
public health sector included 94 hospitals and
479 clinics. The private health sector consisted
of 728 hospitals and 13,170 clinics. Hospital
beds per 10,000 population were 46.30. The
number of medical personnel per 10,000 population was 49.62, and the number of physicians
per 10,000 population was 12.03 [1]. Under the
Health and Medical Care Plan, the establishment of the Medical Care Network in the
Taiwan Area project was initiated in 1985 to
balance the development of medical care resources, to allow medical manpower and facilities to grow at a reasonable rate and in full
operation, to upgrade the quality of medical
care services and to make available and accessible to every citizen in need the most adequate
health and medical care services in the shortest
possible period. The project divides the Taiwan
Area into 17 medical care regions [1,11,14,16].
The evolution of health care delivery includes
three phases: expansion (1945-1985), consolidation (1985-1994) and restriction (1995 and
thereafter) [14]. Major problems exist in Taiwan's current health care delivery system, including:
1. Only 56% of the general population is
covered by health insurance.
2. Inadequate financial discipline to rationalize
the health care delivery system and control
cost inflation.
3. Irrational pricing policy.
4. Lack of integration between financing and
delivery of health care.
5. Insufficient supply of qualified practitioners
and hospital beds to meet increased demand
under national health insurance.
6. Insufficient quality control.
P. Huang
7. Insufficient resources allocated for prevention.
8. Lack of effective control on capital expansion [8].
During the Dutch occupation period (16221662), the East India Company sent over some
Dutch doctors to Taiwan. Medical education in
Taiwan can be divided into three stages of
development: pioneer (1865-1895), establishment (1895-1945) and expansion (1945present) [2,22], Graduates from high schools
are eligible to take the Joint Entrance Examination (JEE) of Universities and Colleges administered by the Ministry of Education (MOE) for
admission to all undergraduate medical schools
[19]. At present, there are various medical
schools, which include: Medicine, Chinese
Medicine, Dentistry, Pharmacy, Public Health,
Nursing, Medical Technology, Rehabilitation
Medicine, Nutrition and Health.
As provided in the University Law, the
School of Medicine offers a 7 year curriculum;
the School of Dentistry a 6 year curriculum and
the other Schools a 4 year curriculum, excluding
the School of Pharmacy of the Chinese Medical
College, which offers a 5 year curriculum [19].
At the end of 1992, there were 10 medical
schools, 12 medical science junior colleges and
15 medical science vocation high schools, each
year graduating 1200 medical students, 400 dental students, 650 medical technologists and technicians, 1000 pharmacists and 7800 nurses and
midwives [1].
Health insurance and direct patient payments
are the two main sources of health care financing in Taiwan. Health insurance, in fact, constitutes the medical care benefits of the social
insurance system. Presently, there are 13 different kinds of health insurance schemes under
three major social insurance systems: Labour
Insurance (LI), Government Employees' Insurance (GEI) and Fanners Health Insurance
(FHI), covering about 56% of the total population. Currently, health care financing in
Taiwan is faced with three major problems: the
lack of insurance for 44% of the population or 9
million persons, the financial crisis of the existing social insurance system and the rapid escalation of system health care costs [6,13]. In 1988,
the National Health Insurance (NHI) planning
committee was organized under the Council for
77
Quality assurance in Taiwan, ROC
Economic Planning and Development to draft
an overall national health insurance plan. After
that, the planning task force and the Provisional
Bureau of NHI were created by the DOH in
1991. The national health insurance system will
be launched in March of 1995.
HISTORICAL EVOLUTION
As in many other countries, QA in health
care came from industrial experience in the
development of systematic QA concepts, theories and practices [27]. The historical evolution
of QA in Taiwan can be defined as having four
phases: (1) quality obligation; (2) quality education: (3) quality models; and (4) quality system.
1. Quality as a conscientious obligation (before
1978;
Although QA has become a common daily
language among health professionals, no action
was taken until the initiation of hospital accreditation in 1978 [19]. In addition, in 1986, the
Medical Care Act was promulgated. This
required both health professionals and organizations to put more effort into the implementation of QA activities. Before 1988, there were
no official and formal training programs for
physicians entering medical practice. They were
allowed to practice if they had medical licenses.
Even though registration for practice was
required, continuation or renewal of the registration did not require any continuing medical
education. Therefore, the health professional
licensure system played a very important role in
QA during this period.
tals. In 1982 the International Conference on
Quality Assurance in Medicine was held in
Taipei. This was the first meeting under the
auspices of the DOH to review the health care
delivery system, medical education, specialty
and sub-specialty training, QA in medicine and
hospital-based specialities in Taiwan. Subsequently in 1989 the Council for Economic
Planning and Development and the DOH sponsored the International Symposium on Health
Care Systems to learn from the developed
nations. In 1991 and 1992, two symposia on
Hospital Quality Assurance in the ROC were
held in Taipei to disseminate QA knowledge
and techniques to Taiwan's hospitals [3,4].
3. Quality assurance models (1986-1992)
Following the introduction of Continuous
Quality Improvement (CQI) or Total Quality
Management (TQM) theories in Western
countries, several QA models for improvement
of hospital services were initiated in some hospitals in Taiwan. These include the Tri-Service
General Hospital (TSGH), the Taipei Veterans' General Hospital (VGH), the Taipei
McKay Memorial Hospital, the Chang-Gung
Memorial Hospital, the Taiwan Adventist Hospital, the Chi Mei Foundation Hospital and the
China Medical College Hospital. Questions
about the effectiveness of these QA models
remained; nevertheless, the situation impelled
hospitals to greater efforts. In the transition
from QA to QI, more and more hospitals used
the statistical quality control techniques to manage their QA data, and examined variations in
practice [3,4,24-26].
4. Quality assurance system (1993-j
2. Quality education (1978-1986,)
After the first teaching hospital accreditation
was conducted in 1978, QA became both an
imperative strategy for hospital management
and the basis of the health insurance scheme's
payment system. Most hospitals invested substantial resources in preparation for hospital
accreditation every three years. A pre-survey
conference was held by the DOH to explain the
standards and procedures for hospital accreditation. Unquestionably, QA education became
one of the issues of greatest concern in hospi-
A QA system cannot be established until
integration of QA philosophy, informatics,
tools, criteria and standards, education, finance
and evaluation is accomplished. In Taiwan, QA
activities embody primarily four domains:
Medical departments, nursing departments,
allied health professional departments and
administrative departments. The composition
of a QA system should include at least five
major factors: (1) quality resources, (2) quality
education, (3) development of quality assessment tools, (4) quality information systems,
78
and (5) quality professional societies. Currently, Taiwan is moving to integrate these
factors into a complete QA system.
SYSTEMATIC APPROACHES
QA in Taiwan can be generally analyzed from
six different systematic approaches: (1) government, (2) health care providers, (3) consumers,
(4) health professionals' societies, (5) education, and (6) research.
1. Government
The DOH takes responsibility not only for
formulating national health policies but also for
monitoring and conducting external QA audits.
At the present time, major QA measures in
government approaches include: (1) health professionals' licensure, (2) hospital accreditation,
(3) the pharmaceutical industries Good Manufacturing Process (GMP) system, (4) medical
technology assessment, (5) the regional health
care network project, (6) the medical care act,
(7) blood usage and clinical pathology quality
review, (8) clinical trials program review, and
(9) malpractice cases review [11,16].
P. Huang
standards consisted of: (1) quality of personnel,
facilities, hospital management and community
services; (2) quality of medical care services in
both internal medicine and surgery; (3) quality
of radiological diagnosis and therapy; (4) quality of laboratory testing; (5) quality of nursing
care; (6) quality of pharmaceutical services; (7)
quality of emergency care; and (8) quality of
psychiatric care. The accreditation is valid for
three years. Of all hospitals assessed in the
Taiwan Area, 557 have met the requirements:
12 medical centers, 45 regional hospitals, 54
district teaching hospitals, 416 district hospitals,
10 specialty teaching hospitals and 20 psychiatric hospitals [17,18].
1.3. The pharmaceutical industries GMP. To
upgrade the quality of the pharmaceutical
industries in 1982, the DOH and the Ministry of
Economic Affairs jointly issued the Good
Manufacturing Practice (GMP) standards. By
December 1983, 229 pharmaceutical factories
had been approved as GMP factories [1].
1.4. Medical technology assessment. Access
to and control over medical technologies, especially the innovative and expensive ones, have
1.1 .Health professionals' licensure. The licen- also become major decision-making concerns in
sure system for health professionals includes a Taiwan which depends heavily on imported
license examination (physician, Chinese medi- technologies. In June 1983, the DOH approved
cine doctor, dentist, dental assistant, pharma- the "Guidelines on the Purchase and Use of
cist, assistant pharmacist, medical technologist, Delicate Medical Devices by Hospitals and Climedical technician, medical radiological tech- nics" as the policy basis for planning and regunologist and technician, registered nurse and lating the availability and distribution of new
midwife) and specialty certification (physician and expensive medical technology. Presently,
medical technologies and/or services which
only) [1,12].
need to be approved before purchase include
1.2. Hospital accreditation. Of all QA laser trabeculoplasty, ultrasonography, posimeasures, hospital accreditation is the most tron tomography, cyclotron, extracorporeal
important approach to upgrade QA in hospi- Shockwave lithotripsy (ESWL), computed
tals. The first accreditation of teaching hospitals tomography scanner (CT) and MRI [7].
in Taiwan was jointly conducted by the MOE
and the DOH in 1978. Following passage of the
2. Health care providers
Medical Care Act in 1986, accreditation was
divided into two parts: teaching hospital
In Taiwan, self-discipline is still the most
accreditation and hospital accreditation. The important motive for health care professionals
former was conducted by the DOH in collabor- to implement QA activities. In addition, the
ation with the MOE; the latter was carried out expectations of patients and relatives, medical
by the DOH alone. The accreditation com- regulation, and advanced medical technology
mittee designated by the DOH was composed are also major driving forces. Basically, there is
of senior physicians, nurses, pharmacists and no comprehensive QA system in Taiwan. In
hospital management specialists. Criteria and hospitals, the hospital accreditation system,
Quality assurance in Taiwan, ROC
health professional licensure system and health
insurance schemes are the three chief forces
that influence the development of QA. Consequently, most hospitals' QA programs are
based mainly on the DOH's hospital accreditation requirements. Usually, QA organizations are formed as a QA committee or QA
department. At present, fewer than 10 hospitals
have established formal QA departments. A
study by the National Defense Medical Center
(NDMC) found that the majority of hospitals in
Taiwan have set up QA committees to formulate QA policy, monitor QA activities and to
solve QA related issues [3,4]. However, the QA
organizations in hospitals, in general, do not
function very well. Hospital QA in Taiwan can
be divided into two major parts: hospital-wide
QA and department-wide QA. The former consists of infection control, medical record review,
medical equipment review, hospital day control
review, blood usage review, accident review,
hospital safety and health review; the latter are
nursing quality review, surgical services review,
medical services review, clinical laboratory services review, pharmaceutical services review,
emergency services review, OB/GYN services
review, pediatric services review, radiation
safety control, administration services quality
review, anesthesia services review, pathology
services review, dietetic services review, rehabilitation services review, psychiatric services review and nuclear medicine services review [3].
In primary health care, QA activities have
recently made a debut in Taiwan. Unfortunately, these are not sufficiently systematically
documented [25,26].
3. Consumers
79
and screening procedures. Nineteen medical
specialty societies are entrusted with the responsibility of conducting reviews and scTeening a large number of specialties including
family medicine, internal medicine, surgery,
pediatrics, obstetrics and gynecology, orthopedics, neurology, neurosurgery, urology, ENT,
ophthalmology, dermatology, psychiatry,
rehabilitation medicine, anesthesiology, radiology (radiological diagnosis, tumor and nuclear radiology), pathology, nuclear medicine
and plastic surgery. By the end of 1993, 17,903
individuals in these specialties had been qualified by the DOH. Presently, 23 main medical
specialty and sub-specialty societies have been
founded in Taiwan [19]. Through the mechanisms of the regular by-law and Board Examination, all societies conduct membership
qualification systems to regulate professional
quality. However, the societies' QA systems
emphasize primarily individual quality only.
Peer practice review and clinical guidelines
are still lacking. There is plenty of room for
medical societies to improve approaches to
QA.
On 28 July 1993, the Association for Healthcare Quality of the Republic of China (AHQ)
was established in Taipei. The mission of this
organization is both to organize healthcare
quality professionals from all levels of health
care institutions and to promote QA activities in
the Taiwan area. Its goals include promotion of
QA knowledge and techniques, education of
quality professionals, initiation of QA-related
R&D, collection of QA materials, promotion of
international cooperation, and conduct of QA
projects sponsored by the government or other
medical societies.
Patient's health care preferences are strongly
5. Quality education
influenced by culture [8]. Consideration of
patients' views is an essential component of
Traditionally, medical education in Taiwan is
consumer rights. After the Consumer Protec- classified into two stages: medical school edution Law was proclaimed in 1994, QA for con- "cation and continuing education.
sumers seeking health care will be enforced
throughout the health industry.
5.1. Medical school education. Currently, few
medical schools give QA courses in the undergraduate curriculum. However, graduate
4. Health professional societies
schools offer some QA programs in courses on
In Accordance with the Physician's Law, the hospital administration, health care delivery,
DOH promulgated regulations on 29 June 1988 health care financing or health services regoverning medical specialties and their review search. For medical school QA education, the
80
main difficulty comes from the shortage of
appropriate teaching staff. In addition, there
are several reasons for being unable to promote
QA knowledge and technique during the period
of school education, such as (1) shortage of
Chinese QA materials; (2) lack of effective
QA models; and (3) insufficiency of teaching to
develop comprehensive QA teaching programs.
5.2. Continuing education. The responsibilities of improving quality of health care have
been gradually moved from individual health
professionals to health care organizations.
Therefore, rebuilding QA knowledge will become more and more important in health professionals' continuing education. In addition,
based on the Physician Law, physicians are
required to take continuing education courses
to renew their specialty certificates.
P.Huang
view systems [8]. Issues and problems that exist
in the Taiwan QA system include the following:
1. Lack of an acceptable definition ofQA of
Chinese or oriental origins
Universally, there is no acceptable definition
of QA. Besides, most QA definitions come
from Western culture. There are no Chinese or
Oriental sources to draw on for defining the
philosophy of QA.
2. Shortage of quality professionals
Most quality professionals have backgrounds
in medicine, nursing, hospital administration,
public health, medical technology and so on.
However, less than 3% of quality professionals
are full-time staff in hospitals [3]. All the QA
professionals lack formal QA education and
training.
6. Research
In Taiwan, research in QA is in the pioneer
stage. For the past decade, fewer than 50 different QA-related research projects have been
conduced in the health care industry. Topics for
QA research in Taiwan are defined as hospital
QA and primary health care QA. The former
can also be divided into hospital-wide (or general) QA and department-wide (or specific)
QA; and the latter consists of clinic QA and
public health services QA. Topics of hospital
QA projects focus especially on departments,
for instance: nursing, anesthesia, clinical pathology, radiology, medical record review, etc.
Recently, the national survey of hospital QA
programs in Taiwan has been completed by the
NDMC. In addition, several hospitals have
adopted CQI/TQM theories in different clinical
and administrative departments for improvement of the quality of services.
ISSUES AND PROBLEMS
Taiwan's laissez-faire policy extends to the
QA of the health care delivery system. There
are few regulations that require health care
providers to monitor their own behavior. However, there are still no comprehensive systematic approaches to deal with medical practice,
patient outcome evaluation, or even peer re-
3. Incomplete QA monitoring system
The QA monitoring system focuses principally on survey, case review, document review,
or medical record review. Some hospitals have
set up intra-hospital QA monitoring systems;
however, most hospitals lack an inter-hospital
QA monitoring system.
4. Tedious hospital accreditation standards
Although the hospital accreditation system
did upgrade the quality of hospital services, the
tedious accreditation standards are primarily
structure oriented. Reliability and validity of
the QA criteria and standards need to be questioned and revised. In addition, the relationship
between QA and accreditation needs to be
verified. Process and outcome standards are
strongly recommended to monitor Q A in hospitals [23].
FUTURE DEVELOPMENTS AND
CHALLENGES
Over the past 40 years, the Republic of China
has produced a universally acknowledged economic miracle in Taiwan. It is a high government priority to invest our limited resources
81
Quality assurance in Taiwan, ROC
prudently in establishing a comprehensive
social security system. While marching on to the
arena of the developed countries, Taiwan still
needs to make every effort to fight for improvements. In the health care industry, we believe
that a QA system will be established step by step
to work collaboratively among the government,
health care providers, consumers and health
professionals societies.
Therefore, future developments and challenges are recommended as follows:
1. Government
1.
2.
3.
4.
5.
6.
Formulate national and local QA policies.
Revise hospital accreditation QA standards.
Promote quality improvement models.
Encourage QA research and development.
Participate in international quality societies.
Educate and train health quality professionals.
2. Hospitals
1. Arrange quality education for health professionals.
2. Develop quality assessment tools.
3. Conduct quality improvement programs.
4. Establish quality management organization.
5. Implement inter- or intra-hospital quality
improvement projects.
3. Medical schools
1. Design QA education and training courses.
2. Conduct QA research.
4. Health professionals societies
1. Develop standard procedures or manuals for
health professionals.
2. Set up quality assessment and monitoring
indicators, clinical guidelines or quality standards.
3. Provide quality education for health professionals.
4. Develop quality improvement demonstration programs.
In conclusion, based on the Medical Care Act
and National Health Insurance Law, QA activities in Taiwan should be gradually integrated
into the health care delivery system and
national health insurance system.
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