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International Journal for Quality in Health Care Advance Access originally published online on November 23, 2006
International Journal for Quality in Health Care 2007 19(1):21-28; doi:10.1093/intqhc/mzl063
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International Journal for Quality in Health Care vol. 19 no. 1 © The Author 2006. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Development and implementation of a nationwide health care quality indicator system in Taiwan

Wen-Ta Chiu1,3, Che-Ming Yang1,2,3, Hui-Wen Lin3 and Tu-Bin Chu2,3

1 Taiwan College of Healthcare Executives, Taipei, Taiwan, 2 Taipei Madical University School of Healthcare Administration, Taipei, Taiwan, and 3 Taipei Municipal Wan Fang Hospital, Taipei, Taiwan

Quality issues. Quality is an increasingly important issue to the health care sector. The Taiwanese government also recognizes the need to implement a nationwide health care quality indicator system to strengthen quality surveillance.

Choice of solution. In 1999, the Department of Health funded a 2-year project led by the Taiwan Healthcare Executive College to develop a comprehensive performance assessment system, subsequently named as Taiwan Healthcare Indicator Series (THIS). The series includes four categories of indicators, namely outpatient, in-patient, emergency care, and intensive care, and has 139 items in total.

Implementation. The system was officially launched in 2001. Participation is voluntary. The Taiwan Healthcare Executive College processes the data and provides feedback to the participating hospitals. The information is for the participating hospitals’ own use and is not released to the public.

Evaluation. Participating hospitals have increased from 45 in 2001 to 227 in 2006 and now constitute ~50% of the total hospital population in Taiwan. The reporting rate averaged 77.7% in 2004. The first five most reported indicators are the percentage of first-visit outpatients to outpatient clinics, the average length of in-patient stay, the nosocomial infection rate, the occupancy rate, and the crude mortality rate.

Lessons learned. How the data are interpreted and how data interpretation can lead to quality improvement are the principal concerns of participating hospitals. In light of the success of the indicator series, the Bureau of National Health Insurance (BNHI) of Taiwan has proposed participation in the series as being one of the criteria to be reimbursed for quality.

Keywords: health care indicator, performance assessment, quality

Address reprint requests to Che-Ming Yang, Taipei Medical University School of Healthcare Administration, No. 250, Wu-Hsing Street, Taipei 110, Taiwan. E-mail: cyang{at}tmu.edu.tw

Accepted for publication October 25, 2006.


   Quality issues
Top
 Quality issues
Choice of solution
 Implementation
 Evaluation
 Lessons learned
 Conclusions
 References
 
Quality is an increasingly important issue to the health care sector. Health care professionals around the world apply all sorts of methods to improve the quality of care delivery. The tools range from the very sophisticated to simpler ones. Nonetheless, the aims of all of these efforts are to increase the benefits to patients. Although most of these kinds of efforts stem from health care providers’ own initiatives, those from governments and third-party payers certainly play a pivotal role in promoting improvements in quality of care.

Similar to its counterparts around the world, Taiwan’s health care sector continually strives to improve quality by various means. Total quality management began to take root in Taiwan’s health care industry in the 1990s. Over time, the Department of Health has undertaken several initiatives to facilitate the trend, such as the critical path and quality control circle. In 1997, the ORYX initiative of the US Joint Commission on Accreditation of Healthcare Organizations caught the eye of the Taiwanese authorities. The US Joint Commission’s ORYX initiative integrates outcomes and other performance measurement data into the accreditation process, and on 1 July 2002, accredited hospitals began collecting data on core performance measures [1].

Health care indicators can be used as a mechanism of benchmarking. For instance, the Quality Indicator Project, one of the leading quality indicator systems in the United States nowadays [2], was initiated in 1985 by a group of seven member hospitals of the Maryland Hospital Association to share data on 10 in-patient care indicators to objectively ascertain their institutional profiles [3]. Recent developments in Europe are also worth noting. The World Health Organization Regional Office for Europe launched a performance assessment tool for quality improvement in hospitals in 2003, which aims for a comprehensive assessment of hospital performance [4]. This European initiative identified six dimensions for assessing hospital performance, namely clinical effectiveness, safety, patient centeredness, production efficiency, staff orientation, and responsive governance, and pilot programs are currently being implemented in eight countries to refine its framework.


   Choice of solution
Top
 Quality issues
 Choice of solution
Implementation
 Evaluation
 Lessons learned
 Conclusions
 References
 
Taiwan’s Department of Health realizes the importance of quality indicators and has long been thinking of the possibility of establishing a nationwide indicator system to simultaneously monitor and help improve health care quality. Although the Taiwan Joint Commission on Hospital Accreditation became the local sponsor of the Quality Indicator Project in 1999 [5], the Department of Health still aims to establish an indigenous health care quality indicator system that caters to the needs of local hospitals. The need for a local system can be exemplified by the UK experience as well. Although the Quality Indicator Project was begun in the United Kingdom in 1992, the UK Department of Health subsequently developed its own performance management indicators for National Health Services hospitals [6]. In the same year in which the Quality Indicator Project was inaugurated in Taiwan, the Department of Health funded the Taiwan College of Healthcare Executives to develop a health care indicator system, which was subsequently named the Taiwan Healthcare Indicator Series (THIS).

During the research and development stage, the college gathered local experts, including physicians, nurses, pharmacists, health care administrators, epidemiologists, and so on, from diverse sectors to select and modify indicators in terms of the validity, reliability, and local context. The college also stressed the importance of clinician participation throughout the process because indicators have to be practical to be useful. The quality indicator system was designed in line with Donabedian’s structure, process, and outcome definitions [7] and classified according to hospital functions, primarily encompassing acute care functions at present. The series includes four categories of indicators, namely outpatient (n = 17), emergency (n = 40), in-patient (n = 56), and intensive care (n = 26), and has 139 items in total (Appendix). The recent trend in the development of performance measures is tilted toward outcome and process measurements rather than structural measurements. For instance, one of the performance measurement system requirements for the US ORYX listing in each performance measure is a defined process or outcome measure [8]. In keeping with this trend, we tried to design the indicators to be more process- and outcome-oriented rather than structure-oriented with only one exception in the outpatient category, which still has slightly more structural indicators (Appendix).

Although it is debatable as to how one can best classify quality indicators, Donabedian’s original article enunciating this quality assessment classification is one of the most cited [9] and is said to have influenced the quality assessment/quality assurance movement of the 1970s, the total quality management of the 1980s, and the more recent performance measurement initiatives, such as HEDIS, ORXY, and CONQUEST in the United States [10]. Therefore, adopting this trilogy in our system became the consensus of our local experts.


   Implementation
Top
 Quality issues
 Choice of solution
 Implementation
Evaluation
 Lessons learned
 Conclusions
 References
 
After 2 years of research and development, THIS was officially launched in 2001. Participation is voluntary. Participating hospitals can choose whichever indictors they feel are suitable for their own settings and report them to the Taiwan College of Healthcare Executives monthly via a web-based interface. The college processes the data, provides feedback to them, and is responsible for the statistical analyses by applying the overall data or the data of subgroups, according to ownership, accreditation level, and so on. Participating hospitals learn the statistical distributions of all indicators, including the mean, standard deviation, range, percentile, and so on. The information derived from the database is for participating hospitals’ own uses and is not yet meant to be released to the general public. Hospitals are allowed to publicize their participation in the system, but not the results.

Participation is not free but quite affordable. Hospitals have to pay annual fees ranging from US$300 to US$2000 according to the accreditation level. The Taiwan College of Healthcare Executives regularly holds workshops and user group meetings to help member hospitals implement the system and initiate quality improvements. In its annual user group meetings, the college encourages member hospitals to submit their actions that resulted from implementing this system for a poster competition. The number of submissions increased from 44 at the third annual user group meeting to 182 at the fourth meeting.


   Evaluation
Top
 Quality issues
 Choice of solution
 Implementation
 Evaluation
Lessons learned
 Conclusions
 References
 
Participating hospitals increased from 45 in 2001 to 227 in 2006 and constitute ~50% of the total hospital population in Taiwan. Of these 227 institutions, 8 are medical centers, 53 are regional hospitals, 33 are district teaching hospitals, and 133 are district hospitals. According to Taiwan’s Medical Care Act and its implementing regulations, hospitals have to be accredited and, according to the results, are assigned as a medical center, regional, district teaching, or district hospital [11]. Most medical centers and regional hospitals are teaching hospitals at the same time. Medical centers are supposed to be tertiary care hospitals, whereas regional hospitals are secondary care hospitals, and district teaching and district hospitals are responsible for primary care. Medical centers are generally larger hospitals in terms of bed number, whereas district hospitals are likely smaller. Although most of the member hospitals are district hospitals, district teaching hospitals are generally more interested in joining our system in terms of the percentage of the same accreditation level at 89.2%, followed by regional hospitals at 75.7% (Table 1).


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  		Table 1 Distribution of participating hospitals according to accreditation level

 

Not every hospital that signs up with the series reports its data regularly. The reporting rate is 100% for medical centers, 94.8% for regional hospitals, 75.8% for district teaching hospitals, and 70.2% for district hospitals, with an overall average of 77.7% in 2004. The range of reported items varied from 3 to 123. It appears that hospitals that are more teaching-oriented and tertiary care-oriented are more likely to report data. Twenty-seven of the indicators were reported by >60% of the participating hospitals in the fourth quarter of 2004. The first five most reported indicators were the percentage of first-visit outpatients to outpatient clinics, the average length of in-patient stay, the nosocomial infection rate, the occupancy rate, and the crude mortality rate (Table 2).


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  		Table 2 Reporting frequencies of selected indicators in the fourth quarter of 2004

 

The college conducted a survey in 2002 to assess how member hospitals reacted to and implemented THIS. Of the respondents, 65.6% thought the leadership of their hospitals supported the implementation of the indicator system. Administrative departments are in charge of data collection in 52.7% of the hospitals, as opposed to medical departments being in charge in 32.4%. The data collection process is mostly done semiautomatically (87.7%), whereas 9.6% is done manually and 2.7% totally by computer [12]. It appears that the data collecting processes are still very labor intensive, and this might contribute to the fact that there are low reporting rates for a substantial portion of our indicators.


   Lessons learned
Top
 Quality issues
 Choice of solution
 Implementation
 Evaluation
 Lessons learned
Conclusions
 References
 
Data interpretation and quality improvement
After 5 years, the indicator system’s database has accumulated a significant amount of information that can be analyzed to improve the delivery of services. How the data are interpreted and how data interpretation can lead to quality improvement are the principal concerns of participating hospitals. For instance, the Cesarean section rate of participating hospitals averaged 32% in 2004, which is similar to the national average of 33% [13]. Apart from first timers, the repeat Cesarean section rates ranged from 72.2 to 90.7% in 2004. Unavoidably, hospitals ask how such data should be interpreted. Do they need to decrease or increase the rate?

The same confusion arose in 2002 in the United States as well, when the US Joint Commission designated the rate of vaginal births after a prior cesarean section as one of the core measures of pregnancy care. The average cesarean section rate in the United States was ~20% from 1981 to 1997, whereas the rate of successful vaginal births after a prior cesarean section delivery rose from 3 to 27.4%. However, owing to the possibility of increased uterine rupture, the American College of Obstetricians and Gynecologists revised standards to subsequently restrict vaginal births after a prior cesarean section attempts to patients with only one or two prior cesarean deliveries. The trend has decreased since 1997. Therefore, the US Joint Commission declared that vaginal birth after a prior cesarean section rate was configured as a neutral measure and that it did not intend to promote vaginal birth after a prior cesarean section [14].

Similar to the US Joint Commission’s intentions, our indicator series was configured to contain neutral measures as well. Most of the health care indicator systems are designed along two distinct dimensions: measurement and evaluation; measurement is value-free, whereas evaluation is value-laden [15]. There is no predetermined threshold value for any given indicator of this system. The interpretation of the measurement results is therefore customized. Hospitals can look at their own data in comparison with their peers to determine whether there is a need to improve their care delivery. Furthermore, one should not readily make value judgments without carefully scrutinizing each hospital’s particular situation.

The college’s hope is that the adoption of a quality indicator system will lead to improvements in individual hospitals. Therefore, the effect of quality improvement can demonstrate itself at two levels: the individual hospital level and the aggregate level. It has been demonstrated that the scope of quality improvement implementation in hospitals is significantly associated with hospital-level quality indicators [16]. Likewise, there were notable efforts within the participating hospitals, and the college, as the sponsor, does not intervene. Hospitals share their own experiences in communications and user group meetings. Fortunately, the college has also noted a few changes in trends at the aggregate level over the years. For instance, the 3-year average of nosocomial infection rate is at 3% for all participating and reporting hospitals. In comparison with other countries’ relevant rates, for instance, the point prevalence rate in Thailand’s hospitals in 2001 was 6.4% [17], and it was 12% in Auckland in the 1990s [18]; so, our hospitals’ performance is quite acceptable as a whole, although this comparison is probably not justified on account of variations of definitions across studies. There appears to be a downward trend in the overall nosocomial infection rate from 2003 to 2005 (Figure 1). District hospitals seemed to have contributed the largest share of improvement, from an average of 4.1% in the first quarter of 2003 to 1.4% by the end of 2005. What prompted this change remains to be ascertained. The best scenario is that district hospitals might have benchmarked with other levels of hospitals to improve their infection-control measures after joining the indicator system. However, the college is cautious in interpreting these self-reported data. Underreporting whether intentionally or unintentionally is a major limitation. There are also many other confounding factors [such as the Severe Acute Respiratory Syndrome (SARS) epidemic] that might have caused this phenomenon, and further studies are warranted.


Figure 1
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  		Figure 1 Trends of quarterly average percentage distribution of nosocomial infection rates of participating hospitals since 2003.

 

The recognition of national health insurance
Taiwan adopted a national health insurance system in 1995. Pursuant to the National Health Insurance Act [19] and associated regulations, the government established the Bureau of National Health Insurance (BNHI), and all citizens were required to be insured by and pay premiums to the Bureau, which is responsible for the management of premiums and has become the single purchaser in Taiwan’s health care market. Starting from 2005, 0.155% of the annual total reimbursement budget was to go to the pay-for-performance initiative; in light of the success of the indicator series, the BNHI has proposed participating in our series as being one of the criteria to be reimbursed for quality [20]. In fact, owing to expectations of moving in this direction, the number of our participating hospitals surged from 138 to 247 in 2004.


   Conclusions
Top
 Quality issues
 Choice of solution
 Implementation
 Evaluation
 Lessons learned
 Conclusions
References
 
THIS has become the largest health care quality indicator system in Taiwan. The Taiwan College of Healthcare Executives instilled unique elements of National Health Insurance and local culture into an international consensus in the field of performance measurement. After 5 years, the indicator series has been used and analysed among various levels of hospitals. Although this system has proved its utility in Taiwan’s acute care settings, the college’s immediate goals are to facilitate Taiwan’s hospitals benchmarking internationally with other world-renowned systems, such as the US ORYX initiative and the performance indicators of the Australian Council on Healthcare Standards, and to expand the applications of our series to other health care settings, such as psychiatric care and long-term care.


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  		Appendix: Distribution of indicators according to functional department and Donabedian’s stratification

 

   References
Top
 Quality issues
 Choice of solution
 Implementation
 Evaluation
 Lessons learned
 Conclusions
 References
 
  1. Joint Commission on Accreditation of Healthcare Organizations: http://www.jcaho.org/accredited+organizations/hospitals/oryx/oryx+facts.htm Accessed 19 September 2005.

  2. Conn J. Leading indicator. Mod Healthc 2005; 35: 38–39.[Medline]

  3. Kazandjian VA, Wood P, Lawthers J. Balancing science and practice in indicator development: the Maryland Hospital Association Quality Indicator (QI) Project®. Int J Qual Health Care 1995; 7: 39–46.[Abstract/Free Full Text]

  4. Veillard J, Champagne F, Klazinga N, Kazandjian V, Arah OA, Guisset AL. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Health Care 2005; 17: 487–496.[Abstract/Free Full Text]

  5. Taiwan Joint Commission on Hospital Accreditation: http://www.tjcha.org.tw/quality/quality.asp Accessed 19 September 2005.

  6. Thomson R, Taber S, Lally J, Kazandjian V. UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development. Int J Qual Health Care 2004; 16: i51–i56.[Abstract]

  7. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q 2005; 83: 691–729.

  8. Joint Commission on Accreditation of Healthcare Organizations: http://www.jcaho.org/pms/reference+materials/listingrequirements1.pdf Accessed 13 October 2005.

  9. Sunol R. Avedis Donabedian, 7 January 1919–9 November 2000. Int J Qual Health Care 2000; 12: 451–453.[Abstract/Free Full Text]

  10. Larson JS, Muller A. Managing the quality of health care. J Health Hum Serv Adm 2002; 25: 261–280.[Medline]

  11. Taiwan Department of Health. Medical Care Act, 1986 (in Chinese).

  12. Tai LC. The Evaluation of Outpatient Indicators of Taiwan Healthcare Indicator Series (THIS). Master Thesis. National Defense Medical Center (NDMC) Institute of Public Health of Taiwan, 2003 (in Chinese).

  13. Taiwan Bureau of National Health Insurance: http://www.hcquality.helthe.net/reports/showreports.php?id=1_3 Accessed 21 September 2005.

  14. Harer WB. Vaginal birth after cesarean delivery. JAMA 2002; 287: 2627–2630.[Free Full Text]

  15. Kaznadjian VA, Matthes N, Wicker KG. Are performance indicators generic? The international experience of the Quality Indicator Project. J Eval Clin Pract 2003; 9: 265–276.[CrossRef][ISI][Medline]

  16. Weiner BJ, Alexander JA, Shortell SM, Baker LC, Becker M, Geppert JJ. Quality improvement implementation and hospital performance on quality indicators. Health Serv Res 2006; 41: 307–334.[CrossRef][ISI][Medline]

  17. Danchaivijitrmd S, Dhiraputra C, Santiprasitkul S, Judaeng T. Prevalence and impacts of nosocomial infection in Thailand 2001. J Med Assoc Thai 2005; 88: S1–S9.

  18. Nicholls TM, Morris AJ. Nosocomial infection in Auckland Healthcare hospitals. N Z Med J 1997; 110: 314–316.[ISI][Medline]

  19. Taiwan Department of Health. National Health Insurance Act (in Chinese), 1994.

  20. Taiwan Bureau of National Health Insurance. 2005 Pay for Performance Initiative, 2005 (in Chinese).


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