To identify whether attributes of perceived clinic quality and patient education are associated with patient satisfaction and recommendation of a primary care provider. Data used in this study were obtained through a national telephone survey by random sampling. Clinics throughout Taiwan. A total of 1910 patients. Overall patient satisfaction and recommendation were measured by single item questions. Attributes of clinic quality were measured using 11 items: doctor's technical skill (four items), doctor's interpersonal skill (three items), staff care and access (four items). Patient education was measured on the basis of education provided on disease prevention and control during the visit. With regard to clinic quality, doctor's technical skill was most related to overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access were associated with overall satisfaction but were not associated with recommendation. Patient education was related to both overall satisfaction and recommendation. Doctor's technical skill is the most critical attribute of primary care quality for both overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access are associated with improved overall satisfaction but not related to increasing the likelihood of recommending a clinic to relatives and friends. Doctor's technical and interpersonal skills rather than staff care and access can be the essence of quality competition in the primary care market. Providing patient education during the visit on how to prevent or control diseases may also relate to improved patient satisfaction and recommendation.

Although volume-outcome and weekend-outcome relationships have been explored for various procedures and interventions, limited information is available concerning "physician volume" and the "weekend effect" on stroke mortality. Moreover, little is known about the relative and combined influence of physician and hospital volume on stroke mortality. We used nationwide population-based data to explore the influences of physician volume and weekend admissions on stroke mortality. We analyzed all 34,347 ischemic stroke patients admitted in 2005, treated by 2424 physicians practicing in 245 hospitals in Taiwan through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to explore the individual and combined impact of annual physician volume and annual hospital volume, as well as the impact of weekend admissions, on 30-day mortality. Higher physician volume, simultaneous contribution of higher physician and higher hospital volume, and weekday admissions were associated with decreased 30-day mortality, after adjusting for patient gender and age, comorbidities, surgery, physician age and specialty, hospital ownership, accreditation level, teaching status, geographic location, regional resources, and competition. Higher physician volume, rather than higher hospital volume is associated with lower 30-day ischemic stroke mortality, but the relationship has become stronger in higher-volume hospitals. Stroke patients admitted on weekends also have a higher mortality than those admitted on weekdays.

Thirty-day readmission rates after acute myocardial infarction (AMI) and heart failure are important patient outcome metrics. Early post-discharge physician follow-up has been promoted as a method of reducing 30-day readmission rates. However, the relationships between early post-discharge follow-up and 30-day readmission for AMI and heart failure are inconclusive. We used nationwide population-based data to examine associations between 7-day physician follow-up and 30-day readmission, and further associations of 7-day same physician (during the index hospitalization and at follow-up) and cardiologist follow-up with 30-day readmission for non-ST-segment-elevation myocardial infarction (NSTEMI) or heart failure. We analyzed all patients 18 years or older with NSTEMI and heart failure and discharged from hospitals in 2010 in Taiwan through Taiwan’s National Health Insurance Research Database. Cox proportional hazard models with robust sandwich variance estimates and propensity score weighting were performed after adjustment for patient and hospital characteristics to test associations between 7-day physician follow-up and 30-day readmission. The study population for NSTEMI and heart failure included 5,008 and 13,577 patients, respectively. Early physician follow-up was associated with a lower hazard ratio of readmission compared with no early physician follow-up for patients with NSTEMI (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.39–0.57), and for patients with heart failure (HR, 0.54; 95% CI, 0.48–0.60). Same physician follow-up was associated with a reduced hazard ratio of readmission compared with different physician follow-up for patients with NSTEMI (HR, 0.56; 95% CI, 0.48–0.65), and for patients with heart failure (HR, 0.69; 95% CI, 0.62–0.76). For each condition, patients who have an outpatient visit with a physician within 7 days of discharge have a lower risk of 30-day readmission. Moreover, patients who have an outpatient visit with the same physician within 7 days of discharge have a much lower risk of 30-day readmission.

Objective The aim of this study was to systematically and simultaneously examine the association of intrinsic and extrinsic motivating factors with physician burnout and job dissatisfaction. Design A nationally representative survey was fielded from September to November 2017. Setting Hospitals and clinics throughout Taiwan. Participants A total of 6674 physicians. Main exposure measure The main exposure measures were intrinsic motivators (sense of calling, personally rewarding hours per day and meaningful, long-term relationships with patients) and extrinsic motivators (income, work hours, autonomy, and pay-for-performance (P4P) and bundled payment initiatives). Main outcome measures The main outcome measures were physician burnout and job dissatisfaction. Results A total of 1152 physicians returned the surveys. More sense of calling and personally rewarding hours per day were associated with less physician burnout (OR 0.16, 95% CI 0.10 to 0.26 and OR 0.25, 95% CI 0.13 to 0.47, respectively) and job dissatisfaction (OR 0.35, 95% CI 0.21 to 0.57 and OR 0.46, 95% CI 0.26 to 0.83, respectively). Longer work hours were associated with more physician burnout (OR 2.67, 95% CI 1.54 to 4.63) and job dissatisfaction (OR 1.71, 95% CI 1.05 to 2.79). Not receiving P4P bonuses from their organisations was associated with more physician burnout (OR 1.56, 95% CI 1.02 to 2.38). Not sharing the losses from caring for patients included in the bundled payment system was associated with less physician burnout (OR 0.59, 95% CI 0.36 to 0.97). Conclusions Fostering a healthcare work environment that supports intrinsic motivation and improves work hours may reduce physician burnout and job dissatisfaction. Rewarding physicians fairly and equitably may prevent them from feeling burned out. Value-based care delivery and payment model innovations, such as bundled payments, may encourage healthcare professionals to coordinate care through the standardisation of care to decrease burnout.

A volume-outcome relationship has been found for acute myocardial infarction (AMI); however, the mechanisms underlying the relationship remain unclear. In particular, it is not known whether processes of care are mediators of the volume-outcome relationship, that is, whether the mechanisms underlying the relationship are through processes of care. We used nationwide population-based data to examine the mediating effects of processes of care on the relationships of physician and hospital volume with AMI mortality. We analyzed all 6838 ST-elevation myocardial infarction (STEMI) patients admitted in 2008, treated by 740 physicians in 142 hospitals through Taiwan's National Health Insurance Research Database. Multilevel meditational models were performed after adjustment for patient, physician, and hospital characteristics to test the relationships among physician and hospital volume, processes of care, and 30-day STEMI mortality. Physicians with higher volume had higher use of percutaneous coronary intervention and aspirin, and lower mortality in the following year, and the processes of care were mediators of the relationship between physician volume and mortality. Low-volume hospitals had higher mortality in the following year than medium-volume hospitals. In stratified analyses the relationships only existed in nonlarge hospitals. Physicians with high volume perform better on certain processes of care than those with medium and low volume, and have better outcomes for patients with AMI. The processes of care could partly explain the relationship between physician volume and AMI mortality. However, the relationships existed in nonlarge hospitals but not in large hospitals.

Mackay Memorial Hospital (MMH) is a medical centre with 2149 beds and more than 9000 outpatient visits per day. In order to enhance its competition, MMH is the first hospital in Taiwan to implement the Balanced Scorecard (BSC) fully for the entire organisation, not just for a specific department. This paper will assess both direct and indirect outcomes since its inception in 2001. From 2003 to 2005, the revenue from services not covered by the National Health Insurance (NHI) increased from NT$1407 million (US$1 = NT$32.9; €1 = NT$39.0) to NT$17,894 million. Inpatient satisfaction rose from 89.07% to 91.9%. The number of visits by disadvantaged patients (those with economic, social or physical disabilities) increased from 82,350 to 97,658 visits. The number of research projects also increased from 46 to 61 projects. The percentage of patients admitted to an intensive care unit in less than 3 hours from arrival in the emergency department increased from 47.8% in 2004 to 82.5% in 2005. BSC has thus been successfully developed and implemented at MMH, most likely for two main reasons. First, right from the beginning, the BSC executive team included the Board of Directors along with senior management personnel. Secondly, departmental BSCs were successfully launched and linked to budget planning after two years of full implementation. It is hoped that the experience of MMH in implementing BSC can be applicable to other healthcare organisations.