Governance Structure:
The hospital’s governance framework is founded on the principles of “independent oversight and professional management.” Through a clear division of responsibilities and collaborative mechanisms between the Board of Directors and the management team, we ensure transparency in decision-making, forward-looking planning, and effective execution. The following outlines the composition and operations of both the oversight team and the management team, illustrating the functioning and effectiveness of our governance system in concrete terms.
The oversight team and the management team hold regular quarterly management meetings. These meetings are jointly convened by two representatives from the Board of Directors, members of the management team, and employee representatives. From 2022 to 2024, a total of 13 management meetings were held, with 43 proposals submitted over three years. Among these, 39 proposals were reviewed and resolved by the Board of Directors. In addition, all matters identified by the President as significant events are reported to the Board.
👔Board of Directors of Chung Shan Medical University Hospital
The Board of Directors of Chung Shan Medical University Hospital, established under the Private School Act and corporate charter, is the highest governing body for both the University and the Hospital. It reviews major policies, annual plans, and long-term strategies, and plays a key role in managing ESG-related risks.
In recent years, ESG issues have been a recurring focus in Board meetings, with the University President and Hospital Superintendent regularly reporting on sustainability strategies and institutional progress. On February 29, 2024, President Chien-Ning Huang signed the “University Sustainability Initiative,” committing to net-zero carbon emissions by 2050. In April 2024 and April 2025, the Board reviewed progress on the Carbon Neutrality Plan, climate risk responses, ESG results, and international certifications such as HIMSS and AAHRPP.
From October 7 to 17, 2024, the Board delegated a representative to join University leaders in the U.S. to promote international cooperation and ESG development. In December 2024, the Hospital received the National Sustainable Development Award – Education Category Honorable Mention for achievements in net-zero goals, gerontechnology healthcare, and smart energy management, alongside strong results in SDG 3 (Good Health and Well-Being) and SDG 5 (Gender Equality).
Future Outlook and Board Composition
On September 6, 2025, the Hospital will host the 2025 International Conference on Climate Change in Medicine and Education, inviting international partners such as Duke University and the National University of Singapore to strengthen contributions to sustainability and global engagement. Looking ahead, the Board will further institutionalize ESG governance, integrating major sustainability issues into its proposal and review process—from topic selection and policy direction to resource allocation and performance oversight—ensuring a long-term balance between development and responsibility.
The Board consists of nine directors, including two women. The Chairperson, elected by the directors, does not hold any hospital management position, ensuring a clear separation of governance and operations. Hospital operations are led by the Superintendent, appointed by the Board, who oversees both medical and administrative affairs. The current (15th) Board’s term runs from August 2, 2022, to August 1, 2026.
Two independent supervisors review the execution of Board strategies and budgets: Supervisor Sung-Hu Lin (term: February 2, 2023 – November 15, 2028) and Supervisor Wang (term: November 16, 2024 – November 15, 2028). All directors and supervisors serve without compensation, maintain independence from hospital operations, uphold conflict-of-interest avoidance principles, and ensure transparent, impartial decision-making—reflecting a sound corporate governance framework and a culture of integrity in ESG oversight.
🏅Hospital Management Team
The management team of Chung Shan Medical University Hospital is led by the Superintendent, who holds the highest governing authority over hospital operations. This team is directly responsible for managing the hospital’s overall operations, overseeing the Daqing Main Hospital, Wenxin Branch, and Zhongxing Branch. The team comprises 11 Vice Superintendents, each in charge of six major divisions: Medical Affairs, Hospital Administration, Medical Education, Medical Research, Medical Services, and Nursing. They also supervise five major medical centers, including the Cancer Center, Lung Cancer Diagnosis and Treatment Research Center, Dementia Care Center, Medical Quality Center, and Medical Imaging Center, as well as the Wenxin Branch. This structure demonstrates the hospital’s comprehensive management framework and ability to integrate clinical resources.
Members of the management team are typically senior executives with extensive experience and outstanding performance within the hospital. The selection process follows the hospital’s “Staff Recruitment and Appointment Guidelines” and other relevant internal regulations, taking into account professional expertise, past performance, and contributions to the organization to ensure the fulfillment of professional duties and governance responsibilities. The profiles of the management team members are as follows:
📊Management Team Performance Management
🏆Integrity Management
Hospital governance has always been a core focus of our institution. We are committed to establishing a transparent, responsible, and integrity-based organizational culture as the foundation for promoting long-term sustainable development. Through an institutionalized governance framework, we continuously enhance operational management and honestly disclose the outcomes and challenges of our operational performance.
Our hospital recognizes the critical importance of risk management for stable organizational operation. Whether facing market, environmental, or governance risks, we adopt systematic assessment and response strategies to ensure flexibility in managing uncertainties and steadily advancing toward long-term value realization.
Internal Audit and Regulatory Compliance
Our hospital has established an internal audit mechanism in accordance with the “Ministry of Health and Welfare’s Internal Control Task Force Guidelines for Medical Institutions.” Risk-oriented audits have been implemented based on the “Standards for Establishment of Medical Institutions” and hospital accreditation criteria, ensuring compliant and effective organizational operations while strengthening governance efficiency. During this reporting period, our hospital did not violate any medical service, health, or safety-related regulations, nor was it penalized for environmental protection violations, and no incidents met the threshold for major violations. Major violations are defined by the Financial Supervisory Commission as fines exceeding NT$1 million, administrative penalties that impact operations or reputation, or violations causing significant social or environmental impact.
However, due to extended working hours caused by unforeseen events and untimely reporting procedures, we were fined once by the labor authority NT$20,000. The hospital has since reviewed and optimized related procedures; the Human Resources Office now proactively verifies time card records and authorizes overtime pay, improving timeliness and compliance while continuously strengthening labor law adherence and risk management.
The audit unit reports directly to the Board of Directors, maintaining independence and objectivity. It is responsible for planning the annual audit plan, conducting audit operations, following up on deficiencies, and regularly reporting to the Board and senior management. The audit scope covers medical, administrative, and financial units, focusing on process controls, legal compliance, information security, patient safety, and risk management measures. The internal control system design is based on risk assessment results and follows the Executive Yuan’s “Common Business Operation Items” for control system design scope. All control procedures are integrated within business workflows, ensuring that controls are effectively embedded in daily operations to achieve process-control and policy-implementation goals.
Meanwhile, the hospital promotes a unit-level self-assessment system where supervisors regularly review risks and internal control execution, with audit units providing guidance and tracking improvements. Additionally, internal and external audits (such as Health Bureau inspections and internal audits), third-party certifications (e.g., hospital accreditation), benchmarking, and stakeholder feedback are used to evaluate compliance performance and system effectiveness, creating a rolling governance structure that enhances overall operational resilience and transparency.
Operational Performance and Financial Transparency
Upholding principles of integrity and responsibility, our hospital strives to improve operational performance and financial transparency through institutionalized management that ensures efficient resource utilization and builds trust with external stakeholders.
In financial management, a complete annual budgeting and final accounts process is established in accordance with the “Budget and Final Accounts Compilation Procedures.” This includes unit budget preparation, budget committee review, management meeting approval, Board of Directors ratification, and submission to the Ministry of Education for record-keeping. This process ensures forward-looking financial planning and controllable execution. Budget implementation progress is regularly tracked, analyzed in two phases—mid-year and full academic year—and a final account is prepared and approved by the Board, forming a systematic financial management cycle.
Regarding operational performance, units implement management goals according to budget indicators and work plans, integrating strategic direction and resource allocation through management meetings. Furthermore, the hospital undergoes regular external evaluations (such as hospital accreditation and Joint Commission indicators monitoring), regulatory inspections, and stakeholder feedback to conduct cross-verification and review of financial and operational effectiveness.
To strengthen financial transparency and regulatory compliance responsibility, related budget and final account summaries are disclosed to the Board and Ministry of Education as required. The Financial Management Office proactively provides analysis reports to assist management and units in understanding resource utilization. This system operation balances vertical governance and horizontal collaboration, enhancing overall operational resilience and organizational transparency.
| Item | Fiscal Year 2023 (Final Accounts) | Fiscal Year 2022 (Final Accounts) | Fiscal Year 2021 (Final Accounts) |
| Revenues | |||
| Medical Service Revenue | 12,708 | 12,626 | 10,871 |
| Medical Service Discounts | -1,102 | -1,193 | -973 |
| Financial Income | 26 | 15 | 2 |
| Other Income | 299 | 460 | 584 |
| Total Revenues | 11,931 | 11,908 | 10,484 |
| Expenditures | |||
| Personnel Costs | 3,180 | 3,359 | 2,842 |
| Pharmaceutical & Material Costs | 4,930 | 4,920 | 4,427 |
| Medical Costs | 2,301 | 2,158 | 2,084 |
| Administrative Expenses | 200 | 149 | 143 |
| Financial Expenses | 21 | 20 | 18 |
| Loss on Disposal of Assets | 28 | 71 | 18 |
| Other Expenses | 0 | 2 | 0 |
| Total Expenditures | 10,660 | 10,679 | 9,532 |
| Current Surplus/Deficit | 1,271 | 1,229 | 952 |
🥅Risk Management
The hospital has established a Crisis Management Committee chaired by the Superintendent, comprising first-level supervisors from medical, nursing, and administrative departments. The committee emphasizes cross-departmental integration and resource utilization to strengthen disaster prevention and risk management. Meetings are held quarterly to review the results of the Hazard Vulnerability Analysis (HVA) and oversee the development and implementation of subsequent response plans and drills.
Using the HVA methodology, the hospital annually ranks 25 disaster risks and formulates key management priorities accordingly. The top five high-risk items are submitted to the Crisis Management Committee for review to supervise the effectiveness of risk handling and continuously adjust response strategies. The table below lists the top five disaster risks ranked for the years 2022 to 2024:
| Rank | 2022 | 2023 | 2024 |
|---|---|---|---|
| 1 | Earthquake | Information System Failure | Radioactive Material Leakage |
| 2 | Information System Failure | Fire | Earthquake |
| 3 | Fire | Medical Disputes | Typhoon |
| 4 | Violent Incidents | Mass Casualties | Elevator Accidents |
| 5 | Hospital Cluster Infection | Public Complaints | Mass Casualties |
🩺Medical Innovation and Research & Development
Our hospital actively promotes clinical innovation and translational medical research, focusing on smart healthcare, precision health, and interdisciplinary collaboration as core drivers for sustainable medical and academic development. Overseen by the Vice Superintendent of Medical Research, the hospital houses units such as the Translational Medicine Center, Artificial Intelligence Center, Lung Cancer Diagnosis and Treatment Research Center, Clinical Trial Center, and Human Research Protection Center. These units integrate basic research, clinical application, and ethical oversight to form a comprehensive R&D system.
Each center is equipped with shared laboratories, molecular imaging facilities, health data analytics, and biobanks, staffed by PhD-level researchers and full-time assistants to support research from cellular experiments to clinical trials. The research teams focus deeply on cancer, rare diseases, toxicology, and elderly care, collaborating with domestic and international academic institutions to advance precision medicine and innovative treatment models, showcasing the medical center’s strong innovation and research capabilities.
R&D Resources
In 2024, the hospital invested a total of NT$464 million in research and development, accounting for over 4.2% of total revenue. Of this, internal expenditures reached NT$190 million. The hospital secured 121 funded research projects from the National Science and Technology Council, Ministry of Health and Welfare, and other agencies, totaling NT$274 million. To encourage young physicians’ research involvement, a special project funding scheme is in place, allowing resident doctors to participate as co-investigators or principal investigators.
The Institutional Review Board (IRB) has received FERCAP international accreditation. In 2024, 374 new cases were reviewed with a 90.1% approval rate and an average review time of 40.1 days. A journal article verification system was established, auditing 1,047 papers from 2022 to 2024, with no violations recorded. Between 2022 and 2024, the hospital obtained 28 patents, including 21 invention patents. In 2024, a startup spin-off company was established to promote technology transfer and commercialization.
Clinical Contributions
| Innovation Area | Representative Achievements and Contributions |
|---|---|
| Cancer Care | Developed CAR-T cell therapy, LAGA® minimally invasive lung cancer localization, next-generation gene sequencing, and Da Vinci single-port surgery, establishing a comprehensive cancer diagnosis and treatment system. Leading thyroid ablation technology nationwide, supporting external hospital teaching and training. |
| Cardiovascular and Geriatric Health | Established a heart failure care team and Taichung’s first dementia integrated care center, providing comprehensive care services and promoting community continuity of care. |
| Maternal and Child Health | Strengthened obstetrics, gynecology, and neonatal services to respond to declining birth rates, providing comprehensive maternal and infant care resources. |
| Smart Pharmacy and Safety | Implemented ADC+S visualization dashboard and SEMO injection identification system, secured 3 patents, integrated into clinical practice, significantly reducing medication errors and waiting times. |
| Drug Control | Established a drug testing center, the first urine testing lab in central Taiwan certified by the Ministry of Health and Welfare, and the largest hair drug testing unit in Taiwan, assisting forensic investigations and abuse prevention. |
💻Information and Network Security
To ensure the accuracy, completeness, and availability of medical information, Chung Shan Medical University Hospital has established an Information Security Management System in accordance with the “Cybersecurity Management Act” and ISO 27001 standards. The hospital has set up an Information Security Committee chaired by the Vice Superintendent, which convenes quarterly to oversee cybersecurity policies and implementation progress. The hospital employs one Chief Information Security Officer (CISO) and four full-time cybersecurity personnel responsible for system establishment, vulnerability scanning, penetration testing, and risk management.
In 2024, the hospital continued to strengthen information security and service management by conducting multiple cybersecurity drills and technical assessments. Vulnerability scans using the OpenVAS tool targeted 23 items in January, identifying 11 high-risk vulnerabilities, all of which have been fully addressed, demonstrating effective remediation. Annual penetration testing was also completed, with no high-risk vulnerabilities found in initial or follow-up scans, indicating stable system protection capabilities.
Social engineering drills covered 3,855 accounts, with email open rates at 14.14%, link click rates at 3.89%, and attachment open rates at 0.57%. These results have been used to optimize cybersecurity education. The hospital also conducted a system outage response drill to validate system response and recovery capabilities under emergency conditions.
On the information services front, the hospital handled 4,039 service requests in 2024, achieving a closure rate of 98.61% by year-end, reflecting stable improvements in overall performance and quality.
The data center employs multi-layered protection measures, including access control, surveillance equipment, environmental monitoring, and fire suppression systems, incorporated into daily inspection routines. Core systems have offsite backups and automated backup mechanisms, with annual failover and data restoration tests conducted to ensure disaster recovery capability. Key business interruption drills were held twice in 2024.
To mitigate personal data leakage risks, the hospital implements anomaly access alerts, strict permission controls, and audit mechanisms. All staff are required to complete at least three hours of cybersecurity and personal data protection training annually. The anomaly access rate remains below 0.6%. Medical record access and usage are controlled according to the “Medical Record Confidentiality Guidelines” and “Personal Data Security Maintenance Plan,” supported by role-based authorization and audit trail systems. No information leakage, privacy breaches, or data loss incidents occurred in 2024.
Since 2010, the hospital has been ISO 27001 certified and completed the transition to ISO 27001:2022 in 2024. The certification scope covers all core systems such as HIS and PACS. The hospital also participates in H-SOC cybersecurity joint defense and H-ISAC intelligence sharing networks, enhancing cross-hospital response capabilities and real-time protection.
A robust information security and data protection system not only reduces operational risks and data breach incidents but also improves system availability and stability, optimizing data management processes and healthcare operational efficiency to ensure continued delivery of safe and efficient smart healthcare services.
Smart Healthcare Support
The hospital actively promotes smart healthcare transformation by collaborating across the IT department, clinical, and administrative units to develop integrated application systems that enhance patient safety, care quality, and organizational operational efficiency. Key achievements in 2024 information system integration include:
| No. | Theme | Highlights |
|---|---|---|
| 1 | Building Patient Safety-Oriented Systems | Implemented modules for incident reporting and drug interaction alerts, combined with app and SMS push notifications, delivering 2,200 monthly safety alerts. |
| 2 | Prototype Development to Enhance Cross-Department Collaboration | Adopted a prototype model with intensive collaboration with clinical departments, attracting visits and learning from National Taiwan University Hospital and Changhua Christian Hospital. |
| 3 | Strengthening Decision Support and Data Utilization | Built BI visualization dashboards integrated with National Health Insurance cloud data, enhancing real-time analysis and clinical decision support. |
| 4 | Optimizing System Maintenance and Service Quality | Established a maintenance platform handling 4,039 service requests in 2024, achieving a 98.61% closure rate. |
| 5 | Promoting Digital Learning and Knowledge Management | Offered 1,602 courses on the digital learning platform with 256,928 views in 2024, continuously fostering digital literacy and self-learning culture. |
| 6 | Supporting Public Health and Telemedicine | Executed the “Heping District Medical Payment Effectiveness Improvement Project” (IDS), serving 315 teleconsultation visits. |
| 7 | Advancing Electronic Medical Records and Data Exchange | Completed declarations of 277 electronic medical record items (about 97%), automated vaccine dose and interval checks, enhancing medication and vaccination safety. |
| 8 | Supporting Clinical Research and Innovative Applications | Built research systems and partnered with TriNetX; publications increased from 13 in 2023 to 31 in 2024, receiving national-level awards, demonstrating outstanding research achievements. |