2.3 Regulatory compliance

Amid increasingly stringent regulatory oversight and growing demands for sustainable governance in the public healthcare system, Taichung Armed Forces General Hospital positions “regulatory compliance” as the cornerstone of its governance framework. By implementing institutionalized, procedural, and data-driven management mechanisms, the hospital comprehensively strengthens its execution in integrity, ethics, risk control, and compliance supervision. This approach ensures that medical services, administrative operations, and resource allocation adhere to national laws, military medical system regulations, and international governance principles, while continuously enhancing organizational transparency and public trust.

The hospital’s regulatory compliance governance framework is centered on the Supervisory Office, which serves as the primary oversight unit responsible for coordinating key functions such as internal control systems, compliance audits, integrity risk assessments, and investigations of irregular incidents throughout the hospital. Adhering to the governance philosophy of “prevention over audit,” the Supervisory Office not only conducts regular and ad hoc audits but also employs a risk-based management approach to focus monitoring and system optimization on high-risk operational areas—such as procurement, medical billing, contract management, and resource allocation—thereby establishing a proactive internal control management structure. Through this mechanism, the hospital can issue early warnings and implement improvements before risks materialize, reducing the likelihood of violations and misconduct.

Regarding regulatory compliance

The hospital strictly adheres to key integrity laws, such as the Act on Avoidance of Conflicts of Interest for Public Servants and the Whistleblower Protection Act, implementing these requirements through concrete internal control systems and operational procedures. For example, in managing conflicts of interest, a comprehensive, full-process mechanism covering declaration, review, and follow-up has been established to ensure that all personnel involved in decision-making or resource allocation disclose potential conflicts of interest in accordance with the law and appropriately recuse themselves. Regarding whistleblowing, multiple confidential reporting channels have been established, supported by legal protection mechanisms that fully safeguard the identity and rights of whistleblowers, thereby further enhancing internal supervisory capacity.

In terms of execution effectiveness

In 2025, the hospital reported no cases of violations related to integrity, ethics, or relevant laws, nor any financial losses or legal liabilities resulting from medical fraud or misconduct. This outcome demonstrates that the hospital has developed a highly mature and stable compliance management system encompassing system design, internal controls, and employee behavior management. It has effectively implemented a three-stage governance mechanism: prevention before the fact, control during the process, and follow-up after the fact.

Regarding the asset declaration system

The hospital complies with the Property Declaration Act for Public Servants, which mandates that all commanding officers, deputy commanding officers, and supervisors at the rank of colonel and above adhere to the declaration regulations and procedures to ensure institutional transparency regarding assets and disclosure of interests. In 2025, 28 personnel were required to submit declarations, and all 28 completed them, achieving a 100% compliance rate. This outstanding achievement not only reflects the rigor of the system’s implementation but also demonstrates colleagues’ strong cooperation and commitment to integrity regulations. Through regular declarations, spot checks, and anomaly analyses, the hospital effectively identifies potential risks and promptly addresses them, further enhancing financial transparency and strengthening the foundation of organizational integrity.

To strengthen the culture of integrity, the hospital employs a multi-level promotion strategy that extends clean governance from institutional frameworks to organizational culture. In addition to conducting integrity promotion activities during festive periods, the hospital actively establishes positive incentive mechanisms by publicly recognizing exemplary acts of integrity, thereby enhancing colleagues’ appreciation for and commitment to the value of honesty. Furthermore, colleagues are encouraged to refuse gifts and improper benefits that exceed social etiquette standards. An integrity ethics incident registration form is used to establish reporting and recording mechanisms, fostering integrity and cultivating a culture where “self-discipline surpasses external regulation.”

In human resource management, as well as in education and training

The hospital integrates regulatory compliance and ethical integrity into mandatory courses for new employees. All new staff are required to sign a conflict of interest avoidance declaration upon onboarding and to participate in systematic legal education and training. In 2025, a total of 93 training sessions were conducted, covering fundamental principles of regulatory compliance, identification of integrity risks, practical management of conflicts of interest, and case analysis. By combining theoretical knowledge with practical application, the training enhances employees’ understanding and implementation of compliance measures. Additionally, the hospital continues to provide on-the-job education and special lectures to ensure that compliance concepts are continuously updated in accordance with regulatory changes and evolving environmental factors.

Overall

The hospital has established a multi-layered regulatory compliance and integrity governance system that integrates system design, internal controls, education and training, and cultural promotion. Through the dedicated supervisory mechanism of the Supervisory Office and cross-departmental collaboration, it ensures that all compliance requirements are effectively implemented in core medical and administrative processes. This governance model not only meets the core requirements of the “Governance (G)” aspect in international ESG frameworks but also addresses the public sector’s high expectations for transparent governance and integrity management.

Looking ahead, the hospital will continue to advance the cultivation of a strong integrity culture and foster innovation in compliance education. This approach aims to transform regulatory compliance from a mere system requirement into a core value and behavioral norm embraced by all staff, thereby supporting the long-term stability and sustainable competitiveness of the medical system.

Explanation and Improvement Measures Concerning Regulatory Violations at the Hospital in 2025

Category of Disposition	Type	Number of Cases	Description of Violated Regulations	Content of Disposition	Improvement Measures
Penalty Fine Incident	Publicly Funded Vaccine Compensation	1 Case	Due to human error causing the loss of publicly funded vaccines, the Health Bureau requires our hospital to compensate for the loss at the original price according to the compensation level for damaged publicly funded vaccines.	A fine of NT$1,060 has been imposed.	1. The vaccine assessment form has been revised to include arrow indicators, making the vaccination items more intuitive. 2. Strengthened promotion to ensure thorough verification of vaccination history and adherence to the “three checks and five rights” during vaccination.
	Insufficient Employment of Persons with Disabilities	2 cases	Article 38, Paragraph 1 of the Protection Act for Persons with Disabilities: The number of employed persons with disabilities did not meet the legally required quota.	Total fine: NT$57,180	The legally required number of employed persons with disabilities was met on September 15, 2025.