The Tertiary Hospital Restructuring Project in South Korea: A Reflexive Thematic Analysis of Hospital Directors' Perspectives on Barriers and Policy Recommendations.

Background: In September 2024, South Korea launched a nationwide Tertiary Hospital Restructuring Project to refocus tertiary hospitals on severe, emergency, and rare disease care, amid a tertiary care system long burdened by patient concentration and acutely strained by the mass resignation of trainee doctors. In the early phase of implementation, understanding how the decision-makers who translate policy into institutional change perceive the project is essential. Methods: We employed a qualitative design using reflexive thematic analysis. Semi-structured, in-depth interviews were conducted with directors from five tertiary hospitals-four in the capital area and one in a non-capital area-selected through purposive sampling. Interviews were conducted between 30 October and 7 November 2025, transcribed verbatim, and analyzed following the six-phase approach of Braun and Clarke. Results: Four themes were constructed. First, directors described the project as catalyzing a cultural shift toward a high-severity-centered model, though contested at the departmental level. Second, a severity paradox emerged, in which treating sicker patients worsened profitability while large restructuring costs strained sustainability. Third, referral networks expanded but were constrained by the absence of an integrated information technology (IT) system across the referral network. Fourth, a specialist- and physician assistant (PA)-centered workforce model stabilized care yet remained institutionally unsettled. Participants recommended refined severity criteria, complexity-based reimbursement, a legal framework for PAs, an integrated IT referral system, and network-based training. Conclusions: As perceived by the participating directors, the project reshaped organizational culture and clinical case-mix, but its long-term viability depends on financial, infrastructural, and workforce supports that have not kept pace with structural change. Sustaining the reform will likely require a shift from competition toward a collaborative, region-centered network.