The process of deriving the results of this qualitative study involved the incremental stages of description, analysis, and interpretation. The results of the word cloud visualization (Figure 1, 2, 3) and thematic analyses (Table 2) were described and interpreted with reference to theories explaining the use of medical care and previous studies.
(1) Frequency analysis and visualization by area
The content of five interviews conducted with 13 members of the National Participation Committee were divided into three areas: “Hospitals I would prefer to visit,” “Good doctors,” and “Preferred health care system.” A word cloud image was created to visualize words after frequency analysis.
The results of the first area, “Hospitals I would prefer to visit,” are shown in Figure 1. The most common word that appeared in this part of the interviews was “big” (12 times), followed in order by “patient” (8 times), “talk” (6 times), “person” (5 times), and “local” (5 times), accounting 18.8% of the total. The interviewees said that they used a nearby hospital for minor illnesses, but they preferred “big” hospital when they were seriously ill. Participants often did not know which hospital they should go to, but if a lot of other “people” used a certain hospital, they would perceive it as appropriate to go to that hospital. In addition, respondents wanted hospitals to be places that prioritized patients, provided patients a place to rest, and sincerely listened to patients.
In terms of physical accessibility, respondents stated that if people who live in the “countryside” have fewer options than those who live in S-city, which is why they often go to hospitals in S-city. For this reason, respondents indicated that the countryside was inadequate to live during old age or to have a second home such as a villa.
The second analyzed theme was “Good doctors,” and the results of the word cloud analysis are shown in Figure 2. In this theme, the most common extracted word was “kindness” (19 times), followed by “explanation” (17 times), “patient” (13 times), and “trust” (12 times). The four words accounted for 24.2% of the extracted words. These findings confirm that personal characteristics and qualities took precedence in the characteristics of a good doctor. In particular, the personal characteristic of “kindness” was desired, as well as the functional role of providing a detailed “explanation” to the patient and a relationship characterized by “trust.”
Finally, the results of the word cloud analysis of the desirable medical system are shown in Figure 3. The five most frequent words (“national,” “regulation,” “program,” “need,” and “benefit”) all appeared seven times, followed by “health insurance,” “benefit,” “linkage,” and “physician training system,” which appeared 5-6 times. These nine words accounted for 29.4% of the total.
Regarding the desirable medical system, the words “direction” and “values” were prominently expressed. It can be said that it is “necessary” for the “nation” to be more actively involved in the provision and management of medical services deemed essential, to “regulate” those services, and to provide practical “programs in the long-term perspective.” Opinions were divided regarding whether policies should be implemented universally or prioritize those who need benefits more urgently according to income and disease severity. No definitive conclusions on this issue were reached during the interviews.
As a practical and specific measure for the health care system, respondents hoped that health insurance coverage would be expanded. They also hoped that treatments carried out individually at each hospital would be integrated with each other. The interviewees felt that hospitals did not treat patients in an integrative manner, and one of the solutions they discussed was the primary healthcare system. If patients’ medical and family history could be incorporated into the primary healthcare system, it would be possible to provide linked treatment.
(2) Thematic analysis
- 1- A. Hospitals people would like to visit: An adventure to find new medical services
As respondents began to think that their symptoms were related to a disease, they sought new treatment methods or other hospitals. This process was like a patient or caregiver embarking upon a new adventure on their own in the absence of an appropriate guide. In order to minimize the risk, they thought that it would be much more reliable to visit a familiar or frequently used hospital. In the Korean medical system, the process of searching for information about hospitals is the responsibility of patients who are ill—that is, medical service users.
Some people went through the process of visiting hospitals near their residence, identifying the medical department related to their symptoms by guesswork, or remembering hospitals close to home. Those who prepared meticulously in advance pre-identified the hospital they wanted to use by scrutinizing the attitudes of medical staff and the flow of hospital services while visiting the hospital with their family members or acquaintances. In addition, participants became familiar with the names of specialized fields and information on specialized hospitals through the mass media, as well as learning about hospitals’ reputations and gathering anecdotal information from acquaintances. Many people also searched online for hospital-related information before going to the hospital, and the amount of information circulated through social networking services (SNS) has increased. Additionally, a service that provides outpatient appointments for tertiary hospitals has recently emerged.
1-A-a. Patients must have a high level of information acquisition.
As the internet and SNS have entered into widespread use, patients were able to obtain a large amount of information by searching blogs and personal websites before going to the hospital. A participant described spending three days and two nights looking for information while contemplating which hospital to visit due to her father-in-law's illness. The participant said that she could find detailed information about medical expenses, doctors’ reputations, and hospital equipment through internet searches. However, the information obtained in this way is limited because it is not generally applicable, since each patient is unique in terms of disease progression and the conditions for which they receive treatment.
"Last year, one of my relatives had a severe illness—cancer—so I could feel it my bones for the first time in my life. I didn't have anyone who had cancer on my mother’s or my father’s side of the family. I didn't know anything about it because it was my first time seeing it. First, I had to find a hospital, so I went online for two nights and three days, then I was able to find all the information; the most experienced doctor in surgery, the most trusted hospital, the duration of waiting time, which steps to take to get admitted, all of this information was all over the internet.” (Interview participant #13, Female, 50s)
1-A-b. Large hospitals require a personal connection to make an appointment
The interviewees expressed that if they thought they would eventually need to go to a tertiary general hospital for treatment due to painful symptoms, visiting a large hospital in the first place would ultimately save time and money. In other words, if presenting to a small hospital for treatment is likely to result in a referral to a large hospital, it would be better to save time and money by directly going to a larger hospital upon first recognizing their symptoms.
“If you go to a small hospital, they tell you to go to a bigger hospital. You end up going to a university hospital. It is exhausting and I spend all my money and time. I think it’s better just to go to a big hospital in the first place (Interview participant #9, Male, 50s)"
Respondents living in the provinces said that they felt the difference in the quality of medical services provided by the major metropolitan area and local small and medium hospitals. They also believed that there were differences in diagnostic and treatment methods between large hospitals in the major metropolitan area and small and medium-sized hospitals in provincial areas even for the same disease. For the interviewees, the high quality of medical services was an important selection criterion that went beyond geographical accessibility and economic affordability. They said that one of the reasons they were reluctant to live in a rural area was because they were worried about not being able to receive treatment immediately if they became ill.
The most reliable hospitals in Korea are concentrated in the major metropolitan area, and as these tertiary hospitals have famous professors and medical staff in each department. However, it is difficult to make an outpatient appointment at a large hospital and the waiting period is long; thus, participants reported using the strategy of personally asking a hospital employee whom one knows through relatives to make an appointment.
The life insurance products provided by private companies now include a service that makes outpatient appointments at tertiary hospitals if a special contract is added at the time of subscription. If a specific disease is suspected, these services say that they would make an appointment for patients in a snap, giving them the option of making an outpatient appointment at three or four hospitals. Participants thought that it was not a loss to sign up for these services because they could receive substantial benefits even if they paid additional money. In fact, the participant who used the outpatient appointment service was ill, but said that this service, which was recommended by an insurance company, would provide substantial comfort.
“Even though it was difficult to make an appointment at a big hospital, it seemed that there was a system or a contact network that could do this right away within a few days. It seemed like there were a few seats saved for one life insurance company. The system was connected between a big hospital and a life insurance company. (Interview participant #13, Female, 50s)
1-B. Hospitals people would prefer to visit: The main hospital selection criteria
The main hospital selection criteria, such as accessibility, affordability, and quality, were indeed important criteria that the interviewees considered. In case of an emergency, participants hoped to go to a hospital that was geographically close and could be expected to respond quickly. Regarding terms of availability, it was possible to find out about “acquaintances” through hospital staff or the availability of price discounts. In addition, there was a tendency to seek tertiary hospitals or specialized hospitals that specialize in specific departments for diseases with a high degree of severity.
When participants did not have any hospital information, they went to a hospital where many other people went, or to a hospital equipped with cutting-edge facilities and equipment. Numerous factors were involved in the process of choosing a hospital.
1-B-a. More people flocking to crowded hospitals
An interviewee stated that when choosing a hospital, just like what occurs with trendy restaurants that have long lines, if many other people use a hospital, it seems that they must have a reason for doing so, so that others follow along even without knowing the exact reason. It seems that the larger the hospital, especially if it is considered to be a high-quality institution, the more crowded the hospital will be, and the more patients wait to be seen, the more patients will have a psychological expectation that there will be something worth waiting for at the hospital. In other words, even if the waiting time is long, the presence of many patients in the waiting room elicited a certain degree of trust. However, this tendency disproves the argument that there are few opportunities to obtain actual information about the hospital.
"So, I thought about why people are like that… You know those restaurants where people stand in line for a long time, and it’s not even delicious (laughs), but they still go and eat. They all stand in line because they expect something good while they’re waiting in line (Interview participant #12, Male, 50s)."
1-B-b. Fascinated by state-of-the-art facilities and equipment
Respondents stated that when large-scale capital had been invested and they encountered a large hospital with good facilities, such as advanced medical equipment, they expected that the hospital facilities and equipment would be rigorously managed. They said that seeing advanced medical equipment is a reminder that the hospital is well-managed. In contrast, if they encountered an old and discolored machine that had been used for more than ten years, they would doubt that disinfection procedures will be properly performed in the hospital.
“Usually, the good facilities are kept clean. Because they pour a lot of money into it. Who wouldn’t take care of it, because they have all fancy medical equipment? They’re trying to use it for a long time, I think all of the parts of management are linked together” (Interview participant #1, Female, 20s).
Since a short amount of time is spent interviewing the patient or performing a physical examination, and treatment is chosen based on blood tests and imaging, patients also focused on how the test results were obtained and whether the test was up-to-date to ensure credibility. This concern is reflected by the fact that the selection criteria also depended on the performance of the diagnostic modalities.
1-B-c. Last hope for a reputable hospital
The interviewees stated that they would like to receive treatment at a tertiary hospital if they had enough money and were given the opportunity to receive treatment. This reflected the earnest desire to solve the basic dilemma of living at the crossroads of death and life brought about by disease, rather than a simple desire for the best treatment in a state of severe disease. Rooted in their basic desire to live for themselves and their family, there was an expectation that a high-level general hospital in major metropolitan area like as S-city would provide excellent treatment, unlike other hospitals.
Respondents wanted to hold onto a thread of hope that, if they were diagnosed with a serious disease, they would be able to try innovative treatments by finding a hospital that provides leading treatment through clinical research. However, they also replied that they would be able to accept the judgment that treatment was impossible if the decision was made at a hospital considered to be among the best in the country. It was thought that patients’ treatment depended on the ability of each medical staff member to practice medicine and the systematic management of a tertiary hospital.
“If you are financially capable, then who wouldn’t want to go to a big hospital? First of all, money is important, but if their kid is sick, even if they don't have money, they all try to go to a big hospital. Trying everything that they could. If the best-known hospital says there’s nothing they could do, then they’ll accept the call." (Interview participant 11, Male, 50s)."
Although the medicine is advancing rapidly, research-oriented hospitals that can make new treatment attempts by combining cutting-edge medicine or the latest medical technology are considered to offer the best treatment in the current situation, with existing limitations.
2. Good doctors: The ideal medical team
The interviewees hoped that doctors would have professionalism in the clinical field. They hoped that doctors would be trained in a systematic education system and provide sufficient explanations to patients based on their expertise. They also hoped that based on regular treatment with a doctor with appropriate character, the patient could take the initiative in receiving treatment for a sufficient period of time and discuss the treatment directions to ultimately decide upon the optimal path forward.
2-a. Professional qualifications: The University where the doctor graduated from and major hospital experience form the basis for trust
The interviewees expected doctors to be human figures, while still having the expertise formed by performing treatment for many years based on their medical expertise and encountering various patient cases. In Korea, from the interviewees’ perspective, a “professional” referred to a doctor with a university diploma displayed inside the hospital and experience in a large hospital. The presence of a doctor’s name on a diploma from a prestigious university gave confidence in the fact that he/she was a specialist and that he/she would have a sense of personal vocation.
Most of all, doctors were expected to accept patients as individuals with their own consciousness and decision-making rights and participate in a common decision-making process by accurately conveying medical explanations about the patient's current condition. If a detailed explanation is provided using videos, images, or other modalities to explain why symptoms occur due to the current disease, anxiety disappears and the patient feels reassured. A doctor who provides reliable guidance on future treatment directions and accepts the family’s opinions when making quick judgments in critical situations embodies as a good doctor.
2-b. Personality: Ensuring the patient’s choice based on a mutual bond
The interviewees wanted doctors to move away from clerical and insincere attitudes when dealing with patients, to empathize with patients, and to build mutual trust. They hoped to form a long-term, close relationship with the doctor by meeting them several times a year at intervals of a month or more so that they could actively inform the doctor about changes in their condition and discuss those changes. Even beyond consultations related to specific disease-related conditions, respondents felt that regular visits with taking care of patient’s recent affairs would help reduce the psychological distance between the doctor and the patient.
In order to build a trusting relationship and familiarity with each other, respondents expressed that regular appointments would be necessary. If the doctor was already familiar with the patient's personal or family history, they expected to receive appropriate treatment. The interviewees said that, if a primary care physician or dedicated physician system, which is not present in Korea, is established, the inconveniences caused by redundant examinations, history-taking, reviews of current symptoms during the first visit to a medical institution, misunderstandings, and incorrect prescriptions arising from a lack of understanding of patients’ circumstances would disappear.
"Of course, a doctor who explains well is a good doctor. And a doctor who performs surgery quickly is also a good doctor, but in an emergency situation, making judgments quickly is important so that the guardians can make a quick decision. And a doctor who respects the guardian’s opinion is also good in my view. I don't know if you've experienced it before, but there aren't many doctors who explain it well. Most of the explanations are given by the nurses, or doctors only explain about the costly procedures that they want to perform. After the explanation of the procedures, if it feels like excessive care from the perspective of a patient or guardian, I don’t want it. So, if I say that I will think about it, I felt like I was pushed away. Once the doctor told me that I needed an MRI, I told him that I had paid for an MRI from the last hospital and didn’t understand why I need another MRI. Then the doctor told me to go to the last hospital to get treatment.” (Interview participant #4, Female, 40s)
Furthermore, when patients visited a hospital, they felt that it was inappropriate for the doctor to just prescribe medication. They expressed their desire to return to the hospital and receive treatment from the doctor again, with examples including manual blood pressure measurements or simple procedures such as nasal irrigation.
The interviewees said that they lost trust in medical staff when they came across media information about poor ethical behavior, including sexual assault and overtreatment by medical staff. In the interviews, respondents expressed a need for regulations that ensure character qualifications for medical personnel who directly deal with the human body. They also described their own needs and suggested practical policies. They proposed an entrance exam system requiring a personality test for final admission in addition to the evaluation of college entrance exam scores when applying to medical school. Furthermore, they recommended introducing a retirement age system, prohibiting doctors from serving when they cannot accept the latest medical knowledge or their memory is poor.
“Is there some kind of regulatory system like the medical retirement system? As long as the doctor has the ability to properly care for the patient, he or she can continue to treat the patient. However, I wish the regulations were strengthened when the doctors were not able to treat patients.” (Interview participant #3, Female, 50s)
The interview participants hoped to have a relationship where doctors make eye contact and acknowledge the patient's existence. They said that the qualifications of the future artificial intelligence era are kindness and listening, which means that doctors are in the service industry. The interviewee had high expectations for doctors. The “human” attribute expected of doctors is added to the sense of ethics, morality, and sense of duty represented by the Hippocratic Oath, and when discussing the personality of a doctor, there are interview participants who compared a doctor to a “saint.”
3-A. A desirable medical system: Discomfort under the current medical system
3-A-a. The journey to find the correct diagnosis
Interviewees had experiences of having to visit various hospitals or departments to find the correct diagnosis for their symptoms. Male interviewees in their mid-50s said that it is necessary to visit at least three hospitals in the vicinity to know the exact diagnosis. One of the interview participants went to her usual obstetrics and gynecology office due to stomach pain, and the obstetrician found that it was not a gynecological problem, but could not find the cause of the stomach pain. Despite the fact that she had recently visited a developing country in Southeast Asia, she spent a long time waiting for a diagnosis as she continued testing, even though it was a diagnosis that could be easily made.
“My right belly hurt, so I went to the obstetrics and gynecology clinic for medical treatment, because it was where I had my regular examinations. They did an ultrasound and kept pressing it and told me that nothing was wrong. It was really hurting… They told me if I was really concerned I should go see a general surgeon. So, I did, next thing I know I was hospitalized for appendicitis.” (Interview participant #10, Female, 20s).
If a patient does not have a disease that is mainly diagnosed in a specific department, there are many cases in which a drug is prescribed only as a temporary measure without specific guidance, instructions, or a diagnosis suitable for their symptoms. Another participant stated that bleeding continued after defecation, so she went to the obstetrics and gynecology clinic and the internal medicine department for various tests, including endoscopy.
3-A-b. Hopeless waiting
Interviewees said that they experienced a situation where they were not welcomed by the medical staff, and did not receive a prompt response even when they arrived at the hospital emergency room in a situation where their symptoms were emergent. One interviewee said that she went to the emergency room for acute hepatitis and acute appendicitis, but after the busy medical staff did not pay attention to his symptoms or respond at all, she was eventually transferred to another hospital for treatment. However, she said that even at the transferred hospital, it took a long time from undergoing a test to receiving its results, so the time to receive the diagnosis felt long. From the point of view of the sick patient, he said that the waiting time felt very long.
“I was so sick, sweating, but a medical staff just told me that I had to wait without any advice or decision. I had to sit and wait for another hour. I think waiting was difficult.” (Interview participant #10, Female, 20s)
3-A-c. Getting used to the view of patients as a revenue source
Hospital is a legal non-profit organization, but the hospital director, who has to operate the facility, is expected to seek profits. Therefore, market principles such as revenue generation are applied in hospital settings. Consumers who use hospitals are also aware of this view, and if new drugs are prescribed or additional tests are carried out, they immediately whether it is over-care. The interviewees said the main focus when deciding treatment was on whether the patient would agree to undergo treatment or the treatment would earn money from the hospital's perspective, rather than on promoting full recovery.
“I get used to it by thinking "It's just people who do business." I think to myself that this is unfair and why is it all such a high price? But then, all the medical equipment is brand new, the hospital is located in a downtown area, and the doctor’s profile is all fancy, then it's a way to get a little more money… and they hire one or two more employees… um…. If you’re doing business in the neighborhood, then the doctor might not need more employees. I asked them why is the price different from this clinic and others, the doctor would just tell me that the manufacturing company is different…. the material is different. Honestly, I've never heard of an explanation of why the price is so expensive. The hospital staff just ask “Are you just going to receive the treatment in here [my hospital] Or not?” and that’s it! They only care about whether if the patients get a medical procedure in their hospital or not.” (Interview participant #1, Female, 20s)
3-B. A desirable healthcare system: A harsh response within the current system
3-B-a. Turn to silence
When going to the hospital to see a doctor, patients thought that they should refrain from speaking excessively because they could be misunderstood as challenging the authority of medical professionals if they speak their opinions hastily. Patients suffering from physical symptoms, even if they have suspected or predicted disease names, are concerned about the possibility of intruding on medical personnel's territory, which could lead to unpleasantness. Thus, due to fear of hurt feelings, they did not talk to the doctor about the condition they were concerned about and instead quietly searched the internet before and after treatment or talked with people around them. Participants described a situation in which expressing knowledge of health care as an ordinary person or as a non-medical person is actually a disadvantage for receiving care.
"I can't talk enough when I see a doctor – they are supposed to listen to my words and give me additional explanations, but when I visit doctors, doctors are like, "we are specialists, and the patients are not." I had pain in my ear and I thought that I had otitis media- But, we can't mention that I might have otitis media. It’s like, why otitis media should be diagnosed by the doctor, who are you to make the call? - So, I have to keep quiet when I meet the doctor. When I say, "I think it is -," they say something. “Why don’t you be the doctor here?” It's harsh.” (Participant 11, Male, 50s)
3-B-b. Treatment that the patient chooses arbitrarily
In one hospital, the medical departments were divided into sections, so that patients had to choose which department to visit based on their symptoms, and the institution did not provide integrated care for the disease.
Interview participant #13 visited orthopedic clinics and received only X-ray tests, which are considered necessary, although she preferred to receive medical treatment from an oriental medical clinic for back pain. The interviewee said that she visits orthopedic clinics only to see if there are any remarkable abnormalities in her bones, and that she has decided not to receive orthopedic physical therapy for a condition that was not treatable. Instead, she hoped to receive treatment for back pain from an oriental medicine clinic. The patient dealt with her disease in an integrated way by arbitrarily and selectively receiving care that she thought was necessary.
“Last week, I went to the nearest hospital to see an orthopedic surgeon, and then I went to have an X-ray to see that there was nothing wrong with my bones. I went there only to get an X-ray. After checking that there were no problems with the bones, I immediately went to the oriental clinic (laughs), I went to the oriental clinic and received treatment for a week last week because I don’t need to drag it for a long time.” (Interview participant #13, Female, 50s)
3-C. A desirable healthcare system: Utopia
3-C-a. Attempt to induce doctors to provide essential and basic care
The interviewees stated that they perceived qualitative and quantitative differences in medical care between S-city and the provincial areas are largely different, and that it is difficult to expect this gap to be reduced even though people pay the same insurance premiums nationwide. However, respondents believed that the medical gap between local areas and major metropolitan area s, such as S-city could be resolved through government regulations self-originated solutions from within the medical profession.
"The gap between local and major metropolitan area s is something that even the president of this country can't solve. This is an avoidable phenomenon, but from the doctor's view, it seems that some regulations should be followed by doing an aptitude test or something like that.” (Interview participant, Female, 50s)
Many medical practitioners prefer to go into the fields of dermatology and plastic surgery, which do not always directly involve life-threatening conditions, and medical students are reluctant to perform essential surgeries in urgent situations such as heart disease and severe trauma. The interviewees agreed that active incentives and regulations should be tried to encourage medical staff to work at clinics that provide essential services (e.g., cardiothoracic departments) and to increase the distribution of talented personnel in local areas.
3-c-b. Equal use of medical care regardless of power and wealth
The interviewees expressed that patients should not receive care according to their power or wealth; instead, they should choose hospitals based on the guidelines and receive appropriate medical treatment according to their condition.
Respondents hoped that it would be possible to implement a structure wherein a single clinician could consistently handle the healthcare and welfare needs that arise as a person grows older. In the current medical system, doctors who provide longitudinal primary care are specialists that only a few wealthy people can enjoy. Instead, participants hoped to have a designated primary care physician who would provide care from birth to old age and refer patients to specialists as necessary.
“People like me don't have a consultant, a doctor who knows... I thoroughly looked for them, but couldn't find them. (Interview participant #8, Male, 50s)
Interviewees said they would not visit the public health centers that have been established nationwide. They perceived the doctors employed at public health centers less reliable since they have relatively little experience and are more strongly aware of their role as administrative agencies in carrying out administrative work. In addition, participants perceived the health checkups provided every other year through the Health Insurance Corporation as unnecessary since they only provided minimal and simple medical services. Considering an interviewee’s age group and genetic risk factors, she had to apply for additional tests such as endoscopy and ultrasound; thus, she went to the hospital only when she felt that it was necessary.
People who pay health insurance premiums want medical services to be provided to those who absolutely need them, but when they feel that they are being wasted, they complain about the unnecessary waste of money. One of the interviewees hoped that a powerful government would actively intervene to adjust the prices of hospital health services using economies of scale, allowing people to benefit. He expressed his willingness to pay public insurance fees if he believed that it would be equally effective as private insurance.
"Then if I pay 10,000 won [$10] here, I can get a bigger benefit if I pay 10,000 won here. Because the NHS can attract more people - even if you sign a contract with S-university, you can lower the 10,000 won bill to 5,000 won. That's why it's possible. But I paid 500,000 won, but I don't have to do it if I get benefits here and there, and if the person who walks in gets benefits, I don't have to do it. I paid for Korean health insurance to get fast and speedy treatment. It's a matter for health insurance to think about. Before we run out of health insurance, the private insurance company is making a living. If the money goes up a lot, the public will get a lot of money. If the money goes up, the people will get a lot of money. If it comes out, they can give other benefits to ordinary people. We actually invested 500,000 won, but we were treated more than that, and with that extra money, we could afford to give aid to the lower class again.” (Interview participant #9, Male, 50s)
In wasting unnecessary medical expenses for so-called "Nylon [fake]" patients; Patients admitted to the hospital for insurance reimbursement even though the actual injury is not serious, the interviewees thought that small groups were more problematic because of the loopholes in the system, which are bound to exist everywhere. In their opinion, the system could not improve without reflecting the opinions of the people themselves, and a desirable medical system could be properly established only when the people's consciousness matured. Nevertheless, it would be necessary to anticipate specific factors that could cause this moral hazard before proposing a policy and to closely evaluate the side effects of the policy.
3-c-c. Control mechanisms of medical institutions themselves
The interviewees thought that along with the government's efforts, hospitals should also make efforts to reform themselves. They thought that clinicians could change their attitudes and improve the quality of health care by educating themselves on protocols. Participants clearly articulated the idea that the hospital staff was kind because of the well-established hospital education system. They thought that the quality of a hospital could be ensured only if the hospital itself had the ability to collect and reflect patients' opinions.