An exploration of the organizational performance of a care pathway applied to ambulatory surgery: a systems approach

Abstract

Background

Ambulatory surgery is experiencing significant growth in France and OECD countries, accompanied by a profound transformation of care pathways. Existing performance evaluation approaches remain fragmented, limited to a single dimension, an isolated segment of the pathway, or the perspective of a single category of stakeholders. A systemic and multidimensional approach, grounded in real-world practices, is lacking.

Objective

As part of research aimed at developing a framework for evaluating the organizational performance of care pathways in ambulatory surgery, the primary objective of this study was to identify the dimensions and sub-dimensions of this performance, and then to explore their interactions within a systemic approach.

Method

A qualitative study using non-participant observation was conducted in nine French healthcare facilities (public and private, with varied organizational models), covering the entire in-hospital pathway. The observations utilized three analytical perspectives: the facility, patients and their pathways, and professional practices. The data were analyzed using an inductive approach inspired by grounded theory (descriptive, axial, and matrix coding), with double coding and thematic saturation achieved at the seventh facility.

Results

The analysis identified 103 codes, grouped into 24 sub-dimensions and then synthesized into five dimensions of organizational performance: flow management, working conditions, professional–patient communication, clinical outcomes, and patient experience/satisfaction. No sub-dimension contributes to only a single dimension; the sub-dimensions are part of an interdependent system. Some emerge as priority cross-cutting levers, notably the quality of the professional-patient relationship (N = 544), the organization of the in-hospital pathway (N = 365), and the information provided to the patient (N = 457).

Conclusions

This research provides an empirical basis for the development of a multidimensional evaluation framework that can be applied to other healthcare systems and used to develop performance evaluation tools at both the institutional level and the macro level by regulators.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-14985-2.

Background

Ambulatory surgery (AS), defined by the International Association for Ambulatory Surgery [1] as “all surgical or investigative procedures scheduled and performed under the technical safety conditions of an operating room, under variable anesthesia, and allowing the patient to be discharged on the same day as their admission,” has grown significantly in recent years, particularly in OECD [2–3].

In a context where health policies encourage the development of ambulatory surgery, organizational performance is a major challenge for policymakers and healthcare facility managers. Indeed, the expansion of these outpatient care services implies extending this practice to more complex procedures, as well as broadening the target population [1, 4–5]. This results in a transformation of care pathway organization, requiring enhanced coordination between healthcare facilities and community care providers, given the strict time constraints inherent for inpatient stays of fewer than twenty-three hours. These changes and the specific coordination needs of an ambulatory surgical care pathway require a better understanding of the factors that contribute to the organizational performance of these care pathways [6].

The evaluation of healthcare system performance is generally presented as requiring a multidimensional approach that integrates clinical, organizational, and economic dimensions, among others [7]. Researchers have proposed models to analyze healthcare organization performance, such as the Balanced Scorecard applied to the hospital sector [8–9] or the EGIPSS model [10]. However, these models are primarily designed to evaluate performance at the level of a healthcare system or a single facility. They are most often based on indicator systems defined from institutional or managerial perspectives. Finally, they do not specifically allow for an understanding of the organizational performance of a care pathway, which involves interactions and coordination mechanisms between different actors and segments of the pathway [11].

However, the literature [12] highlights the great heterogeneity of existing evaluation approaches, the lack of consensus on performance dimensions, and their fragmented perspective. These are often addressed from perspectives limited to certain actors in the healthcare system, particularly payers or managers [13], without incorporating a comprehensive view that includes the patient experience. While many studies focus on evaluating efficiency and clinical outcomes defined by the healthcare system—such as complication rates or readmission rates [5, 14–17], the literature remains more limited regarding outcomes defined from the patient’s perspective, particularly in terms of satisfaction and quality of life [5], as well as organizational dimensions [11, 18–19]. These approaches thus tend to prioritize the assessment of financial impacts and certain clinical impacts, at the expense of human and social dimensions.

From this perspective, it seems necessary to supplement the study of organizational performance with a less fragmented and more systemic vision, adopting different points of view. Within the broader context of research aimed, in the long term, at proposing a new framework for evaluating the organizational performance of an ambulatory surgical care pathway, the main objective of this study was to explore the interactions between dimensions and sub-dimensions of performance after identifying them.

New contributions

This research makes several contributions to the study of organizational performance in ambulatory surgical pathways.

Conceptually, it proposes a systemic approach to performance, viewing performance as a system of interdependent dimensions and sub-dimensions.

Methodologically, it adopts an inductive approach based on direct observation of practices and interactions among actors in various organizational contexts. This approach grounds the identification of performance dimensions in real-world practice rather than relying on predefined indicators.

Empirically, it enables the identification of cross-cutting organizational levers capable of influencing multiple dimensions of performance. These findings provide useful analytical insights to guide the organizational decisions of frontline teams, managers, and leadership, by highlighting action points likely to produce multidimensional effects on the performance of care pathways.

Methods

This qualitative study was conducted in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) criteria [20] to ensure transparency of the research process. The complete checklist (item-by item responses) is provided in Additional file 1.

This study is grounded in a constructivist epistemological position, considering that organizational performance is not a single objective reality but is constructed through care practices and interactions among actors [21–23]. From this perspective, accessing this constructed reality requires observing situations in their natural context and capturing interactions as they occur. The study thus relies on non-participant direct observation within French healthcare facilities performing ambulatory surgery. The choice of direct observation was justified by the desire to understand organizational performance in real-life care situations, as this method enables systematic documentation of professional practices, actor interactions, and coordination mechanisms that structure the organization of care pathways—elements that are difficult to access through other methods.

Study setting

The study was conducted in nine French healthcare facilities, selected using a purposive sampling method designed to include a variety of organizational contexts [24], particularly in terms of geographic location, size, legal status, and organizational models for ambulatory surgery (integrated, autonomous, satellite, or independent). These facilities thus reflect the diversity of French hospital settings.

The selected healthcare facilities were contacted by email (nursing management or department managers), an agreement was formalized with each facility’s management and the research team. The researcher briefly explained the research objectives to the teams in the facility departments.

Scope of the observations

The observation combined three analytical perspectives: the facility, the patients and their care pathways, and professional practices within the hospital setting, ranging from preoperative consultations through to follow-up the day after ambulatory surgery. Patients were followed through the various care areas: administrative check-in, medical consultations, nurse consultation regarding their care pathway, admission and setup in the Ambulatory Surgery Unit (ASU), operating room, recovery room, monitoring within the ASU, and postoperative consultations. The third component focused on professional practices, defined as the totality of observable practices of professionals involved in patient care throughout the care pathway. These practices include both technical elements (performance of care procedures, application of protocols) and relational elements (interactions with patients, coordination and communication among professionals).

The observer was also able to accompany the professionals at their workstations during the various stages of the care pathway.

Study population

To capture the diversity of care situations encountered in these units, we included all patients treated in the ambulatory surgery unit, regardless of procedure type. Only two exclusion criteria were defined: age < 18 years and being subject to a protective measure (guardianship).

Data collection methods

The observation took place for one week (5 working days) per facility between November 2021 and December 2023 (details of the observation week, item 21 of the COREQ grid).

Non-participant observation [25], based exclusively on direct observations [26] with handwritten notes, without video recordings, was carried out by a single researcher, a healthcare professional not practicing in ambulatory surgery. The observer had no prior connection to the facilities or the professionals being observed. The absence of a prior relationship with observed individuals is a feature of the observation context, accounted for in the analysis of data production conditions.

The observer’s interactions with patients and professional were limited but considered part of the data production conditions and were the subject of reflexive attention during the analysis. Teamwork, organizational conditions, and training practice were examined through the observation of interactions among professionals, coordination methods between departments, work situations observed within the units, and informal exchanges among professionals during the observation periods.

From a constructivist perspective, data production is considered the result of an interaction between the researcher and the field, subject to a reflexive approach throughout the research process.

Observation grid

The observation was based on a structured grid (presented in Additional file 2), developed from a literature review and validated international tools (AEDET, Algoplus, Calgary Cambridge Guide, GPPS, etc.). It focused on architecture, patient flows, human and material resources, communication, as well as pain and stress management. The observation grid was completed for each field observation and guided the collection of data in the field. It served as a structuring framework for recording elements related to the facility’s organization, patient pathways, and observed professional practices. However, it remained flexible throughout the fieldwork, allowing the process to be enriched through a dynamic approach combining inductive and deductive reasoning. Certain elements were adjusted or clarified as observations progressed. For example, a free-form section dedicated to interactions between stakeholders was added, as the initial table on behavior and communication did not allow for the inclusion of all professionals involved in the care pathway.

In addition, unstructured observation (“floating observation” [27]), complemented this data collection with emerging, unanticipated elements, particularly during informal meetings or crisis situations. Furthermore, reflective notes helped contextualize the observations made. These elements were recorded in the observation journals and integrated into the corpus analyzed during the thematic analysis.

The constructivist epistemological approach guided the use of in situ observation as well as an inductive analysis strategy inspired by grounded theory [28], allowing the dimensions of performance to emerge gradually from the empirical data.

Data processing and analysis

Data processing and analysis relied on an inductive analysis inspired by grounded theory.

The information collected using the grid was integrated with the observation logs and analyzed jointly with the notes from the floating observations as part of thematic analysis. The reflective notes recorded during fieldwork informed the analysis process and analytical discussions within the research team.

A thematic content analysis [29] of the observation logs was carried out using NVivo software by the observer and other members of the research team. Regular meetings were held to ensure coding with a double-coding process, with discrepancies discussed until consensus was reached among the three researchers. The analysis was based on an iterative process involving several coding phases and regular discussions within the research team to compare interpretations and minimize the risk of confirmation bias in the construction of analytical categories.

The analysis was carried out in three stages (see Fig. 1), inspired by the grounded theory approach [28], and guided by the three angles of analysis defined in advance (healthcare facilities, patients and professional practices). These perspectives primarily served to structure the initial organization of data derived from observations and stem from the data production framework. Thematic analysis then enabled the identification of sub-dimensions and subsequently dimensions of organizational performance that appeared to cut across these initial categories, thereby allowing for a more integrated understanding of organizational performance and highlighting interactions between different components of the care pathway.

Fig. 1.

Steps in thematic content analysis with its three levels of coding: example simplified and limited to a few codes and subcategories. matrix coding

Initially, descriptive coding was performed. This inductive and open phase [30] identified, based on excerpts from observation logs, units of meaning translated into codes without recourse to predefined themes. These codes related to both factual elements of the patient journey (reception, waiting room, access, etc.) and more interpretative aspects (relationships between professionals, patient perceptions, etc.). At the end of this stage, a coding book was developed containing all the codes, their definitions, and examples. For example, the code “service organization plus” includes positive elements observed or verbalized in the organization of the ambulatory surgery service that contribute to optimizing the pathway. Thematic saturation was reached during the observation of the seventh facility. However, observations continued in two other facilities to confirm the absence of new codes and consolidate the results.

In a second step, axial coding was performed. Within the three categories (corresponding to the three angles of analysis), the codes were then grouped into subcategories (for example in Fig. 1, the comfort subcategory includes the “physical comfort” code as well as three other codes), which represent the sub-dimensions of performance. Of the 30 subcategories initially identified, only 24 were retained, as the others were observed only marginally in the observation logs—that is, characterized by low recurrence, presence limited to a small number of institutions, and an analytical contribution deemed secondary to the research problem.

Finally, a third stage involving matrix coding was conducted to explore and interpret the links between codes and sub-categories. The aim was to focus on the key elements of the pathway’s performance. Each code remains attached to a main category but can also have relationships with codes or subcategories from other categories. Figure 1 thus presents a simplified example of the code grouping process. The code “physical comfort” is presented there for illustrative purposes. This cross-categorical approach makes it possible to identify the structural elements of performance by going beyond the initially defined angles of analysis. The interpretation is based on the approach proposed by Charmaz [31]. The links between the different elements were established based on a cross-analysis of the observation logs and the coding book. The interpretation of the relationships between subcategories and categories took into account both their recurrence in the data, their relative weight in the analysis, and the qualitative content of the associated observations. A constructivist approach guided the interpretation of the data, with particular attention paid to organizational contexts and the interactions observed in care situations.

This analytical process led to the construction of a concept map of the organizational performance of the ambulatory surgery pathway. The categories and subcategories resulting from the analysis were interpreted as dimensions and sub-dimensions of performance, enabling the proposal of an integrated model of the phenomenon under study.

Rigor and reliability

The credibility of the results [32] is based on the duration of observation, the organizational variety of the facilities included, data saturation reached at the 7th facility, the robustness of the interpretation conducted by 3 researchers —supported by regular exchanges that allowed for the resolution of analytical discrepancies and the mitigation of interpretive biases—as well as the observer’s reflective stance. Transferability is supported by the diversity of the institutions observed, the variety of their organizational configurations, and the detailed description of the observation contexts, allowing the reader to assess the extent to which the results can be applied in comparable organizational contexts. As for confirmability, it was ensured by the traceability of methodological and analytical choices, documented throughout the research process.

The results of the analysis were presented to the managers of the ambulatory surgery units and to the nursing directors as part of a presentation of the study’s main findings. Managers and the clinical leadership team could share this report with the care teams. This presentation took the form of a report sent to the participating institutions, which led to some feedback and minor adjustments, particularly regarding the operation of the departments (schedules or volume of activity). The lack of further feedback from the institutions should not be interpreted as an endorsement of the analyses produced. However, this presentation did not constitute a formal validation process involving all participants, as the objective of this study was primarily exploratory.

The differences observed between facilities, whether specific mechanisms (i.e., nurse pathway consultation, protocols), material conditions (i.e., shared software between departments), or organizational conditions (i.e., autonomy of ASU teams) were discussed within the research team.

These various elements support the validity of the study.

Ethics

This research received CNIL (French Data Protection Authority, France) approval (No. 2219053, MR004 framework for non-interventional research). Professionals and patients were informed of the presence of the observer researcher and the non-intrusive nature of the observations. Any potential objections were respected; no refusal or withdrawal was reported. The notes were fully anonymized to ensure confidentiality.

Results

Healthcare facilities included

We conducted the study in seven public and two private institutions (Table 1), located in seven departments in urban (6), semi-urban (2), and rural (1) areas, representing three of the four organizational models in AS (six integrated, two autonomous, and one satellite).

Table 1.

Overview of healthcare facilities included (2022 data)

	No. 1	No. 2	No. 3	No. 4	No. 5	No. 6	No. 7	No. 8	No. 9
Territory	Semi-urban	Rural	Semi-urban	Urban	Urban	Urban	Urban	Urban	Urban
Legal status*	Public	Public	Public	Public	Public	Public	Public	Private	Private
Number of Medical, surgical and obstetric (MSO) beds (and surgical beds) *	346 (62)	63 (20)	266 (40)	383 (66)	840 (214)	584 (136)	802 (181)	109 (97)	173 (107)
Ratio of surgical beds to total number of beds*	18%	32%	15%	17%	25%	23%	23%	89%	62%
Average age of surgery patients **	59.77	59.06	58.56	49.89	49.89	49.89	49.89	51.38	38.35
Average length of stay in Surgery ** (days)	3.87	2.23	3.36	4.74	4.74	4.74	4.74	0.72	0.40
Number of sectors of AS	1	1	1	1 but dedicated services in gynecology and digestive medicine	1	1	1	3 including one pediatric sector and two adult sectors	4 including two ultra-short circuit sectors, one adult and one pediatric sector
Organizational model of the AS unit	Integrated	Integrated	Integrated	Integrated	Satellite	Autonomous	Autonomous	Integrated	Integrated
AS unit structure	Bedroom/rest area	Bedroom	Bedroom	Bedroom	Cubicle / rest area	Rest area	Rest area	Bedroom/Rest area	Bedroom/Rest area
Manager dedicated to the ASU	No	No	No	No	Yes	Yes	Yes	Yes	Yes
Number of ASU places *	14	10	15	15	7	14	47	44	51
Number of procedures in AS *	1848	1382	1620	2683	3621	5341	13,903	13,502	14,334
AS rate * (Number of ambulatory surgical stays to total number of surgical stays)	33%	60%	38%	43%	31%	54%	63%	66%	85%
Number of specialties within ASUs (= Ambulatory Case Mix) *	> 6 D	4 B	5 C	< 3 A	5 C	5 C	4 B	< 3 A	5 C
Proportion of patients > 60 years old during the observation phase	50%	56%	35%	15%	46%	40%	36%	51%	58%

*Source: HospiDiag¹

**Source: ScanSanté²

¹HospiDiag: online platform of the Technical Agency for Information on Hospitalization (ATIH) that disseminates indicators of activity, resources, and performance of healthcare institutions in France

²ScanSanté: ATIH portal providing access to activity data (PMSI) produced by healthcare institutions in France

The facilities varied in size from 100 to 800 beds, with a number of AS beds ranging from 7 to 51.

Surgical activity accounted for less than a third of beds in seven facilities. The two facilities that devoted more resources to surgery were private facilities.

The volumes, ambulatory surgery rates, and specialties offered varied greatly. Most facilities performed fewer than 5,500 procedures per year, but three exceeded 13,000. Four facilities had an ambulatory rate of more than 60%, indicating that their activity was mainly focused on ambulatory care (facility No. 8: 85%). While most facilities had a single sector for ambulatory care, three had several (public pediatric and specialties). The nature of the procedures performed determined the volume of activity (the duration of the procedure determines the turnover rate), the ambulatory rate, and the number of sectors. The majority of ASUs offered between four and five specialties. Orthopedics was the predominant surgical specialty in four ASUs, followed by ophthalmology and gastroenterology (two ASUs) and gynecology (one ASU).

The average length of stay (ALOS) for surgery ranged from 0.40 to 4.74 days, which was higher in public institutions, as is typically the case, probably due to the more comorbid profile of the patients admitted.

Five institutions had a healthcare manager dedicated to this activity.

Dimensions and sub-dimensions of the performance of a care pathway

Our coding method identified 103 codes: 49 relate to professional practices, 34 to patients, and 20 to institutions. These codes were then grouped into subcategories, interpreted as sub-dimensions of performance. Analysis of the links between these subcategories led to the emergence of 24 sub-dimensions. Details of these 24 sub-dimensions are presented in Table S1 (Additional file 3: Table S1), which provides definitions and illustrative elements for each identified sub-dimension.

These were then synthesized and organized into five major dimensions of care pathway performance in AS as shown in the concept map (see Additional file 4: Figure S1). The dimensions correspond to analytical constructs derived from the coding process. The concept map is the result of the inductive analysis process; it proposes an analytical structuring of the dimensions and sub-dimensions of organizational performance.

Figure 2 illustrates the distribution of sub-dimensions by dimension.

Fig. 2.

Occurrence of sub-dimensions by dimension of organizational performance of a care pathway in AS. *E = Establishment

The occurrences indicate the relative salience of certain elements in the empirical data and are provided for descriptive purposes. They are not intended to establish a normative hierarchy among the dimensions of organizational performance.

The “flow management” dimension, with a total of 1,441 occurrences in the corpus, is the most significant dimension in the analysis and is broken down into 7 sub-dimensions. It corresponds to the synchronized management of patient, professional, and logistical flows within the legal time limit for an emergency care stay (12 h in France). Based on the data collected in our research, the main contributing factors are the accessibility of the ASU (i.e., clear, legible signage), architecture (i.e., geographical proximity of the ASU to the operating room and technical platform), management of surgical activity (i.e., planning of AS at the start of the surgical program), the organization of the ASU (i.e., staff management, software shared with other departments), the organization of the intra-hospital pathway (i.e., coordination of consultations and additional examinations in a single visit), organization of the pathway hospital-city (i.e., liaison letter, anticipated pathway coordinated with other structures), and no professional errors (i.e., adherence to the operating schedule and accurate estimation of operating time).

Working conditions (1,138 occurrences) were defined as a set of material, organizational, and psychosocial aspects that frame the exercise of professional activity. These mainly include physical conditions (i.e., layout of the premises, presence and condition of medical and non-medical equipment), organizational conditions (i.e., 12-hour work shifts desired by teams to promote work-life balance), teamwork (i.e., respect, trust, autonomy, etc.), training (i.e., training in innovative equipment, training dedicated to specific categories of professionals), and patient behavior (i.e., compliance with instructions, absence of inappropriate behavior). etc.).

Professional/patient communication (1,001 occurrences) reflects effective, fluid, caring, and respectful exchanges aimed at promoting the transmission and understanding of information, active listening, and empathy. Two sub-dimensions contribute to this: the quality of the information conveyed (clear, precise, supported by visual aids or explanatory sheets) and the relationship between the two parties (reassuring, calming, and comforting attitude of staff, respect and listening to the patient).

Clinical outcomes (1,081 occurrences) are understood as the observation on the day by the patient and/or professionals of the effects of the overall ambulatory surgical care on the patient’s symptoms, functioning, and well-being. These include pain and stress control (i.e., systematic use of painkillers, maintenance of catheters at home to allow intravenous delivery of painkillers, offering different therapies to reduce stress, such as hypnosis), the absence of complications (i.e., no bleeding, nausea, or vomiting), the safety of care (i.e., identity vigilance, checklists, liaison letters), and patient characteristics (i.e., medical history, medication, precariousness). These factors influence clinical outcomes by reducing symptoms or improving patient well-being.

The dimension of patient experience and satisfaction (721 occurrences) refers to how patients experience and perceive their care throughout their care journey, as understood from the observations made. Patient experience is understood as the totality of interactions the patient has with the healthcare system—including organizations, professionals, and the care received—during their care journey [33]. Patient satisfaction is defined as the perception of the adequacy of the response provided by professionals and the institution to their expectations and needs [34]. Contributing factors include comfort (i.e., heated blankets, music therapy, clothing that allows privacy), confidentiality (i.e., reception in a closed office, partitions between chairs, explanations given in a dedicated, closed space), prior direct or indirect interactions with the institution (e.g., experience in the same facility, the same specialty, the same surgeon), and attention paid to patients and their accompanying persons (e.g., assistance in filling out administrative documents, exceptional authorization for companions in the department, dedicated facilities for companions).

Figure 3 illustrates the complexity of the relationships between the 24 sub-dimensions and the five dimensions of organizational performance. In this figure, the thickness of the links reflects the relative strength of the associations identified during the analysis (recurrence of elements in the data, their relative weight in the analysis, as well as the qualitative content of the excerpts from the observations); the color of the links indicates the performance dimension to which each association is linked. The circles correspond to the sub-dimensions and the hexagons to the performance dimensions.

Fig. 3.

Relationships between the sub-dimensions and the dimensions of organizational performance in ambulatory surgery pathways

Analysis of this figure shows that certain sub-dimensions of have a particularly high frequency of occurrence. Thus, Information (N = 457), In-hospital Pathway Organization (N = 365), and Quality of Patient-Professional Relationships (N = 544) are particularly prominent and simultaneously contribute to several dimensions of performance, making them priority cross-functional organizational levers. Others have more targeted contributions: Architecture (N = 146) primarily influences workflow management, while Training (N = 33) affects clinical outcomes and working conditions. This differentiated structure suggests prioritizing interventions on sub-dimensions with high cross-functional potential.

The organizational sub-dimension of the in-hospital pathway particularly well illustrates this cross-functional nature; it highlights its interactions with the five dimensions of organizational performance in an ambulatory surgical care pathway. It contributes to flows management, notably through the implementation of the “forward march, which improves patient flow,” or “coordination between anesthesia consultations and nursing staff, no waiting, a very smooth pathway.” This intra-facility organization also impacts the patient experience and satisfaction, as “having all preoperative appointments on the same day, including radiology, tests, blood tests, and cardiologist consultations, avoids patients having to make multiple trips and limits travel, which can be complex depending on where patients live,” and “completing the administrative discharge process directly at the ASU reception desk allows patients to leave immediately after their procedure without having to stop at the admissions office or at the secretariats of the various specialties.” These two elements of the pathway organization are perceived positively by patients. The quality of professional-patient communication, and in particular the allocation of time dedicated to listening to the patient and providing information, is made possible, among other things, by the “nurse consultation pathway, where the nurse can use photos to improve the patient’s understanding of the pathway on the day of the operation.” The delivery of information to the patient is also improved by “access to surgeons’ scheduling sheets by staff from other departments, which enables staff to provide clear and precise answers to patients about the duration of the procedure, the type of anesthesia, etc.” “Holding a nursing consultation prior to surgery allows for a better assessment of eligibility criteria, particularly psychosocial risks, and a better understanding of the patient’s overall life context and stress levels,” which can contribute to certain clinical outcomes by enabling, for example, effective stress management. " scheduling, which aims to position patients in the different areas of ambulatory care,” or “patient preparation (taking vital signs, inserting catheters), which is carried out within the ASU for certain specialties only,” allow for a better distribution of work between the teams in the different departments and therefore influence working conditions. The sub-dimension “organization of the inpatient pathway” can positively or negatively influence all dimensions of the organizational performance of a care pathway. In accordance with the criteria for causal propositions defined by Denzin [35], the links identified between the sub-dimensions and the performance dimensions were interpreted based on their observed temporality in the field and their empirical recurrence.

Conversely, each of the five dimensions is fed by a set of sub-dimensions. Clinical outcomes are therefore fed by 20 sub-dimensions, patient satisfaction by 16, working conditions by 15, flows management by 15, and professional/patient communication by 12 sub-dimensions.

Discussion

Our research, conducted in the context of the French healthcare system, identified five dimensions of organizational performance: flows management, working conditions, professional/patient communication, clinical outcomes, and patient experience / satisfaction. These dimensions are influenced by a set of twenty-four sub-dimensions. However, no sub-dimension acts in isolation on a single dimension: they interact and contribute simultaneously to several aspects of performance. This cross-cutting nature explains why each dimension is fed by a significant number of sub-dimensions, the most integrative being clinical outcomes (20 sub-dimensions).

This systemic organization is evident in the structure of the relationships between sub-dimensions and dimensions presented in Fig. 3. This figure highlights that certain sub-dimensions occupy a central position in the system, simultaneously contributing to the whole or to several dimensions of performance, while others make more targeted contributions. This differentiated structuring underscores the existence of organizational levers with strong cross-cutting potential: certain organizational components, although linked to a dominant dimension, produce effects across multiple dimensions of performance. To concretely illustrate these cross-cutting effects, certain organizational elements identified in this research can be analyzed as organizational levers capable of simultaneously improving multiple dimensions of performance. For example, establishing a nursing consultation dedicated to the care pathway during the preoperative phase allows for informing the patient about the different stages of the pathway, anticipating certain difficulties, and assessing the patient’s anxiety. This organizational approach can contribute to improving several dimensions of organizational performance, including workflow management, communication with patients, and clinical outcomes. This example illustrates how certain organizational components can act as cross-cutting levers of performance in ambulatory surgical care pathways.

This interdependence can be interpreted considering approaches derived from the science of complexity, which view care pathways as complex adaptive systems characterized by dynamic interactions among their components [36]. From this perspective, the relationships observed between sub-dimensions and dimensions do not reflect linear causality, but rather multiple and contextual mechanisms of influence, where a single organizational component can produce different effects depending on the situation.

In this research, ambulatory surgery constitutes the empirical context from which the observations were made. While certain dimensions identified in this study (communication, working conditions, or clinical outcomes) are also described in other studies on the performance of healthcare organizations, the specificity of the ambulatory surgery context is more evident in the way these dimensions are articulated within the organization of the care pathway. These results must therefore be interpreted in light of the organizational specificities of ambulatory surgery; the methodological approach used in this study, based on in situ observation of care pathways and an inductive analysis of the observed situations, could be applied to analyze the organizational performance of other care pathways. Certain sub- dimensions, particularly those related to flow management and the organization of the pathway, thus appear to be closely dependent on these specific organizational constraints.

Methodically, while many studies evaluating the performance of ambulatory surgery are based on criteria defined according to a top-down approach and focused on the institutional or expert management (ANAP - (French Agency for Care Performance)) perspective [13, 37], our research adopts an inductive approach based on the observation of care pathways. This approach identifies the dimensions, and sub-dimensions of organizational performance arising directly from observed care situations.

Furthermore, where previous work often remains fragmentary, either by limiting itself to a particular segment of the pathway (planning, preoperative consultation) [38–39], or by focusing on a single dimension such as efficiency, working conditions, or clinical outcomes [40–42], our study covers the entire in-hospital pathway (preoperative, operative, and postoperative), as well as the interfaces between these segments, including the ongoing adjustments made by professionals (i.e., regulating the flow of patients between the ASU and the operating suite to ensure the surgical schedule proceeds as planned).

These interfaces represent significant points of vulnerability in the organization of the care pathway. As such, they constitute critical points in process management, potentially leading to a negative impact on the patient experience and the occurrence of adverse events [43–44]. Our research not only covers these interfaces but also highlights the contribution of each segment of the pathway and these interfaces to the overall organizational performance of the care pathway. We were able to observe the preoperative pathway, including, for example, consultations with specialist physicians (surgeons, anesthesiologists), with nurses, administrative reception (i.e., admissions), and the organization of surgical activity (i.e., planning, scheduling). The operative segment has been incorporated with the follow-up of patients and professionals from the ASU and the technical platform on the day of surgery, as well as the immediate post-operative segment (i.e., recovery room, return to the AS department, organization of discharge). Remote observation of the post-operative segment has been included through follow-up contact the next day (listening to telephone calls to patients). Observation of this remote post-operative segment is limited due to surgical follow-up consultations taking place more than a month after the procedure and the limited duration of the observation phases in each establishment which did not allow for optimal integration of this segment of the care pathway.

Similarly, unlike studies focusing on a single category of actors (funders, doctors, or patients) [45–52], our research incorporates a plurality of viewpoints, including patients, medical staff (i.e., surgeons, anesthetists), paramedical staff (i.e., registered nurses, nurse anesthetists, surgical nurses, nursing assistants), orderlies, administrative staff, bed managers, logistics personnel and team leaders, in their actual working context. Care leadership was involved later on through the transmission of a file containing the main elements from the observation, with the possibility of feedback and correction. This multi-stakeholder approach allows for a better understanding of organizational performance as a collective construct resulting from interactions among multiple professionals.

Finally, while other studies focus on a single dimension of performance, whether it be efficiency, working conditions, or clinical outcomes [15, 40–42, 53–55], our analysis highlights the intertwining of sub-dimensions: they appear to be interdependent and often contribute to several dimensions. For example, while clinical outcomes naturally depend on sub-dimensions such as pain management, stress management or the safety of care, they are also influenced by factors generally associated with other dimensions, such as the layout of the premises, the organization of the care pathway, and the quality of the relationship between patients and professionals.

Outlook

Beyond these contributions, this research opens several avenues, both scientifically and operationally. Three major areas for further development emerge from this research. First, work to validate the evaluation framework appears necessary. This could draw on complementary methods, notably interviews with various stakeholders (healthcare professionals, patients, management), to discuss the relevance, completeness, and transferability of the identified dimensions and sub-dimensions. The development of more participatory approaches that involve various stakeholders in the discussion and interpretation of results could also help deepen the collective understanding of the organizational dynamics observed. This step would help consolidate the robustness of the proposed framework and clarify its contours across different organizational contexts.

Second, the results of this research could lead to the creation of a tool for evaluating the organizational performance of an AS care pathway that can be applied at multiple levels: at the micro level, by professionals within healthcare facilities as part of a self-assessment and continuous improvement of the AS care pathway, and at the macro level, by the regulator, who could use it to enhance existing systems by integrating dimensions that have been little explored to date. From this perspective, the dimensions and sub-dimensions identified in the concept map could constitute a first step toward developing indicators to operationalize the assessment of the organizational performance of ambulatory surgery pathways. The third focus would aim to conduct a comparative analysis of the various existing organizational models in ambulatory surgery departments to identify convergences and divergences regarding the dimensions and sub-dimensions of this performance.

Strengths and limitations of the study

This study has limitations inherent in qualitative observational research. This methodological approach relies on prolonged immersion in the field, involving data collection —understood as a process of data production in line with a constructivist perspective—processing, and analysis that are particularly time-consuming. However, this extended period allowed for a deep immersion in the field, enabling a nuanced understanding of the observed situations and the interactions among participants. In this type of approach, the observer’s presence may have influenced certain observed situations (Hawthorne effect). From a constructivist perspective, this influence is one of the conditions under which the data were produced. The data produced depend, in fact, on the situations accessible to the researcher and the interactions observed, which introduces variability in the observation contexts that must be taken into account when analyzing the results, to the extent that it can influence the weight of the observations. Furthermore, since the data were collected by a single observer, the observations necessarily rely on the researcher’s position and perspective in the field. This positioning created favorable conditions for generating rich data: familiarity with healthcare environments allowed access to practices and interactions among actors, while the absence of institutional ties to the facilities ensured the analytical distance necessary for non-participant observation. This research approach thus made it possible to document in depth the organization of ambulatory surgical pathways and the interactions among stakeholders, within the framework of a reflexive analysis. However, this research did not involve a formal validation process for the analyses that included all stakeholders, which is a limitation of this exploratory study.

This methodological choice, focused on observing care situations and interactions among frontline actors, also led to limiting the scope of the research to intra-hospital operations with a focus on patients and frontline professionals, which restricted the observation and articulation of dimensions such as efficiency, even though it was briefly mentioned by ASU managers who convey the vision of hospital administration. Furthermore, although ambulatory surgical pathways involve coordination with community care and professionals in the sector, this research focused primarily on the intra-hospital organizational dynamics that can be directly observed during the care pathway. Interactions with community care were therefore examined only indirectly. However, this choice allowed for a detailed documentation of organizational dimensions as they manifest in care and interactions among stakeholders.

In our study, the sample consists primarily of facilities operating under an integrated organizational model, which may influence certain results, particularly regarding the organization of care pathways and coordination among stakeholders. Nevertheless, the diversity of facilities in terms of size, status, and organization allows for coverage of a variety of organizational contexts. Including facilities with other organizational models in future research represents a promising avenue for further study.

Finally, despite a deliberate effort toward multidimensional integration, we could only partially account for the economic dimension. This is due to the methodological approach, which relies on direct observation of care pathways and does not allow access to the institutions’ financial mechanisms or economic data. Indeed, this research focuses on the organizational dimensions of performance as they manifest in care practices and interactions among stakeholders, as far as they were observable. While the absence of the economic dimension limits the ability to fully grasp the trade-offs between organizational, clinical, and economic dimensions, it falls within the scope of this study and offers a complementary research perspective that could be explored using other data sources and methodological approaches.

This study has several strengths. It is based on in situ observation conducted in nine French healthcare facilities with varied organizational structures in ambulatory surgery, allowing for the documentation of different organizational models of care pathways. Furthermore, prolonged observation of care situations provided direct access to professional practices and interactions among stakeholders involved in ambulatory surgical pathways. This approach also made it possible to document the interfaces between the different stages of the care pathway, which constitute critical points. The analysis also highlights the interdependencies between the dimensions and sub-dimensions of organizational performance, as certain organizational components contribute simultaneously to multiple dimensions. Finally, the concept map derived from the analysis provides an empirical structuring of the dimensions and sub-dimensions of organizational performance. The results of this research can inform the future development of assessment tools by offering broad and integrated coverage of the organizational dimensions of performance.

Conclusion

This study offers a fresh perspective on the organizational performance of ambulatory surgical pathways, highlighting its systemic, multidimensional, and deeply interdependent nature. It suggests that performance cannot be understood through isolated dimensions, but rather rests on cross-functional organizational dynamics, where levers of action produce simultaneous effects across multiple dimensions of the care pathway.

In this sense, this work helps move beyond fragmented approaches to performance by proposing an integrated analytical framework grounded in the observation of real-world practices. It thus opens avenues for the development of more holistic evaluation tools capable of better capturing the complexity of healthcare organizations.

Finally, the inductive approach employed could be applied to other healthcare contexts and systems to test the robustness of this framework and enrich our understanding of the organizational mechanisms at work in diverse environments.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ALOS

Average Length Of Stay

AS

Ambulatory Surgery

ASU

Ambulatory Surgery Unit

Author contributions

CM collected the data. All authors contributed to the analysis and interpretation of the data, as well as to the writing and revision of the manuscript. All authors read and approved the final version of the manuscript.

Funding

The author(s) received no financial support for the research, writing, and/or publication of this article.

Data availability

The data that support the findings of this study are available from the corresponding author, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the institutions, in compliance with article 6 of the agreement signed.

Declarations

Consent for publication

Not applicable.

Ethical approval and consent to participate

This research falls under the category of “research not involving human subjects” (RNIPH), as defined in Article R.1121-1 of the Public Health Code. As such, it does not fall within the scope of Law No. 2012 − 300 of March 5, 2012 (the Jardé Law) on research involving human subjects: obtaining written informed consent from participants is therefore not required under French national regulations, and the study is not subject to prior review by a Committee for the Protection of Persons (CPP). In accordance with these regulations, no written informed consent was obtained from participants. This study nevertheless follows the MR-004 reference methodology of the French Data Protection Authority (CNIL), according to which participation in the study was based not on obtaining written consent, but on individual notification accompanied by a right to object: all participants (healthcare professionals and patients) were informed of the presence of the observer-researcher, the non-interventional and non-intrusive nature of the observations, as well as the possibility to object or withdraw at any time, without justification. All objections raised by participants were respected; no refusals or withdrawals were recorded. The processing of personal data was carried out in accordance with the GDPR and the French Data Protection Act, within the framework of the CNIL’s MR-004 reference methodology. The University of Toulouse, as the data controller, filed a declaration of compliance with this framework (CNIL reference no. 2219053). The research received a favorable opinion from the University of Toulouse’s Data Protection Officer under number 00011835. Field notes were strictly anonymized: no names, dates, or identifying details were retained, ensuring the confidentiality of individuals.

Norm or standard observed

This study was conducted through non-participant observations of patient pathways and professional practices in ambulatory surgery units. There was no direct interaction with patients, and no identifiable personal or medical data were collected in the observation logs. In accordance with French regulations, the study falls under the Reference Methodology MR-004, and data processing complied with the requirements of the French Data Protection Authority (CNIL) (compliance number: 2219053). Although the study does not fall under the scope of interventional medical research as defined by the Declaration of Helsinki, it was conducted in accordance with the fundamental ethical principles of the Declaration of Helsinki, including respect for human dignity, privacy, confidentiality, and integrity in the conduct of research.

Competing interests

The authors declare no competing interests.