Paradoxes of an approach centered on the resources and efficiency of health establishments. The example of ambulatory surgery[Paradoxes d’une approche centrée sur les ressources et l’efficience des établissements de santé. L’exemple de la chirurgie ambulatoire]

The objectives of productive efficiency are increasingly significant in the health system due to the regulation of expenditure and the introduction of activity-based pricing. They have led health agencies and decision-makers to use tools for management of care from the industry. This is particularly the case for day surgery, which is gradually replacing conventional surgery with strong incentives put in place by the public authorities and health insurance. To do this, they use lean management techniques to optimize accelerated care and manage incoming and outgoing patient flows. The latter are then considered as a standardized economic asset at the heart of reinvented productive "transformations". We show that the benefits of this type of approach stop at the borders of the hospital, with a patient satisfaction that is limited, as well as a burden for caregivers poorly considered. Moreover, productive efficiency is not always achieved and the effects of deferring costs on ambulatory care, or the patient and his entourage remain insufficiently quantified. To further increase the day surgery rate as desired by the authorities, it will now be necessary to extend the eligibility criteria, which raises questions about the very relevance of care at all costs outside the walls of hospitals.