Exploring factors influencing enhanced recovery after surgery implementation in tertiary hospitals using a DEMATEL–ISM mixed methods approach

Despite increasing evidence supporting enhanced recovery after surgery (ERAS), its adoption and depth of implementation remain inconsistent across institutions and surgical specialties. ERAS implementation is influenced by multiple factors; therefore, understanding their structural roles is important for informing implementation strategies. A systems modeling approach informed by the Technology–Organization–Environment (TOE) framework was employed. Influencing factors were identified through a literature review and semi-structured expert interviews conducted in tertiary hospitals in China. An expert panel of 18 evaluated factor relationships. The Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was used to analyze influence patterns, and Interpretive Structural Modeling (ISM) was applied to construct a hierarchical representation of factor dependencies. Nineteen factors were identified across four dimensions: technology, organization, environment, and human. DEMATEL analysis identified successful ERAS pilot programmes (E5), mature organizational structures and support systems (O1), and innovative care model exploration and implementation (O4) as factors with the highest prominent within the influence network. Construction of medical alliances and tiered healthcare systems (E1) showed the highest positive net influence, followed by innovations in medical technology (T1), hospital information system development (T2), and institutional clinical capacity and expertise (O3). ISM revealed a five-level hierarchical structure, with organizational structures and support systems (O1) occupying the deepest structural level, suggesting the foundational role within the ERAS implementation structure. This exploratory systems model provides a structured perspective on the interrelationships and hierarchical dependencies among ERAS implementation factors and may inform implementation priorities while considering local organizational contexts.