Assessing clinical pathways use in a community hospital: it depends on what "use" means.
BACKGROUND
Many benefits have been associated with the use of clinical pathways, yet developing them can be costly, and implementing them is not always successful. A 300-bed Midwestern community hospital began a clinical pathways program in 1995, and by fall 1998, 15 pathways were in various stages of implementation, with 3 under development. Many challenges had been encountered, but hospital leaders were eager to find ways to increase pathway use.


METHODS
A qualitative case study design was used to investigate four clinical pathways, two perceived as being "used" and two that were perceived as "not used". Each pathway was analyzed as a separate case, followed by cross-case analysis. Qualitative data were collected in 65 semistructured interviews with administrators, physicians, physicians' office staff, nurses, and allied health professionals at the hospital. Data were also collected through observation and document analysis.


RESULTS
The two used pathways had been introduced as part of a larger change in care, whereas the two pathways not used had been introduced as stand-alone innovations. Confusing and inadequately developed aspects of the hospital's clinical pathways program included its purposes, the definition of pathway use, pathway procedures, accountability, education, and incentives. A new case management department, ongoing administrative support, and a sophisticated medical information system were viewed as supports for continued growth in the program.


CONCLUSIONS
Implementation of clinical pathways was delayed and complicated by the varied perceptions of the program among stakeholders. Lack of clarity and consistency in how information about the program was communicated made it difficult for clinicians to develop a shared understanding of clinical pathways.
Hoffart
Nancy
N
University of Kansas School of Nursing, 3901 Rainbow Boulevard, Kansas City, KS 66160-7502, USA. Nhoffart@kumc.edu
Cobb
Ann Kuckelman
AK
D001291:Attitude of Health Personnel; D003142:Communication; D019091:Critical Pathways / Q000458:organization & administration / Q000706:statistics & numerical data*; D004059:Diffusion of Innovation; D019983:Guideline Adherence; D006302:Health Services Research; D006764:Hospitals, Community / Q000592:standards*; D006801:Humans; D007255:Information Services / Q000600:supply & distribution; D008332:Management Quality Circles; D015146:Midwestern United States; D019982:Organizational Case Studies; D010348:Patient Care Team; D016730:Program Development / Q000379:methods*; D015397:Program Evaluation; D012941:Social Responsibility; D017749:Total Quality Management / Q000379:methods*