28

Journal of INTEGRATED CARE PATHWAYS

ORIGINAL ARTICLE

Prevalence and use of clinical pathways in

23 countries - an international survey by the
European Pathway Association
1 4
Kris Vanhaecht , Marcus Bollmann2 , Kathy Bower', Clare Gallagher ,
Andrea Gardini'l.jen Guezo", Uwejansen, RashadMassoud8 , Karen Moody",
Walter Sermeus 1 , Ruben Van Zelm 1(), Claire Whittle 11, Anne-Marie Yazbeck 12,
Karen Zander', Massimiliano Panella 13
1 Centrefor Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium; 2 SANA
Kliniken, Munich, Germany; 3 Centre for Case Management, Boston, USA; 4Patient Concern & Healthcare
Events, London, E/1gland, UK; 5lniernational Society for Quality in Healthcare, A/lCO/la, Italy; 6 Board cif
Health, Castel, Guernsey; 7KISS Project & General practitioners part, County if Senderjylland, Denmark;
8Institutefor Healthcare Improvement, Boston, USA; 9Integrated Care Pathway User Group, GlasgouJ, Scotland,
UK; lOInstitute for Healthcare Improvement CBO, Utrecht, The Netherlands; 11 School of Health Sciences,
Birmingham University, Birmingham, England, UK; 12 Ministry (?f Health, Department for Quality, Liubljana,
Slovenia; 13University of Eastern Piedmont 'Amedee Avogadro', Novara, Italy

ABSTRACT. Objectives: To give an overview on the use and prevalence of clinical pathways. Design:
Cross-sectional descriptive study. Study participants: European Pathway Association (E-P-A) contact
persons in 23 countries. Results: Clinical pathways, also known as critical pathways or integrated care
pathways, have been used in health care for 20 years. Although clinical pathways are well established, little
information exists on their use and dissemination around the world. The E-P-A has performed their first
international survey on the use and dissemination of clinical pathways in 23 countries. At present,
pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that
clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and
efficiency of evidence-based care. Pathways were also used as a communication tool between professionals
to manage and standardize outcome-oriented care. Conclusions: There is a future for the use of clinical
pathways, but there is a need for international benchmarking and knowledge sharing with regard to their
development, implementation and evaluation.

Kris Vanhaecht, Marcus Bollmann, Kathy Bower, Clare

Gallagher, Andrea Gardini, Jen Guezo, Uwe Jansen,
Rashad Massoud, Karen Moody, Walter Sermeus, INTRODUCTION
Ruben Van Zelm, Claire Whittle, Anne-Marie Managers and clinicians have always searched for
Yazbeck, Karen Zander, Massimlliano Panella, novel methods to improve the quality and efficiency
European Pathway Association, Kapucijnenvoer 35, of health-care processes. The development, imple-
4th .floor, 3 000 Leuven, Beloiuni. mentation and evaluation of clinical pathways is one
Correspondence to: KV of these structured care methodologies. 1-1'\ The idea of
Email: Kris. Vimhaecht@med.kulclwen.bc pathways originated in industry; pathways were first
introduced into health care in 1985 in the United

JOURNAL OF INTEGRATED CARE PATHWAYS (2006) to. 28-34 .. nil' R")',,I SN;l'f)' ,,(.\Il'd;(;1I1' Pres: 200(,
 29
[ournal if INTEGRATED CARE PATHWAYS

Box 1 The European Pathway Association

The European Pathway Association (www.E-P-A.org) was officially launched during a workshop on the European Focus on Clinical
Pathways in Jesi, Italy, in September 2004. This association is an International Network of Clinical Pathway Networks, Clinical Pathway
User Groups, academic institutions, supporting organizations and individuals who want to support the development, implementation, and
evaluation of clinical pathways, critical pathways, care pathways and integrated care pathways. The association is complementary to
local or national pathway associations. The main focus of this association is to determine the relationship between clinical pathways and
high-quality patient-centred care. Our initial goal is to set up an international network of peers that work on pathways and on the
organization of care processes. We have already established a mechanism for knowledge sharing of local clinical pathway projects and
networks, new methodologies and international networking activities. The official communication channel of the association is the
SmartGroup on Clinical Pathways. The E-P-A is chairing the scientific committee of the yearly Healthcare Events International
Integrated Care Pathways Conference in London. Today, the E-P-A has contact persons both inside and outside of Europe.
To become a member of the European Pathway Association, please visit www.E-P-A.org

States. <) Although 20 years of experience with this We invited representatives from 2R countries to
approach already exists, there is still a great deal of participate in our survey. Each was provided with
uncertainty surrounding the actual use and dissemina- an explanation of the aims and the content of our
tion of pathways, the methods used to develop and survey. Initially, we contacted the E-P-A board
implement them, and the effect of their introduction members in 11 countries, inviting them to participate
.
111to hea It h-care processes...'.
1 2 5 7-??
-- in our survey. Representatives from four other
A recent study by the European Health Property countries were contacted through attendees at the
Network (EHPN) revealed that, within 17 European October 2004 ISQUA Amsterdam Conference. The
countries, information is lacking on the use, dissemina- remaining 13 countries were contacted by email
tion and comprehension of pathways.4,23 To remedy through the SmartGroup on Clinical Pathways27
this situation, the European Pathway Association (www.smartgroups.com/groups/ clinicalpathways), a
(E-P-A, www.e-p-a.org) is attempting to organize an forum promoting the development, implementation
international knowledge-sharing network inside and and evaluation of clinical pathways. SmartGroup
outside of Europe (Box 1). This association aims to members provided suggestions for key contacts from
further understand the problems as well as potential these countries. Of the 28 countries invited to participate
benefits of clinical pathways. To this end, the first in the survey, five (Turkey, South Afi-ica, Iran, Poland
international survey on the use and dissemination of and Russia) were unable to for a variety of reasons. We
pathways inside and outside of Europe was undertaken. determined that pilot projects on clinical pathways
were already underway in these five countries, Thus,
23 of2R countries (R2% response rate) were willing to
participate (Figure 1). All contact persons from these
METHODS 23 countries received the final version of the survey
(downloadable from www.E-P-A.org) by email in
Development and dissemination of the January 2005.
24
E-P-A survey Each contact person from each country organized
The E-P-A survey''" was based on the Belgian the distribution of and responses from the survey.
National Survey on Clinical Pathways.f" the Bryson Some countries returned one survey completed by
and Browning report (Scotlandj.f" the EHPN report the primary contact person, whereas other countries
, . I pat h ways ane:I strategic
on cI lI1ICa . asset pI ' 4?1
anrnng, ,-, returned either one survey resulting from discussions
and the Eleven International Trends in clinical or research carried out within those countries, or
pathways.') The survey was finalized during an E-P- several surveys (maximum number allowed was 10). In
A board meeting (International Society for Quality total, a convenience sample of 76 surveys from 23
in Healthcare [ISQUA] Amsterdam Conference, countries was sent by mail or £1X to the E-P-A at
October 2(04), and the finalized survey was sent to Leuven University by April 2005.
all board members by email. The survey received The representatives from the participating countries
approval by members worldwide in December 2004. had a median of five years experience in developing or
The survey addressed three main questions dealing managing clinical pathways (range: 1-17). About 40'X,
with clinical pathways: (1) How do individuals define of the representatives worked in acute hospital trusts,
a clinical pathway? (2) To what extent are clinical 19% worked in teaching hospitals and R% worked in
pathways disseminated worldwide? (3) What approach universities. A minority of the representatives worked
is used to develop, implement and evaluate a pathway? in rehabilitation centres, primary care centres, psy-
30 INTEGRATED CARE PATHWAYS
Journal of

Figure 1 Twenty-three countries involved in the European Pathway Association survey

chiatric hospitals or home-care organizations. In all, Siovenian, n = 2). A definition for clinical pathway
71% were managers, 25% were clinicians and 19% was provided by 67 respondents. The definitions were
were researchers (some took on two or three of these ambiguous. For most of the definitions, published
roles). research articles or other references were not cited.
Otherwise, the works from 18 different authors were
Data analysis used as references to support the respondent's
We analysed the survey-response data with descriptive definition of clinical pathway.
statistics using Excel(!l! and Stats Direct'!". To obtain We asked all the participants to rank, according to
individual country scores for countries returning more importance, the 21 features of clinical pathways.
than one survey, we calculated median scores or These characteristics are listed below and appear in
2H
averages for each country. For the global results, equal the literature review by De Bleser et al. ;
weight was given to all countries. 1. communication tool (between patients and
professionals)
RESULTS 2. communication tool (between professionals)
3. data collection tool
Firstly, we will focus on the definition of a clinical 4. education tool for patients
pathway. Secondly, we will describe the dissemination 5. education tool for staff members
of clinical pathways of the 23 participating countries, 6. focus on cost efficiency
and finally we will discuss the approach taken by these 7. cost efficiency for homogeneous p~fient groups
countries. 8. improvement of compliance.
9. improvement of patient satisfaction
Definition of clinical pathways 10. improvement of quality of care
The representatives from all participating countries 11. improving efficiency of care
used the term clinical pathway. In all, 13 different 12. improving evidence-based care
English synonyms were mentioned: care map, 'care 13. including a timeline (not always time can also be
pathway, clinical protocol, collaborative care plan, stages or objectives)
critical pathway, disease management plan, integrated 14. including variance analysis
care pathway, model of integrated care pathway, 15. inventory of actions (record of care)
patient pathway, patient's journey, standard operating 16. multidisciplinary use
procedure and standardized order set. Additionally, 17. outcome oriented
more than one term was provided in other languages 18. plan to manage the respondent's care
(German, n = 7; Dutch, n = 3; Italian, n = 10; 19. process oriented
 31
Journal of INTEGRATED CARE PATHWAYS
20. standardization of care In most countries, clinical pathways were used in
21. use of guidelines. the treatment of a minority of patients (Table 1). Only
three (13%) countries (Estonia, Singapore, and USA)
From these rankings, we calculated a total rank stated that 21-40% of patients in their countries
score for each participating country (n = 23). A global received pathway-based treatment during the previous
ranking was obtained based on the 23 scores. The top year. About 15 (65%) countries estimated that about
10 pathway characteristics were (1) improvement of 60% of patients could have received pathway-based
quality of care, (2) improving evidence-based care, (3) treatment if a pathway had been available. Two (9%)
multidisciplinary use, (4) improving efficiency of countries (India and Spain) estimated that less than
care, (5) communication tool between professionals, 10% of patients will receive pathway-based treatment
(6) standardization of care, (7) plan to manage the in the next five years, whereas 13 (57%) countries
respondent's care, (8) outcome oriented, (9) use of estimated that about 40% of their patients will receive
guidelines and (10) communication tool between pathway-based treatment in the next five years
patient and professional. The least important pathway (Table 1). Nearly all countries surveyed wanted to at
features were the education tool for patients and the least double the number of patients receiving
data collection tool. pathway-based treatment in the next five years.
Additional survey data on the use and dissemination
of clinical pathways revealed that, in 83% of the
Dissemination of pathways countries, pathways were mainly used in teaching
To determine how many patients received treatment hospitals. Next to teaching hospitals, pathways were
based on a clinical pathway in the participating used in acute hospital trusts (65%), rehabilitation
countries, we asked each country representative three centres (43%), psychiatric hospitals (43%), and
questions: (1) How many patients during the last year primary care settings (39%). Most pathways were
received clinical pathway-based treatment? (2) Of the developed for delivering care within one organization.
patients that did not receive pathway-based treatment, Only 10% of the pathways (range: 0-49%) were
how many would have received this treatment if applied across different health-care settings (i.e. from
pathways were available? (3) How many patients will hospital to home care or from hospital to rehabilita-
receive pathway-based treatment in the next five years? tion centre).

Table 1 Present and future dissemination of clinical pathways in 23 countries (approximate estimations by contact persons)

Patients who will receive

Patients receiving pathway-based Patients eligible for pathway-based treatment in
treatment during last year? (%) pathway-based treatment? (%)a five years? (%)

81-100%
61-80% Australia, Canada, England, Estonia, UAE
Estonia, Saudi Arabia, Scotland,
USA, Wales
41-80% Austria, Belgium, Germany, Australia, Canada, Saudi Arabia,
Netherlands, Singapore, Singapore, USA, Wales
Switzerland, UAE
21-40% Estonia, Singapore, USA Guernsey, India, Italy, Spain Austria, Germany, Netherlands,
Scotland, Slovenia, Switzerland,
England
16-20% China, Denmark, New Zealand, Belgium, China, Denmark, Guernsey,
Slovenia (1-20) Italy, New Zealand (11-20)

11-15% Australia, Canada, England

6-10% Austria, Saudi Arabia, Scotland, Wales India, Spain (1-10)

1-5% Belgium, China, Denmark, Germany, Guernsey,

Italy, Netherlands, New Zealand, Slovenia,
Spain, Switzerland
0% India, UAE
UAE, United Arab Emirates: USA, United States of America
"Percentaqe of patients that would have received pathway-based treatment if pathways were available
32
Journal of INTEGRATED CARE PATHWAYS
Approach used for developing clinical pathways based guidelines. In 52% of the countries, less than
Clinical pathways are developed for and by multi- 40% of the pathways were based on the latest
disciplinary teams. 3.5 .7 In some of the participating evidence-based guidelines. With respect to the format
countries, representatives from certain disciplines did of the pathways, 21 (91%) countries had used paper-
not contribute to the development of pathways. based pathways; only five (22%) replaced the paper
Nurses were involved in developing 96% of pathways record. About 13 (57%) countries had experience
(range 70-100), whereas doctors and allied health with information support (IT) support for clinical
professionals were involved in developing 85% (range pathways.
45-100) and 69% (range 10-100) of pathways, The survey also assessed how pathway information
respectively. Management was involved in developing was shared within and between health-care organiza-
only 48% of pathways (range 0--63), and general tions. In 15 countries (65%), pathway information
practitioners were involved in developing 27% (range was shared within individual organizations, and in
~O) of pathways. The most important stakeholders, 12 countries (52%), information was shared between
patients, were involved in developing only 26% of different organizations. In 11 countries (48%),
the pathways (range 0--60). The type of contribution networking and knowledge sharing existed on a
made by patients differed, ranging from patient national level, and in seven countries (30%), network-
satisfaction surveys and focus groups to the participa- ing and sharing information existed on an inter-
tion of patient organizations' representatives as part of national level.
the clinical pathway development team.
In most of the countries, senior management of a
minority of organizations actively participated in DISCUSSION
developing pathways. The senior management had
an active role in 40% of health-care organizations in The results of our survey indicate that health-care
only four (17%) countries (Australia, Estonia, USA providers predominantly view clinical pathways as
and Wales). In 12 (52%) countries, senior manage- multidisciplinary tools to improve the quality and
ment was involved in less than 10'}(') of the organiza- efficiency of evidence-based care. Pathways were
tions that used pathways. Nine (40'Yc,) countries rated used as a communication tool among professionals
the importance of pathways as a health-care strategy to to manage and standardize outcome-oriented care.
be used in their organizations with a score of seven on Clinical pathways were not viewed as data collection
a one-to-ten point scale. Eight (35%) countries rated tools or tools to educate patients. Although pathways
the importance of pathways with a score of three or have been defined as multidisciplinary tools,3.5.7 we
lower. In all, 13 (57%) countries indicated that their found that the professionals involved in pathway
governments supported pathway projects, mostly by development were mainly nurses and doctors. The
either funding projects or by supporting networking wide ranges we found in the percentages of the
events. disciplines involved (e.g. doctors, 45-100%; allied
Only 10 (43%) countries used a systematic health professionals, 10-100%; general practitioners,
approach to develop, implement and evaluate clinical 0--80%) revealed that international differences exist in
pathways. Using the five domains of the clinical the development of clinical pathways. If the number
pathway compass (22) as the framework for pathway of patients receiving pathway-based treatment is to be
evaluation, we found that 17 (74%) countries system- doubled within five years, all disciplines will have to
atically used clinical indicators (pain, mortality, etc.) to be highly and actively involved in developing and
implementing pathways. -1.6.29 Not only clinicians but
follow up pathways. In all, 18 (78%) countries used
also health-care managers, including both operational
financial indicators (cost, length of stay, etc.) and
and senior managers, will need to support the
service indicators (satisfaction, anxiety, etc.) and 16
pathway concept. Development of state-of-the-art
countries (70%) used process indicators (waiting
pathways that are linked to operations management
times, variances, etc.). Only six (26'Yc,) countries used will be possible only when pathways become part of
team indicators (team effectiveness, job satisfaction, the strategic agenda of an organization.i'" Further-
etc.). Additionally, 19 (83%) countries used locally more, health-care organizations will need to search for
developed indicators to evaluate pathways. Only seven validated methods to involve patients in pathway
(30%) and two (9%) countries, respectively, used development and implementation. An additional
national and international indicators. Three (13%) challenge is the development of pathways that can
countries (Australia, Singapore and Wales) stated that be applied across several organizations, since only 10%
81-100% of their pathways were based on evidence- of the pathways are currently applied in this way.
 33
Journal of INTEGRATED CARE PATHWAYS
Because of worldwide patient safety problems, it is implement and evaluate these pathways. Even though
necessary to evaluate and continuously follow up on some problems and many reservations remain, clinical
the efficiency and effectiveness of pathways.7,H,!(,,2'J,31 pathways do provide some important opportunities to
There is certainly a need for valid and reliable clinical improve the quality of health care.
indicators, Indeed, this need is supported by our Clinical pathways are in use worldwide. None-
finding that 26% of the countries we surveyed do not theless, international differences exist. These inter-
systematically evaluate the clinical effectiveness of national differences must be viewed as opportunities
pathways used in their health-care facilities. These to determine why pathways do not always improve
indicators will enable health-care professionals to the quality or efficiency of health care. 7,H, 15 Legal,
benchmark how pathways affect the quality and safety financial or cultural requirements may underlie some
of health care. Although it is difficult to establish a of these differences.(,,33 Global experience, not only
direct relationship between pathway variability and with the clinical pathway concept but also with
errors, reducing variability by standardizing evidence- specific topics like IT integration, presents an
based clinical processes is an effective tool to minimize opportunity for networking to take place within and
the probability of medical errors. 30 International between countries. Regional or national networks
benchmarking can also lead to knowledge sharing have already been established in several coun-
about the integration of evidence-based guidelines . -I ,.,
tnes. 5 'J ?() 3-1
,-,. T h ese network s are orgamze
. d 111
.
in standardized pathways. Our international survey different ways: some are linked to universities; some
revealed that health-care organizations worldwide are supported by the government; and some are
often fail to include evidence-based guidelines in groups of volunteers. Creating a means to facilitate the
pathways. In most of the participating countries, we sharing of pathway knowledge among these various
found that clinical pathways were primarily based on organizations could be a future task for the E-P-A.
expert opinions and local data. Only a limited number International knowledge sharing will be necessary
of pathways comprised content that cited published to improve the clinical pathway concept and meth-
reports of the latest evidence-based guidelines. Future odology. In the near future, E-P-A hopes to
pathways will have to be based on well-structured collaborate with other international groups involved
and internationally accepted evidence-based guide- in clinical pathway development, implementation and
lines. 5,32 evaluation, with the goal of preparing a more detailed
The present study describes the first E-P-A overview of the use, dissemination and approach of
international survey on the use of clinical pathways clinical pathways in different countries. This informa-
in 23 countries. While useful, this study has some tion will be open to the public and published on the
inherent limitations. Although the median experience World Wide Web.
of the country representatives was five years, most of
their survey responses represented opinions and Acknowledgements
approximate estimations, not auditable statistics. We would like to thank all E-P-A survey contacts and
Another limitation is that we did not include South respondents in the 23 countries that participated in
American and African countries in our international this study. We would also like to thank our colleagues
survey, even though pathways were used in both these at the Catholic Leuven University in Belgium for
continents at the time of our study." Methodological their help and support in finalizing this survey.
limitations exist in the way we obtained the global, More information on the European Pathway
equally weighted data. One alternative would have Association can be obtained by emailing:
been to statistically weight each country based on the Kris.Vanhaecht@med.kuleuven.be or by visiting
number of years their health-care organizations used www.E-P-A.org
pathways. The method we chose was to calculate
the percentage of organizations that used clinical
pathways. References
Because of the paucity of published data on the use
of pathways worldwide.Y it was difficult to compare Pearson S\), Goulart-Fisher D, Lee TH. Critical pathways as
our findings with those from other studies. None- a strategy for improving care: problems and potential. A/III
theless, most of our survey results were comparable to Intern ivIed 1'i'i5;123:'i41--R
those obtained in the EHPN study.-I,23 Our survey 2 Campbell H, Hotchkiss R, Bradshaw N, Porteous M.
results led us to conclude that, at the international Integrated care pathways. BM] 1'i'iH;316: 133-7
level, numerous obstacles remain. in using clinical 3 Zander K. Integrated care pathways: eleven international
pathways and in the methodologies used to develop, trends.] 1111':Rr Car,. HIIllIPays 2002;6:101-7
34
Journal if INTEGRATED CARE PATHWAYS
4 Hindle D, Yazbeck AM. Clinical pathways in 17 European and pathway characteristics using qualitative comparative
Union countries: a purposive survey. A list Health Rev analysis. Health Serv Res 2005;40:499-516
2005;29:94-104 19 Van Herck 1', Vanhaecht K, Serrneus W. Effects of Clinical
5 Panella M, Marchisio S, Di Stanislao E Reducing clinical Pathways: do they work? ] IntegI' Care Pathways 2004;8:
variations with clinical pathways: do pathways work? lilt ] 95-105
Qllal Health Care 2003;15:509-21 20 Whittle CL, McDonald I~ Dunn L. Developing the
6 Degeling P, Maxwell S, Kennedy j, Coyle B. Medicine, Integrated Care Pathway appraisal tool (ICPAT): a pilot
management, and modernisation: a 'danse macabre'? BI\!lj study.] lntcor Care Pathways 2004;8:77-81
2003;326:649-52 21 De Luc K. Are different models of care pathways being
7 Sermeus W, De Bleser L, Depreitere R, De Waele K, developed? Int] Health Care Qllal Assllr 2000;13:80--()
Vanhaecht K, Vlayen J. An introduction to clinical pathways. 22 Vanhaecht K, Sermeus W. The Leuven Clinical Pathway
In: Devriese S, Lambert ML, Eyssen M, Van De Sande S, Compass.] lntcgr Care Pathways 2003;7:2-7
Poelmans j, Van Brabandt H ct al., eds. The Use e!f Clinical 23 Hindle D, Yazbeck AM. Report q(a SlIrvey qf Clinical Pathways
Pathways and Guidelines tel Determine Physicians' Hospital Fees and Stratcoic Asset PlilIllling ill 17 EU Countries. EU Health
Prospectively: Easier Said than Done. KCE Reports. Vol. 18A Property Network and the Netherlands Board of Health
Brussels: Belgian Healthcare Knowledge Centre (KCE), Policy, 2004;1-37
2005, http://www.kenniscentrum.fgov.be/nll publicaties. 24 Vanhaecht K, Bollmann M, Bower K et al. The International
html SlIrvey on Clinical Pathways 2005, www.E-P-A.org
8 Trowbridge R, Weingarten S. Making Health Care Safer, a 25 Sermeus W, Vlayen J. De Bleser L, Depreitere R, Vanhaecht
Critical Analysis qf Patient Safety Practices. Chapter 52: Critical K. Use of clinical pathways in Belgium, 2006 (submitted for
Pathways. Agency for Healthcare Research and Quality, publication)
2001, http://www.ahrq.gov/clinic/ptsafety/chap52.htm 26 Bryson A, Browning J. Clinicat Audit and Qnality Using
9 Zander K. Integrated care pathways: eleven international Integrated Pathways '?f Care. CA96/01. Edinburgh: CRAG,
trends.] IlItegr Care Pathways 2002;6:101-7 Clinical Resource and Audit Group, 1999;1-74
10 Every NR, Hochman J. Becker R, Kopecky S, 27 Vanhaecht K, Guezo J. The SmartGroup on Clinical
Cannon CPo Critical pathways: a review. Circulation Pathways.] IIIt{:~r Care Pat/lIm)'s 2005;9: 114-15
2000;101:461-5 28 De Bleser L, Vlayen ], Depreitere R, De Waele K, Vanhaecht
11 Pearson SD, Kleefield SF, Soukop jR, Cook EF, Lee TH. K, Sermons W. Defining pathways. 2005 (submitted for
Critical pathways intervention to reduce length of hospital publication).
stay. Alii] Med 2001;110:175-80 29 Kwan-Gett TS, Lozano 1', Mullin K, Marcuse EK. One-year
12 Darer j, Pronovost I~ Bass E. Use and evaluation of critical experience with an inpatient asthma clinical pathway. Arch
pathways in hospitals. ~ff Cliu Pract 2002;5: 114-19 Pediatr Adolcsc Med 1997; 151 :684...1)
13 Renholm M, Leino-Kilpi H, Suominen T. Critical path- 30 Kohn LT, Corrigan jM, Donaldson MS. To Err Is Human:
ways: a systematic review.] Nurs Admin 2002;32: 196-202 Bllilding a S<!fa Health System. Washington DC: National
14 Kim S, Losina E, Solomon DH, Wright J. Katz IN. Academic Press, 1999
Effectiveness of clinical pathways for total knee and total 31 Committee on Quality of Health Care in America 10M.
hip arthroplasty: literature review. ] Arthroplasty 2003; Crossino The Qllality Chasm: A Nell' Health System For The
18:69-74 21st Cmtllry. Washington DC: National Academy Press, 2001
15 Kwan j, Sandercock P In-hospital care pathways for stroke. 32 Vlayeu ], Aertgeerts B, Hannes K, Sermeus W, Ramaekers D.
Cochrane Database Syst ReI' 2004;18(4):CD002924 A systematic review of appraisal tools for clinical practice
16 Bandolier. Independent evidence-based health care. On guidelines: multiple similarities and one common deficit.
Care Pathways, 2003, http://www.jr2.ox.ac.uk/bandolier/ lilt] Qllal Health Care 2005;17:235-42
Extraforbando/Forum2.pdf 33 Mallock NA, Braithwaite J. A template for clinical pathway
17 Dy SM, Garg PI', Nyberg D ct al. Are critical pathways design based on international evidence. Clin G"" BIIII
effective for reducing postoperative length of stay? Mcd Care 2005;5:2-4
2003;41:637-48 34 Serrneus W, Vanhaecht K, Vleugels A. The Belgian - Dutch
III Dy SM, Garg 1', Nyberg D ct al. Critical pathway Clinical Pathway Network. ] blt{:~r Care Pathways 2001 ;5:
effectiveness: assessing the impact of patient, hospital care, 10-14