The development and implementation of an integrated multidisciplinary clinical pathway.

Clinical pathways, linear time-related representations of patient care processes, are widely encouraged as a mechanism to outline efficient, cost-effective, multidisciplinary care. The translation of pathways from concept to reality is, however, predictably difficult. All caregivers are dedicated to a common goal, but organizational, personal, and professional perspectives are barriers to development of a common tool. Moreover, the building process requires the discovery, articulation, and communication of previously tacit patient care processes. Although no prescription can work for all pathway development, some strategies can help ensure the best possible chance of pathway success. Participants must recognize that between-patient variability can be expected to decrease with pathway implementation, and educational processes must support that aim. "Stakeholder groups" must be identified and their investment must be assessed, with careful attention paid to acquiring the unconditional support of institutional leadership. Planning of precise building, implementation, and piloting processes, with provision for facilitation of building and implementation processes, is critical. Those charged with pathway development must commit to the establishment and explication of clear goals (economic and quality outcomes) and to careful integration of the pathway with planned and existing continuous quality improvement processes. These strategies are illustrated with actual experiences in implementing cystectomy and pressure ulcer pathways in one academic medical center.