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Joint Clinical Pathways for Collaboration

Partner Institute: 
Kinugasa Research Institute, Ritsumeikan University, Kyoto
Survey no: 
(12) 2008
Ryozo Matsuda
Health Policy Issues: 
System Organisation/ Integration
Reform formerly reported in: 
Detailed planning for secure health care delivery
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes no yes yes no no


To develop collaboration between acute and rehabilitative hospitals, the Government has introduced additional payments to hospitals that have established formal collaboration structures through joint clinical pathways for treatment of hip replacement and stroke. Hospitals have tried to establish collaboration in various ways and developed professional networks, better collaboration, and more simultaneous diffusion of knowledge.

Purpose of health policy or idea

Although developing collaboration between healthcare providers in treating patients with chronic diseases has been a long-existing challenge to health policy makers, policy measures have not been developed until recently to promote such collaboration, except mere encouragement and a small amount of subsidies for experimental collaboration and/or networking.

Pressures to use hospital beds more efficiently without lowering the quality of care, however, have made it necessary to develop more direct policy measures that could lead to a decrease of the average length of stay. For that purpose, the Government has promoted formal collaboration using joint pathways between hospitals, rehabilitative hospitals, and community care providers.

Those joint pathways are generally called "Community Collaborative Critical Pathways (CCCPs)", which is translated literally from Japanese. The term may sound confusing and contradictory because the process of discharge varies far more than in-hospital treatment and it would be difficult to set "goals" for community care. But as explained above the term actually means collaboratively developed, joint clinical pathways between acute and rehabilitative hospitals, encompassing the following points:

  1. They clarify what patient information shall be shared between relevant providers;
  2. They stipulate on what conditions, including activities of daily living, patients can be transferred from acute hospitals to rehabilitative hospitals or to the community, or from rehabilitative hospitals to the community;
  3. They outline what kind of services shall be provided by hospitals, rehabilitative hospitals, and community care providers; and
  4. They stipulate what procedures shall be done in discharging from acute hospitals or rehabilitative hospitals.

Here I will use the term Joint Clinical Pathways (JCP) to explain this policy to avoid misunderstandings.

Usually the JCPs are developed in collaborative efforts by health professionals working at acute and rehabilitative hospitals. Local governments sometimes support those efforts as well. The established joint pathways are supposed to be used for explaining possible clinical pathways to patients and families and are often given as tables describing standardized procedures on a timeline.

The Government has gradually developed financial incentive for this kind of joint guidelines for treatment. In 2006, the Government firstly introduced additional payments for acute and rehabilitative hospitals that establish and use this kind of joint guidelines on hip replacement patients into the payment rules of the public health insurance. The National Cancer Care Plan, established in 2007, stated that JCPs for cancer shall be developed at all prefectural centers in five years. In 2008, financial incentives for JCPs on stroke treatment have been introduced.

Main points

Main objectives

The policy intends to promote collaboration between acute and rehabilitative hospitals, for the purpose of shortening length of stay at acute hospitals, and improving quality of care and explanation on medical treatments to patients and their families.

Type of incentives

The Government currently uses financial incentives, i.e. additional payments from the public health insurance to hospitals. But the idea of using joint pathways to develop collaboration between relevant providers seems to attract health professionals.

Groups affected

Acute hospitals providing hip replacement and stroke treatment, rehabilitative hospitals providing hip replacement and stroke treatment, patients and families

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent rather system-neutral system-neutral

The policy is innovative because it will include a new policy instrument, ie. joint pathways. Also, how joint pathways are used by hospitals will be monitored by the Government through assessment at discharge. Because it is primarily a matter within healthcare professionals, it's not so controversial up to now and has little system impacts and low visibility.

Joint pathways can be transferred to other healthcare systems with similar divisions between acute and rehabilitative hospitals. Also, joint pathways for treating other diseases that have a long duration could be developed.

Political and economic background

Hospitals have been under pressure to work more efficiently and discharge patients as quickly as possible. Shortening length of stay, however, may create serious conflicts with patients and rehabilitative hospitals. Therefore new instruments to develop collaboration on treatment that can be monitored by the Government have become necessary.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes no yes yes no no

Origins of health policy idea

Since the late 1990s, new managerial instruments such as critical pathways and disease management, developed in the U.S. and other countries, have been investigated. Critical pathways had become popular among hospital nurses in the early 2000s.

Some hospitals developed CCCPs to promote collaboration between providers, and these have attracted the attention of the Government as a policy instrument.

Initiators of idea/main actors

  • Government
  • Providers

Innovation or pilot project

Pilot project - Yes, as described below.
Else - Self-organized development by hospitals.

Stakeholder positions

Joint pathways have been developed by some active hospitals. Based on these experiences, leaders of health professionals spread the idea of joint pathways through professional publications. The Government supported those activities, firstly, as research and, later, as a managerial innovation. Patients and their families allegedly have been welcoming the new instrument. But no formal and external evaluation has been available.

Actors and positions

Description of actors and their positions
Governmentvery supportivesupportive strongly opposed
Acute hospitalsvery supportivesupportive strongly opposed
Rehabilitative hospitalsvery supportivesupportive strongly opposed

Influences in policy making and legislation

The Health Care Act was amended in 2006 to include provisions requiring healthcare providers to collaborate with and give necessary information to other health and social service providers when patients leave hospital in order to ensure continuity of care. Although the provisions outlined general principles for collaboration, the amendment clarifies responsibilities of healthcare providers.

Actors and influence

Description of actors and their influence

Governmentvery strongvery strong none
Acute hospitalsvery strongneutral none
Rehabilitative hospitalsvery strongneutral none
Acute hospitals, Rehabilitative hospitalsGovernment

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The Government supported research on the development of joint pathways. For example, the Ministry of Economy, Trade and Industry commissioned a research project on developing a joint pathway on stroke. Also, the Government requested local governments to support it.

The number of hospitals that established formal collaboration through joint clinical pathways on hip replacement increased from 78 in 2006 to 209 in 2007. The figure for hospitals establishing collaboration on stroke is not available (MHLW 2008:7).

The Government has restricted the incentives for collaboration on stroke treatment to hospitals who have been described as delivering stroke treatment in prefectural health care delivery plans (see a previous report). 

Dimensions of evaluation


Results of evaluation

A survey on acute and rehabilitative hospitals that had established collaboration through joint pathways on hip replacement showed that average length of stay for hip replacement at acute hospitals was 38.2 days before the introduction of the financial incentives, and decreased to 33 days after that (MHLW 2007).

Expected outcome

The policy probably will promote collaborative efforts between acute and rehabilitative hospitals. Developing joint pathways needs workshops and meetings involving health professional at those hospitals, which facilitate exchange of knowledge and mutual understandings.

Due to methodological limitations, it is difficult to determine the exact effect of the policy from the survey. But considering the relatively longer length of stay at acute hospitals in Japan compared to other industrialized countries, the policy will probably be successful in shortening length of stay.

Diffusion of the new instruments to other hospitals shall be monitored.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low high very high

The policy is likely to improve quality of care and efficiency as described above, but unlikely to be concerned with equity.


Sources of Information

Ministry of Health, Labour and Welfare (MHLW) (2007). A Survey on Collaboration at Hospitals that Established Joint Pathways.

MHLW (2008). Number of Facilities Conforming with Standards for Specified Services.

Reform formerly reported in

Detailed planning for secure health care delivery
Process Stages: Implementation, Legislation

Author/s and/or contributors to this survey

Ryozo Matsuda

Ryozo Matsuda is a professor in community health and health policy at the College of Social Sciences, Ritsumeikan Univerisity.

Suggested citation for this online article

Matsuda, Ryozo. "Joint Clinical Pathways for Collaboration". Health Policy Monitor, October 2008. Available at