Clinical pathways are often promoted as the holy grail of efficient healthcare provision. However, our experiences during the Swiss research project Hospital of the Future demonstrated that most Swiss hospitals do not implement clinical pathways in the sense of ‘… a document describing the common process of a multidisciplinary treatment for a particular type of patient’. In this paper, we will discuss reasons for the lack of pathway implementations. We differentiate between three different categories of explanations: (i) organization-specific impediments, (ii) environmental hurdles, and (iii) inherent problems of clinical pathways. Without additional support and regulation by the policy maker, it seems rather unlikely that an increase of pathway implementations will take place in the near-future in Switzerland.