BACKGROUND Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies as well as quality initiative data from our institution demonstrated that only 40–75% of patients underwent cholecystectomy on index admission. STUDY DESIGN In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay (LOS), and readmission rates in pre-pathway (1/05–2/08) and post-pathway patients (1/09–5/10). RESULTS Demographic and clinical characteristics were similar between pre-pathway (n=455) and post-pathway patients (n=112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (P<0.0001). There were no differences in operative mortality or operative complications between the two groups. For patients undergoing cholecystectomy on initial hospitalization, the mean LOS decreased after pathway implementation (7.1 days to 4.5 days; P<0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; P<0.0001). 33% of pre-pathway and 10% of post-pathway patients required readmission for gallstone-related problems or operative complications (P<0.0001), and each readmission generated an average of $19,000 in additional charges. CONCLUSIONS Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.