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R. Sipilä et al.
shows the rehabilitation-related objectives for change.
The implementation plan template is shown in Appen-
dix SI 1 . The group decided on the steps, responsibilities,
and timetable for implementation, and how to follow
and measure change. Table IV shows the agreed actions.
The new generic model of care for patients with
musculoskeletal diseases was developed and published
on the CC website (https://www.kaypahoito.fi/). Ma-
terials for patients and the education were produced.
Four different multidisciplinary education sessions
were organized between October 2017 and February
2018, with an orthopaedic surgeon, a physiatrist, 2
physiotherapists and a facilitator acting as instructors.
Each session included lectures, as well as hands-on
education on diagnostic tests and therapeutic exercises
in which a physician and a physiotherapist worked as a
pair. The generic model of care for patients with muscu-
loskeletal diseases was introduced. In addition, self-care
instructions were gathered and tips for motivating the
patients were shared. There were 74 participants, 40 of
whom were physicians and 34 were physiotherapists. An
electronic feedback questionnaire was sent to the partici-
pants after the sessions; however, only 27% responded.
The majority of respondents found the sessions useful.
Respondents also stated that they were committed to
changing their behaviour concerning shoulder tendon
disorders. Respondents expressed gratitude specifically
for the hands-on sessions on diagnostics and exercises.
An important part of implementation is to follow how
change occurs. The group described the objectives of
change and possible measures for change. For example,
to measure the objective “timely given, systematically
and progressively executed and long enough therapeutic
exercises in degenerative tendon problems”, the following
measures were identified: exercise groups established
(yes/no), number of participants, time on “waiting list”,
Western Ontario rotator cuff -index in use, number of
sick-leave days due to shoulder problems, and electronic
training diary in use (yes/no). However, the group recog-
nized several barriers to the use of these measures. For
example, problems in obtaining reports from electronic
health records were found to be an important barrier.
DISCUSSION
Based on our experience, it is feasible for a guideline
producer to achieve systematic inclusion of rehabili-
tation into guidelines and thereafter into GItools. We
successfully forged co-operation between a guideline
producer and a healthcare organization in a local imple-
http://www.medicaljournals.se/jrm/content/?doi=10.2340/16501977-2597
1
www.medicaljournals.se/jrm
mentation project, although some difficulties occurred
in following the scheduled timetable.
This project lacks data on the effectiveness of our
GItools. Based on the questionnaire, however, the GI-
tools, particularly the patient versions and information
for patients, were well received and considered useful.
According to a Cochrane Review, a GItool developed
by the guideline producers may moderately increase
adherence to the guidelines (9). However, there was a
limited number of randomized controlled trials (RCTs),
and there was variation in the clinical conditions, types
of healthcare professionals included in the studies,
types of behaviour targeted, and the GItools. Due to
this heterogeneity, it was not possible for the Cochrane
Review to draw conclusions about the comparative
effectiveness of GItools.
Implementation interventions are often complex.
Theory-based careful planning is therefore crucial,
particularly with complex interventions, such as imple-
mentation of seamless care pathways (5). To plan the
implementation project we used a similar theory-based
structured approach as that used by French et al. (10).
This process began with asking the question “Who
needs to do what differently?”, followed by barrier
identification, selection of intervention components
and planning of evaluation. The last additional step was
the planning of responsibilities and drafting a schedule.
Implementation at the local level facilitates the iden-
tification of aims and barriers, and offers expertise on
facilities and resources (4, 6, 11, 12).
Based on our analysis of aims and barriers, we chose
a multifaceted intervention. Although there is no solid
evidence that multifaceted interventions are more ef-
fective than single ones, multifaceted interventions
allow targeting several barriers and persons at different
stage of change at the same time (11). Intervention
components consisted of using the services of opinion
leaders, interprofessional mixed educational sessions,
and dissemination of guideline-based materials. These
intervention components have proven to have a small-
to-moderate effect on guideline implementation.
Educational meetings alone, or combined with other
interventions, can improve professional practice and
healthcare outcomes for patients. However, educatio-
nal meetings should not be used alone when the aim is
to change complex behaviour. When using educational
interventions, mixed interactive and didactic education
meetings are the most effective educational interven-
tions, although the effect is small-to-moderate (13).
Studies have shown variable effects for interprofes-
sional education interventions. It may be beneficial
to include attendees from a single organization. Ac-
cording to our feedback the attendees felt that the
presence of both physicians and physiotherapists was