Problem

Physicians working in Ontario, Canada are legally obligated to report patients who may be medically unfit to drive to the Ministry of Transportation of Ontario (MTO). This law is particularly relevant to our organisation, University Health Network – Toronto Rehabilitation Institute (TRI), which is one of the leading rehabilitation centres in North America.1 TRI consists of five stand-alone facilities located in a large urban Canadian city and offers both inpatient and outpatient rehabilitation services. There are approximately 530 inpatient admissions to the stroke and acquired brain injury (ABI) rehabilitation programs per year and a large proportion of these patients have cognitive or physical impairments that may affect driving safety.

To date, there have been no standardised reporting or return to driving processes at TRI. Over the past 5 years, the hospital has received 10 formal patient complaints related to license suspension and lack of information provided regarding the reporting and return to driving process. As a result, we performed an institutional review of these practices across the three inpatient and six outpatient stroke and ABI rehabilitation programmes to identify potential areas for improvement.

Our organisation chose to pilot the project on the Stroke inpatient rehabilitation unit, which is a 23-bed ward. Patients are admitted under a hospitalist physician with consultation services provided by one of two Physical Medicine and Rehabilitation (PMR) specialists. After each patient’s initial consultation, the PMR specialist should evaluate whether the patient must be reported to the MTO based on the presence and severity of any physical or cognitive poststroke impairments, and informs the patient regarding their decision. The PMR consultant’s note, the hospitalist’s admission note and the discharge summary are sent to the community family physician and should include information about the patient’s driving status. After discharge from the inpatient stroke rehabilitation unit, many patients continue to be followed at TRI in an interdisciplinary outpatient stroke rehabilitation programme, where return to driving is commonly addressed as an outpatient rehabilitation goal. The problem was that the processes above were not consistently followed.

The project aim was to use Lean Methods to achieve 100% reporting using the official government-issued driver reporting form while increasing the percentage of PMR consultation notes and discharge summaries that document driver reporting status to >90% within 12 months. A secondary aim was to optimise communication and education of drivers admitted to a 23-bed inpatient stroke rehabilitation unit.

Background

In 2013, approximately 405 000 Canadians living in the community experienced the effects of a stroke, with a prevalence of 1.15%.2 Stroke is a leading cause of disability and death in Canada, costing an estimated $3.6 billion in healthcare expenditures and productivity loss.3

Stroke can lead to physical and cognitive impairments, including hemiparesis, ataxia, inattention, neglect, reduced processing speed and visuospatial impairments, which can negatively impact driving safety.4 In fact, individuals post-stroke have a twofold higher risk of motor vehicle collisions compared with those without stroke.5 As a result, identification of high-risk patients post-stroke is crucial for patient and public safety on the road.

National physician guidelines are available regarding medical conditions that may pose a risk to driving safety.4 However, there are no available guidelines regarding the optimal process for reporting patients or the appropriate information to provide stroke survivors regarding driving after a stroke. A previous systematic review by Frith found that only half of stroke survivors in acute care were provided with driving education prior to discharge home.6 Qualitative studies suggest patients are given limited recommendations and inadequate information about driving poststroke from both acute care and rehabilitation facilities.7

Driving is considered an instrumental activity of daily living and the inability to drive negatively impacts patients’ ability to reintegrate into the community and participate in work, social and recreational activities.8 Qualitative studies have shown that loss of driving privileges negatively impacts patient quality of life and independence.7

A systematic process for reporting patients to the MTO would potentially improve consistency in information provided to patients and members of their healthcare team, as well as patient satisfaction.

Measurement

A baseline chart audit of patients admitted to the stroke inpatient rehabilitation unit was performed in February 2016. Only 50% of PMR consultations described a plan to address driving, and the standardised government-issued medical conditions report form was used for none (0%) of the patients reported to the MTO. Instead, a triplicate form generated by our institution was sent for all reported patients. We performed a retrospective chart audit of patients discharged in February 2016 and found that none (0%) of the discharge summaries stated whether the patient was reported to the MTO.

The selected process measures for our intervention included: (i) percentage of charts using the standardised MTO medical conditions report form, (ii) percentage of patients with driver status documented in the PMR consultation note and (iii) percentage of drivers with MTO reporting status documented in the hospitalist’s discharge summary. These process measures were objective, easy to measure and represented important communication methods between the hospitalist, PMR consultant, community family physician and patient. The PMR consultation notes and the discharge summaries are frequently used to communicate with the patient’s outpatient rehabilitation team. Furthermore, patients receive a copy of their discharge summary when leaving the hospital, which informs them whether they were reported to the MTO or not. Patients who were not drivers prior to their stroke were excluded from the chart audit. Staff satisfaction was assessed qualitatively as a balancing measure.

Monthly chart audits were performed and the results were plotted and analysed on run charts. The dates of meetings with key stakeholders and staff changeover were indicated on the run charts to contextualise the findings.

Design

Prior to the intervention, individual physician interviews were performed with nine hospitalists and PMR consultants, which confirmed variability in reporting practices as well as inconsistent communication regarding driving with patients and among healthcare providers.

Process mapping, also known as value stream mapping, was completed in a meeting that included relevant stakeholders, including the Medical Director of the Brain Programme, Medical Doctors, Occupational Therapists, Psychologist and Lean process improvement coaches. Several key opportunities for improvement on the stroke rehabilitation unit were identified: (i) the standard MTO reporting form was not being used, (ii) reporting practices were inconsistent and (iii) there was a lack of communication regarding the MTO reporting decision to patients, community physicians and outpatient teams.

In order to standardise and improve the MTO reporting process, we prioritised steps that would have most impact and aimed to: (i) standardise the use of the MTO’s medical conditions report form, (ii) improve consistency in indicating driver status in PMR consultations and (iii) identify reported drivers in the discharge summary.

With support from the Lean process improvement coaches, the process map was used to generate a standard work form outlining the key steps to assess and, potentially, report stroke rehabilitation inpatients’ fitness to drive. The major steps, in brief, included the following: (i) a blank MTO medical conditions report form is inserted in the chart on chart assembly; (ii) PMR performs their consultation; and (iii) the patient is categorised as unfit to drive, safe to drive or unclear. There are three separate pathways based on this initial categorisation. If the patient is to be reported, the following steps are taken: (i) the MTO form is completed, (ii) patient education is provided, (iii) form is faxed, (iv) faxed copy with confirmation is placed in the chart, (v) the decision to report is documented in the PMR consultation note and (vi) the reporting status is documented in the discharge summary. To ensure staff accountability for the standard work, clear role responsibility for completion of each task was assigned to one team member.

Strategy

We employed iterative quality improvement cycles while collecting data continuously over time. The charts and electronic medical records of patients admitted between February 2016 and April 2017 were audited. Chart audits of PMR consultations and discharge summaries were completed on a monthly basis from February to July 2016, with a retrospective chart audit completed in May and June 2017.

Lessons and limitations

Despite our education sessions for the physicians on the stroke rehabilitation unit, staff changeover posed a consistent challenge for sustaining our results. Our initial meeting with stakeholders did not include all PMR consultants. We realised the importance of in-person meetings as opposed to email communication to have all stakeholders invested in the change processes.

When we started this endeavour, there were certain factors that were not accounted for, including staff vacations and rotating medical trainees, resulting in coverage by individuals unfamiliar with the initiative. In order to mitigate these, we liaised with PMR staff to ensure that all trainees were familiar with the standard work. We were initially unaware of the e-discharge initiative, which may have been a confounding factor for the discharge summary results.

We did not perform monthly prospective PDSA cycles throughout the entire span of the project, which was a part of the initial strategy. Although this data was eventually collected retrospectively, the delay in data collection may have resulted in missed opportunities to address issues regarding MTO reporting in the PMR consultation in a more timely fashion.

One of the major limitations of this project was that patient satisfaction regarding the reporting process as well as the education provided to them was not evaluated, although the number of patient complaints received was used as a surrogate measure. Our institution plans to formally evaluate patient satisfaction with these processes in the future.