PDSA #1: Pre-intervention assessment, Ishikawa and Key Driver
diagrams, process map, and development of institutional guideline
(November 1, 2015 to January 31, 2016).
Ishikawa results were compiled and analyzed, and a process map was
completed. Barriers such as lack of automated triggers/reminders for
testing, inconsistent criteria used for testing and supplementation, and
inability to obtain follow-up testing post-supplementation were
identified. Key drivers included: Physicians’ knowledge about when to
test and how to supplement Vitamin D; guideline and decision-making tree
widely available; integration into clinical workflows and facilitated by
automated triggers in EMR; and leadership awareness and support (Figure
2). In collaboration with a pediatric endocrinologist we reviewed
national best practices and created an institutional guideline and
clinical decision-making tree for Vitamin D testing, supplementation and
follow-up testing post-supplementation (Figure 3). We utilized 25(OH)D
as the most accurate way to measure Vitamin D status in our patients.
The pediatric endocrinologist provided input regarding supplementation
and follow-up testing post-supplementation based on the Endocrine
Society Guidelines.13 We defined Vitamin D deficiency
as 25(OH)D concentration of <20 ng/ml, insufficiency ≥20 and
<30 ng/ml, and sufficiency ≥30 ng/ml. Based on the patient’s
25(OH)D concentration, supplementation was prescribed and follow-up
testing post-supplementation was completed per the clinical
decision-making tree (Figure 3).