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).