Interventions
Our institution has successfully used and sustained evidence-based order
sets that include clinical decision-making elements for other
conditions.15 The team used this existing framework,
QI tools, and the PDSA methodology14 to understand
barriers to improvement and implement interventions. To enable rational
design of interventions, the QI team identified factors that drive the
Vitamin D testing, supplementation and follow-up testing
post-supplementation. Potential barriers and facilitators and primary
drivers are described in Ishikawa (Figure 1) and Key Driver (Figure 2)
diagrams.
After considering the feasibility, evidence, and local culture, the team
decided on the following interventions: 1) development of an
institutional guideline for Vitamin D testing, supplementation and
follow-up testing post-supplementation; 2) education on Vitamin D
deficiency and insufficiency testing and supplementation for oncology
providers; 3) creation and distribution of a clinical decision-making
tree for Vitamin D deficiency, insufficiency, and sufficiency [Figure
3]; 4) incorporation of EMR triggers and Vitamin D automated testing
options; 5) inclusion of the Vitamin D laboratory order into the
pre-existing oncology order sets; and 6) creation of a Best Practice
Advisory (BPA) alert to be triggered if the patient did not have recent
Vitamin D testing, or if testing was done but the patient was not taking
Vitamin D.