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.